Abstract
Introduction
The distal resection margin (DRM) has been considered an important factor for the oncological outcome of rectal cancer surgery. However, the optimal distal margins required to achieve safe oncological outcome remains to be controversial.
Material and methods
More recently, as circumferential resection margin or mesorectal margin has been additionally reported to be more important factors predicting patient outcome than the distal mucosal margin, a re-evaluation of the impact of DRM on patient outcome is needed.
Results
The extent of distal tumor spread is known to be influenced by a variety of factors such as tumor location, lymph node metastasis, and tumor size. DRM might affect survival more than a local recurrence. Because distal intramural tumor spread rarely exceeds 1 to 2 cm in most rectal cancers, and local control and survival do not seem to be compromised by shorter distal resection margins, the generally accepted practice is to aim for a 2-cm DRM. However, in the recent trend of curative resection after preoperative chemoradiotherapy, with an otherwise favorable tumor such as well-differentiated tumor and no lymph node metastasis, a DRM at ≤1 cm does not necessarily portend a poor prognosis. In cases with preoperative chemoradiotherapy, distal resection margins need to be evaluated individually.
Discussion
It has been suggested that down-staging of low-lying rectal cancers after preoperative radiation might well include the pathological clearance of distal intramural microscopic spread. Moreover, the measurement of DRM varies with respective study, making it difficult to compare.
Conclusion
We need an applicable intraoperative method to accurately measure distal resection margin, enabling comparative outcome.
Similar content being viewed by others
References
Andreola S, Leo E, Belli F, Lavarino C, Bufalino R, Tomasic G, Baldini MT, Valvo F, Navarria P, Lombardi F. Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis. Dis Colon Rectum 1997;40:25–29.
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;70:150–154.
Shirouzu K, Isomoto H, Kakegawa T. Distal spread of rectal cancer and optimal distal margin of resection for sphincter preserving surgery. Cancer 1995;76:388–392.
Vernava AM 3rd, Moran M, Rothenberger DA, Wong WD. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet 1992;175:333–336.
Goligher JC, Dukes CE, Bussey HJR. Local recurrence after sphincter-saving excisions for carcinomas of the rectum and rectosigmoid. Br J Surg 1951;39:199–211.
Copeland EM, Miller LD, Jones RS. Prognostic factors in carcinoma of the colon and rectum. Am J Surg 1968;116:875–879.
Enter WE, Laffer UT, Block GE. Enhanced survival of patients with colon and rectal cancer based upon wide anatomic resection. Ann Surg 1979;190:350–355.
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;70:150–154.
McDermott FT, Hughes ESR, Phil E, Johnson WR, Price AB. Local recurrence after potentially curative resection for rectal cancer in a series of 1008 patients. Br J Surg 1985;72:34–37.
Wilson SM, Beahrs OH. The curative treatment of carcinoma of the sigmoid, rectosigmoid, and rectum. Ann Surg 1976;183:556– 565.
Paty PB, Enker WE, Cohen AM, Lauwers GY. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg 1994;219:365–373.
National Comprehensive Cancer Network (NCCN). Colon Cancer and Rectal Cancer Guidelines, version 1. Fort Washington: National Comprehensive Cancer Network (NCCN), 2007.
Wibe A, Rendedal PR, Svensson E, Norstein J, Eide TJ, Myrvold HE, Søreide O. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 2002;89:327–334.
Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection Histopathological study of lateral tumour spread and surgical excision. Lancet 1986;2:996–999.
Birbeck KF, Macklin CP, Tiffin N, 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;235:449–457.
Marijnen CA, Nagtegaal ID, Kapiteijn 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 multicenter randomized trial. Int J Radiat Oncol Biol Phys 2003;55:1311–1320.
Phillips RKS, Hittinger R, Blesovsky L, Fry JS, Fielding LP. Local recurrence following `curative` surgery for large bowel cancer: II. The rectum and rectosigmoid. Br J Surg 1984;71:17–20.
Fain SN, Patin S, Morgenstern L. Use of a mechanical suturing apparatus in low colorectal anastomosis. Arch Surgh 1975;110:1079–1082.
Knight CD, Griffith FD. An improved technique in low rectal carcinoma. Proc R Soc Med 1972;65:975–976.
Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery: The clue to pelvic recurrence? Br J Surg 1982;69:613–616.
Scott N, Jackson P, Aljaberi T, Dixon MF, Quirke P, Finan PJ. Total mesorectal excision and local recurrence: a study of tumour spread in the mesorectum distal to rectal cancer. Br J Surg 1995;82:1031–1033.
Tocchi A, Mazzoni G, Lepre L, Liotta G, Costa G, Aqostini N, et al. Total mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences. Arch Surg 2001;136:216–220.
Zhao GP, Zhou 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;11:319–322.
Willams NS. The rationale for preservation of the anal sphincter in patients with low rectal cancer. Br J Surg 1984;71:575–581.
Hida J, Yasutomi M, Fujimoto K, 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;184:584–588.
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.
Bokey EL, Ojerskog B, Chapuis PH, Dent OF, Newland RC, Sinclair G. Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection. Br J Surg 1999;86:1164–1170
Karanjia ND, Schache DJ, North WRS, Heald RJ. “Close shave” in anterior resection. Br J Surg 1990;77:510–512.
Leo E, Belli F, Miceli R, Mariani L, Gallino G, Battaglica L, et al. Distal clearance margin of 1 cm or less: a safe distance in lower rectum cancer surgery. Int J Colorectal Dis 2009;24:317–322.
