- Email: [email protected]
75. Features on MRI after transanal endoscopic microsurgery in patients with rectal cancer
754 Tumour response to neoadjuvant therapy ranges from complete response to little or no response at all and is related with outcomes. The aim of this study was to determine the correlation between clinical, pathological parameters and molecular biomarkers in diagnostic endoscopic biopsies with tumour regression grading in the resected specimens. Materials and methods: Ninety five patients with mid (56%) and low (44%) locally advanced rectal adenocarcinoma who received neoadjuvant radiotherapy with or without chemotherapy followed by radical surgical resection were included in the study. Mean age was 68 years. Sixty four (67%) were males and 31 (33%) females. Several clinical and pathological parameters were collected. Paraffin-embedded sections obtained in diagnostic biopsies before therapy were assessed by immunohistochemical staining for p53, her-2, VEGFr, bcl-2, beta-catenin, COX-2, APAF-1 and Ki-67. These stains were correlated with T-downstaging and tumour regression grade (TRG) using Mandard’s scoring system on surgical specimens. Data were analyzed with chi-square and Spearman’s correlation tests. Results: Pathologic complete response was seen in 17% and T downstaging in 48.2%. There was correlation between TRG and pretreatment expression of bcl-2 (p¼0.04), beta-catenin (p¼0.03) and VEGFr (p¼0.04). T-downstaging was significantly associated with expression of APAF-1 (p¼0.04) and VEGFr (p¼0.03). We did not find any correlation with any other molecular marker (p53, her-2, COX-2, Ki-67), clinical and pathological parameters (age, gender, tumour location, pretreatment CEA level, interval to surgery), excepting histologic grade (p<0.001). Conclusions: Pathological and immunohistochemical evaluation of diagnostic biopsies may be a useful tool to predict tumour response to neoadjuvant therapy in patients with locally advanced rectal adenocarcinoma. 73. Changing patterns of recurrent disease in colorectal cancer I. Grossmann1, J.M. Klaase1, P.M. Doornbos2, G.H. de Bock2, T. Wiggers3 1 Medisch Spectrum Twente, Surgery, Enschede, The Netherlands 2 UMC Groningen, Epidemiology, Groningen, The Netherlands 3 UMC Groningen, Surgery, Groningen, The Netherlands Introduction: Due to changes in staging and (neo)-adjuvant treatment of colorectal cancer (CRC), it is expected that the recurrence pattern, relevant for follow-up, changes as well. This study analyzes the incidence and time to recurrent disease (RD), the localization(s) and the eligibility for renewed curative treatment. Materials and methods: A prospective consecutive cohort of CRC patients treated with curative intent from 2007 till 2010 was analyzed (n¼511). This cohort was routinely staged before treatment with abdominal CT and chest X-ray or CT and underwent (neo)-adjuvant treatment according to the current guidelines. Results: The incidence of RD was 15% for patients with stage 0-III disease and 19% when including curatively treated stage IV patients, after a median FU of 33 months. The annual incidences in the stage 0-III group (n¼472) were for year one 7.3%, year two 6.3%, year three 3.6%, year four 2.8% and year five 2.0%. In the stage IV group (n¼39) these were for year one 39% and year two 57%. The majority of RD was confined to one organ (59%) and 25% of patients were treated with curative intent. Conclusions: The incidence of RD has decreased significantly in comparison to historical estimates of 30-50%. This decrease is probably due to improved staging before treatment, the decrease of local recurrences from rectal cancer and better adjuvant treatment in colon cancer. The annual incidences are the highest in the first two years but tend to retain in succeeding years for stage 0-III patients. The efforts to find RD with the intention to offer a second chance on cure do seem to be amenable.
