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Giner F, Frasson M, Cholewa H, Sancho-Muriel J, García-Gómez E, Hernández JA, Flor-Lorente B, García-Granero E. A comparison of whole-mount and conventional sections for pathological mesorectal extension and circumferential resection margin assessment after total mesorectal excision. Cir Esp 2024:S2173-5077(24)00049-8. [PMID: 38373616 DOI: 10.1016/j.cireng.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/24/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION The objective of the study is to compare 2 techniques for histological handling of rectal cancer specimens, namely whole-mount in a large block vs conventional sampling using small blocks, for mesorectal pathological assessment of circumferential resection margin status and depth of tumor invasion into the mesorectal fat. METHODS This is a prospective study including 27 total mesorectal excision specimens of rectal cancer from patients treated for primary rectal carcinoma between 2020 and 2022 in a specialized multidisciplinary Colorectal Unit. For each total mesorectal excision specimen, 2 contiguous representative tumoral slices were selected and comparatively analyzed with whole-mount and small blocks macroscopic dissection techniques, enabling comparison between them in the same surgical specimen. The agreement between the 2 techniques to assess the distance of the tumor from the circumferential resection margin as well as the depth of tumor invasion was evaluated with the Student's t-test for paired samples, Pearson's correlation coefficient, and the Bland-Altman method comparison analysis. RESULTS Complete mesorectal excision was observed in 8% of cases. Circumferential resection margin involvement was observed in only one case (4 %). The whole-mount and small block techniques obtained similar results when we assessed the distance to the circumferential resection margin (t-test P = 0.8, r = 0.92) and the depth of mesorectal infiltration (t-test P = 0.6, r = 0.95). CONCLUSIONS Both gross dissection techniques (whole-mount vs multiple small cassettes) are equivalent and reliable to assess the distance to circumferential resection margin and the depth of mesorectal infiltration in the mesorectal fat in rectal cancer staging.
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Affiliation(s)
- Francisco Giner
- Pathology Department, University of Valencia, Valencia, Spain; Pathology Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Matteo Frasson
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain; Surgery Department. University of Valencia, Spain.
| | - Hanna Cholewa
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain
| | - Jorge Sancho-Muriel
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain
| | | | | | - Blas Flor-Lorente
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain; Surgery Department. University of Valencia, Spain
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Lianos GD, Bali CD, Vlachos K, Drosou P, Rausei S, Mitsis M, Schizas D. Complete mesogastric excision for gastric cancer: is it the future of gastric cancer surgery? Per Med 2023; 20:461-466. [PMID: 37811582 DOI: 10.2217/pme-2023-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Gastric cancer remains undoubtedly one of the most common and deadly cancers worldwide. The global incidence shows wide geographic variation with a high prevalence in Asia. Besides that, there are evident differences in epidemiology, histopathology, tumor location, diagnosis and treatment strategy between east and west countries. Gastric cancer represents an aggressive disease, with many factors influencing its development and also recurrence after surgical resection. New knowledge of disease spread and new routes of metastases are now emerging and the 'novel' concept of complete mesogastric excision for gastric cancer is under consideration and debate. This article aims to analyze and highlight this new concept after a careful literature review, offering also a view toward the future.
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Affiliation(s)
- Georgios D Lianos
- Department of Surgery, University Hospital of Ioannina, Ioannina, 45500, Greece
| | - Christina D Bali
- Department of Surgery, University Hospital of Ioannina, Ioannina, 45500, Greece
| | | | - Panagiota Drosou
- Department of Surgery, University Hospital of Ioannina, Ioannina, 45500, Greece
| | - Stefano Rausei
- Department of Surgery, Cittiglio-Angera Hospital, ASST Settelaghi, Cittiglio, 21033, Italy
| | - Michail Mitsis
- Department of Surgery, University Hospital of Ioannina, Ioannina, 45500, Greece
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, 11527, Greece
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Required distal mesorectal resection margin in partial mesorectal excision: a systematic review on distal mesorectal spread. Tech Coloproctol 2023; 27:11-21. [PMID: 36036328 PMCID: PMC9807492 DOI: 10.1007/s10151-022-02690-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 08/15/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The required distal margin in partial mesorectal excision (PME) is controversial. The aim of this systematic review was to determine incidence and distance of distal mesorectal spread (DMS). METHODS A systematic search was performed using PubMed, Embase and Google Scholar databases. Articles eligible for inclusion were studies reporting on the presence of distal mesorectal spread in patients with rectal cancer who underwent radical resection. RESULTS Out of 2493 articles, 22 studies with a total of 1921 patients were included, of whom 340 underwent long-course neoadjuvant chemoradiotherapy (CRT). DMS was reported in 207 of 1921 (10.8%) specimens (1.2% in CRT group and 12.8% in non-CRT group), with specified distance of DMS relative to the tumor in 84 (40.6%) of the cases. Mean and median DMS were 20.2 and 20.0 mm, respectively. Distal margins of 40 mm and 30 mm would result in 10% and 32% residual tumor, respectively, which translates into 1% and 4% overall residual cancer risk given 11% incidence of DMS. The maximum reported DMS was 50 mm in 1 of 84 cases. In subgroup analysis, for T3, the mean DMS was 18.8 mm (range 8-40 mm) and 27.2 mm (range 10-40 mm) for T4 rectal cancer. CONCLUSIONS DMS occurred in 11% of cases, with a maximum of 50 mm in less than 1% of the DMS cases. For PME, substantial overtreatment is present if a distal margin of 5 cm is routinely utilized. Prospective studies evaluating more limited margins based on high-quality preoperative magnetic resonance imaging and pathological assessment are required.
