Association of Plane of Total Mesorectal Excision With Prognosis of Rectal Cancer Secondary Analysis of the CAO/ARO/AIO-04 Phase 3 Randomized Clinical Trial

Kitz, Julia and Fokas, Emmanouil and Beissbarth, Tim and Stroebel, Philipp and Wittekind, Christian and Hartmann, Arndt and Rueschoff, Josef and Papadopoulos, Thomas and Roesler, Elisabeth and Ortloff-Kittredge, Peter and Kania, Ulrich and Schlitt, Hans and Link, Karl-Heinrich and Bechstein, Wolf and Raab, Hans-Rudolf and Staib, Ludger and Germer, Christoph-Thomas and Liersch, Torsten and Sauer, Rolf and Roedel, Claus and Ghadimi, Michael and Hohenberger, Werner (2018) Association of Plane of Total Mesorectal Excision With Prognosis of Rectal Cancer Secondary Analysis of the CAO/ARO/AIO-04 Phase 3 Randomized Clinical Trial. JAMA SURGERY, 153 (8): e181607. ISSN 2168-6254, 2168-6262

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Abstract

IMPORTANCE Previous retrospective studies have shown that surgical quality affects local control in rectal cancer.. OBJECTIVE In this secondary end point analysis, we evaluated the prognostic effect of the total mesorectal excision (TME) plane in the CAO/ARO/AIO-04 phase 3 randomized clinical trial. DESIGN, SETTING, AND PARTICIPANTS The CAO/ARO/AIO-04 trial enrolled 1236 patients with cT3-4 and/or node-positive rectal adenocarcinoma from 88 centers in Germany between July 25, 2006, and February 26, 2010. INTERVENTIONS Patients were randomized to receive treatment with standard fluorouracil-based preoperative chemoradiotherapy (CRT) alone (control arm) or oxaliplatin (experimental arm) followed by TME and adjuvant chemotherapy. MAIN OUTCOMES AND MEASURES The TME quality (mesorectal, intramesorectal, and muscularis propria plane) was prospectively assessed in 1152 operation specimens. An assessment was performed independently by pathologists and surgeons. The results were correlated with clinicopathologic data and the clinical outcome was tested, including multivariable analysis with the Cox regression model. RESULTS Of 1152 German Caucasian participants, 332 (28.8) were women and the mean age was 63 years. The plane of TME was mesorectal in 930 patients(80.7%), intramesorectal in 169(14.7%), and muscularis propriain 53(4.6%). In a univariable analysis, the TME plane was significantly associated with 3-year disease-free survival (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 73.1-78.8 vs 61.6-76.0vs 55.6-81.3, respectively; P=.01), cumulative incidence of local and distant recurrences (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 2.0-4.5 vs 1.2-8.1 vs 2.5-20.5, respectively; P<.001; and mesorectal vs intramesorectal vs muscularis propria, 95% CI, 17.0-22.4 vs 18.3-32.0vs 14.2-39.0, respectively; P=.03, respectively), and overall survival (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 88.3-92.3 vs 79.7-91.0vs 81.6-98.7, respectively; P=.02). In contrast to the pathologist-based evaluation, the assessment of TME plane by the operating surgeon failed to demonstrate prognostic significance for any of these clinical end points. In a multivariable analysis, the plane of surgery (mesorectal vs muscularis propria TME) constituted an independent factor for local recurrence (P=.002). CONCLUSIONS AND RELEVANCE This phase 3 randomized clinical trial confirms the long-term clinical effect of TME plane quality on local recurrence, as initially reported in the MRC CR07 study. The data highlight the key role of pathologists and surgeons in the multidisciplinary management of rectal cancer.

Item Type: Article
Uncontrolled Keywords: PREOPERATIVE CHEMORADIOTHERAPY; LOCAL RECURRENCE; CIRCUMFERENTIAL MARGIN; POSTOPERATIVE CHEMOTHERAPY; GERMAN CAO/ARO/AIO-04; TUMOR-REGRESSION; RESECTION; QUALITY; OUTCOMES; SURGERY;
Subjects: 600 Technology > 610 Medical sciences Medicine
Divisions: Medicine > Lehrstuhl für Chirurgie
Depositing User: Dr. Gernot Deinzer
Date Deposited: 06 Mar 2020 06:15
Last Modified: 06 Mar 2020 06:15
URI: https://pred.uni-regensburg.de/id/eprint/14148

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