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Pelvic Diameter is not Associated with Positive Circumferential Resection Margin in Rectal Cancer: Retrospective Analysis of 78 Cases

Abstract

Objective

To identify if there is an association between pelvic entry and pelvic outlet diameters with increased positive circumferential resection margin (CRM) in rectal cancer.

Introduction

Positive CRMin rectalcancerisa majorpredictor forlocal anddistant recurrence. Pelvic diameters may be related to the difficulty of dissection, as well as intrinsic tumor characteristics such as tumor size, location, distance from the anal margin, and T stage, which may compromise the integrity of the mesorectum and circumferential margin involvement.

Methods

A retrospective review of the patient’s medical records who underwent surgical resection of rectal adenocarcinoma from January 2012 to June 2022 was performed. The patient’s preoperative staging, operative characteristics, and histopathologic outcomes were gathered from the medical records. Preoperative MRI scanning was done in all patients. MRI pelvimetry was done by two observers. CRM involvement was recorded as stated in the pathology report. Pelvimetry variables were dichotomized according to their mean values for correlation analysis. The odds ratio (OR) was calculated from a binary logistics regression model to assess the relation between the positive CRM and the independent variables.

Results

A total of 78 patients were included in this study. A positive CRM was reported in 10 patients (12.8%). BMI >27.4 + 6.6 (p = 0.02), positive extramural vascular invasion (p = 0.027), positive CRM by MRI scanning (p = 0.004), and anal sphincter involvement (p = 0.03) were associated with positive CRM. Pelvimetry values were not associated with a positive CRM.

Conclusion

No association was found between the pelvic diameters measured by MRI pelvimetry with a positive CRM.

Keywords
magnetic resonance pelvimetry; pelvic outlet diameter; pelvimetry; circumferential resection margin; rectal cancer

Introduction

Colorectal cancer is the third most common cause of cancer in both men and women worldwide, while it represents the second most common cause of cancer-related deaths.11 You YN, Hardiman KM, Bafford A, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Vol. 63. Diseases of the Colon and Rectum; 2020:1191–1222 The surgical management of rectal cancer remains one of the cornerstones in its treatment, with the primary objective of achieving complete oncologic resection and avoiding locoregional recurrence.22 Zhou XC, Su M, Hu KQ, et al. CT pelvimetry and clinicopathological parameters in evaluation of the technical difficulties in performing open rectal surgery for mid-low rectal cancer. Oncol Lett 2016;11(01):31–38

Since 1988 when Prof. Heald described the “holy plane” of rectal surgery,33 Heald RJ. The ‘Holy Plane’ of rectal surgery. J R Soc Med 1988;81(09):503–508 the importance of total mesorectal excision (TME) was noted to the point that it has now been established as the gold standard of surgical resection in rectal cancer.44 Salerno G, Daniels IR, Brown G, Norman AR, Moran BJ, Heald RJ. Variations in pelvic dimensions do not predict the risk of circumferential resection margin (CRM) involvement in rectal cancer. World J Surg 2007;31(06):1313–1320 The circumferential resection margin (CRM) status, distal margin status, and total lymph nodes retrieved have been recognized as the main criteria assessing the quality of the procedure and the most important prognostic factors associated with local recurrence, distant metastasis, and overall survival.55 Simon HL, de Paula TR, Profeta da Luz MM, Kiran RP, Keller DS. Predictors of Positive Circumferential Resection Margin in Rectal Cancer: A Current Audit of the National Cancer Database. Dis Colon Rectum 2021;64(09):1096–1105, 66 Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 2008;26(02):303–312, 77 Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 2002;89(03):327–334

