Updated protocol for the examination of specimens from patients with carcinomas of the colon and rectum, excluding carcinoid tumors, lymphomas, sarcomas, and tumors of the vermiform appendix: a basis for checklists. Cancer Committee

Amide proton transfer-weighted MRI for assessing rectal adenocarcinoma T-staging and perineural invasion: a prospective study

OBJECTIVE

To investigate the value of the pre-operative amide proton transfer-weighted (APTw) MRI to assess the prognostic factors in rectal adenocarcinoma (RA).

METHODS

This prospective study ran from January 2022 to September 2023 and consecutively enrolled participants with RA who underwent pre-operative MRI and radical surgery. The APTw signal intensity (SI) values of RA with various tumor (T), node (N) stages, perineural invasion (PNI), and tumor grade were compared by Mann-Whitney U-test or t-test. The receiver operating characteristic curve was used to evaluate the diagnostic performance of the APTw SI values.

RESULTS

A total of 51 participants were enrolled (mean age, 58 years ± 10 [standard deviation], 26 men). There were 24 in the T1-T2 stage and 9 with positive PNI. The APTw SI max, 99th, and 95th values were significantly higher in T3-T4 stage tumor than in T1-T2; the median (interquartile range) (M (IQR)) was (4.0% (3.6-4.9%) vs 3.4% (2.9- 4.3%), p = 0.017), (3.7% (3.2-4.1%) vs 3.2% (2.8-3.8%), p = 0.013), and (3.3% (2.8-3.8%) vs 2.9% (2.3-3.5%), p = 0.033), respectively. These indicators also differed significantly between the PNI groups, with the M (IQR) (4.5% (3.6-5.7%) vs 3.7% (3.2-4.2%), p = 0.017), (4.1% (3.4-4.8%) vs 3.3% (3.0-3.9%), p = 0.022), and (3.7% (2.7-4.2%) vs 2.9% (2.6-3.5%), p = 0.045), respectively.

CONCLUSION

Pre-operative APTw MRI has potential value in the assessment of T-staging and PNI determination in RA.

CLINICAL RELEVANCE STATEMENT

Pre-operative amide proton transfer-weighted MRI provides a quantitative method for noninvasive assessment of T-staging and PNI in RA aiding in precision treatment planning.

KEY POINTS

The efficacy of APTw MRI in RA needs further investigation. T3-T4 stage and PNI positive APTw signal intensities were higher than T1-T2 and non-PNI, respectively. APTw MRI provides a quantitative method for assessment of T staging and PNI in RA.

Using of endoscopic polypectomy in patients with diagnosed malignant colorectal polyp - The cross-sectional clinical study

The aim of this study was to evaluate the efficacy of endoscopic polypectomy as a therapeutic treatment for malignant alteration of colorectal polyps. In a 5-year research, 89 patients were included, who were tested and treated at the University Clinical Center Kragujevac, Kragujevac, Serbia, with the confirmed presence of malignant alteration polyps of the colon by colonoscopy, which were removed using the method of endoscopic polypectomy and confirmed by the histopathological examination of the entire polyp. After that, the same group of patients was monitored endoscopically within a certain period, controlling polypectomy locations and the occurrence of a possible remnant of the polyp, in the period of up to 2 years of polypectomy. We observed that, with an increasing size of polyps, there is also an increase in the percentage of the complexity of endoscopic resection and the appearance of remnant with histological characteristics of the invasive cancer. The highest percentage of incomplete endoscopic resection and the appearance of remnant with histological characteristics of the invasive cancer were shown at malignant altered polyps in the field of tubulovillous adenoma. Eighteen patients in total underwent the surgical intervention. In conclusion, our data support the high efficacy of endoscopic polypectomy for the removal of the altered malignant polyp.

Dense Dilated Multi-Scale Supervised Attention-Guided Network for histopathology image segmentation

Over the last couple of decades, the introduction and proliferation of whole-slide scanners led to increasing interest in the research of digital pathology. Although manual analysis of histopathological images is still the gold standard, the process is often tedious and time consuming. Furthermore, manual analysis also suffers from intra- and interobserver variability. Separating structures or grading morphological changes can be difficult due to architectural variability of these images. Deep learning techniques have shown great potential in histopathology image segmentation that drastically reduces the time needed for downstream tasks of analysis and providing accurate diagnosis. However, few algorithms have clinical implementations. In this paper, we propose a new deep learning model Dense Dilated Multiscale Supervised Attention-Guided (D2MSA) Network for histopathology image segmentation that makes use of deep supervision coupled with a hierarchical system of novel attention mechanisms. The proposed model surpasses state-of-the-art performance while using similar computational resources. The performance of the model has been evaluated for the tasks of gland segmentation and nuclei instance segmentation, both of which are clinically relevant tasks to assess the state and progress of malignancy. Here, we have used histopathology image datasets for three different types of cancer. We have also performed extensive ablation tests and hyperparameter tuning to ensure the validity and reproducibility of the model performance. The proposed model is available at www.github.com/shirshabose/D2MSA-Net.