74. The treatment of local recurrent rectal cancer in the TME Era S. Bosman1, F.A. HolmanMD 2, R. Dudink1, H.J. Rutten1 1 Catharina Hospital, Surgery, Eindhoven, The Netherlands 2 TweeStedenZiekenhuis, Surgery, Tilburg, The Netherlands
ABSTRACTS Background: In recent years, an improvement in prognosis for patients with rectal cancer is achieved, partly due to the Total Mesorectal Excision (TME) technique, and the introduction of preoperative radiotherapy and chemotherapy. Despite improved outcomes, some patients develop locally recurrent rectal cancer. The majority of patients with local recurrent rectal cancer have already received irradiation during the initial treatment for the primary tumour. This has led to the question whether reirradiation improves the local tumour response and survival or leads to late toxicity and a better outcome. The objective of this article is to evaluate the outcome of treatment in a large population patients with local recurrent rectal carcinoma. Materials and methods: The Catharina Hospital is a national referral centre for patients with recurrence rectal cancer. Patients were treated following the TME rules whenever possible. Before surgery, patients underwent irradiation, re-irradiation, chemotherapy, a combination, or no neoadjuvant treatment. Patient follow up was enrolled in a database; complications post-operative, presence of local recurrence, metastasis and overall survival was reported. Follow-up ranged from 0 to 202 months with a median of 27 months. Results: From 1994 until 2011, 222 patients (mean age 63; 133 male, 89 female) with local recurrence were treated with curative intent. One hundred and two patients were reirradiated, the dose ranged from 2500 to 6000 centigrays (cGy), with a median dose of 4250 cGy. Two hundred and twenty two patients underwent surgery; in 57% (n¼126) of the surgical procedures, a radical resection was achieved. On univariate cox regression analysis, a radical resection showed high significance, compared with R1 or R2 resections; respectively (HR2.54 p¼0.000 and HR4.10 p¼0.000). The overall survival after five years was 35%. The five years cancer specific survival was 41%. Fifty one percent developed local recurrence within five years and 46% developed distant metastases. The overall relapse free survival was 34%. Conclusions: Neoadjuvant treatment, re-irradiation or reirradiation combined with chemotherapy, has influence on cancer specific survival. However, radical resection is the main prognostic variable for oncological outcome. Even after TME surgery in combination with radiotherapy, treatment of local recurrence with reirradiation (in combination with chemotherapy) is feasible and yields good oncological outcome. 75. Features on MRI after transanal endoscopic microsurgery in patients with rectal cancer G.L. Beets4, M.H. Martens1, M. Maas2, L.A. Heijnen1, D.M.J. Lambregts2, J.W.A. Leijtens3, R.G.H. Beets-Tan2 1 Maastricht University Medical Centre, Surgery/Radiology, Maastricht, The Netherlands 2 Maastricht University Medical Centre, Radiology, Maastricht, The Netherlands 3 Laurentius Hospital, Surgery, Roermond, The Netherlands 4 Maastricht University Medical Centre, Surgery, Maastricht, The Netherlands Background: Standard treatment for rectal cancer is total mesorectal excision (TME) with or without neo-adjuvant treatment. This major surgery is associated with significant morbidity and mortality. Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for the local resection for T1 and selected T2 tumors and is associated with lower morbidity and mortality rates than TME. It is also an emerging option for good responders after chemoradiation. In most centres, the follow-up of patients treated with TEM includes regular MRI in addition to endoscopy. So far, rectal wall morphology on MRI after TEM has not yet been described. This study aimed to describe the rectal wall MRI morphology during short-term and long-term follow-up in patients that received TEM. Methods: Thirty-six patients had a post-TEM MRI in our center between 2006 and 2011. For half of the patients (n¼19) only one post-operative MRI was available in our institute. In 17 cases two or more MRIs were available. The MR morphology of the TEM site was studied on the consecutive MR examinations. 29 patients were primary treated with TEM, 7 patients had a long course of chemoradiation followed by TEM.