A negative CRM requires a distance greater than 1 mm between the tumor and the mesorectal fascia and levator muscles and the absence of invasion into the intersphinteric plane. On the other hand, a positive CRM is defined as a tumor ≤ 1 mm from the margin.88 Benson AB, Venook AP, Al-Hawary MM, et al. Rectal Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022;20(10):1139–1167 CRM may be evaluated preoperatively either by CT or MRI scan allowing the surgeon a better understanding of the patient’s anatomy and surgical planning to obtain complete integrity of the mesorectum during the procedure.22 Zhou XC, Su M, Hu KQ, et al. CT pelvimetry and clinicopathological parameters in evaluation of the technical difficulties in performing open rectal surgery for mid-low rectal cancer. Oncol Lett 2016;11(01):31–38, 99 Brown G, Radcliffe AG, Newcombe RG, Dallimore NS, Bourne MW, Williams GT. Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging. Br J Surg 2003;90(03):355–364, 1010 de’Angelis N, Pigneur F, Martínez-Pérez A, et al; EuMaRCS Study Group. Predictors of surgical outcomes and survival in rectal cancer patients undergoing laparoscopic total mesorectal excision after neoadjuvant chemoradiation therapy: the interest of pelvimetry and restaging magnetic resonance imaging studies. Oncotarget 2018;9(38):25315–25331 High spatial resolution MRI is the imaging modality of choice in the evaluation of local staging for rectal cancer.88 Benson AB, Venook AP, Al-Hawary MM, et al. Rectal Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022;20(10):1139–1167, 1111 Mahadevan LS, Zhong J, Venkatesulu B, et al. Imaging predictors of treatment outcomes in rectal cancer: An overview. Crit Rev Oncol Hematol 2018;129:153–162 Optimal treatment of rectal cancer requires a precise endoscopic and pathologic evaluation of the tumor, as well as accurate staging by MRI scanning, use of neoadjuvant chemoradiotherapy when indicated, complete dissection of the mesorectum and management by a multidisciplinary team.1212 Youssef H, Collantes EC, Rashid SH, Wong LS, Baragwanath P. Rectal cancer: involved circumferential resection margin - a root cause analysis. Colorectal Dis 2009;11(05):470–474

Difficult surgical dissection has been related to an incomplete mesorectal specimen, therefore increasing the risk of local recurrence. Among the anatomical factors, the assessment of the bony pelvis either by CT or MRI scanning is related to the quality of the rectal cancer resection.22 Zhou XC, Su M, Hu KQ, et al. CT pelvimetry and clinicopathological parameters in evaluation of the technical difficulties in performing open rectal surgery for mid-low rectal cancer. Oncol Lett 2016;11(01):31–38, 1313 Boyle KM, Petty D, Chalmers AG, et al. MRI assessment of the bony pelvis may help predict resectability of rectal cancer. Colorectal Dis 2005;7(03):232–240, 1414 Atasoy G, Arslan NC, Elibol FD, Sagol O, Obuz F, Sokmen S. Magnetic resonance-based pelvimetry and tumor volumetry can predict surgical difficulty and oncologic outcome in locally advanced mid-low rectal cancer. Surg Today 2018;48(12):1040–1051. Doi: 10.1007/s00595-018-1690-3
https://doi.org/10.1007/s00595-018-1690-...
The pelvic width and depth, the size of the tumor relative to the pelvic dimensions, the presence of other enlarged organs and the height of the tumor measured from the anal verge might relate to the difficulty of the procedure and surgeons have to customize their surgery plan according to the patient’spelvic anatomy.44 Salerno G, Daniels IR, Brown G, Norman AR, Moran BJ, Heald RJ. Variations in pelvic dimensions do not predict the risk of circumferential resection margin (CRM) involvement in rectal cancer. World J Surg 2007;31(06):1313–1320, 1515 Chau J, Solomon J, Liberman AS, Charlebois P, Stein B, Lee L. Pelvic dimensions on preoperative imaging can identify poor-quality resections after laparoscopic low anterior resection for mid- and low rectal cancer. Surg Endosc 2020;34(10):4609–4615, 1616 Gu J, Bo XF, Xiong CY, et al. Defining pelvic factors in sphincter-preservation of low rectal cancer with a three-dimensional digital model of pelvis. Dis Colon Rectum 2006;49(10):1517–1526 Regarding this relationship between the anatomy of the pelvis and the surgical difficulty, several scores have been proposed to predict it preoperatively.1717 de’Angelis N, Pigneur F, Martínez-Pérez A, et al; EuMaRCS Study Group. Assessing surgical difficulty in locally advanced mid-low rectal cancer: the accuracy of two MRI-based predictive scores. Colorectal Dis 2019;21(03):277–286, 1818 Escal L, Nougaret S, Guiu B, et al. MRI-based score to predict surgical difficulty in patients with rectal cancer. Br J Surg 2018; 105(01):140–146 In this study, we aim to identify if the pelvic diameters are related to a positive circumferential resection margin in patients with rectal cancer.