Recent advances of pathomics in colorectal cancer diagnosis and prognosis

Colorectal cancer (CRC) is one of the most common malignancies, with the third highest incidence and the second highest mortality in the world. To improve the therapeutic outcome, the risk stratification and prognosis predictions would help guide clinical treatment decisions. Achieving these goals have been facilitated by the fast development of artificial intelligence (AI) -based algorithms using radiological and pathological data, in combination with genomic information. Among them, features extracted from pathological images, termed pathomics, are able to reflect sub-visual characteristics linking to better stratification and prediction of therapeutic responses. In this paper, we review recent advances in pathological image-based algorithms in CRC, focusing on diagnosis of benign and malignant lesions, micro-satellite instability, as well as prediction of neoadjuvant chemoradiotherapy and the prognosis of CRC patients.

Sarcobesity, but not visceral fat, is an independent risk factor for complications after radical resection of colorectal cancer

Background

The influence of body composition on the outcome of colorectal cancer surgery is controversial. The aim of this study was to evaluate the effects of visceral obesity and sarcobesity on the incidence of total and surgical complications after radical resection of colorectal cancer.

Methods

We collected a total of 426 patients who underwent elective radical resection of colorectal cancer at Beijing Friendship Hospital, Capital Medical University from January 2017 to May 2018. According to the inclusion and exclusion criteria, 387 patients were finally included. A CT scan at the level of the L3-L4 intervertebral disk was selected to measure the values of visceral fat area and skeletal muscle area. Multivariate analysis was used to explore the independent risk/protective factors affecting postoperative complications.

Results

128 (33.1%) patients developed complications, and 44 (11.4%) patients developed major complications. Among them, 111 patients developed surgical complications and 21 developed medical complications. Visceral fat area (Z = -3.271, p = 0.001), total fat area (Z = -2.613, p = 0.009), visceral fat area to subcutaneous fat area ratio (V/S, Z = -2.633, p = 0.008), and sarcobesity index (Z = -2.282, p = 0.023) were significantly associated with total complications. Visceral fat area (Z = -2.119, p = 0.034) and V/S (Z = -2.010, p = 0.044) were significantly associated with total surgical complications. Sarcobesity index, smoking, stoma, blood loss, surgery time, and American Society of Anesthesiology (ASA) score were selected as risk factors for total postoperative complications according to LASSO regression. Multivariate logistic regression analysis suggested that sarcobesity index was an independent risk factor for postoperative total complications and surgical complications. Subgroup analysis suggested that albumin level was an independent protective factor for postoperative total complications in male patients. Smoking, operative time, and sarcobesity index were independent risk factors, and cholesterol was an independent protective factor for total postoperative complications in female patients.

Conclusion

Increased sarcobesity index is an independent risk factor for postoperative complications in patients with colorectal cancer, while visceral fat area is not. For female patients, smoking, operation time, and obesity index are independent risk factors for postoperative complications, while cholesterol is an independent protective factor. For male patients, serum albumin is an independent protective factor for postoperative complications.

Molecular characteristics of young-onset colorectal cancer in Vietnamese patients

BACKGROUND

Colorectal cancer (CRC) is one of the most common cancer globally. Understanding the genetic characteristics of CRC is essential for appropriate treatment and genetic counseling.

METHODS

The genetic profile of CRC tumor tissues was identified using next-generation sequencing of 17 target genes (MLH1, MSH2, MSH6, PMS2, EPCAM, APC, SMAD4, BMPR1A, MUTYH, STK11, PTEN, TP53, ATM, CDH1, CHEK2, POLE, and POLD1) in a cohort of 101 Vietnamese patients diagnosed with young-onset CRC. Corresponding germline genetic alterations of determined somatic mutations were subsequently confirmed from patients' blood samples.