ABSTRACTS Twenty-three patients had a T1 tumor, 10 patients had a T2, and one patient had a T3 tumor. In 2 patients, no tumor was found. These patients had a TEM after polypectomy. Two patients received chemoradiation after TEM because of a suspect lymph node. Results: Three morphological patterns on MRI after TEM could be identified: (1) rectal wall thickening with or without fibrosis, (2) a notch at the TEM-location, and (3) irregular delineation of the rectal wall (figure 1). In eight cases edema was present during short-term follow-up and remained present during long-term follow-up (up to 36 months) in patients with TEM after CRT. A notch was observed in 15 patients, and persisted during long-term follow-up in 83%of these patients. Sixteen patients had irregular rectal wall, which normalized after 6 months. Six luminal recurrences occurred; 5 of these patients had an irregular rectal. In 3 of these 6 patients, there was also a notch present. Wall thickening was also present in 3 of the 6 patients. 3 patients had a nodal recurrence. Conclusion: Three patterns were identified on MRI after TEM. This enables radiologists to monitor this group of patients more accurately. Since minimal invasive techniques are gaining, it is very important for radiologists and surgeons to have knowledge about the normal follow-up findings after TEM. 76. Epidural analgesia e Associated with survival in colon cancer? F.J. Vogelaar 1 , A. van den Bogerd 1 , V.E. Lemmens 2 , J.C. van der Linden3, H.G.J.M. Cornelisse4, F.R.C. van Dorsten4, K. Bosscha5 1 Jeroen Bosch Ziekenhuis, Surgery, Hertogenbosch, The Netherlands 2 Comprehensive Cancer Centre South, Eindhoven, The Netherlands 3 Jeroen Bosch Hospital, Pathology, den Bosch, The Netherlands 4 Jeroen Bosch Hospital, Anaesthesiology, den Bosch, The Netherlands 5 Jeroen Bosch Hospital, Surgery, den Bosch, The Netherlands Background: Surgery is still the mainstay of treatment for potentially curable colon cancer. Otherwise, the surgical stress response increases the likelihood of cancer dissemination and metastasis during and after cancer surgery. The possibility that anesthetic drugs can influence cancer recurrence is a subject of more recent debate. Based on animal studies and only a few clinical investigations, epidural analgesia during cancer surgery has been suggested to reduce cancer metastasis. Material and methods: A follow-up study in a historical cohort was performed in 605 patients with colon cancer UICC stage I-III undergoing surgery at the Jeroen Bosch Hospital, Den Bosch, The Netherlands over the period January 1995 to December 2003. The patients were allocated into two groups; those receiving epidural analgesia peri-operatively and those not receiving epidural analgesia, but patient-controlled analgesia. From all participants additional information was obtained from the Dutch Comprehensive Cancer Centre South. Follow-up measurements and visits were conducted according to the criteria of the Dutch cancer centre and all patients were followed up until January 2011. Mortality risks were estimated with Cox-proportional hazard models. Results: The study population comprised of 306 females. Mean age was 69 years. 59 (10%) underwent an emergency operation. 407 (67%) patients received epidural analgesia perioperatively and 198 (33%) patients were operated without epidural anaesthesia. Mean follow-up was 10 years. Patients receiving epidural analgesia had a significant better overall survival (HR 0.93, 95% CI 0.93-0.98, p¼0.01). Results were adjusted for gender, age, UICC stage, emergency surgery and adjuvant chemotherapy. Conclusions: In our study epidural analgesia during surgery for colon cancer was associated with significant better overall survival even after correcting for many confounding variables. Interestingly, the benefit of epidural analgesia seems to be more than only analgetic. A possible mechanism is that regional anaesthesia attenuates the immunosuppressive effect of surgery. Also the lower requirements of opioid, which seems to inhibit the immune system, could play a role in the survival benefit. The observed reduction in mortality rate when colon cancer surgery was performed with epidural analgesia suggests that prospective trials
755 evaluating the effects of regional and morphine sparing analgesia on cancer recurrence are warranted. 