Methods

Study Population

A retrospective, observational study was made of patients from our institution submitted to surgical treatment for stage I-III rectal cancer, defined by the lower edge of the tumor being 16cm or less from the anal verge, from January 1, 2012, to June 1, 2022. The distance from the anal verge to the lower margin of the tumor was measured by digital rectal examination (DRE) and/or colonoscopy. Patients were included if they received a preoperative MRI, regardless of the receipt of neo-adjuvant therapy. All patients included had diagnosis of an adenocarcinoma confirmed by biopsy before the surgical procedure. Patients with tumors other than adenocarcinomas, stage IV rectal cancer, or that were treated by surgical derivation for obstructive rectal cancer were excluded.

Patient demographics (age, gender, body mass index, comorbidities defined by the Charlson Comorbidity Index), preoperative staging (distance to anal verge, clinical TNM staging, clinical circumferential (CRM) involvement, use of neoadjuvant treatment), operative characteristics, and histopathologic outcomes (size of tumor, extramural venous invasion (EMVI) involvement, neoadjuvant response, pathological T- and N-stage, lymph node harvest, mesorectal excision grade, CRM involvement, and distal margin involvement) were gathered from the medical records.

All patients included underwent preoperative pelvic MRI scanning for tumor staging and categorization. Indications for neoadjuvant treatment included: T4 disease, close or involved CRM, N≥2, lateral pelvic node involvement, or extramural venous invasion involvement. All surgical specimens underwent histopathologic examination and CRM involvement was described as stated in the pathology report.

MRI Pelvimetry

Sagittal, coronal, and axial T2-weighted sequences of initial MRI scanning were downloaded onto a workstation, and measurements were made by two observers for interobserver variation assessment who were blinded to all clinical information. Six pelvic dimensions were measured, as described in ►Table 1, and demonstrated in ►Fig. 1.

Table 1
Pelvic dimensions measured on MRI scans and mean values

Fig. 1
Magnetic resonance imaging (MRI) scan showing pelvimetric measurements.

Statistical Analysis

The SPSS Statistics IBM software package version 25.0 (Armonk, NY) was used for the statistical analysis. The data are presented as proportion (n/total), mean (SD), or median [Q1-Q3].

The CRM was dichotomized (positive/negative) according to the histopathology report and contingency tables were created to evaluate the association between the dependent and independent variables. Univariate analyses consisted of χ22 Zhou XC, Su M, Hu KQ, et al. CT pelvimetry and clinicopathological parameters in evaluation of the technical difficulties in performing open rectal surgery for mid-low rectal cancer. Oncol Lett 2016;11(01):31–38 or Fisher’s exact tests for categorical variables, and Student’s t or Mann-Whitney U test for quantitative variables. The odds ratio (OR) was calculated with a confidence interval (CI) of 95% from a binary logistics regression model, this model was used to assess the relation between the positive CRM as the dependent variable and one or more of the independent variables. A value of p≤0.05 was considered as statistically significant. Pelvimetry variables were dichotomized based on mean values for the correlation analysis.

Results

A total of 78 patients who underwent surgical resection for rectal adenocarcinoma were included. This cohort included 50 male (64.1%) and 28 female (35.3%) patients. The mean age at the time of surgery was 64.1 ± 11 years. In the unadjusted analysis, positive and negative CRM cohorts were comparable in age, race, comorbidity, and neoadjuvant chemotherapy. The most common tumor location was the middle third of the rectum in at 65.4% (n = 51), followed by the upper third at 21.8% (n = 17) and the lower third at 12.8% (n = 10). The patients’ characteristics are presented in ►Table 2.

Table 2
Patient characteristics, demographics, MRI pelvimetry and surgical outcomes

Extramural venous invasion (EMVI) was found in 20.5% (n = 16) of the patients, and invasion of the anal sphincter complex in 14.1% (n = 11). Mesorectum integrity was complete in 59% (n = 46) of cases, near complete in 9% (n = 7) and incomplete in 29.5% (n = 23). There was 12.8% (n = 10) positive CRM in the pathology report as well as in the preoperative MRI scan. Of the patients with positive CRM 80% were male and 20% female (p = 0.31). BMI was higher in patients with positive CRM vs those with negative CRM (27.4 ±6.6 vs 25.5 ±3.8, p = 0.02). The preoperative characteristics associated in our study with positive CRM were positive EMVI (p = 0.027), anal sphincter complex involvement (p = 0.03), and positive CRM by MRI scan (p = 0.004). Tumor location and height respective to the rectum length were not associated with positive CRM.

