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Distal dissection in total mesorectal excision, and preoperative chemoradiotherapy and lateral lymph node dissection for rectal cancer

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Abstract

The local recurrence rate after total mesorectal excision (TME) appears to be markedly lower than that after conventional operations. We reviewed all relevant articles identified from the MEDLINE databases and clarified the rationale for TME. It is clear that distal intramural spread is rare. Even when present, such spread is not likely to extend beyond 2 cm. Data with attention to mesorectal cancer deposits suggest that mesorectal clearance of at least 4–5 cm distal to the tumor should be sufficient. TME should be performed for most tumors of the mid- and lower rectum. This does not mean that the gut tube needs to be divided at the same level in every case. Dissection of the distal mesorectum off the gut tube can be performed, so the distal line of division of the bowel wall can be made at a minimum of 2 cm below the tumor if such a maneuver would ensure that the sphincters are preserved. In cases with cancer in the upper third of the rectum, the mesorectum and gut tube can safely be divided 5 cm below the tumor without jeopardizing the recurrence rates. Our findings indicate that TME is an essential treatment approach for rectal cancer, and lateral lymph node dissection and preoperative chemoradiotherapy are additional therapies that should be considered for advanced rectal cancer.

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References

  1. Japanese Research Society for Cancer of the Colon and Rectum. Multi-Institutional Registry of Large Bowel Cancer in Japan, vol. 5 (in Japanese). Tochigi, Japan: Japanese Research Society for Cancer of the Colon and Rectum; 1990. p. 56–7.

  2. Galandiuk S, Wieand HS, Moertel CG, Cha SS, Fitzgibbons RJ, Pemberton JH, et al. Patterns of recurrence after curative resection of carcinoma of the colon and rectum. Surg Gynecol Obstet. 1992;174:27–32.

    CAS  PubMed  Google Scholar 

  3. Hida J, Yasutomi M, Shindoh K, Kitaoka M, Fujimoto K, Ieda S, et al. Second-look operation for recurrent colorectal cancer based on carcinoembryonic antigen and imaging techniques. Dis Colon Rectum. 1996;39:74–9.

    CAS  PubMed  Google Scholar 

  4. Nelson H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst. 2001;93:583–96.

    CAS  PubMed  Google Scholar 

  5. Compton CC, Fielding LP, Burgart LJ, Conley B, Cooper HS, Hamilton SR, et al. Prognostic factors in colorectal cancer. College of American Pathologists Consensus Statement 1999. Arch Pathol Lab Med. 2000;124:979–94.

    CAS  PubMed  Google Scholar 

  6. Heald RJ, Husband EM, Ryall RDH. The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg. 1982;69:613–6.

    CAS  PubMed  Google Scholar 

  7. Scott N, Jackson P, Al-Jaberi T, Dixon MF, Quirke P, Finan PJ. Total mesorectal excision and local recurrence: a study of tumor spread in the mesorectum distal to rectal carcinoma. Br J Surg. 1995;82:1031–3.

    CAS  PubMed  Google Scholar 

  8. MacFarlane JK, Ryall RDH, Heald RJ. Mesorectal excision for rectal cancer. Lancet. 1993;341:457–60.

    CAS  PubMed  Google Scholar 

  9. Arbman G, Nilsson E, Hallböök O, Sjödahl R. Local recurrence following total mesorectal excision for rectal cancer. Br J Surg. 1996;83:375–9.

    CAS  PubMed  Google Scholar 

  10. Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg. 1995;181:335–46.

    CAS  PubMed  Google Scholar 

  11. Leo E, Belli F, Andreola S, Gallino G, Bonfanti G, Ferro F, et al. Total rectal resection and complete mesorectum excision followed by coloendoanal anastomosis as the optimal treatment for low rectal cancer: the experience of the National Cancer Institute of Milano. Ann Surg Oncol. 2000;7:125–32.

    CAS  PubMed  Google Scholar 

  12. Law WL, Chu KW. Impact of total mesorectal excision on the results of surgery of distal rectal cancer. Br J Surg. 2001;88:1607–12.

    CAS  PubMed  Google Scholar 

  13. Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345:638–46.

    CAS  PubMed  Google Scholar 

  14. Tocchi A, Mazzoni G, Lepre L, Liotta G, Costa G, Agostini N, et al. Total mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences. Arch Surg. 2001;136:216–20.

