Annals of Surgical Oncology Sign the Guestbook
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Moore, H. G.
Right arrow Articles by Guillem, J. G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Moore, H. G.
Right arrow Articles by Guillem, J. G.
Related Collections
Right arrow Surgery
Annals of Surgical Oncology 10:80-85 (2003)
© 2003 Society of Surgical Oncology

ORIGINAL ARTICLES

Adequacy of 1-cm Distal Margin After Restorative Rectal Cancer Resection With Sharp Mesorectal Excision and Preoperative Combined-Modality Therapy

Harvey G. Moore, MD, Elyn Riedel, MA, Bruce D. Minsky, MD, Leonard Saltz, MD, Philip Paty, MD, Douglas Wong, MD, Alfred M. Cohen, MD and Jose G. Guillem, MD, MPH

From the Departments of Surgery (HGM, PP, DW, JGG, AMC), Epidemiology and Biostatistics (ER), Radiation Oncology (BDM), and Medicine (LS), Memorial Sloan-Kettering Cancer Center, New York, New York.

Correspondence: Address correspondence and reprint requests to: Jose G. Guillem, MD, MPH, 1275 York Ave., Room C-1077, New York, NY 10021; Fax: 646-422-2318; E-mail: guillemj{at}mskcc.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Preoperative combined-modality therapy (CMT) for rectal cancer allows a sphincter-sparing procedure in some individuals who would otherwise require an abdominoperineal resection. To further define the subset of rectal cancer patients suitable for this approach, we determined the adequacy of a distal margin of <=1 cm in patients with locally advanced rectal cancer requiring preoperative CMT.

Methods: Ninety-four consecutive patients, status post curative low anterior resection for rectal cancer after preoperative CMT, were identified from the prospective Colorectal Service Database. Distal margin length, tumor grade, tumor-node-metastasis stage, presence of lymphovascular and perineural invasion, and tumor distance from the anal verge were examined for their effect on recurrence and survival. Median follow-up was 44 months.

Results: Distal margin length ranged from .1 to 9.5 cm (median, 2.0 cm) and did not correlate with local recurrence (hazard ratio, 1.1; P = .34) or recurrence-free survival (hazard ratio, 1.1; P = .29) by univariate analysis. Kaplan-Meier estimates of recurrence-free survival and local recurrence at 3 years for the <=1 cm versus >1 cm and the <=2 cm versus >2 cm groups were not significantly different. Groups were well matched for other clinicopathologic variables.

Conclusions: Our data suggest that for patients with locally advanced rectal cancer undergoing resection and preoperative CMT, distal margins <=1 cm do not seem to compromise oncological outcome.

Key Words: Rectal cancer • Distal margin • Combined-modality therapy • Total mesorectal excision


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Preoperative combined-modality therapy (CMT; external beam radiation and fluorouracil [5-FU]-based chemotherapy) is being increasingly used for locally advanced (T3–4 and/or N1–2, bulky) rectal cancer. The advantages of preoperative CMT include tumor downstaging, improved resectability, an apparent improved survival after a complete pathologic response,1 and an increased likelihood of sphincter preservation.2 Although sphincter preservation is enhanced by a CMT-induced reduction in overall tumor bulk, there exists the notion that preoperative CMT may also justify a shorter distal margin as a result of tumor regression.

Because distal intramural spread (DIS) of tumor rarely exceeds 1 to 2 cm in most rectal cancers3–7 and because local control and survival do not seem to be compromised by shorter distal resection margins,7–14 the generally accepted practice is to aim for obtaining a 2-cm distal margin. However, because the likelihood of distal spread beyond 1 cm increases with tumor stage,5 this policy may not be justified in locally advanced rectal cancers requiring preoperative CMT.

A recent report of a small series of patients receiving preoperative CMT followed by sphincter-sparing (SS) resection demonstrated that patients with distal resection margins of <=1 cm did not have compromised disease-free survival versus those with margins >1 cm and those undergoing abdominoperineal resection (APR). However, no definitive conclusions were possible with regard to differences in local recurrence (LR) because only 1 of 28 patients undergoing restorative resection had local failure.15 The purpose of this study was, therefore, to assess the effect of a distal margin <=1 cm on local control and survival in a large series of rectal cancer patients who were treated with preoperative CMT and underwent restorative resection by using the technique of sharp mesorectal excision (SME).