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Chung JS, Kwak HD, Ju JK. Is Whole-Mount Section in Rectal Cancer Effective for Measuring Lateral Margin? Ann Coloproctol 2020; 36:131-132. [PMID: 32674544 PMCID: PMC7392567 DOI: 10.3393/ac.2020.06.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Jun Seong Chung
- Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Han Deok Kwak
- Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Jae Kyun Ju
- Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
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Brouwer NPM, Hugen N, Nagtegaal ID. More extensive lymphadenectomy in colon cancer; how far are we willing to go for a biomarker? Tech Coloproctol 2020; 24:761-764. [PMID: 32451806 PMCID: PMC7297704 DOI: 10.1007/s10151-020-02239-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/13/2020] [Indexed: 02/07/2023]
Affiliation(s)
- N P M Brouwer
- Department of Pathology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - N Hugen
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - I D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
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Peters FP, Teo MT, Appelt AL, Bach S, Baatrup G, de Wilt JH, Jensenius Kronborg C, Garm Spindler KL, Marijnen CA, Sebag-Montefiore D. Mesorectal radiotherapy for early stage rectal cancer: A novel target volume. Clin Transl Radiat Oncol 2020; 21:104-111. [PMID: 32099912 PMCID: PMC7031087 DOI: 10.1016/j.ctro.2020.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/02/2020] [Indexed: 02/07/2023] Open
Abstract
With the introduction of population-based bowel cancer screening, rectal cancer is diagnosed at earlier stages, yet standard treatment still requires the same extensive surgery that is used for more advanced stages. Organ preserving treatment is rapidly developing and is subject of investigation in numerous clinical trials. The STAR-TREC trial is an international, multi-centre randomised trial investigating organ preservation using (chemo)radiotherapy. Patients with small mrT1-3bN0V0M0 tumours are randomized between three arms: standard TME, organ preservation with SCRT or with CRT. In this trial, the clinical target volume has been tailored to the early staged disease of the included patients. This mesorectal irradiation volume includes the mesorectum and pre-sacral lymph nodes at the level of the tumour, two centimetres below and cranially up to the S2-3 interspace level. In contrast to conventional irradiation volumes, the lateral lymph nodes and the nodes along the superior rectal artery are excluded. As a result, the dose to the bowel, bladder, anal sphincter and the neurovascular plexus in the lower pelvis is substantially decreased, especially when combined with modern irradiation techniques, such as dynamic arc therapy. These lower doses are expected to lead to decreasing acute and late toxicity and beneficial functional outcomes. The implementation of this novel target volume will be accompanied by an extensive quality assurance program in the STAR-TREC trial. We describe the rationale behind the novel, mesorectal only radiotherapy treatment used in the STAR-TREC trial specifically tailored for early stage disease, with the goal of organ preservation.
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Affiliation(s)
- Femke P. Peters
- Department of Radiotherapy, Leiden University Medical Center, Postbus 9600, 2300 RC Leiden, the Netherlands
| | - Mark T.W. Teo
- Leeds Cancer Centre, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK
| | - Ane L. Appelt
- Leeds Institute of Medical Research at St James’s, University of Leeds and Leeds Cancer Centre, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK
| | - Simon Bach
- Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2GW, UK
| | - Gunnar Baatrup
- Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark
| | - Johannes H.W. de Wilt
- Radboud University Nijmegen Medical Centre, Postbus 9101, 6500 HB Nijmegen, the Netherlands
| | - Camilla Jensenius Kronborg
- Department of Oncology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Karen-Lise Garm Spindler
- Department of Oncology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Corrie A.M. Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Postbus 9600, 2300 RC Leiden, the Netherlands
| | - David Sebag-Montefiore
- Leeds Institute of Medical Research at St James’s, University of Leeds and Leeds Cancer Centre, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK
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Pollheimer MJ, Langner C. [Pathology of the R1 classification in visceral cancer surgery]. Chirurg 2017; 88:731-739. [PMID: 28593347 DOI: 10.1007/s00104-017-0448-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The completeness of tumor removal is described in the residual tumor classification (R classification). The R category of a surgical specimen reflects the effects of treatment, influences further treatment decisions and is associated with patient survival. Thorough pathological examination of all resection planes, including the circumferential margin, is necessary for accurate classification.