    CAS  PubMed  Google Scholar 

  15. Vironen JH, Halme L, Sainio P, Kyllonen LE, Scheinin T, Husa AI, et al. New approaches in the management of rectal carcinoma result in reduced local recurrence rate and improved survival. Eur J Surg. 2002;168:158–64.

    PubMed  Google Scholar 

  16. Bülow S, Christensen IJ, Harling H, Kronborg O, Fenger C, Nielsen HJ. Recurrence and survival after mesorectal excision for rectal cancer. Br J Surg. 2003;90:974–80.

    PubMed  Google Scholar 

  17. Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Soreide O. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum. 2004;47:48–58.

    PubMed  Google Scholar 

  18. Twomey P, Burchell M, Strawn D, Guernsey J. Local control in rectal cancer: a clinical review and meta-analysis. Arch Surg. 1989;124:1174–9.

    CAS  PubMed  Google Scholar 

  19. Krook JE, Moertel CG, Gunderson LL, Wieand HS, Collins RT, Beart RW, et al. Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med. 1991;324:709–15.

    CAS  PubMed  Google Scholar 

  20. Adam IJ, Mohamdee MO, Martin IG, Scott N, Finan PJ, Johnston D, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet. 1994;344:707–11.

    CAS  PubMed  Google Scholar 

  21. Dahlberg M, Glimelius B, Påhlman L. Changing strategy for rectal cancer is associated with improved outcome. Br J Surg. 1999;86:379–84.

    CAS  PubMed  Google Scholar 

  22. Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986;1:1479–82.

    CAS  PubMed  Google Scholar 

  23. Keighley MRB, Williams NS. Surgery of the anus, rectum & colon. 3rd ed. Philadelphia: Saunders Elsevier; 2008. p. 1149–50.

    Google Scholar 

  24. Block WA, Waugh JM. The intramural extension of carcinoma of the descending colon, sigmoid and rectosigmoid: a pathologic study. Surg Gynecol Obstet. 1948;87:457–64.

    Google Scholar 

  25. Quer EA, Dahlin DC, Mayo CW. Retrograde intramural spread of carcinoma of the rectum and rectosigmoid: a microscopic study. Surg Gynecol Obstet. 1953;96:24–30.

    CAS  PubMed  Google Scholar 

  26. Grinnell RS. Distal intramural spread of carcinoma of the rectum and rectosigmoid. Surg Gynecol Obstet. 1954;99:421–9.

    CAS  PubMed  Google Scholar 

  27. Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients’ survival. Br J Surg. 1983;70:150–4.

    CAS  PubMed  Google Scholar 

  28. Morita T, Yamanaka Y, Nakamura F, Konn M. Low anterior resction for carcinoma of the lower rectum (in Japanese with English abstract). J Jpn Soc Colo-proctol. 1992;45:1113–22.

    Google Scholar 

  29. Shirouzu K, Isomoto H, Kakegawa T. Distal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery. Cancer. 1995;76:388–92.

    CAS  PubMed  Google Scholar 

  30. Kwok SPY, Lau WY, Leung KL, Liew CT, Li AKC. Prospective analysis of the distal margin of clearance in anterior resection for rectal carcinoma. Br J Surg. 1996;83:969–72.

    CAS  PubMed  Google Scholar 

  31. Andreola S, Leo E, Belli F, Lavarino C, Bufalino R, Tomasic G, et al. Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis. Dis Colon Rectum. 1997;40:25–9.

    CAS  PubMed  Google Scholar 

  32. Hida J, Yasutomi M, Maruyama T, Fujimoto K, Uchida T, Okuno K. Lymph node metastases detected in the mesorectum distal to carcinoma of the rectum by the clearing method: justification of total mesorectal excision. J Am Coll Surg. 1997;184:584–8.

    CAS  PubMed  Google Scholar 

  33. Andreola S, Leo E, Belli F, Bonfanti G, Sirizzotti G, Greco P, et al. Adenocarcinoma of the lower third of the rectum surgically treated with a <10-mm distal clearance: preliminary results in 35 N0 patients. Ann Surg Oncol. 2001;8:611–5.

    CAS  PubMed  Google Scholar 

  34. Ono C, Yoshinaga K, Enomoto M, Sugihara K. Discontinuous rectal cancer spread in the mesorectum and the optimal distal clearance margin in situ. Dis Colon Rectum. 2002;45:744–9.

