Adequate length of the distal resection margin in rectal cancer: from the oncological point of view

Abstract

Introduction: The distal resection margin (DRM) has been considered an important factor for the oncological outcome of rectal cancer surgery. However, the optimal distal margins required to achieve safe oncological outcome remains to be controversial.

Material and methods: More recently, as circumferential resection margin or mesorectal margin has been additionally reported to be more important factors predicting patient outcome than the distal mucosal margin, a re-evaluation of the impact of DRM on patient outcome is needed.

Results: The extent of distal tumor spread is known to be influenced by a variety of factors such as tumor location, lymph node metastasis, and tumor size. DRM might affect survival more than a local recurrence. Because distal intramural tumor spread rarely exceeds 1 to 2 cm in most rectal cancers, and local control and survival do not seem to be compromised by shorter distal resection margins, the generally accepted practice is to aim for a 2-cm DRM. However, in the recent trend of curative resection after preoperative chemoradiotherapy, with an otherwise favorable tumor such as well-differentiated tumor and no lymph node metastasis, a DRM at < or =1 cm does not necessarily portend a poor prognosis. In cases with preoperative chemoradiotherapy, distal resection margins need to be evaluated individually.

Discussion: It has been suggested that down-staging of low-lying rectal cancers after preoperative radiation might well include the pathological clearance of distal intramural microscopic spread. Moreover, the measurement of DRM varies with respective study, making it difficult to compare.

Conclusion: We need an applicable intraoperative method to accurately measure distal resection margin, enabling comparative outcome.