RESULTS

Somatic mutations were determined in 96 out of 101 CRC patients. Two-thirds of the tumors harbored more than two mutations, and the most prevalent mutated genes were TP53 and APC. Among confirmed germline mutations, 10 pathogenic mutations and 11 variants of unknown significance were identified.

CONCLUSIONS

Given the burden of CRC and the gradually reducing cost of genetic testing, multigene panel screening can benefit young-onset CRC patients as well as their relatives.

Using the Fat-Clearing Technique to Improve Lymph Node Retrieval in Colorectal Cancer

College of American Pathologists recommended that at least 12 lymph nodes should be harvested for adequate staging of colorectal carcinoma. Lymph node harvesting is routinely performed by a manual technique of inspection and palpation, which is laborious and time-consuming. The study assessed the influence of the improved fat-clearing technique on the number of lymph nodes retrieved from colorectal cancer specimens and the clinical efficacy. Seventy colorectal cancer resection specimens were examined and assessed by 4 pathology residents. Thirty-five specimens were handled with the conventional manual technique by inspection and palpation, and the other 35 specimens with the improved fat-clearing technique to retrieve lymph nodes. As a result, compared with the conventional manual technique, the numbers of lymph nodes retrieved with the improved fat-clearing technique were significantly increased from 14.7 ± 6.2 lymph nodes to 20.8 ± 9.0 lymph nodes per specimen (P < .05). Besides, the percentage of cases with at least 12 lymph nodes retrieved increased from 80% to 91%. The result of this study pointed out that using the improved fat-clearing technique to process colorectal specimens could increase the lymph node yield effectively, and was effective, practical, and suitable for routine gross examination.

Single nucleotide variants c.-13G → C (rs17429833) and c.108C → T (rs72466472) in the CLDN1 gene and increased risk for familial colorectal cancer

BACKGROUND

The Claudin-1 (CLDN1) protein plays an important role in the function of the tight junction and studies have shown it is aberrantly downregulated in many tumors including colorectal cancer (CRC). The aim of this study was to determine the relationship between four SNVs in the CLDN1 gene [c.-13G → C (rs17429833), c.108C → T (rs72466472), c.369T → C (rs9869263), and c.370G → A (rs140846629)] and the risk of familial colorectal cancer (FCC).

METHODS

A case-control study was conducted with peripheral blood DNAs from 50 patients with CRC that belong to FCC families and 96 healthy control individuals. The analysis of genetic variants was performed by PCR and restriction enzymatic digestion.

RESULTS

The patients and control groups presented in Hardy-Weinberg equilibrium for all evaluated SNVs. No significant differences occurred in wild-type homozygous, heterozygous and variant homozygous genotypes, separately or together, in patient and control groups for the SNVs rs72466472, rs9869263, and rs140846629. However, for the SNV rs17429833, increased frequency of GC genotype occurred in patients compared to healthy individuals (58.30% vs. 41.70%), with an OR = 3.28 (95%CI = 1.22 to 9.09) for CRC. In the patients' group, individuals harboring combined genotypes rs17429833 (GC) and rs72466472 (CC) (26% vs. 8.42%) showed an OR = 3.78 (95%CI = 1.33 to 11.48). Moreover, patients harboring GC genotype for SNV rs17429833 presented significantly association with well differentiated adenocarcinoma when compared to moderately differentiated adenocarcinoma [60% vs. 22.58%, OR = 6.3 (95%CI = 1.15 to 39.76)].

CONCLUSIONS

The GC genotype for the SNV rs17429833 or combined genotypes for SNVs rs17429833 (GC) and rs72466472 (CC) seems to be risk factors for patients with FCC in Brazilian patients; however, a larger number of patients needs to be evaluated to confirm our results.

MILD-Net: Minimal information loss dilated network for gland instance segmentation in colon histology images

The analysis of glandular morphology within colon histopathology images is an important step in determining the grade of colon cancer. Despite the importance of this task, manual segmentation is laborious, time-consuming and can suffer from subjectivity among pathologists. The rise of computational pathology has led to the development of automated methods for gland segmentation that aim to overcome the challenges of manual segmentation. However, this task is non-trivial due to the large variability in glandular appearance and the difficulty in differentiating between certain glandular and non-glandular histological structures. Furthermore, a measure of uncertainty is essential for diagnostic decision making. To address these challenges, we propose a fully convolutional neural network that counters the loss of information caused by max-pooling by re-introducing the original image at multiple points within the network. We also use atrous spatial pyramid pooling with varying dilation rates for preserving the resolution and multi-level aggregation. To incorporate uncertainty, we introduce random transformations during test time for an enhanced segmentation result that simultaneously generates an uncertainty map, highlighting areas of ambiguity. We show that this map can be used to define a metric for disregarding predictions with high uncertainty. The proposed network achieves state-of-the-art performance on the GlaS challenge dataset and on a second independent colorectal adenocarcinoma dataset. In addition, we perform gland instance segmentation on whole-slide images from two further datasets to highlight the generalisability of our method. As an extension, we introduce MILD-Net⁺ for simultaneous gland and lumen segmentation, to increase the diagnostic power of the network.