    PubMed  Google Scholar 

  35. Ueno H, Mochizuki H, Hashiguchi Y, Ishikawa K, Fujimoto H, Shinto E, et al. Preoperative parameters expanding the indication of sphincter preserving surgery in patients with advanced low rectal cancer. Ann Surg. 2004;239:34–42.

    PubMed Central  PubMed  Google Scholar 

  36. Mezhir JJ, Smith KD, Fichera A, Hart J, Posner MC, Hurst RD. Presence of distal intramural spread after preoperative combined-modality therapy for adenocarcinoma of the rectum: what is now the appropriate distal resection margin? Surgery. 2005;138:658–64.

    PubMed  Google Scholar 

  37. Zhao GP, Zhon ZG, Lei WZ, Yu YY, Wang C, Wang Z, et al. Pathological study of distal mesorectal cancer spread to determine a proper distal resection margin. World J Gastroenterol. 2005;11:319–22.

    PubMed Central  PubMed  Google Scholar 

  38. Guillem JG, Chessin DB, Shia J, Suriawinata A, Riedel E, Moore HG, et al. A prospective pathologic analysis using whole-mount sections of rectal cancer following preoperative combined modality therapy: implications for sphincter preservation. Ann Surg. 2007;245:88–93.

    PubMed Central  PubMed  Google Scholar 

  39. Glover RP, Waugh JM. The retrograde lymphatic spread of carcinoma of the “rectosigmoid region”: its influence on surgical procedures. Surg Gynecol Obstet. 1946;82:434–48.

    CAS  PubMed  Google Scholar 

  40. Grinnell RS. Lymphatic metastases of carcinoma of the colon and rectum. Ann Surg. 1950;131:494–506.

    CAS  PubMed Central  PubMed  Google Scholar 

  41. Goligher JC, Dukes CE, Bussy HJR. Local recurrences after sphincter-saving excisions for carcinoma of the rectum and rectosigmoid. Br J Surg. 1951;39:199–211.

    CAS  PubMed  Google Scholar 

  42. Reynolds JV, Joyce WP, Dolan J, Sheahan K, Hyland JM. Pathological evidence in support of total mesorectal excision in the management of rectal cancer. Br J Surg. 1996;83:1112–5.

    CAS  PubMed  Google Scholar 

  43. Yao YF, Wang L, Liu YQ, Li JY, Gu J. Lymph node distribution and pattern of metastases in the mesorectum following total mesorectal excision using the modified fat clearing technique. J Clin Pathol. 2011;64:1073–7.

    PubMed  Google Scholar 

  44. Hida J, Mori N, Kubo R, Matsuda T, Morikawa E, Kitaoka M, et al. Metastases from carcinoma of the colon and rectum detected in small lymph nodes by the clearing method. J Am Coll Surg. 1994;178:223–8.

    CAS  PubMed  Google Scholar 

  45. Hida J, Yasutomi M, Fujimoto K, Maruyama T, Okuno K, Shindo K. Does lateral lymph node dissection improve survival in rectal carcinoma? Examination of node metastases by the clearing method. J Am Coll Surg. 1997;184:475–80.

    CAS  PubMed  Google Scholar 

  46. Enker WE. Operative considerations in rectal cancer-the pelvic dissection. In: Cohen AM, Winawer SJ, editors. Cancer of the colon, rectum, and anus. New York: McGraw-Hill, Inc.; 1995. p. 561–70.

    Google Scholar 

  47. Pollet WG, Nicholls RJ. The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum. Ann Surg. 1983;198:159–63.

    Google Scholar 

  48. Wilson SM, Beahrs OH. The curative treatment of carcinoma of the sigmoid, rectosigmoid, and rectum. Ann Surg. 1976;183:556–65.

    CAS  PubMed Central  PubMed  Google Scholar 

  49. Hojo K. Anastomotic recurrence after sphincter-saving resection for rectal cancer: length of distal clearance of bowel. Dis Colon Rectum. 1986;29:11–4.

    CAS  PubMed  Google Scholar 

  50. Heimann TM, Szporn A, Bolnick K, Aufses AH Jr. Local recurrence following surgical treatment of rectal cancer: comparison of anterior and abdominoperineal resection. Dis Colon Rectum. 1986;29:862–4.

    CAS  PubMed  Google Scholar 

  51. Wolmark N, Fisher B. An analysis of survival and treatment failure following abdominoperineal and sphincter-saving resection in Dukes’ B and C rectal carcinoma: a report of the NSABP clinical trials. Ann Surg. 1986;204:480–9.

