Abstract
Purpose
The oncological results of close distal resection margins (DM) have been mixed due to variations in perioperative treatment protocols and surgical expertise. With the increased application of sphincter-saving surgery in the management of rectal cancer, “close shave” DM is an increasingly encountered phenomenon. Our center aims to examine the oncological outcomes of “close shave” DM in the absence of neoadjuvant therapy in the surgical treatment of rectal cancer.
Methods
A prospective database of 320 patients who underwent curative surgical resection for primary rectal cancer between 1999 and 2007 was reviewed. One hundred forty-eight patients had “close shave” DM (DM <1 cm) and 70 (22 %) patients had stage 1, 102 (32 %) patients had stage 2, and 148 (46 %) patients presented with stage 3 disease. Median follow-up was 45 months.
Results
The overall recurrence rate for the entire study cohort was 29 % (n = 94), with 6.6 % of patients developing locoregional recurrence. Recurrence was noted to be significantly associated with decreasing circumferential resection margin (p = 0.008) and increasing American Joint Committee on Cancer stage (p < 0.001). Five-year cancer-specific survival (CSS) for patients with DM <1 cm was 75.6 % and is higher compared to patients with longer DM (p = 0.041). Multivariate analysis showed that CSS was worsened with T stage, N stage, and perineural invasion status. Decreasing DM, however, was not significantly associated with poorer CSS or recurrence rates.
Conclusion
Close distal resection margins do not negatively impact long-term disease control, even without the use of neoadjuvant therapy, provided that safe, optimal surgical resection is performed. Circumferential radial margin may be a more important indicator for outcomes.
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References
Karanjia ND, Schache DJ, North WRS, Heald RJ (1990) ‘Close shave’ in anterior resection. Br J Surg 77:510–512
Cecil TD, Sexton R, Moran BJ, Heald RJ (2004) Total mesorectal excision results in low local recurrence rates in lymph node-positive rectal cancer. Dis Colon Rectum 47:1145–1150
Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK (1998) Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 133:894–899
Nash GM, Weiss A, Dasgupta R et al (2010) Close distal margin and rectal cancer recurrence after sphincter-preserving rectal resection. Dis Colon Rectum 53:1365–1373
Bokey EL, Ojerskog B, Chapuis PH et al (1999) Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection. Br J Surg 86:1164–1170
Vernava AM III, Moran M, Rothenberger DA, Wong WD (1992) A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet 175:333–336
Rutkowski A, Bujko K, Nowacki MP et al (2008) Distal bowel surgical margin shorter than 1 cm after preoperative radiation for rectal cancer: is it safe? Ann Surg Oncol 15:3124–3131
Moore HG, Riedel E, Minsky BD et al (2003) Adequacy of 1-cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined-modality therapy. Ann Surg Oncol 10:80–85
Heald RJ, Smedh RK, Kald A, Sexton R, Moran BJ (1997) Abdominoperineal excision of the rectum—an endangered operation. Dis Colon Rectum 40:747–751
Simons AJ, Ker R, Groshen S, Gee C, Anthone GJ, Ortega AE et al (1997) Variations in treatment of rectal cancer: the influence of hospital type and caseload. Dis Colon Rectum 40:641–646
Eu KW, Seow-Choen F, Ho JMS et al (1998) Local recurrence following rectal resection for cancer. J R Coll Surg Edinb 43:393–396
Seow-Choen F (2002) Adjuvant therapy for rectal cancer cannot be based on the results of other surgeons. Br J Surg 89:946–947
National Comprehensive Cancer Network (NCCN) practice guidelines in oncology version 1.2010. Rectal cancer.
Jensen LH, Altaf R, Harling H et al (2010) Clinical outcome in 520 consecutive Danish rectal cancer patients treated with short course preoperative radiotherapy. EJSO 36:237–243
Sebag-Montefiore D, Stephens RJ, Steele R et al (2009) Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet 373:811–820
Kusters M, Marijnen CAM, van de Velde CJH et al (2010) Patterns of local recurrence in rectal cancer; a study of the Dutch TME trial. EJSO 36:470–476
Vasen HF, Watson P, Mecklin JP, Lynch HT (1999) New clinical criteria for hereditary nonpolyposis colorectal cancer (HNPCC, Lynch syndrome) proposed by the International Collaborative group on HNPCC. Gastroenterology 116:1453–1456
Edge SB, Byrd DR, Compton CC et al (eds) (2010) AJCC cancer staging manual, 7th edn. Springer, New York
McCall JL, Cox MR, Wattchow DA (1995) Analysis of local recurrence rates after surgery along for rectal cancer. Int J Colorectal Dis 10:126–132
Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R, German Rectal Cancer Study Group (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351(17):1731–40, Oct 21
Roh MS, Colangelo LH, O'Connell MJ, Yothers G, Deutsch M, Allegra CJ, Kahlenberg MS, Baez-Diaz L, Ursiny CS, Petrelli NJ, Wolmark N (2009) Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03. J Clin Oncol 27(31):5124–30, Nov 1
Peeters KC, Marijnen CA, Nagtegaal ID, Kranenbarg EK, Putter H, Wiggers T, Rutten H, Pahlman L, Glimelius B, Leer JW, van de Velde CJ (2007) Dutch Colorectal Cancer Group. 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 246(5):693–701
Siegel R, Burock S, Wernecke KD, Kretzschmar A, Dietel M, Loy V, Koswig S, Budach V, Schlag PM (2009) Preoperative short-course radiotherapy versus combined radiochemotherapy in locally advanced rectal cancer: a multi-centre prospectively randomised study of the Berlin Cancer Society. BMC Cancer 9:50, Feb 6
Bosset JF, Collette L, Calais G, Mineur L, Maingon P, Radosevic-Jelic L, Daban A, Bardet E, Beny A, Ollier JC (2006) EORTC Radiotherapy Group Trial 22921. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 355:1114–1123
Kachnic LA, Hong TS, Ryan DP (2008) Rectal cancer at the crossroads: the dilemma of clinically staged T3, N0, M0 disease. J Clin Oncol 26:350–351
Andreola S, Leo E, Belli F et al (1997) Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis. Dis Colon Rectum 40:25–29
Shirouzu K, Isomoto H, Kakegawa T (1995) Distal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery. Cancer 76:388–392
Ueno H, Mochizuki H, Hashiguchi Y et al (2004) Preoperative parameters expanding the indication of sphincter preserving surgery in patients with advanced low rectal cancer. Ann Surg 239:34–42
Quirke P, Dixon MF (1988) The prediction of local recurrence in rectal adenocarcinoma by histopathological examination. Int J Colorectal Dis 3:127–131
Nagtegaal ID, Quirke P (2008) What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 26:303–312
Adam IJ, Mohamdee MO, Martin IG et al (1994) Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet 344:707–711
Wibe A, Syse A, Andersen E et al (2004) Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 47:48–58
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Lim, J.WM., Chew, MH., Lim, KH. et al. Close distal margins do not increase rectal cancer recurrence after sphincter-saving surgery without neoadjuvant therapy. Int J Colorectal Dis 27, 1285–1294 (2012). https://doi.org/10.1007/s00384-012-1467-x
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DOI: https://doi.org/10.1007/s00384-012-1467-x