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16-06-2022 | Rectal Cancer | Review Article

The Impact of Narrow and Infiltrated Distal Margin After Proctectomy for Rectal Cancer on Patients’ Outcomes: a Systematic Review and Meta-analysis

Authors: Islam H. Metwally, Mohammad Zuhdy, Omar Hamdy, Ahmed M. Fareed, Saleh S. Elbalka

Published in: Indian Journal of Surgical Oncology | Issue 4/2022

Abstract

Rectal cancer is a common tumor within a difficult anatomic constraint. Total mesorectal excision with longitudinal and circumferential free margins is considered imperative for good prognosis. In this article, the authors systematically reviewed all published literature with specific Mesh terms until the end of year 2019. Thereafter, retrieved articles were assessed using the Newcastle–Ottawa Scale and meta-analysis was conducted comparing local recurrence among 1-cm, 5-mm, and narrow (< 1-mm)/infiltrated margins. Thirty-nine articles were included in the study. Macroscopic distal margin < 1 cm carried a higher incidence of recurrence for those who did not receive neoadjuvant radiation, without affecting neither estimated overall nor disease-free survival. Less than 5-mm margin after radiation therapy is accepted oncologically. Infiltrated margins and narrow margins (< 1 mm) microscopically are associated with higher incidence of local recurrence and shorter overall and disease-free survival. Surgeons should aim at 1-cm safety margin in radiotherapy-naïve patients and microscopic free margin > 1 mm for those who received neoadjuvant therapy. The cost/benefit of reoperation for patients with infiltrated margins is still inadequately studied.

Zeng WG et al (2017) A distal resection margin of ≤1 mm and rectal cancer recurrence after sphincter-preserving surgery: the role of a positive distal margin in rectal cancer surgery. Dis Colon Rectum 60(11):1175–1183CrossRef

Manegold P et al (2019) The minimum distal resection margin in rectal cancer surgery and its impact on local recurrence-a retrospective cohort analysis. Int J Surg 69:77–83CrossRef

Bhamre R et al (2019) Impact of length of distal margin on outcomes following sphincter preserving surgery for middle and lower third rectal cancers. Indian J Surg Oncol 10(2):335–341CrossRef

Hojo K (1986) Anastomotic recurrence after sphincter-saving resection for rectal cancer. Dis Colon Rectum 29(1):11–14CrossRef

Kameda K et al (1990) Proposed distal margin for resection of rectal cancer. Jpn J Cancer Res 81(1):100–104CrossRef

Bujko K et al (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):801–808CrossRef

Kiran RP, Lian L, 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(2):157–163CrossRef

Rutkowski A et al (2008) Distal bowel surgical margin shorter than 1 cm after preoperative radiation for rectal cancer: is it safe? Ann Surg Oncol 15(11):3124–3131CrossRef

Pricolo VE, Abodeely A, Resnick M (2010) Distal margins in radical resections for rectal cancer after chemoradiation therapy: how short is long enough? Dig Surg 27(3):185–189CrossRef

10.

Smith F et al (2014) Depth and lateral spread of microscopic residual rectal cancer after neoadjuvant chemoradiation: implications for treatment decisions. Colorectal Dis 16(8):610–615CrossRef

11.

Liu R et al (2014) Clinicopathological study of safe resectional margin in mid and low rectal cancer after neoadjuvant chemoradiotherapy. Zhonghua wei Chang wai ke za zhi= Chinese Journal of Gastrointestinal Surgery 17(6):561–564

12.

Kim T et al (2014) The adequacy of the distal resection margin after preoperative chemoradiotherapy for rectal cancer. Colorectal Dis 16(8):O257–O263CrossRef

13.

Moher D et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS med 6(7):e1000097CrossRef

14.

Pollett WG, Nicholls R (1983) The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum. Ann Surg 198(2):159CrossRef

15.

Williams N, Dixon M, Johnston D (1983) 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 70(3):150–154CrossRef

16.

McDermott F et al (1985) Local recurrence after potentially curative resection for rectal cancer in a series of 1008 patients. Br J Surg 72(1):34–37CrossRef

17.

Heimann TH et al (1986) Local recurrence following surgical treatment of rectal cancer. Dis Colon Rectum 29(12):862–864CrossRef

18.

Secco GB et al (1989) Factors influencing local recurrence after curative surgery for rectal cancer. Oncology 46(1):10–13CrossRef

19.

Karanjia N et al (1990) ‘Close shave’ in anterior resection. Br J Surg 77(5):510–512CrossRef

20.

Vemava A et al (1992) A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet 175(4):333–336

21.

Bozzetti F et al (1997) Impact of distal clearance margin on oncologic outcome after restorative resection of the rectum. Tumori Journal 83(6):907–911CrossRef

22.

Kuvshinoff B et al (2001) Distal margin requirements after preoperative chemoradiotherapy for distal rectal carcinomas: are≤ 1 cm distal margins sufficient? Ann Surg Oncol 8(2):163–169

23.

Andreola S 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(7):611–615CrossRef

24.

Stocchi L et al (2001) Impact of surgical and pathologic variables in rectal cancer: a United States community and cooperative group report. J Clin Oncol 19(18):3895–3902CrossRef

25.

Phang PT et al (2002) Effects of positive resection margin and tumor distance from anus on rectal cancer treatment outcomes. The American journal of surgery 183(5):504–508CrossRef

26.

Glehen O et al (2003) Long-term results of the Lyons R90–01 randomized trial of preoperative radiotherapy with delayed surgery and its effect on sphincter-saving surgery in rectal cancer. Br J Surg 90(8):996–998CrossRef

27.

