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Involvement of tissue changes induced by neoadjuvant treatment in total mesorectal excision (TME): novel suggestions for determining TME quality

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Abstract

Background

Few studies to date have investigated morphological changes after neoadjuvant treatment (NAT) and their implications in total mesorectal excision (TME). This study was primarily designed to evaluate whether tissue changes associated with NAT affected the quality of TME and additionally to suggest a more objective method evaluating TME quality.

Methods

This study enrolled 1322 consecutive patients who underwent curative robot-assisted surgery for rectal cancer. Patients who did and did not receive NAT were subjected to propensity-score matching, yielding 402 patients in each group.

Results

NAT independently reduced complete achievement of TME [odds ratio (OR) = 2.056, p = 0.017]. Intraoperative evaluation identified seven tissue changes significantly associated with NAT, including tumor perforation, mucin pool, necrosis, fibrosis, fat degeneration, and rectal or perirectal edema NAT (p < 0.001–0.05). Tumor perforation (OR = 5.299, p = 0.001) and mucin pool (OR = 14.053, p = 0.002) were independently associated with inappropriate (near-complete + incomplete) TME. Complete TME resulted in significantly reduced local recurrence (4.3% vs 15.3%, p = 0.003) and increased 5-year DFS rate (80.6% vs 67.6%, p = 0.047) compared with inappropriate one. By contrast, two tiers of complete and near-complete TMEs vs incomplete TME did not. Notably, among patients with complete TME, those who received NAT had a lower 5-year DFS than those who did not (77.8% vs 83.3%, p = 0.048).

Conclusions

NAT-associated tissue changes, somewhat interrupting complete TME, may provide unsolved clue to the relative inability of NAT to improve overall survival. The conventional three-tier grading of TME seems to be simplified into two tiers as complete and inappropriate.

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Acknowledgements

The authors would like to thank Hyo Seon Yu, MD, Mi Young Park, MD, Jay Jung, MD, Hyun Joo Jeong, RN, and Jung Rang Kim, RN., for their support with data enrollment, collection, and update.

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Authors and Affiliations

  1. Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea

    Jin Cheon Kim, Chan Wook Kim, In Ja Park, Yong Sik Yoon & Jong Lyul Lee

  2. Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea

    Seong Ho Park

  3. Department of Pathology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea

    Jihun Kim

  4. Department of Radiation Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea

    Jong Hoon Kim

  5. Department of Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea

    Yong Sang Hong & Tae Won Kim

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  1. Jin Cheon Kim
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Contributions

Jin Cheon Kim, and Tae Won Kim contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Jin Cheon Kim, Seong Ho Park, Jihun Kim, Chan Wook Kim, In Ja Park, Yong Sik Yoon, Jong Lyul Lee, Jong Hoon Kim, Yong Sang Hong, and Tae Won Kim. The first draft of the manuscript was written by Jin Cheon Kim and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Jin Cheon Kim.

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Approved by the Institutional Review Board of Asan Medical Center (registration number: 2021–1851).

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Kim, J.C., Park, S.H., Kim, J. et al. Involvement of tissue changes induced by neoadjuvant treatment in total mesorectal excision (TME): novel suggestions for determining TME quality. Int J Colorectal Dis 37, 1289–1300 (2022). https://doi.org/10.1007/s00384-022-04165-z

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