Madsen PM, Christiansen J. Distal intramural spread of rectal carcinomas. Dis Colon Rectum 1986;29:279–282.
Penfold JC. A comparison of restorative resection of the carcinoma of the middle third of the rectum with abdominoperienal excision. Aust N Z J Surg 1974;44:354–356.
Meterissian S, Skibber J, Rich T, Roubein L, Ajani J, Cleary K, et al. Patterns of residual disease after preoperative chemoradiation in ultrasound T3 rectal carcinoma. Ann Surg Oncol 1994;1:111–116.
Meade PG, Blatchford GJ, Thorson AG, Christensen MA, Ternent CA. Preoperative chemoradiation downstages locally advanced ultrasound-staged rectal cancer. Am J Surg 1995;170:609–613.
Burke SJ, Percarpio BA, Knight DC, Kwasnik EM. Combined preoperative radiation and mitomycin/5-fluorouracil treatment for locally advanced rectal adenocarcinoma. J Am Coll Surg 1998; 187:164–170.
Minsky BD, Cohen AM, Kemeny N, Enker WE, Kelsen DP, Reichman B. Enhancement of radiation-induced downstaging of rectal cancer by fluorouracil and high-dose leucovorin chemotherapy. J Clin Oncol 1992;10:79–84.
Grann A, Minksy BD, Cohen AM, Saltz L, Guillem JG, Paty PB, et al. Preliminary results of pre-operative 5-fluorouracil(5-FU), low dose leucovorin, and concurrent radiation therapy for resectable T3 rectal cancer. Dis Colon Rectum 1997;40:515–522.
Nivatvongs S, Stern HS, Fryd DS. The length of the anal canal. Dis Colon Rectum 1982;24:600–601.
Fenner DE, Kriegshauser JS, Lee HH, Beart RW, Weaver A, Cornella JL. Anatomic and physiologic measurements of the internal and external anal sphincters in normal females. Obstet Gynecol 1998;91:369–374.
Kwok SP, Lau WY, Leung KL, Liew CT, Li AK. Prospective analysis of the distal margin of clearance in anterior resection for rectal carcinoma. Br J Surg 1996;83:969–972.
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;8:611–615.
Hojo K. Anastomotic recurrence after sphincter-saving resection for rectal cancer. Length of distal clearance of the bowel. Dis Colon Rectum 1986;29:11–14.
Nelson H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J, et al. Guidelines 2000 for colon and rectal cancer surgery. National Cancer Institute Expert Panel. J Natl Cancer Inst 2001;93:583–596.
Kuvshinoff B, Maghfoor I, Miedema B, Bryer M, Westgate S, Wilkers J, et al. Distal margin requirements after preoperative chemoradiotherapy for distal rectal carcinomas: are < or = 1 cm distal margins sufficient? Ann Surg Oncol 2001; 8:163–169.
Moore HG, Riedel E, Minsky BD, Saltz L, Paty P, Wong D, et al. Adequacy of 1 cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined-modality therapy. Ann Surg Oncol 2003; 10:80–85
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;15:3124–3131.
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;241:465–469.
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;138:658–664.
Bozzetti F, Andreola S, Baratti D, Mariani L, Stani SC, Valvo F, et al. Preoperative chemoradiation in patients with resectable rectal cancer: results on tumor response. Ann Surg Oncol 2002;9:444–449.
Luna-Pérez P, Rodríguez-Ramírez S, Hernández-Pacheco F, Gutiérrez De La Barrera M, Fernández R, Labastida S. Anal sphincter preservation in locally advanced low rectal carcinoma after preoperative chemoradiation therapy and coloanal anastomosis. J Surg Oncol 2003;82:3–9.
Saur 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;351:1731–1740.
Rosen CB, Beart RW Jr., Ilstrup DM. Local recurrence of rectal carcinoma after hand-sewn and stapled anastomoses. Dis Colon Rectum 1985;28:305–309.
Kirwan WO, Drumm J, Hogan JM, Keohane C. Determining safe margin of resection in low anterior resection for rectal cancer. Br J Surg 1988;75:720.
Leff EL, Shaver JO, Hoexter B, Labow S, Moseson MD, Goldstein SD, et al. Anastomotic recurrences after low anterior resection. Stapled vs. hand-sewn. Dis Colon Rectum 1985;28:164–167.
Sondenna K, Kjellevold KH. A prospective study of the length of the distal margin after low anterior resection for rectal cancer Int J Colorect Dis 1990;5:103–105.
Weese JL, O`Grady MG, Ottery FD. How long is the five centimeter margin? Surg Gynecol Obstet 1986;163:101–103.
Fisher RB, Parsons DS. The gradient of mucosal surface area in the small intestine of the rat. J Anat 1950;84:272–282.
Bancroft JD, Stevens A. Theory and Practice of Histological Techniques, 2nd edn. Edinburgh: Churchill Livingstone, 1982, p 27.
Heald RJ, Ryall RDH. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986;1:1479–1482.
Acknowledgment
This work was supported by the Korea Health 21 R&D Project, Ministry of Health, Welfare, and Family Affairs (grant A062254).
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Park, I.J., Kim, J.C. Adequate Length of the Distal Resection Margin in Rectal Cancer: From the Oncological Point of View. J Gastrointest Surg 14, 1331–1337 (2010). https://doi.org/10.1007/s11605-010-1165-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11605-010-1165-3