Objective measurement of the distal resection margin by MRI of the fresh and fixed specimen after partial mesorectal excision for rectal cancer: 5 cm is not just 5 cm and depends on when measured

Abstract

Background

Most studies have directly established the optimal perioperative in situ clearance margin in surgery for rectal cancer from the histologically observed extent of distal spread, neglecting the tissue variability that occurs after resection and fixation of the rectal specimen.

Purpose

To measure the length of the distal resection margin in the fresh and fixed specimen following partial mesorectal excision for rectal cancer using magnetic resonance imaging (MRI) to document tissue shrinkage after surgical removal and fixation.

Material and Methods

The length of the distal resection margin was measured by MRI of the fresh and fixed specimen and at histopathological examination of the fixed specimen in 10 patients who underwent surgery for upper rectal cancer. In addition, tissue shrinkage was estimated by measuring the total length of the fresh and fixed specimen and distance from the peritoneal reflection anteriorly to the distal cut edge of the specimen.

Results

Measured by MRI, the distal resection margin was in the range of 0.6–10.2 cm (mean, 4.6 cm) in the fresh specimen, and 0.5–6.2 cm (mean, 3.2 cm) in the fixed specimen. The tissue shrinkage ratio was a mean of 69% (interquartile range, 61–77%). Taking all ratios from MRI and histopathological examination of tissue shrinkage into account, the collective tissue shrinkage ratio was 70% (95% confidence interval, 67–73%)

Conclusion

The length of the distal resection margin was reduced by 30% after surgical removal and fixation of the specimen.

Keywords

Abdomen/GI magnetic resonance imaging (MRI)rectum neoplasms – primary

Get full access to this article

View all access options for this article.

References

Heald

Husband

Ryall

. The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg 1982; 69: 613–616.

Martling

Holm

Rutqvist

. Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet 2000; 356: 93–96.

Wibe

Møller

Norstein

. A national strategic change in treatment policy for rectal cancer–implementation of total mesorectal excision as routine treatment in Norway. A national audit. Dis Colon Rectum 2002; 45: 857–866.

Bregendahl

Emmertsen

Lous

. Bowel dysfunction after low anterior resection with and without neoadjuvant therapy for rectal cancer: a population-based cross-sectional study. Colorectal Dis 2013; 15: 1130–1139.

Law

Chu

. Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg 2004; 240: 260–268.

Williams

Dixon

Johnston

. 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.

Scott

Jackson

al-Jaberi

. 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.

Shirouzu

Isomoto

Kakegawa

. Distal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery. Cancer 1995; 76: 388–392.

Reynolds

Joyce

Dolan

. Pathological evidence in support of total mesorectal excision in the management of rectal cancer. Br J Surg 1996; 83: 1112–1115.

10.

Kwok

Lau

Leung

. Prospective analysis of the distal margin of clearance in anterior resection for rectal carcinoma. Br J Surg 1996; 83: 969–972.

11.

Hida

Yasutomi

Maruyama

. 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.

12.

Tocchi

Mazzoni

Lepre

. Total mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences. Arch Surg 2001; 136: 216–220.

13.

Ono

Yoshinaga

Enomoto

. Discontinuous rectal cancer spread in the mesorectum and the optimal distal clearance margin in situ. Dis Colon Rectum 2002; 45: 744–749. discussion 742–743.

14.

Wang

Zhou

Wang

. Patterns of neoplastic foci and lymph node micrometastasis within the mesorectum. Langenbecks Arch Surg 2005; 390: 312–318.

15.

Shimada

Takii

Maruyama

. Intramural and mesorectal distal spread detected by whole-mount sections in the determination of optimal distal resection margin in patients undergoing surgery for rectosigmoid or rectal cancer without preoperative therapy. Dis Colon Rectum 2011; 54: 1510–1520.

16.

Komori

Kanemitsu

Ishiguro

. Adequate length of the surgical distal resection margin in rectal cancer: from the viewpoint of pathological findings. Am J Surg 2012; 204: 474–480.

17.

Søndenaa

Kjellevold

. A prospective study of the length of the distal margin after low anterior resection for rectal cancer. Int J Colorectal Dis 1990; 5: 103–105.

18.

MacFarlane

Ryall

Heald

. Mesorectal excision for rectal cancer. Lancet 1993; 341: 457–460.

19.

Danish Colorectal Cancer Guidelines. Guidelines for the diagnosis and the management of Colorectal Cancer (in Danish). ed, 2009. http://www.acpgbi.org.uk/content/uploads/2007-CC-Management-Guidelines.pdf.

20.

The Association of Coloproctology of Great Britain and Ireland. Guidelines for the Management of Colorectal Cancer, London: ACGBI, 2007.

21.

Bondeven

Hagemann-Madsen

Laurberg

. Extent and completeness of mesorectal excision evaluated by postoperative magnetic resonance imaging. Br J Surg 2013; 100: 1357–1367.

22.

Morikawa

Yasutomi

Shindou

. Distribution of metastatic lymph nodes in colorectal cancer by the modified clearing method. Dis Colon Rectum 1994; 37: 219–223.

23.

Zhao

Zhou

Lei

. Pathological study of distal mesorectal cancer spread to determine a proper distal resection margin. World J Gastroenterol 2005; 11: 319–322.

24.

Kuzu

Heald

Brown

. Comprehensive step by step training package on rectal cancer surgery [DVD], Ankara: Ankara University, 2013.

25.

Blomqvist

Rubio

Holm

. Rectal adenocarcinoma: assessment of tumour involvement of the lateral resection margin by MRI of resected specimen. Br J Radiol 1999; 72: 18–23.

26.

Salerno

Chandler

Wotherspoon

. Sites of surgical wasting in the abdominoperineal specimen. Br J Surg 2008; 95: 1147–1154.

27.

Hayden

Jakate

Pinzon

. Tumor scatter after neoadjuvant therapy for rectal cancer: are we dealing with an invisible margin? Dis Colon Rectum 2012; 55: 1206–1212.

28.

Weese

O’Grady

Ottery

. How long is the five centimeter margin? Surg Gynecol Obstet 1986; 163: 101–103.

29.

Goldstein

Soman

Sacksner

. Disparate surgical margin lengths of colorectal resection specimens between in vivo and in vitro measurements - The effects of surgical resection and formalin fixation on organ shrinkage. Am J Clin Pathol 1999; 111: 349–351.