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High Rate of Positive Circumferential Resection Margins Following Rectal Cancer Surgery: A Call to Action

Rickles, Aaron S. MD; Dietz, David W. MD; Chang, George J. MD; Wexner, Steven D. MD; Berho, Mariana E. MD; Remzi, Feza H. MD; Greene, Frederick L. MD; Fleshman, James W. MD; Abbas, Maher A. MD; Peters, Walter MD; Noyes, Katia PhD; Monson, John R. T. MD; Fleming, Fergal J. MDon behalf of the Consortium for Optimizing the Treatment of Rectal Cancer (OSTRiCh)

doi: 10.1097/SLA.0000000000001391
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Objectives : To identify predictors of positive circumferential resection margin following rectal cancer resection in the United States.

Background: Positive circumferential resection margin is associated with a high rate of local recurrence and poor morbidity and mortality for rectal cancer patients. Prior study has shown poor compliance with national rectal cancer guidelines, but whether this finding is reflected in patient outcomes has yet to be shown.

Methods: Patients who underwent resection for stage I-III rectal cancer were identified from the 2010–2011 National Cancer Database. The primary outcome was a positive circumferential resection margin. The relationship between patient, hospital, tumor, and treatment-related characteristics was analyzed using bivariate and multivariate analysis.

Results: A positive circumferential resection margin was noted in 2859 (17.2%) of the 16,619 patients included. Facility location, clinical T and N stage, histologic type, tumor size, tumor grade, lymphovascular invasion, perineural invasion, type of operation, and operative approach were significant predictors of positive circumferential resection margin on multivariable analysis. Total proctectomy had nearly a 30% increased risk of positive margin compared with partial proctectomy (OR 1.293, 95%CI 1.185–1.411) and a laparoscopic approach had nearly 22% less risk of a positive circumferential resection margin compared with an open approach (OR 0.882, 95%CI 0.790–0.985).

Conclusions: Despite advances in surgical technique and multimodality therapy, rates of positive circumferential resection margin remain high in the United States. Several tumor and treatment characteristics were identified as independent risk factors, and advances in rectal cancer care are necessary to approach the outcomes seen in other countries.

*Department of Surgery, Surgical Health Outcomes & Research Enterprise, University of Rochester Medical Center, Rochester, NY

Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH

Department of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX

§Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL

Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, FL

||Cancer Data Services, Levine Cancer Institute, Charlotte, NC

**Department of Surgery, Baylor University Medical Center, Dallas, TX

††Department of Surgery, Cleveland Clinic, Abu Dhabi, United Arab Emirates

‡‡Department of Surgery, Columbia Surgical Associates, Columbia, MO.

Reprints: John R. T. Monson, Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY 14642. E-mail: John_Monson@URMC.rochester.edu.

Disclosure: The authors declare no conflicts of interest.

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