Variation in circumferential resection margin: Reporting and involvement in the South-Netherlands
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.
References (40)
- et al.
Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision
Lancet
(1986 Nov 1) - et al.
Improved overall survival for patients with rectal cancer since 1990: the effects of TME surgery and pre-operative radiotherapy
Eur J Cancer
(2008 Aug) - et al.
Magnetic resonance imaging of rectal cancer
Magn Reson Imaging Clin N Am
(2013 May) - et al.
Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial
Lancet
(2009 Mar 7) - et al.
Role of circumferential margin involvement in the local recurrence of rectal cancer
Lancet
(1994 Sep 10) - et al.
Improved quality of care for patients undergoing an abdominoperineal excision for rectal cancer
Eur J Surg Oncol
(2015 Feb) - et al.
No difference between lowest and highest volume hospitals in outcome after colorectal cancer surgery in the southern Netherlands
Eur J Surg Oncol
(2013 Nov) - et al.
Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial
Lancet Oncol
(2013 Mar) - et al.
What is the role for the circumferential margin in the modern treatment of rectal cancer?
J Clin Oncol
(2008 Jan 10) - et al.
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
(2002 Mar)
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
Prognostic significance of circumferential resection margin following total mesorectal excision and adjuvant chemoradiotherapy in patients with rectal cancer
Ann Surg Oncol
Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery
Ann Surg
Focus on extralevator perineal dissection in supine position for low rectal cancer has led to better quality of surgery and oncologic outcome
Ann Surg Oncol
Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer–a systematic overview
Int J Colorectal Dis
Differences in circumferential resection margin involvement after abdominoperineal excision and low anterior resection no longer significant
Ann Surg
Completeness of cancer registration in Limburg, The Netherlands
Int J Epidemiol
Cited by (12)
Variations in the definition and perceived importance of positive resection margins in patients with colorectal cancer – an EYSAC international survey
2023, European Journal of Surgical OncologyHospital volume and outcome in rectal cancer patients; results of a population-based study in the Netherlands
2019, European Journal of Surgical OncologyCitation Excerpt :Patients with cT1-3 rectal cancer are suitable candidates for a standard TME procedure, although beyond TME surgery is sometimes required if the MRF is involved. Standard TME in patients with close tumour contact to the mesorectal fascia (cT4 or cT3MRF+/) often leads to incomplete resections (R1/2-resections) [14]. Incomplete resections are deleterious for oncological outcome and all efforts should be aimed at avoiding R1/2-resections [15].
Incidence of second tumors after treatment with or without radiation for rectal cancer
2017, Annals of OncologyCitation Excerpt :The results, however, must be interpreted with caution due to the retrospective nature of the study. The study spans over a period of time in which knowledge and attitude toward RT, staging techniques, and pathology reporting have changed significantly [22,26,27]. This may have introduced a potential bias, but should have affected both groups equally.
Morphology of the anterior mesorectum: a new predictor for local recurrence in patients with rectal cancer
2022, Chinese Medical Journal