The primary surgical approach was open surgery in 51 cases (65.4%), 24 cases (30.8%) by laparoscopy, and 3 cases (3.8%) that required conversion from laparoscopic to open surgery.

The pelvic dimensions were measured based on preoperative MRI pelvimetry. The mean distance is described in ►Table 1. Univariate analysis showed an association of a positive CRM with BMI of 27.4 + 6.6 (p = 0.02), positive EMVI (p = 0.027), anal sphincter involvement (p = 0.03), CRM involvement by MRI assessment (p = 0.03) and mesorectum integrity (p = 0.025) (►Table 2).

In the binary logistics regression model, we found as factors associated with a positive CRM the involvement of the anal sphincter complex (OR 5.61, 95% CI (1.26–24.88), p = 0.02), incomplete mesorectum (OR 6.27, 95% CI (1.44–27.25), p = 0.01) and tumor perforation (OR 9.28 95% CI (1.56–55.07) p = 0.01). (►Table 3).

Table 3
Odds ratio (OR) by binary logistics regression model showing the association between positive CRM and the different variables

No association was found between the pelvic diameters measured by MRI pelvimetry with a positive CRM, pelvimetry measurements were dichotomized according to their mean values without finding any significative association with a positive CRM (►Table 3).

Discussion

CRM is one of the major and most significant prognostic factors in rectal cancer surgery that directly impacts the rates of local recurrence, distant metastasis, and overall survival.77 Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 2002;89(03):327–334, 1919 Birbeck KF, Macklin CP, Tiffin NJ, et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery. Ann Surg 2002;235(04):449–457 Our study aimed to identify if there is an association between pelvic diameters measured by MRI pelvimetry and a positive CRM in patients with rectal adenocarcinoma treated by surgical resection. Of the total of 78 patients included in this study, only 12.8% (n = 10) had a positive CRM, which was expected according to previously reported incidence between 1–28%.66 Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 2008;26(02):303–312, 2020 Rickles AS, Dietz DW, Chang GJ, et al; Consortium for Optimizing the Treatment of Rectal Cancer (OSTRiCh) High rate of positive circumferential resection margins following rectal cancer surgery a call to action. Ann Surg 2015;262(06):891–898

In rectal cancer surgery, one of the most important indicators assessing the quality of the procedure is the integrity of the mesorectum, given that TME and negative CRM are the most important prognostic factors.66 Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 2008;26(02):303–312, 77 Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 2002;89(03):327–334, 2121 Quirke P, Steele R, Monson J, et al; MRC CR07/NCIC-CTG CO16 Trial Investigators NCRI Colorectal Cancer Study Group. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 2009;373(9666):821–828 In our study we found that one of the factors closely related to a positive CRM was an incomplete mesorectum specimen, given that when the plane of dissection goes through the mesorectum, close to the rectal wall, the radial margin is often compromised, as stated by Nagtegaal and Quirke.66 Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 2008;26(02):303–312

0 In the study published by Boyle et al1313 Boyle KM, Petty D, Chalmers AG, et al. MRI assessment of the bony pelvis may help predict resectability of rectal cancer. Colorectal Dis 2005;7(03):232–240, the relationships between the pelvic dimensions and the CRM status were evaluated. They found that interspinous distance and the intertuberous distance were significantly narrower in women with positive CRM, whereas in men no association was found. Conversely, Salerno et al. reported no association between the MRI pelvimetry dimensions and CRM involvement.44 Salerno G, Daniels IR, Brown G, Norman AR, Moran BJ, Heald RJ. Variations in pelvic dimensions do not predict the risk of circumferential resection margin (CRM) involvement in rectal cancer. World J Surg 2007;31(06):1313–1320 In our study we analyzed six pelvic measurements by MRI pelvimetry (pelvic inlet, pelvic outlet, pelvic depth, interspinous distance, intertuberous distance, and transverse diameter). No significant association was found between the mean values of such pelvic dimensions and a positive CRM.