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Affiliation(s)
- M J Pollheimer
- Institut für Pathologie, Medizinische Universität Graz, Auenbruggerplatz 25, 8036, Graz, Österreich
| | - C Langner
- Institut für Pathologie, Medizinische Universität Graz, Auenbruggerplatz 25, 8036, Graz, Österreich.
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Xie D, Liu L, Osaiweran H, Yu C, Sheng F, Gao C, Hu J, Gong J. Detection and Characterization of Metastatic Cancer Cells in the Mesogastrium of Gastric Cancer Patients. PLoS One 2015; 10:e0142970. [PMID: 26566136 PMCID: PMC4643961 DOI: 10.1371/journal.pone.0142970] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 09/17/2015] [Indexed: 12/17/2022] Open
Abstract
Gastric cancer is the second leading cause of cancer death worldwide. Here, we propose a novel type of tumor metastasis designated as Metastasis V in gastric cancer. Metastasis V is defined as the appearance of cancer cells in the mesogastrium with perigastric adipose tissue. To detect its incidence and characterize its clinic pathological features, large cross sectional tissue analysis of mesogastrium from 74 patients were used. Metastasis V was detected in 1 of 40 (2.5%) patients with early gastric cancer, 8 of 34 (24%) patients with advanced gastric cancer. The mean distance of Metastasis V from gastric wall was approximately 2.6 cm. Metastasis V was closely associated with tumor invasion depth, along with a number of positive lymph node metastasis. The prognosis of patients with Metastasis V was significantly (P<0.05) worse than those with tumor cell-free mesogastrium. These findings indicate that by using whole-sectional analysis, Metastasis V can be detected in the mesogastrium of gastric cancer patients, and also suggests that it may be a risk factor for patient survival after radical surgery.
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Affiliation(s)
- Daxing Xie
- Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
- * E-mail:
| | - Liang Liu
- Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hasan Osaiweran
- Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chaoran Yu
- Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Fang Sheng
- Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chun Gao
- Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Junbo Hu
- Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jianping Gong
- Tongji Cancer Research Institute, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Gastrointestinal Surgery, Tongji Hospital, Tongji Medical College in Huazhong University of Science and Technology, Wuhan, Hubei, China
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Abstract
BACKGROUND Conventional MRI is limited in the assessment of nodal status and T status after neoadjuvant chemoradiotherapy. Multiparametric MRI strives to overcome these issues by directly measuring the local microcirculation and cellular environment, thus possibly allowing for a more reliable evaluation of response to therapy. OBJECTIVE We assessed the available literature for the value of multiparametric MRI sequences (diffusion-weighted and dynamic contrast-enhanced imaging) in determining the response to neoadjuvant chemoradiotherapy in patients with rectal cancer. DATA SOURCES We conducted a systematic literature research in the PubMed database. STUDY SELECTION English-language publications of the years 2000-2013 that applied multiparametric MRI in the neoadjuvant setting were included in this study. INTERVENTION Patients received neoadjuvant chemoradiotherapy and MRI examinations for staging and assessment of response. MAIN OUTCOME MEASURES Accuracy, specificity, and sensitivity of MRI in prediction/assessment of response to therapy were the included measures. RESULTS Forty-three studies were included in this review; 30 of them included diffusion-weighted imaging sequences, and 13 included dynamic contrast-enhanced MRI. Conventional MRI is limited in the accuracy of both T and N stages and response assessment. Diffusion-weighted imaging and dynamic contrast-enhanced MRIs showed additional value in both the prediction and detection of (complete) response to therapy compared with conventional sequences alone, as well as in correct N staging along with new experimental contrast agents. LIMITATIONS The lack of standardization represents an important technical limitation. Most studies are conducted in an experimental setting; therefore, larger multicenter prospective studies are needed to verify the present findings. CONCLUSIONS Advanced, functional MRI techniques allow for the quantification of tumor biological processes, such as microcirculation, vascular permeability, and tissue cellularity. This new technology has begun to show potential advantages over standard morphologic imaging in the restaging of rectal cancer, allowing for more accurate prognostication of response and potentially introducing an era allowing earlier treatment alteration and more accurate noninvasive surveillance, which could improve patient outcomes.
