Top

Published in:

01-12-2017 | Original Article

A Prospective Study of Distal Microscopic Spread in Rectal Cancer After Neoadjuvant Chemoradiation in Pinned and Unpinned Specimen

Authors: Aravind S. Kapali, K. Chandramohan, A. V. Jayasudha

Published in: Indian Journal of Surgical Oncology | Issue 4/2017

Abstract

The most important margin in determining the prognosis of rectal cancer is circumferential resection margin (CRM). But, the type of surgery is determined by distal rectal margin (DRM), whether sphincter saving procedure is possible or patient needs an abdominoperineal resection. There are no standardized uniform guidelines for measurement of DRM. The purpose of this study is to assess the distal microscopic spread beyond gross margin after neoadjuvant concurrent chemoradiation (CCRT) in rectal cancers, the factors influencing the distal microscopic spread, the shrinkage of the distal margin in pinned and unpinned fresh and fixed specimen, and to find out the best method of measurement of distal rectal margin. A prospective analytical study was conducted from May 2013 through February 2015 in 47 cases of carcinoma rectum (both AR and APR) who had received neoadjuvant CCRT. Fresh specimen was collected within 30 min of specimen retrieval and a longitudinal cut was made in the distal margin of all specimens. One side of the specimen was pinned onto a cork board and the other side was left unpinned. Measurements were made from the distal end of clinical gross tumor. DRM was determined in both pinned and unpinned sides in fresh and fixed specimen. Of the 47 patients, 2 patients (4.2%) had small focus of tumor beyond gross margins, 1 at 6 mm and another at 3.5 mm on the unpinned side. The average margin for fresh and fixed pinned specimens was 3.67 and 3.47 cm, respectively, with percentage shrinkage of 5.4% for the pinned specimens. The average margin for fresh and fixed unpinned specimens was 3.32 and 2.84 cm, respectively, with percentage shrinkage of 14.4% for the unpinned specimens. Six patients (12.7%) had complete pathological response. Correlation of distal margin was better in pinned specimen. A correction factor of 15% for shrinkage needs to be taken into account while assessing unpinned specimen. Only in 4.2% of patients, there was distal submucosal spread beyond gross margin. Long-term follow up is required for assessing adequacy of DRM post neoadjuvant CCRT.

Scott N, Jackson P, Al-Jaberi T, Dixon MF, Quirke P, Finan PJ (1995) Total mesorectal excision and local recurrence: a study of tumour spread in the mesorectum distal to rectal cancer. Br J Surg 82:1031–1033CrossRefPubMed

Hida J, Yasutomi M, Maruyama T, Fujimoto K, Uchida T (1997) Okuno 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 184:584–588PubMed

Reynolds JV, Joyce WP, Dolan J, Sheahan K, Hyland JM (1996) Pathological evidence in support of total mesorectal excision in the management of rectal cancer. Br J Surg 83:1112–1115CrossRefPubMed

Nagtegaal ID, Quirke P (2008) What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 26:303CrossRefPubMed

Quirke P, Durdey P, Dixon MF, Williams NS (1986a) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet 2:996CrossRefPubMed

Gosens MJ, Klaassen RA, Tan-Go I et al (2007) Circumferential margin involvement is the crucial prognostic factor after multimodality treatment in patients with locally advanced rectal carcinoma. Clin Cancer Res 13:6617CrossRefPubMed

Nash GM, Weiss A, Dasgupta R, Gonen M, Guillem JG, Wong WD (2010) Close distal margin and rectal cancer recurrence after sphincter-preserving rectal resection. Dis Colon rectum 53:1365–1373

Kiran RP, Lian I, Lavery IC (2011) Does a subcentimeter distal resection margin adversely influence oncologic outcomes in patients with rectal cancer undergoing restorative proctectomy? Dis Colon rectum 54:157–163

Rutkowski A, Nowacki MP, Chwalinski M et al (2010a) Acceptance of a 5 mm distal bowel resection margin for rectal cancer: is it safe? Color Dis. doi:10.1111/j.14631318.2010.02542.x

10.

Quirke P, Durdey P, Dixon MF, Williams NS (1986b) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet 2(8514):996–999CrossRefPubMed

11.

Nagtegaal ID, van de Velde CJH, van der Worp E, Kapiteijn E, Quirke P, van Krieken JHJM (2002) Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol 20(7):1729–1734CrossRefPubMed

12.

Park IJ, Kim JC (2010) Adequate length of the distal resection margin in rectal cancer: from the oncological point of view. J Gastrointest Surg 14(8):1331–1337. doi:10.1007/s11605-010-1165-3 CrossRefPubMed

13.

