Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial

Abstract

SummaryBackgroundLocal recurrence rates in operable rectal cancer are improved by radiotherapy (with or without chemotherapy) and surgical techniques such as total mesorectal excision. However, the contributions of surgery and radiotherapy to outcomes are unclear. We assessed the effect of the involvement of the circumferential resection margin and the plane of surgery achieved.MethodsIn this prospective study, the plane of surgery achieved and the involvement of the circumferential resection margin were assessed by local pathologists, using a standard pathological protocol in 1156 patients with operable rectal cancer from the CR07 and NCIC-CTG CO16 trial, which compared short-course (5 days) preoperative radiotherapy and selective postoperative chemoradiotherapy, between March, 1998, and August, 2005. All analyses were by intention to treat. This trial is registered, number ISRCTN 28785842.Findings128 patients (11%) had involvement of the circumferential resection margin, and the plane of surgery achieved was classified as good (mesorectal) in 604 (52%), intermediate (intramesorectal) in 398 (34%), and poor (muscularis propria plane) in 154 (13%). We found that both a negative circumferential resection margin and a superior plane of surgery achieved were associated with low local recurrence rates. Hazard ratio (HR) was 0·32 (95% CI 0·16–0·63, p=0·0011) with 3-year local recurrence rates of 6% (5–8%) and 17% (10–26%) for patients who were negative and positive for circumferential resection margin, respectively. For plane of surgery achieved, HRs for mesorectal and intramesorectal groups compared with the muscularis propria group were 0·32 (0·16–0·64) and 0·48 (0·25–0·93), respectively. At 3 years, the estimated local recurrence rates were 4% (3–6%) for mesorectal, 7% (5–11%) for intramesorectal, and 13% (8–21%) for muscularis propria groups. The benefit of short-course preoperative radiotherapy did not differ in the three plane of surgery groups (p=0·30 for trend). Patients in the short-course preoperative radiotherapy group who had a resection in the mesorectal plane had a 3-year local recurrence rate of only 1%.InterpretationIn rectal cancer, the plane of surgery achieved is an important prognostic factor for local recurrence. Short-course preoperative radiotherapy reduced the rate of local recurrence for all three plane of surgery groups, almost abolishing local recurrence in short-course preoperative radiotherapy patients who had a resection in the mesorectal plane. The plane of surgery achieved should therefore be assessed and reported routinely.FundingMedical Research Council (UK) and the National Cancer Institute of Canada.

S3-Leitlinie – Kolorektales Karzinom

“…Vor allem Arbeiten aus den Niederlanden und Großbritannien haben jedoch gezeigt, dass auch bei einem zirkumferentiellen Sicherheitsabstand von weniger als 1 mm das Lokalrezidivrisiko beim Rektumkarzinom deutlich ansteigt (3-Jahres-Lokalrezidivraten: 6 % bei CRM-und 17 % bei CRM+; 3-Jahres-tumorfreies-Über-leben 79 % bei CRM-und 50 % bei CRM+) [685,827]. Bei intaktem Mesorektum betrug das 5-Jahres-tumorfreieÜberleben 65 % im Vergleich zu 47 % bei Defekten des Mesorektums (P< 0,05) [831].…”

Neoadjuvant Treatment Strategies for Locally Advanced Rectal Cancer

“…Pelvic MRI scanning has been established as the investigation of choice for local staging of rectal cancer prior to surgery [13,14,15] [16,17]. This is commonly defined as disease encroaching to within 1mm of mesorectal fascia (MRF) or lower rectal cancers involving the levator-sphincter complex.…”

S3-Leitlinie Kolorektales Karzinom Version 1.0 - Juni 2013 AWMF-Registernummer: 021/007OL

“…Vor allem Arbeiten aus den Niederlanden und Großbritannien haben jedoch gezeigt, dass auch bei einem zirkumferenziellen Sicherheitsabstand von weniger als 1 mm das Lokalrezidivrisiko beim Rektumkarzinom deutlich ansteigt (3-Jahres-Lokalrezidivraten: 6 % bei CRM-und 17 % bei CRM+; 3-Jahres tumorfreies Überleben 79 % bei CRM-und 50 % bei CRM+ [560,702] [706]. Nach 3 Jahren Follow-up betrug die Lokalrezidivrate bei intakter mesorektaler Faszie 4 % (3 -6 %), 7 % (5 -11 %) bei intramesorektalen Einrissen, und 13 % (8 -21 %) bei Erreichen der MuscularisPropria-Ebene [702]. Bei der Beurteilung eines Präparats nach einer Rektumexstirpation wird zwischen zylindrischer Exzision und Standardexzision unterschieden.…”