    CAS  PubMed Central  PubMed  Google Scholar 

  52. Karanjia ND, Schache DJ, North WRS, Heald RJ. ‘Close shave’ in anterior resection. Br J Surg. 1990;77:510–2.

    CAS  PubMed  Google Scholar 

  53. Vernava AM III, Moran M, Rothenberger DA, Wong WD. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet. 1992;175:333–6.

    PubMed  Google Scholar 

  54. Paty PB, Enker WE, Cohen AM, Lauwers GY. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg. 1994;219:365–73.

    CAS  PubMed Central  PubMed  Google Scholar 

  55. Killingback M, Barron P, Dent OF. Local recurrence after curative resection of cancer of the rectum without total mesorectal excision. Dis Colon Rectum. 2001;44:473–86.

    CAS  PubMed  Google Scholar 

  56. Law WL, Ho JWC, Chan R, Au G, Chu KW. Outcome of anterior resection for stage II rectal cancer without radiation: the role of adjuvant chemotherapy. Dis Colon Rectum. 2005;48:218–26.

    PubMed  Google Scholar 

  57. Rullier E, Laurent C, Bretagnol F, Rullier A, Vendrely V, Zerbib F. Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg. 2005;241:465–9.

    PubMed Central  PubMed  Google Scholar 

  58. Rutkowski A, Bujko K, Nowacki MP, Chmielik E, Nasierowska-Guttmejer A, Wojnar A, et al. Distal bowel surgical margin shorter than 1 cm after preoperative radiation for rectal cancer: is it safe? Ann Surg Oncol. 2008;15:3124–31.

    PubMed  Google Scholar 

  59. Pricolo VE, Abodeely A, Resnick M. Distal margins in radical resections for rectal cancer after chemoradiation therapy: how short is long enough? Dig Surg. 2010;27:185–9.

    PubMed  Google Scholar 

  60. Nash GM, Weiss A, Dasgupta R, Gonen M, Guillem JG, Wong WD. Close distal margin and rectal cancer recurrence after sphincter-preserving rectal resection. Dis Colon Rectum. 2010;53:1365–73.

    PubMed  Google Scholar 

  61. Fitzgerald TL, Brinkley J, Zervos EE. Pushing the envelope beyond a centimeter in rectal cancer: oncologic implications of close, but negative margins. J Am Coll Surg. 2011;213:589–95.

    PubMed  Google Scholar 

  62. Topor B, Acland R, Kolodko V, Galandiuk S. Mesorectal lymph nodes: their location and distribution within the mesorectum. Dis Colon Rectum. 2003;46:779–85.

    PubMed  Google Scholar 

  63. Corman MR. Colon and rectal surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 5–10.

    Google Scholar 

  64. Cawthorn SJ, Parums DV, Gibbs NM, A’Hern RP, Caffarey SM, Broughton CI, et al. Extent of mesorectal spread and involvement of lateral resection margin as prognostic factors after surgery for rectal cancer. Lancet. 1990;335:1055–9.

    CAS  PubMed  Google Scholar 

  65. Quirke P, Scott N. The pathologist’s role in the assessment of local recurrence in rectal carcinoma. Surg Oncol Clin North Am. 1992;1:1–17.

    Google Scholar 

  66. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection: a histopathological study of lateral tumor spread and surgical excision. Lancet. 1986;2:996–9.

    CAS  PubMed  Google Scholar 

  67. Ng IO, Luk IS, Yuen ST, Lau PW, Pritchett CJ, Ng M, et al. Surgical lateral clearance in resected rectal carcinomas: a multivariate analysis of clinicopathologic features. Cancer. 1993;71:1972–6.

    CAS  PubMed  Google Scholar 

  68. Goldberg PA, Nicholls RJ. Predition of local recurrence and survival of carcinoma of the rectum by surgical and histopathological assessment of local clearance. Br J Surg. 1995;82:1054–6.

    CAS  PubMed  Google Scholar 

  69. de Haas-Kock DF, Beaten CG, Jager JJ, Langendijk JA, Schouten LJ, Volovics A, et al. Prognostic significance of radial margins of clearance in rectal cancer. Br J Surg. 1996;83:781–5.

    PubMed  Google Scholar 

  70. Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg. 2005;242:74–82.