77. Minimal invasive treatment for clinical complete and good responders after chemoradiation for rectal cancer G.L. Beets2, L.A. Heijnen1, M. Maas1, M.H. Martens1, D.M.J. Lambregts1, R.G.H. Beets-Tan1, J.W.A. Leijtens3 1 Maastricht University Medical Centre, Radiology, Maastricht, The Netherlands 2 Maastricht University Medical Centre, Surgery, Maastricht, The Netherlands 3 Laurentius Ziekenhuis Roermond, Department of Surgery, The Netherlands Background: Patients with a good or complete response after neoadjuvant chemoradiotherapy have excellent long-term outcome. For these patients, less invasive treatment (local excision for the good responders and wait-and-see policy for the complete responders) is increasingly being studied and considered. The combination of MR imaging and endoscopy has shown promise for the detection of complete or good response after chemoradiotherapy. The purpose of this prospective cohort study was to evaluate long-term outcome of patients with a good or complete response who have been treated with less invasive treatment, with strict selection criteria and follow-up based on imaging and endoscopy. Materials and methods: Patients with a cCR after chemoradiotherapy were prospectively selected for [1] the wait-and-see policy or [2] the transanal endoscopic microsurgery (TEM) policy. Selection was performed by magnetic resonance imaging (MRI) and endoscopy plus biopsies. In both treatment groups, intensive 3 to 6 monthly follow-up, using CEA, CT of thorax and abdomen, contrast-enhanced pelvic MRI and endoscopy (with biopsy) was performed. Long-term outcome was estimated by using Kaplan-Meier curves. Results: Thirty-six patients with a complete or good response were included, of which thirty-one in the wait-and-see policy group and five in the TEM-group. 64% was male. Mean follow-up was 24 18 months. Two patients developed a local recurrence within two years and had surgery as salvage treatment, leading to a 2-year local recurrence rate of 9%. These local recurrences occurred in the wait-and-see policy group only. For the 5 patients of the TEM-group, histopathological evaluation of the resection specimens resulted in two pT2 and three pT0 tumours. The cumulative probabilities of 2-year disease-free survival and overall survival were 91% and 100%, respectively. Conclusion: A minimal invasive treatment strategy for good and complete responders after chemoradiotherapy for rectal cancer, shows good results on long-term outcome. These experimental treatment strategies seem feasible and safe if combined with strict selection criteria and follow-up. In future, more extensive long-term outcome results are desirable to further confirm the safety of minimal invasive treatment strategies for good and complete responders. 337. TransAnal Endoscopic Proctectomy (TAEP) e An innovative procedure for difficult resection of rectal tumors in men with narrow pelvis M. Bertrand1, P. Rouanet1, A. Mourregot1, C. Azar1, S. Carrere1, M. Gutowski1, F. Quenet1, B. Saint-Aubert1, P.E. Colombo1 1 Centre Val D Aurelle P Lamarque, Oncological Surgery, Montpellier, France Objective: Radical curative surgery is the key factor for local control of rectal tumors. Summary background data: A negative circumferential radial margin (CRM) is one of the major prognostic criteria of rectal carcinoma. Some situations can be critical such as the anterior topography of locally advanced low tumors with positive predictive radial margin on magnetic resonance imaging, especially in narrow pelvis of fatty men.
74. The treatment of local recurrent rectal cancer in the TME Era S. Bosman1, F.A. HolmanMD 2, R. Dudink1, H.J. Rutten1 1 Catharina Hospital, Surgery, Eindhoven, The Netherlands 2 TweeStedenZiekenhuis, Surgery, Tilburg, The Netherlands
ABSTRACTS Background: In recent years, an improvement in prognosis for patients with rectal cancer is achieved, partly due to the Total Mesorectal Excision (TME) technique, and the introduction of preoperative radiotherapy and chemotherapy. Despite improved outcomes, some patients develop locally recurrent rectal cancer. The majority of patients with local recurrent rectal cancer have already received irradiation during the initial treatment for the primary tumour. This has led to the question whether reirradiation improves the local tumour response and survival or leads to late toxicity and a better outcome. The objective of this article is to evaluate the outcome of treatment in a large population patients with local recurrent rectal carcinoma. Materials and methods: The Catharina Hospital is a national referral centre for patients with recurrence rectal cancer. Patients were treated following the TME rules whenever possible. Before surgery, patients underwent irradiation, re-irradiation, chemotherapy, a combination, or no neoadjuvant treatment. Patient follow up was enrolled in a database; complications post-operative, presence of local recurrence, metastasis and overall survival was reported. Follow-up ranged from 0 to 202 months with a median of 27 months. Results: From 1994 until 2011, 222 patients (mean age 63; 133 male, 89 female) with local recurrence were treated with curative intent. One hundred and two patients were reirradiated, the dose ranged from 2500 to 6000 centigrays (cGy), with a median dose of 4250 cGy. Two hundred and twenty two patients underwent surgery; in 57% (n¼126) of the surgical procedures, a radical resection was achieved. On univariate cox regression analysis, a radical resection showed high significance, compared with R1 or R2 resections; respectively (HR2.54 p¼0.000 and HR4.10 p¼0.000). The overall survival after five years was 35%. The five years cancer specific survival was 41%. Fifty one percent developed local recurrence within five years and 46% developed distant metastases. The overall relapse free survival was 34%. Conclusions: Neoadjuvant treatment, re-irradiation or reirradiation combined with chemotherapy, has influence on cancer specific survival. However, radical resection is the main prognostic variable for oncological outcome. Even after TME surgery in combination with radiotherapy, treatment of local recurrence with reirradiation (in combination with chemotherapy) is feasible and yields good oncological outcome. 