This is a complicated question. A positive resection margin means not radical surgery, a situation which should never happen nowadays. I suggest that you evaluate the case intern in order to see the source of the problem - any limitations of preoperative diagnostis and planning for surgery? False judgement of the resection height? False positive (primary) / fals negative (secondary) histopathology? There are tumor deposits well below the origin of the tumor in mesorectum, but a distant satelite tumor intraluminal 2 cm below the main tumor is really strange.

I am not expecting powerfull studies describing the LR after R1 situation, because there will be not many Ethical Comittees accepting watch and wait strategy in these cases. And, finally, if there is any discussion about a possibility of margin positivity, the patient should not be operated without a frozen section, these are elective cases! In the described situation the patient could have a comfortable R0 situation after primary APR/ELAPE. On the other hand, I perfectly understand the dilemma of optimal recommendation for a 20-years-old. What was the initial stage?

Dear prof

Thanks

Was a t3 cancer 2.5 cm anal verge mucinous, intersphincteric plane free on MRI after CTRT . Our policy is to counsel these patients for aper vs isr (hand sewn coloanl anastomoses) giving local recurrence rates of 6% for isr with occasionally suboptimal bowel function. A permanent stoma is not taken well in india and patients often default treatment.

In accordance with recent evidence fr ultra low anterior resection a tumor free margin of 1cm may be enough. I am not sure, if a frozen section is mandatory for all low rectal cancers having sphincter preservation in our hospital, we had look at 275 anterior rejections for mid low rectal cancers. with frozen section and in only one case with a gross margin of 2 cm was a positive margin involved which was reverted to isr.

We have performed about 33 intersphincteric anterior reactions with hand sewn coloanal anastomoses over last. 6 months with frozen section done on all patients. Unfortunately this was the only one with gross margin 2 cm which did not have fs.

I agree with you e aper would be good but we have to achieve a balance between sphincter preservation and radical aper. As per mercury study apost CTRT mri2 is quite accurate and helps in planning sphincter preservation . But your point is well taken and patients are well counseled before taking on such procedures

Thanks

Dr saklani

I well understand this policy and congratulations to your results in intersphincteric resections. However there is a shortage of good data about longterm functional outcome. So sometimes these very low resections are more a surgeons temptation than a real benefit for the patient. Especially, that a "conventional" amputation should not be performed according to the Holm/Bebenek technique and British data (Quirke, West etc). So an extralevatoric procedure would be my consideration of choice. However, I am well aware of the cultural differences in many parts of the world, so I accept that there are patients prefering perineal stoma instead of abdominal stoma. And the last word - imaging after CTRT is not something, I would rely on, I think a traditional strategy with treatment planning based on the initial staging is still the option of choice. Of course we do want to preserve everything what can be preserved, but first we want to preserve patient's life.

I assume that in the described case the patient`s wish to prevent a stoma (by the way, do you perform intersphincteric resections without protective stoma?) was the imperative, so your treatment was perfectly OK. A frozen section is also not a magical toy and has also its falsepositive and false negative rates.

1.frozen section is mandatory in all ultra low anterior resection.

2.according to nccn guidelines ,positive margins should be treated in intention to achieve R0 ,EVEN IF THE POSSIBILITY TO GET NORMAL SPECIMEN AFTER APR is big (life before function !)

Any references for statement 1?

Thanks

The demand for ultralow and intersphicteric resections is increasing hence frozen section is very useful to achieve Ro resection.We always cover these proceedures with a loop ileostmy.

I agree with Simon Duek remarks

I have been a GI pathologist for over 20 years and have never once been asked to do a frozen section on a margin of any colon cancer resection. It is certainly not common practice in the US (except perhaps the Mayo clinic that freezes everything).

Dear Joel.

Well, it's about time to change your unacceptable practice.

We have to exchange ideas and to learn from each other.

I have spared APR from many patients using the frozen specimen of the distal margins in ultra low anterior resections and they thanks us of not having a permanent stoma,

if i have to comment, i would raise 2 questions:

1st is there any evidence recommending frozen for ultralow?? i never use

2nd i had a similar dilema still preparing for our MDT oncology panel but in my scenario it was ISR and frozen of distal margin was free and turned to be malignant in parrafin, the pathologist claim scattered cells post radiotherapy are sometimes difficult to assess by frozen. Again the ptn was informed and not accepting APR