    PubMed Central  PubMed  Google Scholar 

  71. Hardy KJ, Cuthbertson AM, Hughes ES. Suture-line neoplastic recurrence following large-bowel resection. Aust N Z J Surg. 1971;41:44–6.

    CAS  PubMed  Google Scholar 

  72. Kockerling F, Reymond MA, Altendorf-Hofmann A, Dworak O, Hohenberger W. Influence of surgery on metachronous distant metastases and survival in rectal cancer. J Clin Oncol. 1998;16:324–9.

    CAS  PubMed  Google Scholar 

  73. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997. Arch Surg. 1998;133:894–9.

    CAS  PubMed  Google Scholar 

  74. Lopez-Kostner F, Lavery IC, Hool GR, Rybicki LA, Fazio VW. Total mesorectal excision is not necessary for cancers of the upper rectum. Surgery. 1998;124:612–8.

    CAS  PubMed  Google Scholar 

  75. Zaheer S, Pemberton JH, Farouk R, Dozois RR, Wolff BG, Ilstrup D. Surgical treatment of adenocarcinoma of the rectum. Ann Surg. 1998;277:800–11.

    Google Scholar 

  76. Hall NR, Finan PJ, al-Jaberi T, Tsang CS, Brown SR, Dixon MF, et al. Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent: predictor of survival but not local recurrence? Dis Colon Rectum 1998;41:979–83.

    Google Scholar 

  77. Wibe A, Møller B, Norstein J, Carlsen E, Wiig JN, Heald RJ, et al. A national strategic change in treatment policy for rectal cancer: implementation of total mesorectal excision as routine treatment in Norway. A national audit. Dis Colon Rectum. 2002;45:857–66.

    PubMed  Google Scholar 

  78. Kapiteijin E, Putter H, van de Verde CJ. Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg. 2002;89:1142–9.

    Google Scholar 

  79. Nesbakken A, Nygaard K, Westerheim O, Mala T, Lunde OC. Local recurrence after mesorectal excision for rectal cancer. EJSO. 2002;28:126–34.

    CAS  PubMed  Google Scholar 

  80. Cecil TD, Sexton R, Moran BJ, Heald RJ. Total mesorectal excision results in low local recurrence rates in lymph node-positive rectal cancer. Dis Colon Rectum. 2004;47:1145–50.

    PubMed  Google Scholar 

  81. Kim YW, Kim NK, Min BS, Lee KY, Sohn SK, Cho CH. The influence of the number of retrieved lymph nodes on staging and survival in patients with stage II and III rectal cancer undergoing tumor-specific mesorectal excision. Ann Surg. 2009;249:965–72.

    PubMed  Google Scholar 

  82. Tinley HS, Rasheed S, Northover JM, Tekkis PP. The influence of circumferential resection margins on long-term outcomes following rectal cancer surgery. Dis Colon Rectum. 2009;52:1723–9.

    Google Scholar 

  83. Bernstein TE, Endreseth BH, Romundstad P, Wibe A, on behalf of the Norwegian Colorectal Cancer Group. Circumferential resection margin as a prognostic factor in rectal cancer. Br J Surg 2009;96:1348–57.

    Google Scholar 

  84. Frasson M, Garcia-Granero E, Roda D, Flor-Lorente B, Roselló S, Esclapez P, et al. Preoperative chemoradiation may not always be needed for patients with T3 and T2 N + rectal cancer. Cancer. 2011;117:3118–25.

    PubMed  Google Scholar 

  85. Peng J, Sheng W, Huang D, Venook AP, Xu Y, Guan Z, et al. Perineural invasion in pT3N0 rectal cancer. Cancer. 2011;117:1415–21.

    PubMed  Google Scholar 

  86. Lin HH, Lin JK, Lin CC, Lan YZ, Wang HS, Yang SH, et al. Circumferential margin plays an independent impact on the outcome of rectal cancer patients receiving curative total mesorectal excision. Am J Surg. 2013;206:771–7.

    Google Scholar 

  87. Saito N, Sarashina H, Nunomura M, Koda K, Takiguchi N, Nakajima N. Clinical evaluation of nerve-sparing surgery combined with preoperative radiotherapy in advanced rectal cancer patients. Am J Surg. 1998;175:277–82.

    CAS  PubMed  Google Scholar 

  88. Nagawa H, Muto T, Sunouchi K, Higuchi Y, Tsurita G, Watanabe T, et al. Randomized, controlled trial of lateral node dissection vs. nerve preserving resection in patients with rectal cancer after preoperative radiotherapy. Dis Colon Rectum. 2001;44:1274–80.

