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

Vergara-Fernández, Omar; Ruiz-Muñoz, Erick Alejandro; Peña, Danilo Tueme-de la; Bravo-Ávila, Héctor E.; Hoyos-Torres, Alejandro; Salgado-Nesme, Noel

doi:10.1055/s-0044-1782152

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Journal of Coloproctology (Rio de Janeiro)

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Brasil

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Sumário

Original Article • J. Coloproctol. (Rio J.) 44 (1) • 2024 • https://doi.org/10.1055/s-0044-1782152 copy

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

Authorship SCIMAGO INSTITUTIONS RANKINGS

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

Pelvic dimension	Description	Symbol	Mean measurement (cm)
Pelvic inlet length	Distance in the sagittal axis from the superior, middle aspect of the pubic symphysis to the sacral promontory	a	10.8
Pelvic depth	The line in the sagittal axis between the sacral promontory and the tip of the coccyx	b	11.57
Pelvic outlet length	Distance in the sagittal axis from the inferior, middle aspect of the pubic symphysis to the coccyx	c	8.57
Interspinous distance	The line in the axial axis between both ischial spines	d	9.35
Intertuberous distance	The line in the axial axis between both ischial tuberosities	e	9.94
Transverse diameter	The line in the coronal axis between the outermost point of the iliopectineal lines	f	11.75

Variable		n (%)
Variable		CRM positive (n = 10)	CRM negative (n = 68)	p
Gender	Male	8 (80)	42 (61.8)	0.31
	Female	2(20)	26 (38.2)
Age (SD)	60.7 ± 10.1	64.6 ± 11.1	0.5
Age	30–50 years	1 (10)	6 (8.8)	0.30
	51–70 years	8 (80)	39 (57.4)
	≥ 71 years	1 (10)	23 (33.8)
BMI	27.4 ± 6.6	25.5 ± 3.8	0.02
BMI by group	18.5–24.9	4 (40)	27 (39.7)	0.42
	25–29.9	3 (30)	31 (45.6)
	≥30	3 (30)	10 (14.7)
Charlson Comorbidity Index	No comorbidities	0 (0)	1 (1.5)	0.92
	Low comorbidities	2 (20)	13 (19.1)
	High comorbidities	8 (80)	54 (79.4)
Previous pelvic surgery	2 (20)	13 (19.1)	0.94
Preoperative CEA		17.30 (0.49–46.6)	3.4 (0.2–225)
Approach	Open	7 (70)	44 (64.7)	0.45
	Laparoscopic	2 (20)	22 (32.4)
	Conversion	1 (10)	2 (2.9)
Type of surgery	LAR	2 (20)	23 (33.8)	0.57
	ULAR	6 (60)	22 (32.4)
	APR	1 (10)	9 (13.2)
	ISR	0 (0)	4 (5.9)
	PE	1 (10)	5 (7.4)
	TaTME	0 (0)	5 (7.4)
Tumor height from anal verge	High (10.1–16cm)	3 (30)	14 (20.6)	0.78
	Mid (6.1–10cm)	6 (60)	45 (66.2)
	Low (0–6 cm)	1 (10)	9 (13.2)
Tumor location	Anterior	2 (20)	15 (22.1)	0.64
	Posterior	3 (30)	9 (13.2)
	Circumferential	3 (30)	18 (26.5)
	Lateral	1 (10)	15 (22.1)
	No data	1 (10)	11 (16.2)
Positive CRM by MRI scanning	Positive	6 (60)	10 (14.7)	0.004
	Negative	4 (40)	56 (82.4)
	No data		2 (2.9)
Anal sphincter involvement		4 (40)	7 (10.3)	0.03
Positive EMVI		5 (50)	11 (16.4)	0.027
Neoadjuvant therapy		9 (90)	59 (86.8)	0.62
Type of radiotherapy	Long course	5 (50)	47 (69.1)	0.38
	Short course	1 (10)	7 (10.3)
	No	4 (40)	14 (20.6)
Type of TNT	Induction	3 (30)	30 (44.1)	0.63
	Consolidation	1 (10)	8 (11.8)
	No	6 (60)	30 (44.1)
Interspinous distance		9.11 ± 0.67	9.66 ± 1.00	0.2
Intertuberous distance		9.93 ± 0.80	9.84 ± 1.33	0.07
Pelvic inlet		10.79 ± 0.5	10.82 ± 0.92	0.10
Pelvic outlet		8.76 (6.58–11.07)	8.59 (7.1–10.1)
Pelvic depth		11.43 ± 1.51	11.86 ± 1.41	0.547
Transverse diameter		11.75 ± 1.28	11.79 ± 1.09	0.321
Distal margin involvement		2 (20)	1 (1.5)
Mesorectum integrity	Complete	3 (30)	43 (63.2)	0.025
	Near complete	0 (0)	7 (10.3)
	Incomplete	7 (70)	16 (23.6)
Tumor size		3 (0.5–11)	2.35 (0.2–11.7)
Tumor perforation		3 (30)	3 (4.4)	0.025
Lymphovascular invasion		9 (90)	9 (13.2)	0.000
Perineural invasion		5 (50)	4 (5.9)	0.003
Recurrence		5 (50)	13 (19.1)	0.045
OVS (months)		17.5 (2–69)	41 (0–102)
DFS (months)		11.3 ± 5.5	16.67 ± 12.83	0.19