75. Features on MRI after transanal endoscopic microsurgery in patients with rectal cancer G.L. Beets4, M.H. Martens1, M. Maas2, L.A. Heijnen1, D.M.J. Lambregts2, J.W.A. Leijtens3, R.G.H. Beets-Tan2 1 Maastricht University Medical Centre, Surgery/Radiology, Maastricht, The Netherlands 2 Maastricht University Medical Centre, Radiology, Maastricht, The Netherlands 3 Laurentius Hospital, Surgery, Roermond, The Netherlands 4 Maastricht University Medical Centre, Surgery, Maastricht, The Netherlands Background: Standard treatment for rectal cancer is total mesorectal excision (TME) with or without neo-adjuvant treatment. This major surgery is associated with significant morbidity and mortality. Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for the local resection for T1 and selected T2 tumors and is associated with lower morbidity and mortality rates than TME. It is also an emerging option for good responders after chemoradiation. In most centres, the follow-up of patients treated with TEM includes regular MRI in addition to endoscopy. So far, rectal wall morphology on MRI after TEM has not yet been described. This study aimed to describe the rectal wall MRI morphology during short-term and long-term follow-up in patients that received TEM. Methods: Thirty-six patients had a post-TEM MRI in our center between 2006 and 2011. For half of the patients (n¼19) only one post-operative MRI was available in our institute. In 17 cases two or more MRIs were available. The MR morphology of the TEM site was studied on the consecutive MR examinations. 29 patients were primary treated with TEM, 7 patients had a long course of chemoradiation followed by TEM.
ABSTRACTS Twenty-three patients had a T1 tumor, 10 patients had a T2, and one patient had a T3 tumor. In 2 patients, no tumor was found. These patients had a TEM after polypectomy. Two patients received chemoradiation after TEM because of a suspect lymph node. Results: Three morphological patterns on MRI after TEM could be identified: (1) rectal wall thickening with or without fibrosis, (2) a notch at the TEM-location, and (3) irregular delineation of the rectal wall (figure 1). In eight cases edema was present during short-term follow-up and remained present during long-term follow-up (up to 36 months) in patients with TEM after CRT. A notch was observed in 15 patients, and persisted during long-term follow-up in 83%of these patients. Sixteen patients had irregular rectal wall, which normalized after 6 months. Six luminal recurrences occurred; 5 of these patients had an irregular rectal. In 3 of these 6 patients, there was also a notch present. Wall thickening was also present in 3 of the 6 patients. 3 patients had a nodal recurrence. Conclusion: Three patterns were identified on MRI after TEM. This enables radiologists to monitor this group of patients more accurately. Since minimal invasive techniques are gaining, it is very important for radiologists and surgeons to have knowledge about the normal follow-up findings after TEM. 76. Epidural analgesia e Associated with survival in colon cancer? F.J. Vogelaar 1 , A. van den Bogerd 1 , V.E. Lemmens 2 , J.C. van der Linden3, H.G.J.M. Cornelisse4, F.R.C. van Dorsten4, K. Bosscha5 1 Jeroen Bosch Ziekenhuis, Surgery, Hertogenbosch, The Netherlands 2 Comprehensive Cancer Centre South, Eindhoven, The Netherlands 3 Jeroen Bosch Hospital, Pathology, den Bosch, The Netherlands 4 Jeroen Bosch Hospital, Anaesthesiology, den Bosch, The Netherlands 5 Jeroen Bosch Hospital, Surgery, den Bosch, The Netherlands Background: Surgery is still the mainstay of treatment for potentially curable colon cancer. Otherwise, the surgical stress response increases the likelihood of cancer dissemination and metastasis during and after cancer surgery. The possibility that anesthetic drugs can influence cancer recurrence is a subject of more recent debate. Based on animal studies and only a few clinical investigations, epidural analgesia during cancer surgery has been suggested to reduce cancer metastasis. Material and methods: A follow-up study in a historical cohort was performed in 605 patients with colon cancer UICC stage I-III undergoing surgery at the Jeroen Bosch Hospital, Den Bosch, The Netherlands over the period January 1995 to December 2003. The patients were allocated into two groups; those receiving epidural analgesia peri-operatively and those not receiving epidural analgesia, but patient-controlled analgesia. From all participants additional information was obtained from the Dutch Comprehensive Cancer Centre South. Follow-up measurements and visits were conducted according to the criteria of the Dutch cancer centre and all patients were followed up until January 2011. Mortality risks were estimated with Cox-proportional hazard models. Results: The study population comprised of 306 females. Mean age was 69 years. 