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patient Population
Between March 1991 and August 2000, 170 consecutive patients underwent resection of a primary rectal cancer by low anterior resection (LAR) after preoperative CMT at Memorial Sloan-Kettering Cancer Center. Resection was considered curative in 157 patients (distal and circumferential margins negative, no residual pelvic or unresected metastatic disease). Patients (n = 62) with <24 months of follow-up were excluded. In addition, one patient was excluded because distal margin length was not given in the pathology report, leaving 94 patients available for analysis. There were 66 men and 28 women. Average age was 58 years (range, 28 to 79 years). All tumors were biopsy-proven adenocarcinomas and were located within 12 cm of the anal verge as measured before surgery by rigid proctoscopy. Patients were referred for preoperative CMT on the basis of a preoperative stage of T3–4 and/or N1–2 or for large bulky lesions. Preoperative stage was established by a variety of modalities, including computed tomography and endorectal ultrasound.

Preoperative CMT
All patients in this analysis underwent preoperative CMT at Memorial Sloan-Kettering Cancer Center. The standard off-protocol regimen used during the study period consisted of two cycles of 5-FU and leucovorin (LV) (bolus x 5 days) repeated every 28 days, concurrently with 4680 cGy of pelvic radiation in 180-cGy fractions with a 360-cGy boost to a total dose of 5040 cGy. The details of this regimen have been previously reported.16 Eighty-nine patients received 5040 cGy of radiation, two patients received 4500 and 5000 cGy, and in four patients the final radiation dose was not available, but records indicate that the patients completed a full course of therapy. Eighty-eight patients received 5-FU/LV in combination with radiation. Seven patients received radiation in combination with irinotecan, according to a previously published report.17 Patients underwent surgery between 4 and 7 weeks after completing CMT. After surgery, 81 patients received additional 5-FU/LV (most commonly 4 cycles), 6 patients did not receive chemotherapy, and records regarding postoperative chemotherapy were unavailable in 7 patients.

Surgical Technique
All patients underwent LAR by using the technique of SME. This technique involves dissection in the areolar plane between the fascia propria (visceral fascia) of the rectum and the parietal pelvic fascia. For upper rectal tumors, the rectum and mesorectum were divided 5 cm distal to the caudal tumor edge. For tumors of the mid and distal rectum, a total mesorectal excision was performed.18

Pathologic Assessment
The prospective Colorectal Service Database was queried for distal margin length, tumor differentiation, tumor-node-metastasis stage, presence or absence of lymphovascular or perineural invasion, mucinous histology, and distance from the anal verge. Tumor-node-metastasis staging represents the final pathologic stage of the resected specimen after CMT. For the purposes of analysis, patients who were T0N0M0 on final pathologic assessment were designated as stage 0. Stages I to IV were defined according to the International Union Against Cancer classification.19 There were 8 stage 0, 38 stage I, 30 stage II, 17 stage III patients, and 1 stage IV patient. The one stage IV patient had liver metastases that were curatively resected within 3 months of LAR.

Distal Margin Assessment
In general, distal margins were measured and recorded by the pathologist before tissue fixation in the unpinned specimen. The "donuts" created by circular intraluminal staplers were not included in the measurement of distal margin length, but they were examined and found to be negative for tumor in all cases. When a complete pathologic response of the primary tumor to CMT occurred (no evidence of gross or microscopic tumor remaining), the distal margin was reported as the distance between the caudal edge of the residual scar and the cut margin of the rectum.

Patient Follow-Up
Median follow-up was 44 months (range, 24–118 months). Disease status was available for all surviving patients between January 2000 and January 2001. When an assessment of disease status was not available by either the attending colorectal surgeon or the medical oncologist during this time period, patients or their primary physicians were contacted by telephone. Medical records of all patients, including imaging studies, endoscopy reports, operative reports, carcinoembryonic antigen determinations, and clinic notes, were examined for evidence of local and distal recurrence.

