History

It has been well known for many years that the outcome of colon cancer surgery in the long run is much better than in rectal cancer [2-4]. There have been grounds for the assumption that surgical technique is a major cause for this, for many decades. In the early 1980s, Heald reported a significant decrease of local recurrence rates (<5%) by improving surgical technique, thus challenging the importance of the new, upcoming therapy method of additional post-operative radiotherapy [5]. He stressed the importance of using the total mesorectal excision (TME) in the "holy plane", thus using embryological bloodless planes. In 1995 Hermanek and co-workers of the German Colorectal Cancer Study Group (SGCRC) demonstrated that the surgeon is a prognostic factor in rectal cancer outcome. Surgery is directly related to local recurrence and thus to overall survival [6].

While achievement of adequate proximal and distal margins has been common sense for decades, at about the same time the pathologist Quirke reported on the importance of the possible circumferential margin involvement in rectal cancer. Although the surgeon thought that he did a curative resection, margin-disease-free resection, in 25% circumferential margin involvement could be demonstrated on the pathological specimen leading to a 78% rate of local recurrence [7].

In 2002 Nagtegaal et al. reported that the role of the pathologist is not limited to the microscopic evaluation of the specimen after curative resection but that macroscopic evaluation of the TME specimen will provide feedback to the surgeon with regard to the quality of the operation performed, which may have prognostic significance [8]. A simple classification for the evaluation of the integrity of the mesorectum was proposed (complete, nearly complete and incomplete). In the above-mentioned study in patients with a negative circumferential margin the overall recurrence and survival rates were statistically worse in patients with an incomplete TME compared to those with a complete or nearly complete TME (28.6 vs. 14.9% and 90.5 vs. 76.9%, respectively) [8].

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