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Adequacy of Distal Resection Margin Following Preoperative Combined Modality Therapy for Rectal Cancer

Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, New York, New York

To the Editor:

We appreciate the opportunity to respond to the editorial regarding our report in the January 2003 issue of the Annals of Surgical Oncology.¹ In summary, concerns have been raised regarding our patient population and follow-up interval, surveillance strategy, and sample size. Although we found these concerns of interest, we do not feel that they necessarily detract from the validity of our findings. Most of these issues were addressed in the Discussion section of our report; however, further elaboration is provided.

Our study consisted of 94 consecutive patients who received preoperative combined-modality therapy at Memorial Sloan-Kettering Cancer Center followed by restorative rectal resection. At issue is the inclusion of four patients in whom the final radiation dose was unavailable. However, as stated in our report, our records indicate that a full course of preoperative radiation was given. Of additional concern was the inclusion of seven patients that received concomitant irinotecan, rather than 5-fluorouracil, with preoperative radiation. We do not feel that the inclusion of these seven patients affected our results because the use of irinotecan was equally represented between the groups compared.

Our conclusions are not based solely on the results of 17 patients as suggested by the author, but rather on 94 patients, including the group of 77 patients with >1 cm margins. Furthermore, analysis of distal margin length as a continuous variable using the Cox proportional hazards model in all 94 patients did not reveal any relation between distal margin length and either local or overall treatment failure (hazard ratios of 1.1).

Although follow-up was retrospective in our analysis, we do not agree that the data is necessarily suspect. Seven of 11 local recurrences, and all of the distant recurrences, were confirmed histologically. The follow-up strategy employed did vary to some degree between surgeons and over the 10-year study period and was undoubtedly individualized. The uniform follow-up approach suggested by the reviewer would be ideal but seems unrealistic in the setting of a retrospective analysis.

We wish to reiterate that obtaining a 1–2 cm or greater distal resection margin, whenever possible, remains an important goal in restorative rectal cancer resection. However, our data suggest that following preoperative combined-modality therapy and a restorative resection of an otherwise favorable tumor, a short (but histologically negative) distal resection margin, does not, in itself, indicate a need for further resection. Lastly, we wish to echo the need for prospective studies of larger sample size and longer follow-up to address the relative contributions of distal and circumferential margins on long-term outcome.

REFERENCE

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]

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