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Perez RO, Habr-Gama A, Smith FM, Kosinski L, São Julião GP, Grzona E, Rawet V, Vianna MR, Proscurshim I, Lynn PB, Gama-Rodrigues J. Fragmented pattern of tumor regression and lateral intramural spread may influence margin appropriateness after TEM for rectal cancer following neoadjuvant CRT. J Surg Oncol 2014; 109:853-8. [DOI: 10.1002/jso.23571] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/15/2014] [Indexed: 01/11/2023]
Affiliation(s)
- Rodrigo O. Perez
- Angelita & Joaquim Gama Institute; São Paulo Brazil
- Colorectal Surgery Division; University of São Paulo School of Medicine; São Paulo Brazil
- Ludwig Institute for Cancer Research; São Paulo Brazil
| | - Angelita Habr-Gama
- Angelita & Joaquim Gama Institute; São Paulo Brazil
- University of São Paulo School of Medicine; São Paulo Brazil
| | - Fraser M. Smith
- Angelita & Joaquim Gama Institute; São Paulo Brazil
- North Cumbria University Hospitals NHS Trust; Whitehaven UK
| | - Lauren Kosinski
- Angelita & Joaquim Gama Institute; São Paulo Brazil
- Medical College of Wisconsin; Milwaukee Wisconsin
| | | | - Esteban Grzona
- Angelita & Joaquim Gama Institute; São Paulo Brazil
- Hospital Aleman & Fundación Sanatorio Güemes; Buenos Aires Argentina
| | | | | | | | | | - Joaquim Gama-Rodrigues
- Angelita & Joaquim Gama Institute; São Paulo Brazil
- University of São Paulo School of Medicine; São Paulo Brazil
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Ueno H, Hashiguchi Y, Shimazaki H, Shinto E, Kajiwara Y, Nakanishi K, Kato K, Maekawa K, Nakamura T, Yamamoto J, Hase K. Peritumoral deposits as an adverse prognostic indicator of colorectal cancer. Am J Surg 2014; 207:70-7. [DOI: 10.1016/j.amjsurg.2013.04.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 04/18/2013] [Accepted: 04/29/2013] [Indexed: 01/17/2023]
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Ueno H, Mochizuki H, Akagi Y, Kusumi T, Yamada K, Ikegami M, Kawachi H, Kameoka S, Ohkura Y, Masaki T, Kushima R, Takahashi K, Ajioka Y, Hase K, Ochiai A, Wada R, Iwaya K, Shimazaki H, Nakamura T, Sugihara K. Optimal colorectal cancer staging criteria in TNM classification. J Clin Oncol 2012; 30:1519-26. [PMID: 22430272 DOI: 10.1200/jco.2011.39.4692] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Histologic components of the TNM classification system have been repeatedly revised since the fifth edition (TNM5). TNM classification revisions provide different criteria for categorizing tumor nodules without residual lymph node structure (ND). However, there are few systematic evaluations regarding the effectiveness of these revisions. PATIENTS AND METHODS A multicenter pathologic review for ND in colorectal cancer (CRC) was performed. Tumor staging defined by TNM5, sixth edition (TNM6), and seventh edition (TNM7) were compared on the basis of Akaike information criterion (AIC) and Harrell's concordance index (c-index). Moreover, TNM7's prognostic value was compared between the original ND and modified criteria, which considered all regional NDs as lymph node metastasis (LNM) irrespective of the original structure. RESULTS In 1,716 treated patients with CRC (1994 to 1998), tumor stages (I/II/III) exhibited better prognoses in TNM7 (AIC, 3055.1; c-index, 0.7215) than in TNM6 (AIC, 3063.7; c-index, 0.7149), but not better than in TNM5 (AIC, 3051.6; c-index, 0.7240). Comparing the original TNM7 and modified criteria, 4.2% of patients were classified in different N stages (N0/N1/N2a/N2b); both AIC and the c-index were superior in the modified criteria (AIC, 3029.40; c-index, 0.7271) compared with the original criteria (AIC, 3040.58; c-index, 0.7230). Modified criteria were also associated with improved prognostic power of tumor stages (I/IIA/IIB/IIC/IIIA/IIIB/IIIC). These results were similar in another cohort of 2,242 treated patients with CRC (1999 to 2003). CONCLUSION The prognostic value of TNM7 is better than that of TNM6; however, improvement over TNM5 is insignificant. By considering all regional NDs as LNM irrespective of their morphology, TNM classification can be simplified and its prognostic value improved.
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Affiliation(s)
- Hideki Ueno
- National Defense Medical College, Tokorozawa, Japan.