Deo SVS, Kapali AS, Gupta M, Shukla NK (2012) A review of controversies in the management of colorectal cancers. The Indian Journal of Surgery 74(3):221–227. doi:10.1007/s12262-012-0586-5 CrossRefPubMedPubMedCentral

14.

Goldstein NS, Soman A, Sacksner J (1999) 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 111(3):349–351CrossRefPubMed

15.

Bujko K, Rutkowski A, Chang GJ, Michalski W, Chmielik E, Kusnierz J (2012) Is the 1-cm rule of distal bowel resection margin in rectal cancer based on clinical evidence? A systematic review. Ann Surg Oncol 19(3):801–808. doi:10.1245/s10434-011-2035-2 CrossRefPubMed

16.

Gomes RM, Bhandare M, Desouza A, Bal M, Saklani AP (2015) Role of intraoperative frozen section for assessing distal resection margin after anterior resection. Int J Color Dis 30(8):1081–1089CrossRef

17.

Rutkowski A, Bujko K, Nowacki MP, Chmielik E, Nasierowska-Guttmejer A, Wojnar A (2008) Polish colorectal study group distal bowel surgical margin shorter than 1 cm after preoperative radiation for rectal cancer: is it safe? Ann Surg Oncol 15:3124–3131. doi:10.1245/s10434-008-0125-6 CrossRefPubMed

18.

Rutkowski A, Nowacki MP, Chwalinski M et al (2010b) Acceptance of a 5 mm distal bowel resection margin for rectal cancer: is it safe? Color Dis. doi:10.1111/j.1463-1318.2010.02542.x

19.

Andreola S, Leo E, Belli F et al (2001) Adenocarcinoma of the lower third of the rectum surgically treated with a <10-mm distal clearance: preliminary results in 35 N0 patients. Ann Surg Oncol 8:611–615CrossRefPubMed

20.

Hermanek P, Junginger T (2005) The circumferential resection margin in rectal carcinoma surgery. Tech Coloproctol 9:193–199CrossRefPubMed

21.

Adam IJ, Mohamdee MO, Martin IG, Scott N, Finan PJ, Johnston D et al (1994) Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet 344:707–711CrossRefPubMed

22.

Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Søreide O (2004) Norwegian rectal cancer group. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon rectum 47:48–58

23.

de Haas-Kock DF, Baeten CG, Jager JJ, Langendijk JA, Schouten LJ, Volovics A et al (1996) Prognostic significance of radial margins of clearance in rectal cancer. Br J Surg. 83:781–785CrossRefPubMed

24.

Baik SH, Kim NK, Lee YC, Kim H, Lee KY, Sohn SK et al (2007) Prognostic significance of circumferential resection margin following total mesorectal excision and adjuvant chemoradiotherapy in patients with rectal cancer. Ann Surg Oncol 14:462–469CrossRefPubMed

25.

Zorcolo L, Rosman AS, Restivo A, Pisano M, Nigri GR, Fancellu A, Melis M (2012) Complete pathologic response after combined modality treatment for rectal cancer and long-term survival: a meta-analysis. Ann Surg Oncol 19(9):2822–2832CrossRefPubMed

Title: A Prospective Study of Distal Microscopic Spread in Rectal Cancer After Neoadjuvant Chemoradiation in Pinned and Unpinned Specimen
Authors: Aravind S. Kapali
K. Chandramohan
A. V. Jayasudha
Publication date: 01-12-2017
Publisher: Springer India
Published in: Indian Journal of Surgical Oncology / Issue 4/2017
Print ISSN: 0975-7651
Electronic ISSN: 0976-6952
DOI: https://doi.org/10.1007/s13193-017-0637-2

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

A Prospective Study of Distal Microscopic Spread in Rectal Cancer After Neoadjuvant Chemoradiation in Pinned and Unpinned Specimen

Abstract

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 4/2017

CRS and HIPEC for PMP—Use of the LC-CUSUM to Determine the Number of Procedures Required to Attain a Minimal Level of Proficiency in Delivering the Combined Modality Treatment

Radical Treatment of Rectal Cancer in Elderly Is Feasible than Feared: Results from a Tertiary Care Centre

Ovarian Metastases of Colorectal Origin: Treatment Patterns and Factors Affecting Outcomes

Role of Hepatic Resection for HCC in the era of Transplantation; an Experience of Two Tertiary Egyptian Centers

Postoperative Delirium in Indian Patients Following Major Abdominal Surgery for Cancer: Risk Factors and Associations

Ovarian Cancer in Young Women