Variable		OR	P
Gender	Male	1.00
	Female	2.47 (0.48–12.57)
Age	30–50 years	1.00
	51–70 years	1.23 (0.13–11.67)	0.85
	>70 years	0.261 (0.01–4.80)	0.36
BMI	18.5–24.9	1.00
	25–29.9	0.65 (0.13–3.18)	0.59
	>30	2.02 (0.38–10.68))	0.40
Previous pelvic surgery	No	1.00
	Yes	1.05 (0.20–5.58)	0.94
Charlson Comorbidity Index	No comorbidities	1.00
	Low comorbidities	0.00 (0.00)	1.00
	High comorbidities	1.03 (0.19–5.48)	0.96
Locally advanced tumor	No	1.00
	Yes	0.72 (0.07–6.94)	0.78
Type of radiotherapy	Long course	1.00
	Short course	2.68 (0.63–11.38)	0.18
	None	1.34 (0.13–13.25)	0.80
Type of TNT	Consolidation	1.00
	Induction	1.6 (0.16–15.27)	0.68
		0.8 (0.73–8.76)	0.85
Approach	Laparoscopic	1.00
	Open	1.91 (0.37–9.77)	0.43
Surgery	LAR	1.00
	ULAR	2.68 (0.48–14.46)	0.25
	APE	1.27 (0.10–15.89)	0.84
	Pelvic exenteration	2.30 (0.17–30	0.52
	TaTME	0.00	0.99
Neoadjuvant chemotherapy	Yes	1.00
	No	0.26 (0.05–1.27)	0.09
Tumor height from anal verge	High (10.1–16cm)	1.00
	Mid (6.1–10cm)	0.51 (0.04–5.79)	0.59
	Low (0–6 cm)	0.62 (0.13–2.81)	0.53
Tumor location	Lateral	2.50 (0.34–17.94)	0.36
	Circumferential	1.25 (0.18–8.49)	0.81
	Posterior	0.50 (0.04–6.14)	0.58
	Anterior	0.68 (0.05–8.50)	0.76
Anal sphincter involvement	No	1.00
	Yes	5.61 (1.26–24.88)	0.02
EMVI	Negative	1.00
	Positive	6.12 (0.14–26.58)	0.015
Mesorectum integrity	Complete	1.00
	Near complete	–	–
	Incomplete	6.27 (1.44–27.25)	0.01
Perforation	No	1.00
	Yes	9.28 (1.56–55.07)	0.01

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[1] ⁎Address for correspondence Erick Alejandro Ruiz-Muñoz, MD, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (e-mail: erick.alex.ruiz@gmail.com).