Statistical Analysis
Time to recurrence was measured from the date of surgery. Survival and recurrence distributions were estimated with the Kaplan-Meier method.20 For the analysis of recurrence-free survival (RFS), events were considered to be recurrence (local or distant) and/or death. Distal margin length was treated as both a continuous measure and a categorical variable (<=1 vs. >1 cm, and so on). The relationship between time to recurrence and distal margin was tested by using the Cox proportional hazards model21 when the distal margin was considered continuous and by using a log-rank statistic22 when the distal margin was treated categorically. Comparison between groups for other clinicopathologic variables was performed with Fisher’s exact test for categorical variables and with a Student’s t-test for continuous variables. All analyses were performed with SASTM, version 8 (SAS Institute, Cary, NC).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
At the time of disease status assessment, recurrence had occurred in 17 patients (18%). Isolated LR occurred in eight patients (9%), isolated distant recurrence occurred in six patients (6%), and both LR and distant recurrence occurred in three patients (4%). The overall LR rate was 12%. Complete pathologic response (T0N0M0) occurred in eight patients (9%). Three-year RFS for the entire group was 83%. RFS by final pathologic stage is shown in Fig. 1. Stages III (17 patients) and IV (1 patient) have been combined for analysis.



View larger version (22K):
[in this window]
[in a new window]
  		FIG. 1. Recurrence-free survival by stage.

 
Distal margin length ranged from .1 to 9.5 cm, with a mean of 2.5 cm (±SD of 1.75 cm) and a median of 2.0 cm. On the basis of the median distal margin length of 2 cm, comparison was made between patients with <=2 cm margins (n = 53) and those with >2 cm margins (n = 41). Kaplan-Meier distributions of LR and RFS were compared for the <=2 cm versus >2 cm groups and were noted to be not significantly different (P = .99 and P = .80, respectively). Estimates of LR and RFS at 3 years between the <=2 cm and >2 cm groups were 8% versus 11% and 88% versus 82%, respectively (Table 1).


View this table:
[in this window]
[in a new window]
  		TABLE 1. Three-year Kaplan-Meier estimates of local recurrence and recurrence-free survival stratified by distal margin length
 
Patients were then stratified into <=1 cm (n = 17) and >1 cm (n = 77) groups. Kaplan-Meier estimates of LR (Fig. 2) and RFS (Fig. 3) were compared and were not significantly different (P = .93 and P = .88, respectively). Estimates of LR and RFS at 3 years between the <=1 cm and >1 cm groups were 12% versus 9% and 82% versus 85%, respectively.



View larger version (17K):
[in this window]
[in a new window]
  		FIG. 2. Kaplan-Meier distribution of local recurrence for patients with <=1 cm margins versus >1 cm margins.

 


View larger version (16K):
[in this window]
[in a new window]
  		FIG. 3. Kaplan-Meier distribution of recurrence-free survival for patients with <=1 cm margins versus >1 cm margins.

 
Distal margin length was also considered as a continuous variable. Distal margin length was not found to be associated with RFS (hazard ratio, 1.1; 95% confidence interval, .91–1.4; P = .29) or with LR (hazard ratio, 1.1; 95% confidence interval, .87–1.5; P = .34).

A summary of the other clinicopathologic variables between the <=1 cm and >1 cm groups can be found in Table 2. Comparison with Fisher’s exact test did not reveal any significant differences between groups for stage distribution, mucinous histology, presence of lymphovascular or perineural invasion, or differentiation. The mean distance from the anal verge was, however, significantly different between the <=1 cm and >1 cm groups (P = .0002). Similarly, comparison between the <=2 cm and >2 cm groups did not reveal any significant differences, except that the mean tumor distance from the anal verge was also significantly shorter for the <=2 cm patients (P = .0002). Univariate analysis did not reveal any associations with either LR or RFS for any of the clinicopathologic variables in Table 2, although there was a significant difference in RFS by stage (P = .03). RFS was clearly improved between stage I and stage III/IV patients (Fig. 1).


