Clinical significance of the EMD/mesorectum ratio of T3 mid-low rectal cancer: A retrospective observational study. Gu Chaoyang,Yang Xuyang,Zhang Xubing,Zheng Erliang,Deng Xiangbing,Hu Tao,Wu Qingbin,Bi Liang,Wu Bing,Su Minggang,Wang Ziqiang Medicine Previous studies suggested that the extramural distance (EMD) should be considered in therapeutic decision-making of rectal cancer because it can be used as an indicator of the T3 subclassification; however, reports of impact of EMD/mesorectum ratio on prognosis are rare.The objectives of this study were to evaluate the feasibility of the extramural distance EMD/mesorectum ratio as a maker of the T3 subclassification for T3 mid-low rectal cancer and find the potential radiological marker on MRI for neoadjuvant chemoradiotherapy (nCRT).From December 2012 to December 2016, 287 consecutive patients with MRI-staged T3 mid-low rectal cancer were enrolled. The EMD was defined as the distance from the outer edge of the muscularis propria to the outer edge of tumor, and the mesorectum was measured as the distance from outer edge of muscularis propria to mesorectal fascia (MRF) in the same layer. The association of the EMD/mesorectum ratio and other MRI or clinicopathological factors with survival was analyzed. The independent prognostic factors were estimated by Cox regression analysis.The mean EMD/mesorectum ratio was 0.43. Based on ROC analysis, we chose a EMD/mesorectum ratio of 0.3 for further analyses. Of 287 patients, 163 (56.8%) had a EMD/mesorectum ratio ≥ 0.3. Patients with an EMD/mesorectum ratio ≥ 0.3 had a decreased recurrence free survival (RFS) and overall survival (OS) (P < .001; P = .034, respectively). Of the 163 patients, patients with nCRT had a higher RFS than patients without nCRT (P = .001). Multivariate analysis showed that the EMD/mesorectum ratio was the only independent prognostic factors for RFS.Our study provided evidence that the EMD/mesorectum ratio could be used for T3 subclassification, the optimal cut-off value of EMD/mesorectum ratio was 0.3 when the ratio was applied to classify T3 mid-low rectal cancer patients, and nCRT should be performed for these patients when the EMD/mesorectum ratio is ≥ 0.3. 10.1097/MD.0000000000013468