59 (10%) underwent an emergency operation. 407 (67%) patients received epidural analgesia perioperatively and 198 (33%) patients were operated without epidural anaesthesia. Mean follow-up was 10 years. Patients receiving epidural analgesia had a significant better overall survival (HR 0.93, 95% CI 0.93-0.98, p¼0.01). Results were adjusted for gender, age, UICC stage, emergency surgery and adjuvant chemotherapy. Conclusions: In our study epidural analgesia during surgery for colon cancer was associated with significant better overall survival even after correcting for many confounding variables. Interestingly, the benefit of epidural analgesia seems to be more than only analgetic. A possible mechanism is that regional anaesthesia attenuates the immunosuppressive effect of surgery. Also the lower requirements of opioid, which seems to inhibit the immune system, could play a role in the survival benefit. The observed reduction in mortality rate when colon cancer surgery was performed with epidural analgesia suggests that prospective trials
755 evaluating the effects of regional and morphine sparing analgesia on cancer recurrence are warranted. 77. Minimal invasive treatment for clinical complete and good responders after chemoradiation for rectal cancer G.L. Beets2, L.A. Heijnen1, M. Maas1, M.H. Martens1, D.M.J. Lambregts1, R.G.H. Beets-Tan1, J.W.A. Leijtens3 1 Maastricht University Medical Centre, Radiology, Maastricht, The Netherlands 2 Maastricht University Medical Centre, Surgery, Maastricht, The Netherlands 3 Laurentius Ziekenhuis Roermond, Department of Surgery, The Netherlands Background: Patients with a good or complete response after neoadjuvant chemoradiotherapy have excellent long-term outcome. For these patients, less invasive treatment (local excision for the good responders and wait-and-see policy for the complete responders) is increasingly being studied and considered. The combination of MR imaging and endoscopy has shown promise for the detection of complete or good response after chemoradiotherapy. The purpose of this prospective cohort study was to evaluate long-term outcome of patients with a good or complete response who have been treated with less invasive treatment, with strict selection criteria and follow-up based on imaging and endoscopy. Materials and methods: Patients with a cCR after chemoradiotherapy were prospectively selected for [1] the wait-and-see policy or [2] the transanal endoscopic microsurgery (TEM) policy. Selection was performed by magnetic resonance imaging (MRI) and endoscopy plus biopsies. In both treatment groups, intensive 3 to 6 monthly follow-up, using CEA, CT of thorax and abdomen, contrast-enhanced pelvic MRI and endoscopy (with biopsy) was performed. Long-term outcome was estimated by using Kaplan-Meier curves. Results: Thirty-six patients with a complete or good response were included, of which thirty-one in the wait-and-see policy group and five in the TEM-group. 64% was male. Mean follow-up was 24 18 months. Two patients developed a local recurrence within two years and had surgery as salvage treatment, leading to a 2-year local recurrence rate of 9%. These local recurrences occurred in the wait-and-see policy group only. For the 5 patients of the TEM-group, histopathological evaluation of the resection specimens resulted in two pT2 and three pT0 tumours. The cumulative probabilities of 2-year disease-free survival and overall survival were 91% and 100%, respectively. Conclusion: A minimal invasive treatment strategy for good and complete responders after chemoradiotherapy for rectal cancer, shows good results on long-term outcome. These experimental treatment strategies seem feasible and safe if combined with strict selection criteria and follow-up. In future, more extensive long-term outcome results are desirable to further confirm the safety of minimal invasive treatment strategies for good and complete responders. 337. TransAnal Endoscopic Proctectomy (TAEP) e An innovative procedure for difficult resection of rectal tumors in men with narrow pelvis M. Bertrand1, P. Rouanet1, A. Mourregot1, C. Azar1, S. Carrere1, M. Gutowski1, F. Quenet1, B. Saint-Aubert1, P.E. Colombo1 1 Centre Val D Aurelle P Lamarque, Oncological Surgery, Montpellier, France Objective: Radical curative surgery is the key factor for local control of rectal tumors. Summary background data: A negative circumferential radial margin (CRM) is one of the major prognostic criteria of rectal carcinoma. Some situations can be critical such as the anterior topography of locally advanced low tumors with positive predictive radial margin on magnetic resonance imaging, especially in narrow pelvis of fatty men.