Tailored resection for persistent extramural vascular invasion in locally advanced rectal cancers

Extramural vascular invasion (EMVI) is a bad prognostic feature in rectal cancer and cancers that remain EMVI positive after neoadjuvant therapy are at high risk for having involved circumferential resection margins. Conventional total mesorectal excision (TME) resections are inadequate in such cases and often lead to positive margins. We propose a technique for the surgical management of locally advanced tumours with persistent EMVI after neoadjuvant therapy. Ten such tumours were resected using a "beyond TME" (b-TME) approach with or without lateral pelvic lymph node dissection or seminal vesical excision. A b-TME approach, customized to the anatomy of the tumour allowed for an R0 resection with a negative circumferential resection margin (CRM) in all 10 cases. A tailored b-TME approach can achieve good results in cases at high risk for CRM involvement.