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Ueno H, Mochizuki H, Shirouzu K, Kusumi T, Yamada K, Ikegami M, Kawachi H, Kameoka S, Ohkura Y, Masaki T, Kushima R, Takahashi K, Ajioka Y, Hase K, Ochiai A, Wada R, Iwaya K, Nakamura T, Sugihara K. Actual Status of Distribution and Prognostic Impact of Extramural Discontinuous Cancer Spread in Colorectal Cancer. J Clin Oncol 2011; 29:2550-6. [DOI: 10.1200/jco.2010.33.7725] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To clarify the prognostic impact of tumor nodules without residual lymph node (LN) structure (ND) in colorectal cancer and to determine optimal categorization of ND in tumor staging. Patients and Methods A multicenter, retrospective pathologic review was performed for 1,716 patients with stages I to III curatively resected colorectal cancer treated at 11 institutions between 1994 and 1998. An additional 2,242 patients from nine institutions were enrolled between 1999 and 2003 as a second cohort to validate the results. Results LN metastasis (LNM) and ND were observed in 33.7% and 16.0% (smooth-contour nodule [S-ND], 8.2%; irregular-contour nodule [I-ND], 10.7%) of patients in the first cohort. S-ND and I-ND were similarly distributed in the regional area. There was no considerable difference in the impact on survival between S-ND (hazard ratio [HR], 2.7; 95% CI, 1.9 to 3.8) and I-ND (HR, 4.3; 95% CI, 3.3 to 5.8) or between LNM (HR, 4.5; 95% CI, 3.4 to 6.0) and ND (HR, 4.0; 95% CI, 3.1 to 5.3). LNM and ND were similarly associated with the mode of recurrence. Tumor nodules ≥ 5 mm growing with venous/perineural invasion (ND [v/pni+]), judged with 0.61 κ value among 11 observers, had an independent prognostic value for 5-year survival of 42%; similar results were observed in the second cohort. Conclusion These results do not support the TNM system in which S-ND is treated differently from I-ND in tumor staging; LNM and ND should be considered together in the same category. The presence of ND (v/pni+) has a considerable adverse prognostic effect.
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Affiliation(s)
- Hideki Ueno
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Hidetaka Mochizuki
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Kazuo Shirouzu
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Takaya Kusumi
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Kazutaka Yamada
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Masahiro Ikegami
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Hiroshi Kawachi
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Shingo Kameoka
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Yasuo Ohkura
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Tadahiko Masaki
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Ryoji Kushima
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Keiichi Takahashi
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Yoichi Ajioka
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Kazuo Hase
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Atsushi Ochiai
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Ryo Wada
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Keiichi Iwaya
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Takahiro Nakamura
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
| | - Kenichi Sugihara
- Hideki Ueno and Hidetaka Mochizuki, National Defense Medical College, Tokorozawa; Kazuo Shirouzu, Kurume University Faculty of Medicine, Kurume; Takaya Kusumi, Keiyukai Sapporo Hospital, Sapporo; Kazutaka Yamada, Coloproctology Center, Takano Hospital, Kumamoto; Masahiro Ikegami, Jikei University School of Medicine; Hiroshi Kawachi and Kenichi Sugihara, Tokyo Medical and Dental University; Shingo Kameoka, Tokyo Women's Medical University; Yasuo Ohkura and Tadahiko Masaki, Kyorin University, School of
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Schmitz KJ, Chmelar C, Berg E, Schmid KW. [Pathological work-up of rectal cancer following partial/total mesorectal excision]. DER PATHOLOGE 2011; 32:321-9. [PMID: 21660476 DOI: 10.1007/s00292-011-1439-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Total mesorectal excision (TME) refers to the anatomically accurate surgical resection of the rectum from its surrounding fascias and has become the gold standard for treating rectal cancer. The pathologist plays a key role in the assessment of these specimens and good pathological reporting of rectal cancer is essential to achieving the optimum possible results for patients with rectal cancer. In experienced hands, these techniques result in a dramatic improvement in cancer-related cure rates from 45% to 75% and a reduction in pelvic recurrences from 40% to 5%-10%. Moreover, preservation of sexual and urinary functions is possible in the majority of cases. This article reviews the pathological assessment of the TME specimen in detail with regards to current international guidelines and describes its anatomical background. In addition, particular issues relating to margins, lymph node dissection and effects of neoadjuvant therapy are discussed.
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Affiliation(s)
- K J Schmitz
- Institut für Pathologie und Neuropathologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland.
