Importance Laparoscopic procedures are generally thought to have better outcomes than open procedures. Because of anatomical constraints, laparoscopic rectal resection may not be better because of limitations in performing an adequate cancer resection. Objective To determine whether laparoscopic resection is noninferior to open rectal cancer resection for adequacy of cancer clearance. Design, Setting, and Participants Randomized, noninferiority, phase 3 trial (Australasian Laparoscopic Cancer of the Rectum; ALaCaRT) conducted between March 2010 and November 2014. Twenty-six accredited surgeons from 24 sites in Australia and New Zealand randomized 475 patients with T1-T3 rectal adenocarcinoma less than 15 cm from the anal verge. Interventions Open laparotomy and rectal resection (n = 237) or laparoscopic rectal resection (n = 238). Main Outcomes and Measures The primary end point was a composite of oncological factors indicating an adequate surgical resection, with a noninferiority boundary of Δ = −8%. Successful resection was defined as meeting all the following criteria: (1) complete total mesorectal excision, (2) a clear circumferential margin (≥1 mm), and (3) a clear distal resection margin (≥1 mm). Pathologists used standardized reporting and were blinded to the method of surgery. Results A successful resection was achieved in 194 patients (82%) in the laparoscopic surgery group and 208 patients (89%) in the open surgery group (risk difference of −7.0% [95% CI, −12.4% to ∞]; P  = .38 for noninferiority). The circumferential resection margin was clear in 222 patients (93%) in the laparoscopic surgery group and in 228 patients (97%) in the open surgery group (risk difference of −3.7% [95% CI, −7.6% to 0.1%]; P  = .06), the distal margin was clear in 236 patients (99%) in the laparoscopic surgery group and in 234 patients (99%) in the open surgery group (risk difference of −0.4% [95% CI, −1.8% to 1.0%]; P  = .67), and total mesorectal excision was complete in 206 patients (87%) in the laparoscopic surgery group and 216 patients (92%) in the open surgery group (risk difference of −5.4% [95% CI, −10.9% to 0.2%]; P  = .06). The conversion rate from laparoscopic to open surgery was 9%. Conclusions and Relevance Among patients with T1-T3 rectal tumors, noninferiority of laparoscopic surgery compared with open surgery for successful resection was not established. Although the overall quality of surgery was high, these findings do not provide sufficient evidence for the routine use of laparoscopic surgery. Longer follow-up of recurrence and survival is currently being acquired. Trial Registration anzctr.org Identifier:ACTRN12609000663257

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Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial

OBJECTIVE: To assess the accuracy of preoperative staging of rectal cancer with magnetic resonance imaging to predict surgical circumferential resection margins. DESIGN: Prospective observational study of rectal cancers treated by colorectal multidisciplinary teams between January 2002 and October 2003. SETTING: 11 colorectal units in four European countries. PARTICIPANTS: 408 consecutive patients presenting with all stages of rectal cancer and undergoing magnetic resonance imaging before total mesorectal excision surgery and histopathological assessment of the surgical specimen. MAIN OUTCOME MEASURES: Accuracy of magnetic resonance imaging in predicting a curative resection based on the histological yardstick of presence or absence of tumour at the margins of the specimen. RESULTS: 354 of the 408 patients had a clear circumferential resection margin (87%, 95% confidence interval 83% to 90%). Specificity for prediction of a clear margin by magnetic resonance imaging was 92% (327/354, 90% to 95%). High resolution scans were technically satisfactory in 93% (379/408). Surgical specimens were histopathologically graded as complete or moderate in 80% (328/408), and the median lymph node harvest was 12 (range 0-49). Magnetic resonance imaging predicted clear margins in 349 patients. At surgery 327 had clear margins (94%, 91% to 96%). CONCLUSION: High resolution magnetic resonance imaging accurately predicts whether the surgical resection margins will be clear or affected by tumour. This technique can be reproduced accurately in multiple centres to predict curative resection and warns the multidisciplinary team of potential failure of surgery, thus enabling selection of patients for preoperative treatment.

Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study

The article Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting, written by [§§§ AuthorNames §§§].

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Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting

PURPOSE: To prospectively evaluate the accuracy of magnetic resonance (MR) imaging in depicting the extramural depth of tumor invasion in patients who have rectal cancer, with histopathologic results as the reference standard. MATERIALS AND METHODS: The Magnetic Resonance Imaging and Rectal Cancer European Equivalence (MERCURY) Study received ethics approval from all participating centers, and all patients gave informed consent. Consecutive patients (n = 679) with adenocarcinoma of the rectum consented to participate. Imaging workshops for participating specialist gastrointestinal radiologists were held to ensure standardization of image acquisition techniques. Standardized MR image interpretation and data reporting were performed by using previously validated criteria. MR images were prospectively singly read by the specialist gastrointestinal radiologists. The maximal extramural depth (EMD) of tumor spread, defined at histopathologic analysis as the distance from the outer edge of the longitudinal muscularis propria to the outer edge of the tumor, was measured and recorded. The maximal EMD was the reference standard. The MR and histopathologic results were considered to be equivalent when the 95% confidence interval of the difference between them was within +/-0.5 mm. RESULTS: Tumor EMD measurements obtained at both MR imaging and histopathologic analysis were available for 295 (95%) of 311 patients after primary surgery. Mean EMDs were 2.80 mm +/- 4.60 (standard deviation) and 2.81 mm +/- 4.28 at MR imaging and histopathologic analysis, respectively. The mean difference between the MR-derived and histopathologically derived EMDs was -0.05 mm +/- 3.85 (95% confidence interval: -0.49 mm, 0.40 mm). Therefore, MR and histopathologic assessments of tumor spread were considered equivalent to within 0.5 mm. CONCLUSION: Demonstration of accurate measurement of the depth of extramural tumor spread in the MERCURY Study enabled accurate preoperative prognostication.

Extramural depth of tumor invasion at thin-section MR in patients with rectal cancer: Results of the MERCURY Study

Background
Magnetic resonance imaging (MRI) is increasingly being used for rectal cancer staging. The purpose of this study was to determine the accuracy of phased array MRI for T category (T1–2 vs. T3–4), lymph node metastases, and circumferential resection margin (CRM) involvement in primary rectal cancer.

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Diagnostic Accuracy of MRI for Assessment of T-category, Lymph Node Metastases, and Circumferential Resection Margin Involvement in Patients with Rectal Cancer: A Systematic Review and Meta-analysis

OBJECTIVE. The surgical removal of a rectal carcinoma and the adjacent lymph nodes in an en bloc package lessens the risk of local recurrence due to residual tumor. Heightened awareness of good surgical techniques has created much interest in the anatomy involved in total mesorectal excision surgery, with particular focus on the fascial planes and nerve plexuses and their relationship to the surgical planes of excision. Clear preoperative depiction of these relationships is of value in determining tumor resectability. The aim of this study was to describe the radiologic appearance of these anatomic structures.SUBJECTS AND METHODS. High-spatial-resolution T2-weighted MRI was performed using a 1.5-T system in cadaveric sections and in patients before they underwent total mesorectal excision surgery. Anatomic dissections of sagitally sectioned hemipelves were compared with MRIs obtained in vivo to establish criteria for visualization of the structures relevant to anterior resection of the rectum.RESULTS. Hig...

Joanne Sayman

Papers

High-Resolution MRI of the Anatomy Important in Total Mesorectal Excision of the Rectum