title: Altering the therapeutic paradigm towards a distal bowel margin of < 1 cm in patients with low-lying rectal cancer: a systematic review and commentary.
abstract: OBJECTIVE
  The 1-cm rule of distal bowel clearance in patients with low-lying rectal cancer undergoing anterior resection is based mainly on pathological data showing distal intramural spread. Because clinical data are contradictory, a review that includes only cancers located ≤ 5 or ≤ 6 cm from the anal verge was carried out.
  
  
  METHODS
  A systematic review of the literature identified seven studies that presented results in relation to a margin of ≤ 1 cm (n = 293) vs > 1 cm (n = 315). In six studies, pre- or postoperative radiotherapy was implemented, and in one study patients were treated with surgery alone. Three studies, all implementing radiotherapy, reported results related to a margin of ≤ 5 mm (n = 51) vs > 5 mm (n = 125).
  
  
  RESULTS
  In none of the studies were the differences in local recurrence rate between the small and large margin groups statistically significant. The pooled analysis of six studies, in which patients received perioperative radiotherapy, showed a 1.2% [95% confidence interval (Cl) -4.5-7.0%] higher local recurrence rate in the ≤ 1 cm margin group compared with the > 1 cm margin group (P = 0.6). The corresponding figures for the ≤ 5 mm cut-off point were 0.5% (95% CI -7.6-8.7%, P = 0.9). The 5-year local recurrence rate in the only study in which radiotherapy had not been used was 8.6% higher in the ≤ 1 cm margin group compared with the > 1 cm margin group (P = 0.09).
  
  
  CONCLUSIONS
  Clinical evidence does not support the 1-cm rule in patients with low-lying rectal cancer undergoing pre- or postoperative radiotherapy.
authors: Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
authors: L
authors: L
authors: Pahlman
authors: K
authors: K
authors: Bujko
authors: A
authors: A
authors: Rutkowski
authors: W
authors: W
authors: Michalski
mesh_terms: D006801:Humans; D016001:Confidence Intervals; D009364:Neoplasm Recurrence, Local; D018365:Neoplasm, Residual; D012004:Rectal Neoplasms / Q000532:radiotherapy / Q000601:surgery