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15
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Guerra L, Niespolo R, Di Pisa G, Ippolito D, De Ponti E, Terrevazzi S, Bovo G, Sironi S, Gardani G, Messa C. Change in glucose metabolism measured by 18F-FDG PET/CT as a predictor of histopathologic response to neoadjuvant treatment in rectal cancer. ABDOMINAL IMAGING 2011; 36:38-45. [PMID: 20033405 DOI: 10.1007/s00261-009-9594-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE In order to analyze the changes of glucose metabolism by maximum standardized uptake value (SUVmax) of 18F-FDG PET/CT in patients with rectal cancer submitted to neoadjuvant radiochemotherapy (nRCT) and to correlate SUV changes with tumor regression grade (TRG). METHODS AND MATERIAL Three sequential 18F-FDG PET/CT studies were performed in 31 patients with rectal cancer at the following time point: before starting the treatment (PET/CT1), during the treatment (PET/CT2), and after completion of neoadjuvant treatment (PET/CT3). The SUVmax values of the rectal lesion in the PET/CT1 (SUV1), PET/CT2 (SUV2), and PET/CT3 (SUV3) were obtained; deltaSUV1 [(SUV1 - SUV2)/SUV1] and deltaSUV2 [(SUV1 - SUV3)/SUV1] were also calculated. Metabolic parameters were compared to TRG. RESULTS Significant differences in pathologic responder and non-responder patients were found only for SUV2 (6.4 ± 2.9 in responder and 10.7 ± 4.8 in non-responder patients, respectively; P = 0.006) and SUV3 (3.6 ± 1.4 in responder and 6.6 ± 2.1 in non-responder patients, respectively; P = 0.0009). The best predictor for TRG response was SUV3 (threshold of 4.4) with sensitivity, specificity, accuracy, negative predictive value, and positive predictive value of 77.3%, 88.9%, 80.7%, 61.5%, and 94.4%, respectively. CONCLUSION 18F-FDG PET/CT is a reliable and accurate technique to assess the response to nRCT in rectal cancer. In our population, the absolute value of SUVmax after treatment was the best predictor of pathological response.
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Affiliation(s)
- Luca Guerra
- Department of Nuclear Medicine, PET Unit-Molecular Bioimaging Centre, San Gerardo Hospital-University of Milan-Bicocca, Monza, Italy
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Wang C, Zhou ZG, Yu YY, Yang L, Wang ZQ, Shu Y. Selective laparoscopic lateral dissection of regional micrometastasis in rectal carcinoma - ten years single center experience. MINIM INVASIV THER 2010; 19:345-9. [DOI: 10.3109/13645706.2010.527773] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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17
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Clinical impact of mesorectal extranodal cancer tissue in rectal cancer: detailed pathological assessment using whole-mount sections. Dis Colon Rectum 2010; 53:771-8. [PMID: 20389211 DOI: 10.1007/dcr.0b013e3181cf7fd8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Mesorectal cancer deposits showing no histological evidence of lymph node structure (extranodal cancer tissue) are a common feature in rectal cancer. However, optimal categorization of extranodal cancer tissue using TNM grading is not yet established. We reviewed extranodal cancer tissue in detail using whole-mount sections to clarify its clinical impact. METHODS This retrospective study involved 214 consecutive patients with stage I-III rectal cancer. After fixation, the whole tumor mass including the mesorectum was sliced into longitudinal sections and stained. Mesorectal involvement was classified as direct tumor infiltration, lymph node involvement, or extranodal cancer tissue. Extranodal cancer tissue was classified morphologically, and its maximum size and distance from the primary tumor were measured. The clinical impact of extranodal cancer tissue was evaluated by univariate and multivariate analyses. RESULTS : A total of 498 extranodal cancer deposits were detected in 88 patients (41.1%). Multivariate Cox proportional hazards model analysis indicated that the presence of extranodal cancer tissue was an independent prognostic factor for relapse-free (P < .001) and overall survival (P = .003). The hazard ratio for extranodal cancer tissue was higher than for nodal involvement, irrespective of morphological classification. The clinical impact differed significantly with the number of histological types of extranodal cancer tissue, the number of deposits, their maximum size, and their distance from the primary tumor. CONCLUSIONS In the present study, we have shown that extranodal cancer tissue detected by whole-mount sections has a clinical impact that is more severe than nodal involvement.
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Patterns of local recurrence in rectal cancer; a study of the Dutch TME trial. Eur J Surg Oncol 2010; 36:470-6. [PMID: 20096534 DOI: 10.1016/j.ejso.2009.11.011] [Citation(s) in RCA: 226] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Accepted: 11/19/2009] [Indexed: 12/17/2022] Open
Abstract
AIM OF THE STUDY In patients from the Dutch TME trial patterns of local recurrence (LR) in rectal cancer were studied. The purpose was to reconstruct the most likely mechanisms of LR and the effect of preoperative radiotherapy. METHODS 1417 patients were analyzed; 713 were randomized into preoperative radiotherapy and total mesorectal excision (RT + TME), 704 into TME alone. Of the 114 patients with LR, the subsites of LR were determined and related to tumor and treatment factors. RESULTS Overall 5-year LR-rate was 4.6% in the RT + TME group and 11.0% in the TME group. Presacral local recurrences occurred most in both groups. Radiotherapy reduced anastomotic LR significantly, except when after low anterior resection (LAR) distal margins were less than 5 mm. Abdominoperineal resection (APR) mainly resulted in presacral LR. Even after resection with a negative circumferential resection margin, LR-rates were high. Thirty percent of the patients had advanced tumors, which resulted in 58% of all LRs. Lateral LR comprised 20% of all LR. Presacral and lateral LR resulted in a poor prognosis, in contrast to anterior or anastomotic LRs with a relatively good prognosis. CONCLUSIONS RT reduces LR in all subsites and is especially effective in preventing anastomotic LR after LAR. APR-surgery mainly results in presacral LR, which may be prevented by a wider resection. In the TME trial many advanced tumors were included, rather requiring chemoradiotherapy instead of RT. Currently, with good imaging techniques, better selection can take place. Especially lateral LR might be a problem in the future.
