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Page 8 of 11 Westwood et al. Mini-invasive Surg 2018;2:38 I http://dx.doi.org/10.20517/2574-1225.2018.50

radiological prediction and the final pathology, effort should be made by the pathologist to indicate why
this is the case. One important factor may be correlation with the plane of surgery, i.e., an involved margin
being caused by failure to resect in the planned dissection plane. Another common cause of discrepancy is
the identification of CRM involvement through microscopic nodal deposits and small vessel invasion that
could not be visualised radiologically.

Feedback on the degree of response to neoadjuvant treatment is also very helpful for the oncologists in
terms of regression away from the CRM and general tumour regression grading in order to understand the
sensitivity of individual tumours to specific treatments and to plan subsequent treatment. The four point
tumour regression grading system from TNM8 should be used in all pathology reports; this can be found
in the latest Royal College of Pathologists dataset for colorectal cancer [5,29] .

THE ROLE OF MDT EDUCATION IN IMPROVING THE QUALITY OF TREATMENT FOR RECTAL
CANCER
The MDT provides a patient-centred forum and an opportunity to optimise the treatment plan, improve
[34]
quality of care for patients with cancer, and is likely linked to improved rates of curative resection .
Education of the MDT gives a unique opportunity to optimise surgical practice, improve decision
[35]
making for preoperative treatment, and advance the overall quality of care for patients . Education
programmes directed primarily at surgeons have been shown to improve the oncological quality of surgical
[13]
specimens and patient outcomes in Netherlands, Norway and Sweden . The National Pelican MDT
TME Development Programme was an educational programme aimed at the whole CRC MDT and was
[36]
delivered through the Pelican Cancer Foundation in England . Although there is limited evidence for the
direct effect of the programme, outcomes for rectal cancer patients in the UK were significantly improved
over this time period and a further government funded National MDT educational programme focusing
on low rectal cancer called the Low Rectal Cancer Development Programme (LOREC) was launched
[37]
a few years later . The aim of LOREC was to improve the poor outcomes associated with low rectal
cancer by focusing on preoperative imaging, selective neoadjuvant therapy, optimal surgical treatment,
specialist nursing, and detailed histopathological assessment. LOREC ran workshops for all colorectal
MDT members and take-up across England was excellent with approximately 90% of MDTs attending and
[3 7]
a total 1019 participants . These received excellent feedback and 96% of surgeons attending said it would
alter their future practice [37,38] ; local audit has also shown a change in surgical practice associated with good
[39]
outcomes following the workshops . LOREC has shown the potential positive impact that education on
MDTs can have. A further programme focusing on early colorectal cancers, the Significant Polyp & Early
Colorectal Cancer, has recently finished and there is an ongoing programme, Improving Management for
[40]
Patients with Advanced Colorectal Tumour, with a focus on advanced and metastatic cancers .

CONCLUSION
Outcomes for patients with rectal cancer have markedly improved over the last two decades; these
improvements have resulted from a number of interventions including the description and widespread
introduction of TME surgery [1,41] , the use of MRI for preoperative staging [42,43] , and the use of neoadjuvant
treatment [44,45] . Histopathologists who dissect and report rectal cancer specimens have played an essential
[9]
role in improving patient outcomes by recognising the importance of the CRM , as well as describing the
[26]
assessment of surgical planes of dissection as a means of quality control . More recent focus has been
on the poor outcomes associated with traditional APE surgery for low rectal cancer and pathologists have
played a vital role in this, by identifying evidence to support changes in practice for surgeons, radiologists,
oncologists and pathologists. Many of these improvements have been supported by national MDT
education/development programmes leading to a rapid uptake in optimal practice.