The utility of measuring the pelvic dimensions by MRI pelvimetry is still out for debate. Previous studies have found an association between narrow pelvic dimensions and increased difficulty in surgery, such as an intertuberous distance <10.1cm,1818 Escal L, Nougaret S, Guiu B, et al. MRI-based score to predict surgical difficulty in patients with rectal cancer. Br J Surg 2018; 105(01):140–146 large pelvic outlets,2222 Killeen T, Banerjee S, Vijay V, Al-Dabbagh Z, Francis D, Warren S. Magnetic resonance (MR) pelvimetry as a predictor of difficulty in laparoscopic operations for rectal cancer. Surg Endosc 2010;24(12):2974–2979 S1-S5 pubic symphysis angles ≥74.2°.1515 Chau J, Solomon J, Liberman AS, Charlebois P, Stein B, Lee L. Pelvic dimensions on preoperative imaging can identify poor-quality resections after laparoscopic low anterior resection for mid- and low rectal cancer. Surg Endosc 2020;34(10):4609–4615 Also interspinous distance has been related to positive CRM.2323 Baik SH, Kim NK, Lee KY, et al. Factors influencing pathologic results after total mesorectal excision for rectal cancer: analysis of consecutive 100 cases. Ann Surg Oncol 2008;15(03):721–728 In this study we found no statistically significant relation between CRM involvement and MRI pelvimetry dimensions, our study has limitations regarding its retrospective nature and limitednumber of patients. Even if there was no direct association found between pelvimetryand a positive CRM, variables such as pelvic diameter and BMI may factor into multi-disciplinary meeting decision-making regarding the treatment modality, sequence, and type of therapy recommended. Further investigation studies with a larger sample are needed to clarify the role of MRI pelvimetry in rectal cancer surgery. As stated in the systematic review by Hong et al.,2424 Hong JSY, Brown KGM, Waller J, Young CJ, Solomon MJ. The role of MRI pelvimetry in predicting technical difficulty and outcomes of open and minimally invasive total mesorectal excision: a systematic review. Tech Coloproctol 2020;24(10):991–1000. Doi:10.1007/s10151-020-02274-x
https://doi.org/10.1007/s10151-020-02274...
MRI assessments of soft tissue measurements may also be implicated in the difficulty of the operation.

  • Funding
    The authors received no financial support for the research, authorship, and/or publication of this article.
  • Statement
    What does this paper add to the literature?
    This manuscript shows that no significant association between narrow margins in MRI pelvimetry and CRM involvement was found. Concluding that MRI pelvimetry dimensions are not associated with CRM involvement in rectal cancer surgery.
  • Ethics Approval
    This paper has not been presented in any meeting presentation.
    This paper is not currently under review by another journal. This paper has not been accepted for publication elsewhere.

