TME - Grading the Surgeon

Bryan F Warren

Powerpoint File

Audit is an important part of good medical practice. Multidisciplinary team meetings have crystallized thoughts and processes to do with audit in rectal cancer. Studies from Quirke et al have demonstrated a very close correlation between accuracy of surgery at the mesorectal margin and completeness of resection. Completeness of resection correlates with a good prognosis, incomplete resection correlates with a poor outcome. To assess effectiveness of surgical resection one could wait several years and look at recurrence data and death data and data on metastases. Presence of tumour at the mesorectal margin correlates closely with outcome and therefore a study or audit of mesorectal margin involvement is a valuable process as part of the multidisciplinary team approach to the management of colorectal cancer.

No meaningful audit or study can be carried out without consistency of pathological assessment of the mesorectal margin. This can only come from mutual education of surgeons, pathologists and radiologists. In particular the discussion of the fresh specimen, the fixed specimen and the slices of the specimen. Pathologists who are unfamiliar with the technique may misinterpret diathermy burn marks as deficiencies in the mesorectal margin. Surgeons who give insufficient information with the form may omit to tell the pathologist about adherent structures not native to the rectum which may in some cases be very small such as seminal vesicles or parts of the female genital system or sometimes small parts of abdominal wall or bladder wall. These may be very obvious in the fresh specimen but much less so poorly prepared partly fixed specimen. There needs to be considerable mutual understanding about the suitable method of presenting the specimen to the pathologist. Ideally this should be in a fresh state. The pathologist needs good knowledge of the surgical anatomy of the resected rectum. Pathologists’ knowledge and consistency in approach has been aided by two things in recent history, one is the CRO7 trial where there was a system of teaching pathologists a consistent approach to the dissection of the rectum pioneered by Phil Quirke and Bill Heald. This worked superbly well. More recently the Pelican Centre has established a training course in rectal cancer dissection led again by Professor Quirke and this is a superb teaching day at the completion of which a camera for the purpose of macroscopic photography of rectal cancer specimens in the unsliced and sliced state was provided to each department.

In summary a proper assessment of the TME specimen will allow audit of the performance of the pathologist, audit of the performance of the pre-operative scanning and the estimation of the distance of the tumour from the mesorectal margin and audit of the surgeon. This is sometimes graded numerically but is probably better done descriptively and supported by photographs. This has been in my view the most valuable contribution of multidisciplinary meetings.