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Low Rectal Cancer: A Call for a Change of Approach in Abdominoperineal Resection

From the Department of Pathology, University Medical Centre, St Radboud, Nijmegen; Departments of Surgery and Clinical Oncology, Leiden University Medical Centre, Leiden, the Netherlands; Academic Unit of Pathology, University of Leeds, United Kingdom. The Pathology Review Committee and the Cooperative Clinical Investigators of the Dutch Colorectal Cancer Group.

Address reprint requests to Phil Quirke, MD, FRCPath, Academic Unit of Pathology, University of Leeds, Leeds LS22 4HT, United Kingdom; e-mail: patpq{at}leeds.ac.uk

PURPOSE: Despite the major improvements that have been made due to total mesorectal excision (TME), low rectal cancer still remains a challenge.

METHODS: By investigating a prospective randomized rectal cancer trial in which surgeons had undergone training in TME the factors responsible for the poor outcome were determined and a new method for assessing the quality of surgery was tested.

RESULTS: Survival differed greatly between abdominoperineal resection (APR) and anterior resection (AR; 38.5% v 57.6%, P = .008). Low rectal carcinomas have a higher frequency of circumferential margin involvement (26.5% v 12.6%, P < .001). More positive margins were present in the patients operated with APR (30.4%) compared to AR (10.7%, P = .002). Furthermore, more perforations were present in these specimens (13.7% v 2.5%, P < .001). The plane of resection lies within the sphincteric muscle, the submucosa or lumen in more than 1/3 of the APR cases, and in the remainder lay on the sphincteric muscles.

CONCLUSION: We systematically described and investigated the pathologic properties of low rectal cancer in general, and APR in particular, in a prospective randomized trial including surgeons who had been trained in TME. The poor prognosis of the patients with an APR is ascribed to the resection plane of the operation leading to a high frequency of margin involvement by tumor and perforation with this current surgical technique. The clinical results of this operation could be greatly improved by adopting different surgical techniques and possibly greater use of radiochemotherapy.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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