References

  • 1
    You YN, Hardiman KM, Bafford A, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Vol. 63. Diseases of the Colon and Rectum; 2020:1191–1222
  • 2
    Zhou XC, Su M, Hu KQ, et al. CT pelvimetry and clinicopathological parameters in evaluation of the technical difficulties in performing open rectal surgery for mid-low rectal cancer. Oncol Lett 2016;11(01):31–38
  • 3
    Heald RJ. The ‘Holy Plane’ of rectal surgery. J R Soc Med 1988;81(09):503–508
  • 4
    Salerno G, Daniels IR, Brown G, Norman AR, Moran BJ, Heald RJ. Variations in pelvic dimensions do not predict the risk of circumferential resection margin (CRM) involvement in rectal cancer. World J Surg 2007;31(06):1313–1320
  • 5
    Simon HL, de Paula TR, Profeta da Luz MM, Kiran RP, Keller DS. Predictors of Positive Circumferential Resection Margin in Rectal Cancer: A Current Audit of the National Cancer Database. Dis Colon Rectum 2021;64(09):1096–1105
  • 6
    Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 2008;26(02):303–312
  • 7
    Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 2002;89(03):327–334
  • 8
    Benson AB, Venook AP, Al-Hawary MM, et al. Rectal Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022;20(10):1139–1167
  • 9
    Brown G, Radcliffe AG, Newcombe RG, Dallimore NS, Bourne MW, Williams GT. Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging. Br J Surg 2003;90(03):355–364
  • 10
    de’Angelis N, Pigneur F, Martínez-Pérez A, et al; EuMaRCS Study Group. Predictors of surgical outcomes and survival in rectal cancer patients undergoing laparoscopic total mesorectal excision after neoadjuvant chemoradiation therapy: the interest of pelvimetry and restaging magnetic resonance imaging studies. Oncotarget 2018;9(38):25315–25331
  • 11
    Mahadevan LS, Zhong J, Venkatesulu B, et al. Imaging predictors of treatment outcomes in rectal cancer: An overview. Crit Rev Oncol Hematol 2018;129:153–162
  • 12
    Youssef H, Collantes EC, Rashid SH, Wong LS, Baragwanath P. Rectal cancer: involved circumferential resection margin - a root cause analysis. Colorectal Dis 2009;11(05):470–474
  • 13
    Boyle KM, Petty D, Chalmers AG, et al. MRI assessment of the bony pelvis may help predict resectability of rectal cancer. Colorectal Dis 2005;7(03):232–240
  • 14
    Atasoy G, Arslan NC, Elibol FD, Sagol O, Obuz F, Sokmen S. Magnetic resonance-based pelvimetry and tumor volumetry can predict surgical difficulty and oncologic outcome in locally advanced mid-low rectal cancer. Surg Today 2018;48(12):1040–1051. Doi: 10.1007/s00595-018-1690-3
    » https://doi.org/10.1007/s00595-018-1690-3
  • 15
    Chau J, Solomon J, Liberman AS, Charlebois P, Stein B, Lee L. Pelvic dimensions on preoperative imaging can identify poor-quality resections after laparoscopic low anterior resection for mid- and low rectal cancer. Surg Endosc 2020;34(10):4609–4615
  • 16
    Gu J, Bo XF, Xiong CY, et al. Defining pelvic factors in sphincter-preservation of low rectal cancer with a three-dimensional digital model of pelvis. Dis Colon Rectum 2006;49(10):1517–1526
  • 17
    de’Angelis N, Pigneur F, Martínez-Pérez A, et al; EuMaRCS Study Group. Assessing surgical difficulty in locally advanced mid-low rectal cancer: the accuracy of two MRI-based predictive scores. Colorectal Dis 2019;21(03):277–286
  • 18
    Escal L, Nougaret S, Guiu B, et al. MRI-based score to predict surgical difficulty in patients with rectal cancer. Br J Surg 2018; 105(01):140–146
  • 19
    Birbeck KF, Macklin CP, Tiffin NJ, et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery. Ann Surg 2002;235(04):449–457
  • 20
    Rickles AS, Dietz DW, Chang GJ, et al; Consortium for Optimizing the Treatment of Rectal Cancer (OSTRiCh) High rate of positive circumferential resection margins following rectal cancer surgery a call to action. Ann Surg 2015;262(06):891–898
  • 21
    Quirke P, Steele R, Monson J, et al; MRC CR07/NCIC-CTG CO16 Trial Investigators NCRI Colorectal Cancer Study Group. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 2009;373(9666):821–828
  • 22
    Killeen T, Banerjee S, Vijay V, Al-Dabbagh Z, Francis D, Warren S. Magnetic resonance (MR) pelvimetry as a predictor of difficulty in laparoscopic operations for rectal cancer. Surg Endosc 2010;24(12):2974–2979
  • 23
    Baik SH, Kim NK, Lee KY, et al. Factors influencing pathologic results after total mesorectal excision for rectal cancer: analysis of consecutive 100 cases. Ann Surg Oncol 2008;15(03):721–728
  • 24
    Hong JSY, Brown KGM, Waller J, Young CJ, Solomon MJ. The role of MRI pelvimetry in predicting technical difficulty and outcomes of open and minimally invasive total mesorectal excision: a systematic review. Tech Coloproctol 2020;24(10):991–1000. Doi:10.1007/s10151-020-02274-x
    » https://doi.org/10.1007/s10151-020-02274-x

Publication Dates

  • Publication in this collection
    29 Apr 2024
  • Date of issue
    2024

History

  • Received
    11 Sept 2023
  • Accepted
    07 Feb 2024
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