• Julia Kitz, Emmanouil Fokas, Tim Beissbarth, Philipp Ströbel, Christian Wittekind, Arndt Hartmann, Josef Rüschoff, Thomas Papadopoulos, Elisabeth Rösler, Peter Ortloff-Kittredge, Ulrich Kania, Hans Schlitt, Karl-Heinrich Link, Wolf Bechstein, Hans-Rudolf Raab, Ludger Staib, Christoph-Thomas Germer, Torsten Liersch, Rolf Sauer, Claus Rödel, Michael Ghadimi, Werner Hohenberger, and German Rectal Cancer Study Group.
• Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany.
• JAMA Surg. 2018 Aug 1; 153 (8): e181607.

ImportancePrevious retrospective studies have shown that surgical quality affects local control in rectal cancer..ObjectiveIn 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 ParticipantsThe 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.InterventionsPatients 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 MeasuresThe 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.ResultsOf 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 propria in 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 61.6-76.0 vs 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 18.3-32.0 vs 14.2-39.0, respectively; P = .03, respectively), and overall survival (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 88.3-92.3 vs 79.7-91.0 vs 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 RelevanceThis 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.Trial RegistrationClinicalTrials.gov Identifier: NCT00349076.

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