Moore HG et al (2003) Adequacy of 1-cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined-modality therapy. Ann Surg Oncol 10(1):80–85CrossRef

28.

Chiappa A et al (2005) Results of treatment of distal rectal carcinoma since the introduction of total mesorectal excision: a single unit experience, 1994–2003. Int J Colorectal Dis 20(3):221–230CrossRef

29.

Huh JW et al (2008) Sphincter-preserving operations following preoperative chemoradiation: an alternative to abdominoperineal resection for lower rectal cancer? World J Surg 32(6):1116–1123CrossRef

30.

Leo E et al (2009) Distal clearance margin of 1 cm or less: a safe distance in lower rectum cancer surgery. Int J Colorectal Dis 24(3):317CrossRef

31.

Kim YW et al (2009) Factors associated with anastomotic recurrence after total mesorectal excision in rectal cancer patients. J Surg Oncol 99(1):58–64CrossRef

32.

Nash GM et al (2010) Close distal margin and rectal cancer recurrence after sphincter-preserving rectal resection. Dis Colon Rectum 53(10):1365–1373CrossRef

33.

Silberfein EJ et al (2010) Long-term survival and recurrence outcomes following surgery for distal rectal cancer. Ann Surg Oncol 17(11):2863–2869CrossRef

34.

Tsutsumi S et al (2011) Tumor response and negative distal resection margins of rectal cancer after hyperthermochemoradiation therapy. Anticancer Res 31(11):3963–3967

35.

Bernstein TE et al (2012) What is a safe distal resection margin in rectal cancer patients treated by low anterior resection without preoperative radiotherapy? Colorectal Dis 14(2):e48-55CrossRef

36.

Rutkowski A et al (2012) Acceptance of a 5-mm distal bowel resection margin for rectal cancer: is it safe? Colorectal Dis 14(1):71–78CrossRef

37.

Kwak JY et al (2012) Oncologically safe distal resection margins in rectal cancer patients treated with chemoradiotherapy. J Gastrointest Surg 16(10):1947–1954CrossRef

38.

Lim JW et al (2012) Close distal margins do not increase rectal cancer recurrence after sphincter-saving surgery without neoadjuvant therapy. Int J Colorectal Dis 27(10):1285–1294CrossRef

39.

Mezhir JJ et al (2012) Whole-mount pathologic analysis of rectal cancer following neoadjuvant therapy: implications of margin status on long-term oncologic outcome. Ann Surg 256(2):274–279CrossRef

40.

Han JW et al (2013) Association between a close distal resection margin and recurrence after a sphincter-saving resection for t3 mid- or low-rectal cancer without radiotherapy. Ann Coloproctol 29(6):231–237CrossRef

41.

Debove C et al (2015) What happens after R1 resection in patients undergoing laparoscopic total mesorectal excision for rectal cancer? A study in 333 consecutive patients. Colorectal Dis 17(3):197–204CrossRef

42.

Hong KS et al (2015) Oncologic outcomes in rectal cancer with close distal resection margins: a retrospective analysis. Ann Surg Treat Res 89(1):23–29CrossRef

43.

Kang DW et al (2017) Oncologic outcomes in rectal cancer patients with a ≤1-cm distal resection margin. Int J Colorectal Dis 32(3):325–332CrossRef

44.

Grosek J et al (2017) The influence of the distal resection margin length on local recurrence and long- term survival in patients with rectal cancer after chemoradiotherapy and sphincter- preserving rectal resection. Radiol Oncol 51(2):169–177CrossRef

45.

Manegold P et al (2019) The minimum distal resection margin in rectal cancer surgery and its impact on local recurrence - a retrospective cohort analysis. Int J Surg 69:77–83CrossRef

46.

Metwally IH et al (2019) Clinico-epidemiologic criteria and predictors of survival of rectal cancer among Egyptians in Delta region. Journal of Coloproctology 39(4):339–345CrossRef

47.

Shirouzu K, Isomoto H, Kakegawa T (1995) Distal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery. Cancer 76(3):388–392CrossRef

48.

Hayden DM et al (2012) Tumor scatter after neoadjuvant therapy for rectal cancer: are we dealing with an invisible margin? Dis Colon Rectum 55(12):1206–1212CrossRef

49.

Fekete Z et al (2013) What is the significance of a microscopically positive resection margin in the curative-intent treatment of rectal adenocarcinoma? A retrospective study. J buon 18(4):989–995

50.

Fitzgerald TL, Brinkley J, Zervos EE (2011) Pushing the envelope beyond a centimeter in rectal cancer: oncologic implications of close, but negative margins. J Am Coll Surg 213(5):589–595

51.

Tilly C et al (2014) R1 rectal resection: look up and don't look down. Ann Surg 260(5):794–800

Title: The Impact of Narrow and Infiltrated Distal Margin After Proctectomy for Rectal Cancer on Patients’ Outcomes: a Systematic Review and Meta-analysis
Authors: Islam H. Metwally
Mohammad Zuhdy
Omar Hamdy
Ahmed M. Fareed
Saleh S. Elbalka
Publication date: 16-06-2022
Publisher: Springer India
Keywords: Rectal Cancer
Rectal Cancer
Published in: Indian Journal of Surgical Oncology / Issue 4/2022
Print ISSN: 0975-7651
Electronic ISSN: 0976-6952
DOI: https://doi.org/10.1007/s13193-022-01565-z

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The Impact of Narrow and Infiltrated Distal Margin After Proctectomy for Rectal Cancer on Patients’ Outcomes: a Systematic Review and Meta-analysis

Abstract

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