View this table:
[in this window]
[in a new window]
  		TABLE 2. Comparison of clinicopathologic variables: <=1 cm versus >1 cm
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Careful pathologic studies demonstrate that DIS occurs in only 4% of rectal cancer patients and exceeds 1 and 2 cm in only 2% to 5% and 1% to 2% of cases, respectively.3,5 Thus, distal resection margins of 1 to 2 cm or greater should theoretically be sufficient for the vast majority of patients. Studies in rectal cancer patients receiving either postoperative adjuvant therapy8 or no adjuvant therapy12 indicate that distal resection margins <=1 cm do not seem to adversely affect LR or survival. One study, however, did demonstrate an increased incidence of anastomotic recurrence when the distal resection margin was <.8 cm.11

The importance of distal margin length in patients with advanced rectal cancer undergoing preoperative CMT, however, has not been fully studied. Preoperative CMT may theoretically eradicate any foci of distal intramural tumor spread before surgery, such that distal margins of <=1 cm would be even less likely to compromise outcome in this patient population. However, these patients have advanced and potentially more aggressive rectal cancer, and the conclusions presented previously may not necessarily hold for this group of patients.

One study has addressed the effect of distal margin length in patients receiving preoperative CMT. Thirty-six patients underwent either SS procedures (n = 28) or APR (n = 8) after preoperative radiotherapy and 5-FU–based chemotherapy.15 There was no significant difference in disease-free survival between patients undergoing SS procedures with <=1 cm margins and those with >1 cm margins (P = .06) or those undergoing APR (P = .27). Because LR occurred in only 1 of the 28 SS patients, no meaningful comparison between SS groups could be made, although LR occurred in only 1 of 9 patients with distal margins <5 mm. This study, however, does not provide information regarding other clinicopathologic variables that might have potentially masked differences in outcome attributable to distal margin length. Also included were different SS procedures (LAR and transsacral resection) and recurrent colorectal cancer patients (n = 3).

Our results, in a larger and relatively homogeneous group of rectal cancer patients undergoing preoperative CMT followed by potentially curative LAR, demonstrate that distal margins <=1 cm do not seem to compromise LR or RFS. Although a number of different clinicopathologic variables are associated with outcome in curatively resected rectal cancer, comparison between groups in this study indicates that they are well matched. As expected, the mean distance of tumor from the anal verge was significantly shorter in the <=1 and <=2 cm groups. Despite the fact that more-distal rectal cancers are associated with a relatively poor prognosis, outcome in the shorter-margin groups was equivalent to that in those with longer distal margins.

All patients in this study underwent rectal cancer resection with the technique of SME, as described by Enker et al.23 and Heald et al.24 Use of this technique results in negative circumferential margins in 93% of cases25 and LR rates as low as 3% to 5% in large clinical series of patients with all stages of disease, with most not receiving adjuvant therapy.23,26 In previous series of patients undergoing LAR for rectal cancer with total mesorectal excision, distal resection margins of <=1 cm did not negatively influence LR12 or survival.12,15

The negative prognostic effect of positive circumferential margins is well established.25 In rectal cancer patients undergoing preoperative CMT followed by SS resection, circumferential margins of <=3 mm were associated with increased overall recurrence and disease-free survival.15 However, the retrospective nature of our study did not allow a rigorous measurement of the radial margin. Patients with positive radial margins (considered noncurative resections) were excluded to avoid the potentially confounding influence of this variable.

Although our data clearly support our conclusions, our study is limited by virtue of its retrospective design. Furthermore, although it is commonly believed that approximately 80% of rectal cancer recurrences occur within 2 years, the development of recurrence may be delayed after preoperative CMT. In a recent study of patients receiving preoperative radiotherapy for locally advanced rectal cancer, almost 5 years of follow-up were required to detect 80% of all recurrences.27 Our median follow-up of 44 months compares favorably with other reports, but a median of at least 60 months would seem to be optimal. Finally, the favorable outcome of our patients supports the efficacy of preoperative CMT and SME but limits the number of treatment failures available for analysis.