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Slim K, Blay JY, Brouquet A, Chatelain D, Comy M, Delpero JR, Denet C, Elias D, Fléjou JF, Fourquier P, Fuks D, Glehen O, Karoui M, Kohneh-Shahri N, Lesurtel M, Mariette C, Mauvais F, Nicolet J, Perniceni T, Piessen G, Regimbeau JM, Rouanet P, sauvanet A, Schmitt G, Vons C, Lasser P, Belghiti J, Berdah S, Champault G, Chiche L, Chipponi J, Chollet P, De Baère T, Déchelotte P, Garcier JM, Gayet B, Gouillat C, Kianmanesh R, Laurent C, Meyer C, Millat B, Msika S, Nordlinger B, Paraf F, Partensky C, Peschaud F, Pocard M, Sastre B, Scoazec JY, Scotté M, Triboulet JP, Trillaud H, Valleur P. [Digestive oncology: surgical practices]. ACTA ACUST UNITED AC 2009; 146 Suppl 2:S11-80. [PMID: 19435621 DOI: 10.1016/s0021-7697(09)72398-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- K Slim
- Chirurgien Clermont-Ferrand.
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Wang C, Zhou ZG, Yu YY, Shu Y, Li Y, Yang L, Li L. Occurrence and prognostic value of circumferential resection margin involvement for patients with rectal cancer. Int J Colorectal Dis 2009; 24:385-90. [PMID: 19156431 DOI: 10.1007/s00384-008-0624-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2008] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Total mesorectal excision (TME) was advocated owning to the reduction in local failure, while deficiency in pathologic details limited monitoring of surgical quality assurance. Here, we aimed to examine circumferential resection margin (CRM) by large tissue slice, discussing its rule in occurrence and relationship with prognosis, thus providing proof for the adoption of TME principles and the application of adjuvant therapy. MATERIALS AND METHODS Specimens of 106 patients with rectal cancer, who underwent potentially curative resection from December 2001 to September 2002, were examined. Follow-up data were collected. RESULTS Altogether, 2,068 mesorectal nodes were examined with 272 involved by tumor. CRM involvement (CRMI) was examined in 20 specimens. In these 20 cases, seven, nine, and four were caused by tumor infiltration, lymph node metastasis, and both, respectively. Occurrence of CRMI was more common for lower-located cancers while also statistically related to tumor differentiation, infiltration, and lymph node metastasis. The difference in local recurrence rate, general recurrence rate, disease-free survival rate, and overall survival rate between the group with CRMI and the group without were all proven to be significant. CONCLUSIONS Detailed pathologic examination, including status of CRM, is advocated since it provides accurate prognostic information. Surgeons could maximize the probability of cure by following the principle of TME. Preoperative adjuvant therapy was essential for advanced staged and lower-located lesions, which implied likelihood of CRMI.
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Affiliation(s)
- Cun Wang
- Department of Colorectal and Anal Surgery & Key Laboratory of Biotherapy of Cancer, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
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Moser L, Ritz JP, Hinkelbein W, Höcht S. Adjuvant and neoadjuvant chemoradiation or radiotherapy in rectal cancer--a review focusing on open questions. Int J Colorectal Dis 2008; 23:227-36. [PMID: 18064471 DOI: 10.1007/s00384-007-0419-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND The therapy of rectal cancer has been a matter of debate since decades, especially with regard to the benefits of neoadjuvant or adjuvant therapies. Principles of additional therapies have been established nearly two decades ago and are questioned nowadays on the basis of more recently modified operative techniques. Benefits and sequelae of therapies have to be balanced against each other, and it seems somewhat likely that a more differentiated strategy than simply stating that every patient with stage II and III rectal cancer needs chemoradiation or radiotherapy will, in long term, be recommended. CONCLUSION It should be kept in mind that results of centers of excellence and of phase-III studies with their positively selected patient populations are not representative for all the patients with rectal cancer and physicians treating them.