Novel digital signatures of tissue phenotypes for predicting distant metastasis in colorectal cancer

Distant metastasis is the major cause of death in colorectal cancer (CRC). Patients at high risk of developing distant metastasis could benefit from appropriate adjuvant and follow-up treatments if stratified accurately at an early stage of the disease. Studies have increasingly recognized the role of diverse cellular components within the tumor microenvironment in the development and progression of CRC tumors. In this paper, we show that automated analysis of digitized images from locally advanced colorectal cancer tissue slides can provide estimate of risk of distant metastasis on the basis of novel tissue phenotypic signatures of the tumor microenvironment. Specifically, we determine what cell types are found in the vicinity of other cell types, and in what numbers, rather than concentrating exclusively on the cancerous cells. We then extract novel tissue phenotypic signatures using statistical measurements about tissue composition. Such signatures can underpin clinical decisions about the advisability of various types of adjuvant therapy.

The quality of total mesorectal excision specimen: A review of its macroscopic assessment and prognostic significance

As a surgical procedure which could significantly lower the recurrence rate of cancers, total mesorectal excision (TME) has been the gold standard for middle and lower rectal cancer treatment. However, previous studies have shown that the procedure did not achieve the ideal theoretical local recurrence rates of rectal cancers. Some researchers pointed out it was very likely that not all so-called TME treatments completely removed the mesorectum, implying that some of these TME surgical treatments failed to meet oncological quality standards. Therefore, a suitable assessment tool for the surgical quality of TME is necessary. The notion of “macroscopic assessment of mesorectal excision (MAME)” was put forward by some researchers as a better assessment tool for the surgical quality of TME and has been confirmed by a series of studies. Besides providing rapid and accurate surgical quality feedbacks for surgeons, MAME also effectively assesses the prognosis of patients with rectal cancer. However, as a new assessment tool used for TME surgical quality, MAME has an only limited influence on the current guidelines and is yet to be widely applied in most countries. The aims of this review are to provide a detailed introduction to MAME for clinical practice and to summarize the current prognostic significance of MAME.

Gland segmentation in colon histology images: The glas challenge contest

Colorectal adenocarcinoma originating in intestinal glandular structures is the most common form of colon cancer. In clinical practice, the morphology of intestinal glands, including architectural appearance and glandular formation, is used by pathologists to inform prognosis and plan the treatment of individual patients. However, achieving good inter-observer as well as intra-observer reproducibility of cancer grading is still a major challenge in modern pathology. An automated approach which quantifies the morphology of glands is a solution to the problem. This paper provides an overview to the Gland Segmentation in Colon Histology Images Challenge Contest (GlaS) held at MICCAI'2015. Details of the challenge, including organization, dataset and evaluation criteria, are presented, along with the method descriptions and evaluation results from the top performing methods.

Apoptotic pathways and stemness in the colorectal epithelium and lamina propria mucosae during the human embryogenesis and carcinogenesis

AIM

Programmed cell death is essential both during normal organ development and carcinogenesis. In this study we immunohistochemically analyzed different pathways of cell death in 11 human conceptuses 5th-10th-weeks old, 10 low and high grade colorectal carcinomas (CRC), and 10 normal colon samples by using markers for apoptosis (caspase-3, AIF, TUNEL), proliferation (Ki-67) and stemness (Oct-4).

RESULTS

Between the 5th and 10th week of development, caspase-3 and AIF showed moderate-to-strong expression in the developing gut wall. During development, number of caspase-3-reactive cells decreased, while AIF increased. While healthy colorectal control and low grade CRC showed moderate expression of caspase-3 and AIF, in high grade CRC their expression was strong. Tumor tissues displayed significantly higher number of positive cells than controls. Occasionally, co-expressing of both markers characterized dying cells. In developing colon, Oct-4 and Ki-67 showed moderate-to-strong expression, while some cells co-expressed both markers. Their number decreased in the epithelium and increased in the connective tissue in later development. Healthy colorectal control displayed moderate Ki-67 and mild Oct-4 reactivity. While in low-grade CRC expression Oct-4 and Ki-67 was moderate, in high-grade CRC their expression was strong. Although Oct-4 and TUNEL occasionally co-expressed in all samples, both grades of CRC contained cells that were Oct-4 positive only.