It is important to emphasize that obtaining a negative distal margin of at least 1 to 2 cm remains an important goal in restorative rectal cancer resection. However, in the setting of a curatively resected patient (negative circumferential and distal margins), status post preoperative CMT with an otherwise favorable tumor, a distal resection margin <1 cm does not necessarily portend a poor prognosis. Our data suggest that these patients do not seem to require further resection in an effort to procure a greater distal margin, but that they may be followed nonoperatively without compromising oncological outcome.

Ongoing, prospective studies at our institution will aim to address the relative contributions of distal and circumferential margin status to local control and survival in patients undergoing restorative rectal cancer resection with rigorous pathologic assessment of circumferential margin status and DIS. Long-term follow-up of these patients will elucidate the relative importance of distal and circumferential margin status in patients with advanced rectal cancer undergoing preoperative CMT.


   Acknowledgments
 
The acknowledgment is available online at www.annalssurgicaloncology.org.

Supported by National Cancer Institute grant R01 CA 82534-01 (JGG).


   Footnotes
 
Presented at the 55th Annual Cancer Symposium, Society of Surgical Oncology, Denver, Colorado, March 14–17, 2002.

Although preoperative combined-modality therapy (CMT) can facilitate sphincter preservation, the optimal margin of distal clearance remains undefined. Our results indicate that distal margins <=1 cm do not compromise outcome in locally advanced rectal cancer patients receiving CMT.

Received for publication April 10, 2002. Accepted for publication August 26, 2002.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Ruo L, Guillem JG, Tickoo S, et al. Long-term prognostic significance of extent of rectal cancer response to preoperative radiation and chemotherapy. Ann Surg 2002; 236: 75–81.[CrossRef][Medline]
  2. Grann A, Feng C, Wong D, et al. Preoperative combined modality therapy for clinically resectable uT3 rectal adenocarcinoma. Int J Radiat Oncol Biol Phys 2001; 49: 987–95.[CrossRef][Medline]
  3. Andreola S, Leo E, Belli F, et al. Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis. Dis Colon Rectum 1997; 40: 25–9.[CrossRef][Medline]
  4. Kwok SP, Lau WY, Leung KL, Liew CT, Li AK. Prospective analysis of the distal margin of clearance in anterior resection for rectal carcinoma. Br J Surg 1996; 83: 969–72.[Medline]
  5. Shirouzu K, Isomoto H, Kakegawa T. Distal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery. Cancer 1995; 76: 388–92.[CrossRef][Medline]
  6. Kameda K, Furusawa M, Mori M, Sugimachi K. Proposed distal margin for resection of rectal cancer. Jpn J Cancer Res 1990; 81: 100–4.[Medline]
  7. Williams NS, Dixon MF, Johnston D. 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: 150–4.[Medline]
  8. Andreola S, Leo E, Belli F, et al. 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 2001; 8: 611–5.[Abstract/Free Full Text]
  9. Bozzetti F, Mariani L, Miceli R, Montalto F, Baratti D, Andreola S. Impact of distal clearance margin on oncologic outcome after restorative resection of the rectum. Tumori 1997; 83: 907–11.[Medline]
  10. Paty PB, Enker WE, Cohen AM, Lauwers GY. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg 1994; 219: 365–73.[Medline]
  11. Vernava AM III, Moran M, Rothenberger DA, Wong WD. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet 1992; 175: 333–6.[Medline]
  12. Karanjia ND, Schache DJ, North WR, Heald RJ. ‘Close shave’ in anterior resection. Br J Surg 1990; 77: 510–2.[Medline]
  13. Hojo K. Anastomotic recurrence after sphincter-saving resection for rectal cancer. Length of distal clearance of the bowel. Dis Colon Rectum 1986; 29: 11–4.[Medline]
  14. Pollett WG, Nicholls RJ. 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 1983; 198: 159–63.[Medline]
  15. Kuvshinoff B, Maghfoor I, Miedema B, et al. Distal margin requirements after preoperative chemoradiotherapy for distal rectal carcinomas: are <=1 cm distal margins sufficient? Ann Surg Oncol 2001; 8: 163–9.[Abstract/Free Full Text]
  16. Grann A, Minsky BD, Cohen AM, et al. Preliminary results of preoperative 5-fluorouracil, low-dose leucovorin, and concurrent radiation therapy for clinically resectable T3 rectal cancer. Dis Colon Rectum 1997; 40: 515–22.[CrossRef][Medline]
  17. Minsky BD, Oreilly E, Wong D. Daily low-dose irinotecan (CPT-11) plus pelvic irradiation as preoperative treatment of locally advanced rectal cancer (abstract). Proc Am Soc Clin Oncol 1999; 18: 266a.
  18. Guillem JG, Cohen AM. Treatment options for mid- and low-rectal cancers. Adv Surg 2000; 34: 43–66.[Medline]
  19. Sobin LH, Wittekind C. Colon and rectum. In: Sobin LH, Wittekind C, eds. TNM Classification of Malignant Tumours. 5th ed. New York: Wiley, 1997: 66.
  20. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958; 53: 457–81.[CrossRef]
  21. Cox D, Oakes D. Analysis of survival data. New York: Chapman & Hall, 1990.
  22. Mantel N. Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Rep 1966; 50: 163–70.[Medline]
  23. Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 1995; 181: 335–46.[Medline]
  24. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 1982; 69: 613–6.[Medline]
  25. Adam IJ, Mohamdee MO, Martin IG, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet 1994; 344: 707–11.[CrossRef][Medline]
  26. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 1998; 133: 894–9.[Abstract/Free Full Text]
  27. Ahmad NR, Nagle D. Long-term results of preoperative radiation therapy alone for stage T3 and T4 rectal cancer. Br J Surg 1997; 84: 1445–8.[CrossRef][Medline]



