Variation in circumferential resection margin: Reporting and involvement in the South-Netherlands

doi:10.1016/j.ejso.2015.07.015

European Journal of Surgical Oncology (EJSO)

Volume 41, Issue 11, November 2015, Pages 1485-1492

https://doi.org/10.1016/j.ejso.2015.07.015 Get rights and content

Abstract

Background

Since the introduction of total mesorectal surgery the outcome of rectal cancer patients has improved significantly. Involvement of the circumferential resection margin (CRM) is an important predictor of increased local recurrence, distant metastases and decreased overall survival. Abdomino perineal excision (APE) is associated with increased risk of CRM involvement. Aim of this study was to analyze reporting of CRM and to identify predictive factors for CRM involvement.

Methods

A population-based dataset was used selecting 2153 patients diagnosed between 2008 and 2013 with primary rectal cancer undergoing surgery. Variation in CRM reporting was assessed and predictive factors for CRM involvement were calculated and used in multivariate analyses.

Results

Large variation in CRM reporting was found between pathology departments, with missing cases varying from 6% to 30%. CRM reporting increased from 77% in 2008 to 90% in 2012 (p < 0.001). CRM involvement significantly decreased from 12% to 6% over the years (p < 0.001).

In multivariate analysis type of operation, low anterior resection or APE, did not influence the risk of CRM involvement. Clinical T4-stage [odds ratio (OR) = 3.51; 95% confidence interval (CI) = 1.85–6.65) was associated with increased risk of CRM involvement, whereas neoadjuvant treatment (5 × 5 gray radiotherapy [OR 0.39; CI 0.25–0.62] or chemoradiation therapy [OR 0.30; CI 0.17–0.53]) were associated with significant decreased risk of CRM involvement.

Conclusion

Although significant improvements are made during the last years there still is variation in reporting of CRM involvement in the Southern Netherlands. In multivariate analysis APE was no longer associated with increased risk of CRM involvement.

Introduction

The circumferential resection margin (CRM) is an important prognostic factor in rectal cancer care and a predictor of local recurrence, distant metastases and overall survival.1, 2 The CRM was first described in 1986 by Quirke³ and is part of a standardized histopathological protocol. Transverse sectioning of the excision specimen is one of the key procedures in this protocol, which is now recommended in almost every national rectal cancer guideline in Europe.

Since the introduction of the CRM, the prognosis of patients with rectal cancer has dramatically improved. The introduction of total mesorectal excision (TME) and extralevator techniques for lower rectal tumors have led to a decrease in CRM involvement, and consequently to less local recurrence and improved metastasis free and overall survival.⁴ Besides improved surgical techniques, the introduction of standard magnetic resonance imaging (MRI) has enabled clinicians to properly select patients with locally advanced disease and treat them with preoperatively with (chemo)radiation therapy.5, 6 Also, short course radiotherapy has proved to decrease local recurrence rates,7, 8 similar to long course chemoradiation therapy for locally advanced tumors.⁹ Besides prognostic information, the CRM provides the surgeon of essential feedback on the quality of surgery.³

Determination of predictive factors for CRM involvement is essential to provide the best patient care. According to the literature more extensive tumors (i.e. T4 and N2 stage tumors) are related to higher CRM involvement rates.10, 11, 12 The results of the Dutch TME trial illustrated a significant difference in CRM involvement between low anterior resection (LAR) and abdomino perineal excision (APE), respectively 14% and 29% (p < 0.001).² On the other hand, the introduction of new surgical techniques, such as extralevator APE (ELAPE), resulted in less CRM involvement and better oncological outcome in patients with distal rectal cancer.13, 14

Population-based data on CRM reporting and involvement are rare in the available literature.¹⁵ The aim of the current study was to evaluate variation in CRM reporting within different pathology departments and CRM involvement in different hospitals. Moreover, prognostic factors for CRM involvement were identified using the population-based database of the Eindhoven Cancer Registry (ECR).

Section snippets

Patients and methods

All patients diagnosed with primary rectal cancer (stage I–III) between January 2008 and January 2013 were selected using population-based data from the Eindhoven Cancer Registry (ECR) which is part of the Netherlands Cancer Registry and maintained by the Netherlands Comprehensive Cancer Organization (IKNL). The ECR collects data on all newly diagnosed patients with rectal cancer in the Southern Netherlands. The ECR covers an area with ten community hospitals and six pathology departments. Due

Patients and characteristics

A total of 3348 patients were diagnosed with rectal cancer during the study period. In total 71% of the patients were surgically treated with (beyond) TME surgery, and after exclusion of 224 stage IV patients a total of 2153 patients were included. In 1833 (85%) patients the CRM was reported in the pathological report. Mean age at time of surgery was 66 ± 11 years and 63% of the patients were male. Table 1 gives an overview of different patient and tumor characteristics and CRM involvement

Discussion

The involvement of CRM is the most important factor for local recurrence and overall survival in the treatment of rectal cancer. Several risk factors are known for CRM involvement, such as higher pathological T and N stage. The present study reporting data from a large registry in the South of the Netherlands demonstrated that CRM reporting increased significantly to more than 90% in the recent years. However, significant differences remain in reporting CRM between pathology laboratories. Risk

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Acknowledgments

We would like to thank the participating hospitals of the Comprehensive Cancer Center South: Amphia Hospital, Breda; VieCuri Hospital, Venlo; Bernhoven Hospital, Veldhoven; St. Anna Hospital, Geldrop and Eindhoven; Catherina Hospital, Eindhoven; Elkerliek Hospital, Helmond; Maxima Medical Centre, Eindhoven and Veldhoven; St. Elisabeth Hospital, Tilburg; Jeroen Bosch Hospital, Den Bosch and Twee Steden Hospital, Tilburg.

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Variation in circumferential resection margin: Reporting and involvement in the South-Netherlands

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Patients and characteristics

Discussion

Conflict of interest

Funding

Acknowledgments

Lancet

Eur J Cancer

Magn Reson Imaging Clin N Am

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Lancet

Eur J Surg Oncol

Eur J Surg Oncol

Lancet Oncol

What is the role for the circumferential margin in the modern treatment of rectal cancer?

J Clin Oncol

Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit

Am J Surg Pathol

Local staging of rectal cancer: a review of imaging

J Magn Reson Imaging

Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer

N Engl J Med

Preoperative versus postoperative chemoradiotherapy for rectal cancer

N Engl J Med

European Extralevator Abdominoperineal Excision Study G. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer

Br J Surg

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Ann Surg Oncol

Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery

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Focus on extralevator perineal dissection in supine position for low rectal cancer has led to better quality of surgery and oncologic outcome

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Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer–a systematic overview

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Int J Epidemiol