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Missing Evidence for the Adequacy of a 1-cm Distal Margin in Resected Rectal Cancer

Department of General Surgery, UMC St Radboud, Nijmegen, The Netherlands

To the Editor:

We read with interest the article by Moore et al. from the Surgical Department of Memorial Sloan-Kettering Cancer Center, New York, in the January issue of the Annals of Surgical Oncology.¹

The purpose of their study was to assess if a distal margin of 1 cm after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined-modality therapy (CMT) was adequate. The authors conclude that distal margins 1 cm do not compromise local recurrence (LR) and recurrence-free survival, stating that their conclusions are clearly supported by the data presented. In our opinion, these conclusions are insufficiently supported by the published evidence.

The authors included 94 of 170 consecutive patients treated with CMT in their study. Of these 94 patients, approximately 11 (12%) did not receive CMT following the standard protocol. It is questionable if these patients should have been included.

A proper interpretation of the results is impossible without knowledge about the localization of the tumor. According to the description in the Materials and Methods section, all tumors in the upper rectum (>11 cm from the anal verge) have been resected with a margin of at least 5 cm, according to standard sharp mesorectal excision rules. A total mesorectal excision was done for all mid (7–11 cm) and distal (<7 cm) rectal tumors. Therefore, all midrectal tumors must have a resection margin of at least 2–3 cm; otherwise the patients were not operated on according to the state-of-the art total mesorectal excision technique.

Distal margin length is 1 cm in only 17 patients. One may deduce this concerns patients with distal rectum tumors. Distal margins are at stake in this group only. The authors’ conclusion is therefore based on the results in 17 patients only!

Follow-up was done retrospectively using all the information from the available records. If these data were not available, the primary physicians or the patients were contacted by telephone. Recurrences are difficult to diagnose in patients with rectal cancer. Local recurrence can only be diagnosed with a combination of physical examination, endoscopy, and imaging techniques, such as computed tomography, magnetic resonance imaging, or positron emission tomography. The information from telephone interviews of either physicians or patients is in our opinion unreliable for calculation of LR and recurrence-free survival. Proper interpretation of data can only be done if follow-up is completed according to a standard protocol or if the exact follow-up data are available. Moreover, the follow-up period was too short, as already mentioned by the authors referring to the article of Ahmad et al.²

LR, the only relevant outcome measure when margins are at stake, occurred in 11 patients in this study within a median of 44 months. Only two of these patients had a distal margin 1 cm. In conclusion, the series of patients is too small and the data, concerning tumor localization and follow-up, are insufficient to state that resection margins 1 cm are safe.

REFERENCES

1. Moore HG, Riedel E, Minsky BD, et al. Adequacy of 1-cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined-modality therapy. Ann Surg Oncol 2003; 10: 80–5.[Abstract/Free Full Text]
2. 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]

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