    CAS  PubMed  Google Scholar 

  89. Watanabe T, Tsurita G, Muto T, Sawada T, Sunouchi K, Higuchi Y, et al. Extended lymphadenectomy and preoperative radiotherapy for lower rectal cancer. Surgery. 2002;132:27–33.

    PubMed  Google Scholar 

  90. Law WL, Chu KW. Anterior resction for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg. 2004;240:260–8.

    PubMed Central  PubMed  Google Scholar 

  91. Peeters KC, Marijnen CA, Nagtegaal ID, Kranenbarg EK, Putter H, Wiggers T, et al. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg. 2007;246:693–701.

    PubMed  Google Scholar 

  92. Stewart D, Yan Y, Mutch M, Kodner I, Hunt S, Lowney J, et al. Predictors of disease-free survival in rectal cancer patients undergoing curative proctectomy. Colorectal Dis. 2008;10:879–86.

    CAS  PubMed  Google Scholar 

  93. Kim TH, Jeong SY, Choi DH, Kim DY, Jung KH, Moon SH, et al. Lateral lymph node metastasis is a major cause of locoregional recurrence in rectal cancer treated with preoperative chemoradiotherapy and curative resection. Ann Surg Oncol. 2008;15:729–37.

    PubMed  Google Scholar 

  94. Kusters M, Beets GL, van de Velde CJH, Beets-tan RGH, Marijnen CAM, Rutten HJT, et al. A comparison between the treatment of low rectal cancer in Japan and Netherlands, focusing on the patterns of local recurrence. Ann Surg. 2009;249:229–35.

    PubMed  Google Scholar 

  95. Silberfein EJ, Kattepogu KM, Hu CY, Skibber JM, Rodriguez-Bigas MA, Feig B, et al. Long-term survival and recurrence outcomes following surgery for distal rectal cancer. Ann Surg Oncol. 2010;17:2863–9.

    PubMed Central  PubMed  Google Scholar 

  96. Ceyhan GO, Liebl F, Maak M, Schuster T, Becker K, Langer R, et al. The severity of neural invasion is a crucial prognostic factor in rectal cancer independent of neoadjuvant radiochemotherpy. Ann Surg. 2010;252:797–804.

    PubMed  Google Scholar 

  97. Kusters M, Marijnen CA, van de Velde CJ, Rutten HJ, Lahaye MJ, Kim JH, et al. Patterns of local recurrence in rectal cancer: a study of the Dutch TME trial. EJSO. 2010;36:470–6.

    CAS  PubMed  Google Scholar 

  98. Syk E, Glimelius B, Nilsson PJ. Factors influencing local failure in rectal cancer: analysis of 2315 patients from a population-based series. Dis Colon Rectum. 2010;53:744–52.

    CAS  PubMed  Google Scholar 

  99. Gijn W, Marijnen CA, Nagtegaal ID, Kranenbarg EM, Putter H, Wiggers T, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. Lancet Oncol. 2011;12:575–82.

    PubMed  Google Scholar 

  100. García-Granero E, Faiz O, Lorente-Flor B, García-Botello S, Esclápez P, Cervantest A. Prognostic implications of circumferential location on distal rectal cancer. Colorectal Dis. 2011;13:650–7.

    PubMed  Google Scholar 

  101. Kiran RP, Lian L, Lavery IC. Does a subcentimeter distal resection margin adversely influence oncologic outcomes in patients with rectal cancer undergoing restorative proctectomy. Dis Colon Rectum. 2011;54:157–63.

    PubMed  Google Scholar 

  102. Kelly SB, Mills SJ, Bradburn DM, Ratcliffe AA, Borowski DW, on behalf of the Northern Region Colorectal Cancer Audit Group. Effect of the circumferential resection margin on survival following rectal cancer surgery. Br J Surg 2011;98:573-181.

    Google Scholar 

  103. Patel UB, Taylor F, Blomqvist L, George C, Evans H, Tekkis P, et al. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol. 2011;29:3753–60.

    PubMed  Google Scholar 

  104. Du C, Xue W, Li J, Cai Y, Gu J. Morphology and prognostic value of tumor budding in rectal cancer after neoadjuvant radiotherapy. Hum Pathol. 2012;43:1061–7.