CONCLUSION

Our study revealed two different parallel pathways of cell death, with characteristic increase of AIF-mediated apoptosis when compared to caspase-3, and presence of stemness cells both during colon development and carcinogenesis. These finding might be considered as important diagnostic, survival and CRC therapy predictors.

Measuring the quality of melanoma surgery - Highlighting issues with standardization and quality assurance of care in surgical oncology

In an attempt to ensure high standards of cancer care, there is increasing interest in determining and monitoring the quality of interventions in surgical oncology. In recent years, this has been particularly the case for melanoma surgery. The vast majority of patients with melanoma undergo surgery. Usually, this is with combinations of wide excision, sentinel lymph node biopsy and lymphadenectomy. The indications for these procedures evolved during a time when no effective systemic adjuvant therapy was available, and whilst the rationale has been sound, the justification for differences in extent and thoroughness has generally been supported by inadequate or low-level evidence. This has led to a substantial variation among melanoma centres or even among surgeons within a centre in how these procedures are done. With recent rapid progress in the efficacy of systemic treatments that are impacting on overall survival, the prospect of long-term survival in these previously high risk patients means that more than ever long-term locoregional control of melanoma is imperative. Furthermore, the understanding of effects of systemic therapy on locoregional disease will only be interpretable if surgeons use standardized, high quality techniques. This article focuses on standardization and evolution of quality indicators for melanoma surgery and how these might have a positive impact on patient care.

Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO)

In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.

The role of lymph node revealing solution on the improvement of lymph node harvest in colorectal cancer specimens

AIM

The correct analysis of lymph node status is one of the most important parameters for the accurate pathological diagnosis of colorectal cancer. Our aim was to evaluate the number of lymph nodes among the specimens obtained from colorectal resections due to colorectal cancer, before and after the routine use of a lymph node revealing solution (LNRS).

METHOD

Data from 780 surgical specimens from patients of both genders with colorectal cancer were studied. The cases were divided chronologically into two groups: the conventional group included 497 specimens treated with conventional methods, i.e. without the use of the LNRS (January 2000 to July 2007), and the LNRS group included 283 specimens examined through the routine use of this solution (August 2007 to July 2012).

RESULTS

Most patients were female (57.4%) with a median age of 62 years. The median lymph node number was 18, and 75.9% of the cases (592) had 12 or more nodes dissected. Lymph node metastases were noted in 334 cases (42.8%). A median of 24 lymph nodes was dissected in the LNRS group compared to 15 in the conventional group (P < 0.001). The LNRS group had 9.2% of cases with fewer than 12 lymph nodes dissected compared with 32.6% in the conventional group (P < 0.001).

CONCLUSIONS

The use of the LNRS increases the number of lymph nodes obtained from colorectal cancer surgical specimens and can help to reduce the number of cases with < 12 lymph nodes.

Pathologic Assessment of Rectal Carcinoma after Neoadjuvant Radio(chemo)therapy: Prognostic Implications

Neoadjuvant radio(chemo)therapy is increasingly used in rectal cancer and induces a number of morphologic changes that affect prognostication after curative surgery, thereby creating new challenges for surgical pathologists, particularly in evaluating morphologic changes and tumour response to preoperative treatment. Surgical pathologists play an important role in determining the many facets of rectal carcinoma patient care after neoadjuvant treatment. These range from proper handling of macroscopic specimens to accurate microscopic evaluation of pathological features associated with patients' prognosis. This review presents the well-established pathological prognostic indicators and discusses challenging features in order to provide both surgical pathologists and treating physicians with a checklist that is useful in a neoadjuvant setting.

Long-term oncologic outcomes of robotic low anterior resection for rectal cancer: a comparative study with laparoscopic surgery

OBJECTIVE

The aim of this study is to evaluate long-term oncologic outcomes of robotic surgery for rectal cancer compared with laparoscopic surgery at a single institution.

BACKGROUND

Robotic surgery is regarded as a new modality to surpass the technical limitations of conventional surgery. Short-term outcomes of robotic surgery for rectal cancer were acceptable in previous reports. However, evidence of long-term feasibility and oncologic safety is required.