This article has been cited by other articles:


Home page
 Ann. Surg. Oncol.Home page
H. B. Neuman, D. Schrag, C. Cabral, M. R. Weiser, P. B. Paty, J. G. Guillem, B. D. Minsky, W. D. Wong, and L. K. Temple
Can Differences in Bowel Function After Surgery for Rectal Cancer Be Identified by the European Organization for Research and Treatment of Cancer Quality of Life Instrument?
Ann. Surg. Oncol., May 1, 2007; 14(5): 1727 - 1734.
[Abstract] [Full Text] [PDF]

Home page
 Arch SurgHome page
N. Han and S. Galandiuk
Induction Chemoradiation for Rectal Cancer
Arch Surg, December 1, 2006; 141(12): 1246 - 1252.
[Abstract] [Full Text] [PDF]

Home page
 JCOHome page
R. Rengan, P. Paty, W. D. Wong, J. Guillem, M. Weiser, L. Temple, L. Saltz, and B. D. Minsky
Distal cT2N0 Rectal Cancer: Is There an Alternative to Abdominoperineal Resection?
J. Clin. Oncol., August 1, 2005; 23(22): 4905 - 4912.
[Abstract] [Full Text] [PDF]

Home page
 SURG INNOVHome page
P. A. Paraskeva, S. Purkayastha, and A. Darzi
Laparoscopy for Malignancy: Current Status
Surgical Innovation, March 1, 2004; 11(1): 27 - 36.
[Abstract] [PDF]

Home page
 Ann. Surg. Oncol.Home page
M. L. Smidt, J. A. Wegdam, A. J. A. Bremers, and R. P. Bleichrodt
Missing Evidence for the Adequacy of a 1-cm Distal Margin in Resected Rectal Cancer
Ann. Surg. Oncol., August 1, 2003; 10(7): 823 - 824.
[Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
J. G. Guillem, H. G. Moore, P. B. Paty, A. M. Cohen, and W. D. Wong
Adequacy of Distal Resection Margin Following Preoperative Combined Modality Therapy for Rectal Cancer
Ann. Surg. Oncol., August 1, 2003; 10(7): 824 - 824.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Moore, H. G.
Right arrow Articles by Guillem, J. G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Moore, H. G.
Right arrow Articles by Guillem, J. G.
Related Collections
Right arrow Surgery

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS