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Assessment of mesorectal fascia status in MRI compared with circumferential resection margin after total mesorectal excision and predictors of involved margins

Published:August 12, 2022DOI:https://doi.org/10.1016/j.surg.2022.06.005

      Abstract

      Background

      Circumferential resection margin is an important prognosticator for total mesorectal excision outcome. We investigated the status of mesorectal fascia on magnetic resonance imaging compared with circumferential resection margin on pathology and factors associated with status change.

      Methods

      This was a retrospective analysis of a prospective database of rectal cancer patients who underwent surgery. Mesorectal fascia status on magnetic resonance imaging done before neoadjuvant therapy and circumferential resection margin status on pathology were compared. The study outcomes were factors associated with a margin status conversion between magnetic resonance imaging and pathology, and predictors of involved circumferential resection margin.

      Results

      In total, 244 patients (average follow-up of 25.4 months) were included. Eighty-one (33.2%) patients had potentially involved mesorectal fascia in magnetic resonance imaging and 12 (4.9%) had involved circumferential resection margin in pathology. A total of 2.8% of patients had a conversion of clear mesorectal fascia in magnetic resonance imaging to involved circumferential resection margin. Abdominoperineal resection was significantly associated with this status change (odds ratio: 25, 95% confidence interval: 2.4–255.8, P = .007). In total, 7.4% of patients with potentially involved mesorectal fascia had persistently involved circumferential resection margin. Lack of total neoadjuvant therapy was associated with higher, yet statistically insignificant, odds of persistently involved circumferential resection margin (odds ratio: 12, 95% confidence interval: 0.65–220.8, P = .09). The significant independent predictors of involved circumferential resection margin were body mass index (odds ratio: 1.2, P = .016) and abdominoperineal resection (odds ratio: 4.22, P = .04).

      Conclusion

      Change of clear mesorectal fascia in magnetic resonance imaging to an involved circumferential resection margin in pathology was recorded in 2.8% of patients; abdominoperineal resection might be associated with this change. Approximately 7% of patients had persistent involvement of circumferential resection margin as determined by pathology. Omission of total neoadjuvant therapy might be associated with persistent margin involvement.
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      References

        • Bray F.
        • Ferlay J.
        • Soerjomataram I.
        • Siegel R.L.
        • Torre L.A.
        • Jemal A.
        Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        CA Cancer J Clin. 2018; 68: 394-424
        • Rawla P.
        • Sunkara T.
        • Barsouk A.
        Epidemiology of colorectal cancer: incidence, mortality, survival, and risk factors.
        Prz Gastroenterol. 2019; 14: 89-103
        • Heald R.J.
        • Husband E.M.
        • Ryall R.D.H.
        The mesorectum in rectal cancer surgery: the clue to pelvic recurrence?.
        Br J Surg. 1982; 69: 613-616
        • Nacion A.J.D.
        • Park Y.Y.
        • Yang S.Y.
        • Kim N.K.
        Critical and challenging issues in the surgical management of low-lying rectal cancer.
        Yonsei Med J. 2018; 59: 703-716
        • Song S.B.
        • Wu G.J.
        • Pan H.D.
        • et al.
        The quality of total mesorectal excision specimen: a review of its macroscopic assessment and prognostic significance.
        Chronic Dis Transl Med. 2018; 4: 51-58
        • Liu Q.
        • Luo D.
        • Cai S.
        • Li Q.
        • Li X.
        Circumferential resection margin as a prognostic factor after rectal cancer surgery: a large population-based retrospective study.
        Cancer Med. 2018; 7: 3673-3681
        • Nagtegaal I.D.
        • Quirke P.
        What is the role for the circumferential margin in the modern treatment of rectal cancer?.
        J Clin Oncol. 2008; 26: 303-312
        • Trakarnsanga A.
        • Gonen M.
        • Shia J.
        • et al.
        What is the significance of the circumferential margin in locally advanced rectal cancer after neoadjuvant chemoradiotherapy?.
        Ann Surg Oncol. 2013; 20: 1179-1184
        • Khan S.M.
        • Emile S.H.
        • Barsom S.H.
        • Ahsan S.O.
        Development of the “PREDICT” score through a systematic review and meta-analysis of the predictive parameters for locoregional recurrence after total mesorectal excision.
        Updates Surg. 2021; 73: 35-46
        • Nagtegaal I.D.
        • van de Velde C.J.H.
        • van der Worp E.
        • et al.
        Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control.
        J Clin Oncol. 2002; 20: 1729-1734
        • Schmoll H.J.
        • Van C.E.
        • Stein A.
        • et al.
        ESMO consensus guidelines for management of patients with colon and rectal cancer: a personalized approach to clinical decision making.
        Ann Oncol. 2012; 23: 2479
        • Yamamoto T.
        • Kawada K.
        • Hida K.
        • et al.
        Optimal treatment strategy for rectal cancer based on the risk factors for recurrence patterns.
        Int J Clin Oncol. 2019; 24: 677-685
        • Nagasaki T.
        • Akiyoshi T.
        • Fujimoto Y.
        • et al.
        Preoperative chemoradiotherapy might improve the prognosis of patients with locally advanced low rectal cancer and lateral pelvic lymph node metastases.
        World J Surg. 2017; 41: 876-883
        • Algebally A.M.
        • Mohey N.
        • Szmigielski W.
        • Yousef R.R.
        • Kohla S.
        The value of high-resolution MRI technique in patients with rectal carcinoma: pre-operative assessment of mesorectal fascia involvement, circumferential resection margin and local staging.
        Pol J Radiol. 2015; 80: 115-121
        • Taylor F.G.
        • Quirke P.
        • Heald R.J.
        • et al.
        Magnetic Resonance Imaging in Rectal Cancer European Equivalence Study Group. Preoperative magnetic resonance imaging assessment of circumferential resection margin predicts disease-free survival and local recurrence: 5-year follow-up results of the MERCURY study.
        J Clin Oncol. 2014; 32: 34-43
        • Hermanek P.
        • Junginger T.
        The circumferential resection margin in rectal carcinoma surgery.
        Tech Coloproctol. 2005; 9 (discussion 199–200): 193-199
        • Slater A.
        • Halligan S.
        • Taylor S.A.
        • Marshall M.
        Distance between the rectal wall and mesorectal fascia measured by MRI: effect of rectal distension and implications for preoperative prediction of a tumour-free circumferential resection margin.
        Clin Radiol. 2006; 61: 65-70
        • Rao S.X.
        • Zeng M.S.
        • Xu J.M.
        • et al.
        Assessment of T staging and mesorectal fascia status using high-resolution MRI in rectal cancer with rectal distention.
        World J Gastroenterol. 2007; 13: 4141-4146
        • Kim Y.W.
        • Cha S.W.
        • Pyo J.
        • et al.
        Factors related to preoperative assessment of the circumferential resection margin and the extent of mesorectal invasion by magnetic resonance imaging in rectal cancer: a prospective comparison study.
        World J Surg. 2009; 33: 1952-1960
        • Marr R.
        • Birbeck K.
        • Garvican J.
        • et al.
        The modern abdominoperineal excision: the next challenge after total mesorectal excision.
        Ann Surg. 2005; 242: 74-82
        • Ma B.
        • Gao P.
        • Song Y.
        • et al.
        Transanal total mesorectal excision (TaTME) for rectal cancer: a systematic review and meta-analysis of oncological and perioperative outcomes compared with laparoscopic total mesorectal excision.
        BMC Cancer. 2016; 16: 380
        • Kang L.
        • Chen Y.G.
        • Zhang H.
        • et al.
        Transanal total mesorectal excision for rectal cancer: a multicentric cohort study.
        Gastroenterol Rep (Oxf). 2019; 8: 36-41
        • Kasi A.
        • Abbasi S.
        • Handa S.
        • et al.
        Total neoadjuvant therapy vs standard therapy in locally advanced rectal cancer: a systematic review and meta-analysis.
        JAMA Netw Open. 2020; 3e2030097
        • Chandarana M.
        • Arya S.
        • de Menezes J.L.
        • et al.
        Can CRM status on MRI predict survival in rectal cancers: experience from the Indian subcontinent.
        Indian J Surg Oncol. 2019; 10: 364-371
        • Al-Sukhni E.
        • Attwood K.
        • Gabriel E.
        • Nurkin S.J.
        Predictors of circumferential resection margin involvement in surgically resected rectal cancer: a retrospective review of 23,464 patients in the US National Cancer Database.
        Int J Surg. 2016; 28: 112-117
        • Sun Y.
        • Chi P.
        Impact of body mass index on surgical and oncological outcomes in laparoscopic total mesorectal excision for locally advanced rectal cancer after neoadjuvant 5-fluorouracil-based chemoradiotherapy.
        Gastroenterol Res Pract. 2017; 2017: 1509140
        • Kalb M.
        • Langheinrich M.C.
        • Merkel S.
        • et al.
        Influence of body mass index on long-term outcome in patients with rectal cancer: a single centre experience.
        Cancers (Basel). 2019; 11: 609