METHODS

Between April 2006 and August 2011, 217 patients who underwent minimally invasive surgery for rectal cancer with stage I-III disease were enrolled prospectively (robot, n = 133; laparoscopy, n = 84). Median follow-up period was 58 months (range, 4-80 months). Perioperative clinicopathologic outcomes, morbidities, 5-year survival rates, prognostic factors, and cost were evaluated.

RESULTS

Perioperative clinicopathologic outcomes demonstrated no significant differences except for the conversion rate and length of hospital stay. The 5-year overall survival rate was 92.8% in robotic, and 93.5% in laparoscopic surgical procedures (P = 0.829). The 5-year disease-free survival rate was 81.9% and 78.7%, respectively (P = 0.547). Local recurrence was similar: 2.3% and 1.2% (P = 0.649). According to the univariate analysis, this type of surgical approach was not a prognostic factor for long-term survival. The patient's mean payment for robotic surgery was approximately 2.34 times higher than laparoscopic surgery.

CONCLUSIONS

No significant differences were found in the 5-year overall, disease-free survival and local recurrence rates between robotic and laparoscopic surgical procedures. We concluded that robotic surgery for rectal cancer failed to offer any oncologic or clinical benefits as compared with laparoscopy despite an increased cost.

[Survival rate after D3-lymphadenectomy for right-sided colic cancer: case-match study]

The aim of the study was to compare the effectiveness of D3-lymphadenectomy in compliance with «no-touch» principle and mesocolectomy with traditional hemicolectomy in patients with right-sided colon cancer.

MATERIAL AND METHODS

It is retrospective-prospective comparative case-match study. From prospectively collected database patients with right-sided colon cancer stage I-III treated in 2009-2013 without adjuvant chemotherapy were selected. Patients who underwent conventional right-sided hemicolectomy with D2-lymphadenectomy in the regional oncologic dispensary formed the first group. The second group included patients after right-sided hemicolectomy with D3-lymphadenectomy, «no-touch» principle and mesocolectomy performed in academic hospital of the third level. From both groups 'case-match' patients by gender, age, stage and location of primary tumor were selected. Each group consisted of 50 patients.

RESULTS

Overall and cancer-related 5-year survival was significantly higher in the second group - 80.9% vs. 56.0% (p=0.01) and 93.4% vs. 59.8% (p=0.01), respectively.

CONCLUSION

D3-lymphadenectomy and mesocolectomy for right-sided colon cancer stage I-III without adjuvant chemotherapy provides significantly better overall and cancer-related 5-year survival compared with conventional right-sided hemicolectomy. Thus, D3-lymphadenectomy and mesocolectomy in compliance with «no-touch» principle for right-sided colon cancer is reproducible and effective in Russian conditions.

Lymph node count and prognosis in colorectal cancer: the influence of examination quality

Colorectal cancer guidelines recommend adjuvant chemotherapy in stage II disease when less than 12 lymph nodes are assessed. The recommendation bases on previous studies showing an association of a low lymph node count and adverse outcome. Compared to current standards, however, the quality of lymph node examination in the studies was low. We, therefore, investigated the prognostic role of <12 lymph nodes in cancers diagnosed adherent to current quality measures. Stage I-IV colorectal cancers from 1,899 patients enrolled into a population-based cohort study were investigated for the prognostic impact of a lymph node count <12. The stage specific share of patients diagnosed with ≥12 nodes (stage I-IV: 62, 85, 85, 78%, respectively) was used to compare lymph node examination quality to other studies. We found no impact of a lymph node count <12 on overall, cancer-specific or recurrence-free survival for any tumour stage. Compared to studies reporting an adverse prognostic impact of a low lymph node count in stages II and III the stage-specific shares of patients with ≥12 nodes were markedly higher in this study (85% vs. 24-58% in previous analyses) and this correlated with increased rates of stage III compared to stage II cancers. In conclusion our data indicate, that the previously reported effect of a low lymph node count on the patients' outcomes is eliminated by improved lymph node examination quality and thus question the general applicability of a 12 lymph node cut off for adjuvant chemotherapy decision making in stage II disease.

Lymph node involvement in colon cancer patients decreases with age; a population based analysis

BACKGROUND

The variation in nodal involvement between age groups has not been thoroughly studied in colon cancer, but it may affect strategies for extent of resection in elderly patients. The objective of our study was to compare nodal involvement in colon cancer patients, with a focus on surgical staging practices in the elderly.

