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Clinical Significance of the Mesorectal Extension of Rectal Cancer: A Japanese Multi-institutional Study

Shirouzu, Kazuo MD*; Akagi, Yoshito MD*; Fujita, Shin MD; Ueno, Hideki MD; Takii, Yasumasa MD§; Komori, Koji MD|; Ito, Masaaki MD; Sugihara, Kenichi MD#Cooperative Investigators

doi: 10.1097/SLA.0b013e3182119331
Original Articles

Objective: The aim of this study was to emphasize the importance of a subclassification in the TNM staging system of rectal cancer.

Background: The clinical significance of the mesorectal extension of rectal cancer is unclear.

Patients and Methods: Data from 463 consecutive patients with stage IIa disease (T3N0) undergoing curative surgery at 28 institutes were analyzed. The measurement of the distance of the mesorectal extension (DME) was histologically evaluated. Risk factors for recurrence, for the optimal cutoff point of the DME, independent prognostic factors, and for survivals were studied using receiver operating characteristic curve and logistic and Cox regression analyses. Survivals were calculated using the Kaplan-Meier method.

Results: A value of 4 mm was determined as the optimal cutoff point. The patients were subdivided into 2 groups: DME ≤ 4 mm and DME > 4 mm at the optimal cutoff point. DME > 4 mm had the greatest impact on recurrence-free survival [P = 0.00023, hazard ratio (HR): 2.26, 95% confidence interval (95% CI): 1.465-3.492, L/U ratio: 0.420] and was an independent adverse prognostic factor (P = 0.00323, HR: 1.97, 95% CI: 1.254-3.091). The distant metastasis rate in DME > 4 mm was higher 16.7% than that in DME ≤ 4 mm (P = 0.00177, OR: 2.61, 95% CI: 1.430-4.761). The incidence of local recurrence was not influenced by DME. The recurrence-free 5-year survival rate in DME ≤ 4 mm was significantly better than that in DME > 4 mm (86.6% vs 71.3%, P = 0.00015, HR: 0.44, 95% CI: 0.286-0.683). The cancer-specific survival rate in DME ≤ 4 mm was also significantly better than that in DME > 4 mm (91.3% vs 82.2%, P = 0.000664, HR: 0.52, 95% CI: 0.325-0.843).

Conclusions: A subclassification according to mesorectal extension based on a 4-mm cutoff point is needed for the TNM staging system. However, further prospective study is necessary to prove reproducibility and validity of the cutoff point.

Supplemental digital content is available in the text.The optimal cut-off point in the mesorectal extension of rectal cancer was histologically assessed. The importance of a sub-classification for the TNM staging system based on a 4 mm cut-off point was emphasized.

*Department of Surgery, Kurume University School of Medicine, Fukuoka, Japan.

Colorectal Surgery Division, Department of Surgery, National Cancer Center Hospital, Tokyo, Japan.

Department of Surgery, National Defense Medical College, Saitama, Japan.

§Niigata Cancer Center Hospital, Niigata, Japan.

|Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan.

Colorectal and Pelvic Surgery Division, Department of Surgical Oncology, National, Cancer Center Hospital East, Chiba, Japan.

#Department of Surgical Oncology, Graduate School, Tokyo Medical and Dental University.

**See SDC Appendix: Cooperatve Investigators of the JSCCR (

Reprints: Kazuo Shirouzu, MD, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka, 830-0011, Japan. E-mail:

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

No author has any conflict of interest.

© 2011 Lippincott Williams & Wilkins, Inc.