    PubMed  Google Scholar 

  105. Reshef A, Lavery I, Kiran R. Factors associated with oncologic outcomes after abdominoperineal resection compared with restorative resection for low rectal cancer: patient- and tumor-related or technical factors only. Dis Colon Rectum. 2012;55:51–8.

    PubMed  Google Scholar 

  106. Engelen SME, Maas M, Lahaye MJ, Leijtens JWA, van Berlo CLH, Jansen RLH, et al. Modern multidisciplinary treatment of rectal cancer based on staging with magnetic resonance imaging leads to excellent local control, but distant control remains a challenge. Euro J Cancer. 2013;49:2311–20.

    CAS  Google Scholar 

  107. Trakarnsanga A, Gonen M, Shia J, Goodman KA, Nash GM, Temple LK, et al. What is the significance of the circumferential margin in locally advanced rectal cancer after neoadjuvant chemoradiotherapy? Ann Surg Oncol. 2013;20:1179–84.

    PubMed Central  PubMed  Google Scholar 

  108. Kennelly RP, Rogers AC, Winter DC, on behalf of the Abdominoperineal Excision Sudy Group. Multicenter study of circumferential margin positivity and outcomes following abdominoperineal excision for rectal cancer. Br J Surg 2013;100:160–6.

    Google Scholar 

  109. Akiyoshi T, Ueno M, Matsueda K, Konishi T, Fujimoto Y, Nagayama S, et al. Selective lateral pelvic lymph node dissection in patients with advanced low rectal cancer treated with preoperative chemoradiotherapy based on pretreatment imaging. Ann Surg Oncol. 2013. doi:10.1245/s10434-013-3216-y.

    Google Scholar 

  110. Ishihara S, Watanabe T, Kiyomatsu T, Yasuda K, Nagawa H. Prognostic significance of response to preoperative radiotherapy, lymph node metastasis, and CEA level in patients undergoing total mesorectal excision of rectal cancer. Int J Colorectal Dis. 2010;25:1417–25.

    PubMed  Google Scholar 

  111. Rogers AC, Gibbons D, Hanly AM, Hyland JM, O’Connell PR, Winter DC, et al. Prognostic significance of tumor budding befor neoadjuvant therapy. Mod Pathol. 2013. doi:10.1038/modpathol.2013.124.

    Google Scholar 

  112. Ueno H, Mochizuki H, Shinto E, Hashiguchi Y, Hase K, Talbot IC. Histologic indices in biopsy specimens for estimating the probability of extended local spread in patients with rectal carcinoma. Cancer. 2002;94:2882–91.

    PubMed  Google Scholar 

  113. Shirouzu K, Ogata Y, Araki Y. Oncologic and functional results of total mesorectal excision and autonomic nerve-preserving operation for advanced lower rectal cancer. Dis Colon Rectum. 2004;47:1442–7.

    PubMed  Google Scholar 

  114. Ueno M, Oya M, Yamaguchi T, Muto T. Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer. Br J Surg. 2005;92:756–63.

    CAS  PubMed  Google Scholar 

  115. Sugihara K, Kobayashi H, Kato T, Mori T, Mochizuki H, Kameoka S, et al. Indication and benefit of pelvic sidewall dissection for rectal cancer. Dis Colon Rectum. 2006;49:1663–72.

    PubMed  Google Scholar 

  116. Kim JC, Takahashi K, Yu CS, Kim HC, Kim TW, Ryu MH, et al. Comparative outcome between chemoradiotherapy and laterl pelvic lymph node dissection following total mesorectal excision in rectal cancer. Ann Surg. 2007;246:754–62.

    PubMed  Google Scholar 

  117. Akasu T, Takawa M, Yamamoto S, Ishiguro S, Yamaguchi T, Fujita S, et al. Intersphincteric resection for very low rectal adenocarcinoma: univariate and multivariate analyses of risk factors of recurrence. Ann Surg Oncol. 2008;15:2668–76.

    PubMed  Google Scholar 

  118. Kobayashi H, Mochizuki H, Kato T, Mori T, Kameoka S, Shirouzu K, et al. Outcome of surgery alone for lower rectal cancer with and without pelvic sidewall dissection. Dis Colon Rectum. 2009;52:567–76.

    PubMed  Google Scholar 

  119. Shirouzu K, Akagi Y, Fujita S, Ueno H, Takii Y, Komori K, et al. Clinical significance of mesorectal extension of rectal cancer: a Japanese multi-institutional study. Ann Surg. 2011;253:704–10.