METHODS

We extracted data from the Surveillance, Epidemiology and End Results registry on 208,077 patients diagnosed with stage I-III colon adenocarcinoma between 2000 and 2010. Patients undergoing colon resection, patients with adequate staging with ≥12 lymph nodes examined (LNE, n = 114,351) and with node-positive cancers were compared in age groups using chi-squared test. Relative risk (RR) of node-positive cancer was compared in a multivariable log-linear model, and relative survival in a flexible parametric model.

RESULTS

While the rates of colon resection were similar in all age groups, older patients were significantly less likely to have ≥12 LNE (P < 0.0001). When adequately staged, older patients had a significantly lower proportion of node-positive cancers (P < 0.0001). Survival was better in patients with ≥12 LNE, with no significant difference in the benefit between the age groups (P = 0.25).

CONCLUSIONS

When adequately staged, older patients are less likely to have node positive colon cancer, which may help them avoid adjuvant chemotherapy. Since the survival benefit of adequate nodal staging is similar in every age group, the guidelines for extent of resection and pathological examination should be diligently adhered to in all patients undergoing curative surgery, regardless of age.

Less than 12 nodes in the surgical specimen after total mesorectal excision following neoadjuvant chemoradiation: it means more than you think!

BACKGROUND

A minimum of 12 examined lymph nodes (LN) is recommended to ensure adequate staging and oncologic resection of patients undergoing proctectomy for rectal adenocarcinoma. However, a decreased number of LN is not unusual in patients receiving neoadjuvant chemoradiation.

PURPOSE

We hypothesized that a decreased number of LN in the proctectomy specimen of these patients may be an indicator of tumor response and be associated with improved prognosis.

METHODS

A single-center colorectal cancer database was queried for c-stage II-III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized into two groups according to the number of LN retrieved from the proctectomy specimen: <12 LN versus ≥12 LN. Groups were compared with respect to demographics, tumor and treatment characteristics, and the following oncologic outcomes: overall-survival (OS), cancer-specific-mortality (CSM), cancer-free-survival (CFS), distant (DR), and local recurrences (LR).

RESULTS

The query returned 237 patients. There were 173 (73 %) males, and the median age was 57 years [interquartile range (IQR) 49-66 years]. The median number of LN retrieved was 15 (IQR 10-23) and 70 (30 %) patients had less than 12 nodes examined. The <12 nodes group was older [60 (IQR 51-71 years) vs. 55 (IQR 48-65 years), p = 0.009] and had more pathologic complete responders (36 vs. 19 %, p = 0.01). No <12 nodes patient experienced a LR, whereas the 5-year LR rate was 11 % in the ≥12 nodes group (p = 0.004). Other oncologic outcomes were not significantly different.

CONCLUSIONS

Retrieval of less than 12 nodes in the proctectomy specimen of rectal cancer patients treated with neoadjuvant chemoradiation does not affect OS, CSM, CFS, or DR and may be a marker of higher tumor response and, consequently, decreased LR rate.

Single-incision laparoscopy for colorectal resection: a systematic review and meta-analysis of more than a thousand procedures

AIM

Single-incision laparoscopy for colorectal surgery is of growing importance. The experience of colorectal resection through single-incision laparoscopic surgery was assessed, including the patient outcomes.

METHOD

A meta-analysis was performed of studies comparing single-incision laparoscopic with multiport laparoscopy. Endpoints included conversion to laparotomy, operation time, postoperative morbidity, length of skin incision and length of hospital stay. The MEDLINE database was searched and only comparative studies were included in the meta-analysis. Data were retrieved from full-text manuscripts. Meta-analysis was performed according to the Mantel-Haenszel method for random effects.

RESULTS

From October 2008 to December 2011, 1026 colorectal resections including 921 colonic and 105 rectal procedures using single-incision laparoscopic surgery were reported in 64 studies. Meta-analysis of the 15 comparative studies, including a total of 1075 procedures (494 single-incision and 581 multiport laparoscopies), showed no difference in conversion to open laparotomy [odds ratio (OR) 0.58 (0.24, 1.38); P=0.22], morbidity [OR 0.84 (0.61, 1.15); P=0.27] or operation time [weighted mean difference (WMD) -0.27 (-6.50, 5.95); P=0.93], but a significantly shorter total skin incision [WMD -0.52 (-0.79, -0.25); P<0.001] and a significantly shorter postoperative length of stay [WMD -0.75 (-1.30, -0.20); P=0.008] after single-incision laparoscopic surgery compared with a multiport laparoscopic approach.

