title: Circumferential resection margin positivity after preoperative chemoradiotherapy based on magnetic resonance imaging for locally advanced rectal cancer: implication of boost radiotherapy to the involved mesorectal fascia.
abstract: OBJECTIVE
  To identify patients who are at a higher risk of pathologic circumferential resection margin involvement using preoperative magnetic resonance imaging.
  
  
  METHODS
  Between October 2008 and November 2012, 165 patients with locally advanced rectal cancer (cT4 or cT3 with <2 mm distance from tumour to mesorectal fascia) who received preoperative chemoradiotherapy were analysed. The morphologic patterns on post-chemoradiotherapy magnetic resonance imaging were categorized into five patterns from Pattern A (most-likely negative pathologic circumferential resection margin) to Pattern E (most-likely positive pathologic circumferential resection margin). In addition, the location of mesorectal fascia involvement was classified as lateral, posterior and anterior. The diagnostic accuracy of the morphologic criteria was calculated using receiver operating characteristic curve analysis.
  
  
  RESULTS
  Pathologic circumferential resection margin involvement was identified in 17 patients (10.3%). The diagnostic accuracy of predicting pathologic circumferential resection margin involvement was 0.73 using the five-scale magnetic resonance imaging pattern. The sensitivity, specificity, positive predictive value and negative predictive value for predicting pathologic circumferential resection margin involvement were 76.5, 65.5, 20.3 and 96.0%, respectively, when cut-off was set between Patterns C and D. On multivariate logistic regression, the magnetic resonance imaging patterns D and E (P= 0.005) and posterior or lateral mesorectal fascia involvement (P= 0.017) were independently associated with increased probability of pathologic circumferential resection margin involvement. The rate of pathologic circumferential resection margin involvement was 30.0% when the patient had Pattern D or E with posterior or lateral mesorectal fascia involvement.
  
  
  CONCLUSIONS
  Patients who are at a higher risk of pathologic circumferential resection margin involvement can be identified using preoperative magnetic resonance imaging although the predictability is moderate.
authors.affiliation: Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul.
authors.forename: Kyung Hwan
authors.initials: KH
authors.lastname: Kim
authors.affiliation: Department of Radiology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul.
authors.forename: Min Jung
authors.initials: MJ
authors.lastname: Park
authors.affiliation: Department of Radiology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul jslim1@yuhs.ac mdgold@yuhs.ac.
authors.forename: Joon Seok
authors.initials: JS
authors.lastname: Lim
authors.affiliation: Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul.
authors.forename: Nam Kyu
authors.initials: NK
authors.lastname: Kim
authors.affiliation: Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul.
authors.forename: Byung Soh
authors.initials: BS
authors.lastname: Min
authors.affiliation: Department Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul.
authors.forename: Joong Bae
authors.initials: JB
authors.lastname: Ahn
authors.affiliation: Department Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul.
authors.forename: Tae Il
authors.initials: TI
authors.lastname: Kim
authors.affiliation: Department Pathology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.
authors.forename: Ho Geun
authors.initials: HG
authors.lastname: Kim
authors.affiliation: Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul jslim1@yuhs.ac mdgold@yuhs.ac.
authors.forename: Woong Sub
authors.initials: WS
authors.lastname: Koom
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D059248:Chemoradiotherapy; D005205:Fascia / Q000473:pathology*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods*; D018365:Neoplasm, Residual / Q000473:pathology*; D012004:Rectal Neoplasms / Q000473:pathology* / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D019233:Retreatment; D012680:Sensitivity and Specificity
keywords: chemoradiotherapy; circumferential resection margin; magnetic resonance imaging; mesorectal fascia; rectal cancer