    PubMed  Google Scholar 

  120. Kobayashi H, Mochizuki H, Kato T, Mori T, Kameoka S, Shirouzu K, et al. Lymph node ratio is a powerful prognostic index in patients with stage III distal rectal cancer: a Japanese multicenter sudy. Int J Colorectal Dis. 2011;26:891–6.

    PubMed  Google Scholar 

  121. Akagi Y, Shirouzu K, Fujita S, Ueno H, Takii Y, Komori K, et al. Predicting oncologic outcomes by stratifying mesorectal extension in patients with pT3 rectal cancer: a Japanese multi-institutional study. Int J Cancer. 2012;131:1220–7.

    CAS  PubMed  Google Scholar 

  122. Akiyoshi T, Watanabe T, Miyata S, Kotake K, Muto T, Sugihara K, on behalf of the Japanese Society for Cancer of the Colon and Rectum. Results of a Japanese nationwide multi-institutional study on lateral pelvic lymph node metastasis in low rectal cancer: is it regional or distant disease? Ann Surg 2012;255:1129-34.

    Google Scholar 

  123. Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351:1731–40.

    CAS  PubMed  Google Scholar 

  124. Liang JT. Technical feasibility of laparoscopic lateral pelvic lymph node dissection for patients with low rectal cancer after concurrent chemoradiation therapy. Ann Surg Oncol. 2011;18:153–9.

    PubMed  Google Scholar 

  125. Birbeck KF, Macklin CP, Tiffin NJ, Parsons W, Dixon MF, Mapstone NP, et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery. Ann Surg. 2002;235:449–57.

    PubMed Central  PubMed  Google Scholar 

  126. MERCURY Study Group. Extramural depth of tumor invasion at thin section MR in patients with rectal cancer: results of the MERCURY study. Radiology. 2007;243:132–9.

    Google Scholar 

  127. Kulu Y, Ulrich A, Büchler MW. Resectable rectal cancer: which patient does not need preoperative radiotherapy? Dig Dis. 2012;30(Suppl 2):118–25.

    PubMed  Google Scholar 

  128. Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer. J Clin Oncol. 2008;26:303–12.

    PubMed  Google Scholar 

  129. Glynne-Jones R, Mawdsley S, Novell JR. The clinical significance of the circumferential resection margin following preoperative pelvic chemo-radiotherapy in rectal cancer: why we need a common language. Colorectal Dis. 2006;8:800–7.

    CAS  PubMed  Google Scholar 

  130. Ueno H, Murphy J, Jass JR, Mochizuki H, Talbot IC. Tumour ‘budding’ as an index to estimate the potential of aggressiveness in rectal cancer. Histopathology. 2002;40:127–32.

    CAS  PubMed  Google Scholar 

  131. Syk E, Lenander C, Nilsson PJ, Rubio CA, Glimelius B. Tumour budding correlates with local recurrence of rectal cancer. Colorectal Dis. 2011;13:255–62.

    CAS  PubMed  Google Scholar 

  132. Marijnen CA, Nagtegaal ID, Kapiteijin E, Kranenbarg EK, Noordijk EM, van Krieken JH, et al. Radiotherapy does not compensate for positive resection margins in rectal cancer patients: report of a multi-center randomized trial. Int J Radiat Oncol Biol Phys. 2003;55:1311–20.

    CAS  PubMed  Google Scholar 

  133. Liebig C, Ayala G, Wilks J, Verstovsek G, Liu H, Agarwal N, et al. Perineural invasion is an independent predictor of outcome in colorectal cancer. J Clin Oncol. 2009;27:5131–7.

    PubMed Central  PubMed  Google Scholar 

  134. Liebig C, Ayala G, Wilks J, Verstovsek G, Liu H, Agarwal N, et al. Correspondene: reply to E.M. Poeschl et al. J Clin Oncol 2010;28:e361–3.

    Google Scholar 

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Jin-ichi Hida has no conflict of interest to declare. Kiyotaka Okuno has no conflict of interest to declare. Tadao Tokoro has no conflict of interest to declare.

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Hida, Ji., Okuno, K. & Tokoro, T. Distal dissection in total mesorectal excision, and preoperative chemoradiotherapy and lateral lymph node dissection for rectal cancer. Surg Today 44, 2227–2242 (2014). https://doi.org/10.1007/s00595-013-0811-2

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