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Affiliation(s)
- Lutz Moser
- Klinik für Radioonkologie und Strahlentherapie, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
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Abstract
Although tumour deposits (TD) in the pericolic and mesorectal fat have been recognized since 1935, incorporation in the Tumour Node Metastasis (TNM)/American Joint Committee on Cancer (AJCC) system took place in 1997. The 3-mm rule classified TD as lymph node metastases. This rule was changed in 2002, when the contour of the deposit became the diagnostic feature. This review has evaluated the 3714 patients described in the literature. The incidence of TD varies from 5 to 45%. Their origin has been shown to be heterogeneous; however, their presence indicates a poorer survival. The hazard ratio for death due to disease is 1.96. Various studies have tried to determine the importance of types of TD, based on contour, size and origin, but all fail to provide an evidence base to substantiate its use in the TNM system. To classify TD as positive lymph nodes after neoadjuvant therapy is a misconception, since the presence of tumour microfoci after therapy can be a sign of good response to treatment and indicative of a good prognosis. In conclusion, we did not find adequate evidence for the inclusion of TD in TNM/AJCC staging systems. Moreover, the current directives are confusing, and the definitions should not be used after neoadjuvant therapy.
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Affiliation(s)
- I D Nagtegaal
- Department of Pathology, University Medical Centre St Radboud, Nijmegen, The Netherlands.
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Zheng YC, Zhou ZG, Li L, Lei WZ, Deng YL, Chen DY, Liu WP. Distribution and patterns of lymph nodes metastases and micrometastases in the mesorectum of rectal cancer. J Surg Oncol 2007; 96:213-9. [PMID: 17443720 DOI: 10.1002/jso.20826] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Facts buried in the mesorectum remain to be unveiled. This study investigated the number, size, and detailed distribution of lymph nodes metastases and micrometastases within the mesorectum of rectal cancer. METHODS Thirty-one patients who underwent total mesorectal excision (TME) were treated with lymph node revealing solution to retrieve lymph nodes, which were submitted to hematoxylin and eosin (HE) examination and immunohistochemical (IHC) staining. RESULTS The mean number of mesorectal nodes per case was 17.7. The mean size of metastatic, micrometastatic, and isolated tumor cells (ITC) harbored nodes was 5.2 mm, 4.5 mm, and 3.3 mm, respectively. Most of the metastatic (92.1%), micrometastatic and ITC-involved nodes (69.2%) were located along the superior rectal artery (SRA). Posterior-wall located tumor might spread along both sides of the mesorectum simultaneously (P = 0.34), while lateral-wall located tumor spread preferably to ipsolateral side versus contralateral side (P = 0.012). CONCLUSION Most of the metastases and micrometastases positive lymph nodes were smaller than 5 mm and distributed along the SRA. The patterns of lymph nodes spread were related to the circumferential situation of tumor in the rectal wall. Surgical excision of the rectal cancer should completely remove the whole mesorectum, especially to avoid any damage of the mesorectum on tumor side.
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Affiliation(s)
- Yang-Chun Zheng
- Institute of Digestive Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
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Leong SPL, Cady B, Jablons DM, Garcia-Aguilar J, Reintgen D, Werner JA, Kitagawa Y. Patterns of metastasis in human solid cancers. Cancer Treat Res 2007; 135:209-221. [PMID: 17953419 DOI: 10.1007/978-0-387-69219-7_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Stanley P L Leong
- Department of Surgery, University of California San Francisco, California, USA
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Ramesh H, Bedi MS, Sikora SS. Extent of mesorectal tumor invasion as a prognostic factor after curative surgery for T3 rectal cancer patients. Ann Surg 2006; 244:835-6; author reply 836. [PMID: 17060781 PMCID: PMC1856593 DOI: 10.1097/01.sla.0000243598.94641.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Parfitt JR, Driman DK. The total mesorectal excision specimen for rectal cancer: a review of its pathological assessment. J Clin Pathol 2006; 60:849-55. [PMID: 17046842 PMCID: PMC1994509 DOI: 10.1136/jcp.2006.043802] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Total mesorectal excision (TME) refers to the surgical removal of the complete perirectal soft tissue envelope, using sharp instruments under direct vision, and has become the contemporary standard of care for patients with rectal cancer. Pathologists play a key role in the evaluation of these specimens, including the quality assurance of surgical performance, as well as evaluation of the circumferential radial margin (CRM). While the latter is the most significant predictor of local recurrence, the quality of the excised mesorectum is another important factor in assessing the risk of local recurrence in patients with a negative CRM. Since proper pathological assessment of the TME specimen provides important prognostic information, as well as critical feedback to surgeons regarding technical performance, it is important to have adequate guidelines for the macroscopic handling of these specimens. The CLASSICC study of the Medical Research Council in the United Kingdom, as well as the Dutch TME trial have introduced a new standard for the pathological assessment of TME specimens, including an approach that involves assessment in both the fresh and fixed states, at least 48 hours of fixation of an intact specimen, with observations made on both the external appearance and cross-sectional slices. This article reviews the pathological assessment of the TME specimen, including basic definitions, current international guidelines, an approach to evaluating the mesorectum and a discussion of special issues relating to margins, lymph node retrieval and effects of neoadjuvant therapy.
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Affiliation(s)
- Jeremy R Parfitt
- Department of Pathology, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
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