CONCLUSION

Although only 15 nonrandomized comparative studies of varying methodology have been reported, this systematic review and meta-analysis of more than 1000 colorectal procedures suggest that single-incision laparoscopic colorectal surgery is feasible and safe.

Colorectal carcinoma: Pathologic aspects

Colorectal carcinoma is one of the most common cancers and one of the leading causes of cancer-related death in the United States. Pathologic examination of biopsy, polypectomy and resection specimens is crucial to appropriate patient managemnt, prognosis assessment and family counseling. Molecular testing plays an increasingly important role in the era of personalized medicine. This review article focuses on the histopathology and molecular pathology of colorectal carcinoma and its precursor lesions, with an emphasis on their clinical relevance.

Colorectal carcinoma: Pathologic aspects

Colorectal carcinoma is one of the most common cancers and one of the leading causes of cancer-related death in the United States. Pathologic examination of biopsy, polypectomy and resection specimens is crucial to appropriate patient managemnt, prognosis assessment and family counseling. Molecular testing plays an increasingly important role in the era of personalized medicine. This review article focuses on the histopathology and molecular pathology of colorectal carcinoma and its precursor lesions, with an emphasis on their clinical relevance.

Reliability and Effectiveness of GEWF Solution in the Identification of Lymph Nodes in Specimens of Colorectal Carcinoma

Lymph node status is pivotal in the staging process of cancer. With regards to colorectal cancer, lymph node retrieval is always laborious. Sometimes, it is also a challenge to recover a minimum of 12 lymph nodes from the pericolorectal tissue. Among many proposed adjunctive solutions, GEWF solution (glacial acetic acid, ethanol, distilled water, and formaldehyde) has been introduced recently and suggested to be superior. To further evaluate its efficiency, the pericolorectal tissue, which has been reexamined extensively in the conventional condition, was refixed into GEWF solution in this study. More lymph nodes were found in 75% (n = 6) of the 8 experimental cases, and 50% (n = 4) of them had 12 or more yielded lymph nodes eventually. In addition, no adverse influences on the expressions of immunohistochemical and special stains were seen. These data support the reliability and effectiveness of GEWF solution in improvement of lymph node yield.

Adjuvant therapy in colon cancer

Huge advances have been made in the treatment of colon cancer over the last decade. Success has been most noticeable in stage IV disease - where careful selection of patients with small-volume disease for treatment with surgical resection ± perioperative chemotherapy has resulted in an improvement in survival of approximately 5-50%; and stage III - disease where the advent of 5-fluorouracil/oxaliplatin, as adjuvant treatment has also resulted in a significant prolongation in survival. Progression-free survival is now an established surrogate for overall survival, and has resulted in more timely reporting of adjuvant studies and therefore faster integration of promising agents into the clinic. Targeted agents, which have shown promise in the metastatic setting, are currently being examined in the adjuvant setting, although results so far are disappointing. Patients with high-risk stage II cancer remain a challenging group. They have a poorer prognosis than those with stage IIIA disease, and national and international guidance recommend offering chemotherapy after careful discussion of the pros and cons. Despite the fact that we have identified many of the biological features that make stage II disease higher risk, we still struggle to achieve the same improvement in survival for this subgroup compared with others. It may be that these patients required treatment with alternative regimens and predictive biomarkers would be particularly helpful.

Shifting concepts in rectal cancer management: a review of contemporary primary rectal cancer treatment strategies

The management of rectal cancer has transformed over the last 3 decades and continues to evolve. Some of these changes parallel progress made with other cancers: refinement of surgical technique to improve organ preservation, selective use of neoadjuvant (and adjuvant) therapy, and emergence of criteria suggesting a role for individually tailored therapy. Other changes are driven by fairly unique issues including functional considerations, rectal anatomic features, and surgical technical issues. Further complexity is due to the variety of staging modalities (each with its own limitations), neoadjuvant treatment alternatives, and competing strategies for sequencing multimodal treatment even for nonmetastatic disease. Importantly, observations of tumor response made in the era of neoadjuvant therapy are reshaping some traditionally held concepts about tumor behavior. Frameworks for prioritizing and integrating complex data can help to formulate treatment plans for patients.

Perspectives on current tumor-node-metastasis (TNM) staging of cancers of the colon and rectum

Improvements in classifications of cancers based on discovery and validation of important histopathological parameters and new molecular markers continue unabated. Though still not perfect, recent updates of classification schemes in gastrointestinal oncology by the American Joint Commission on Cancer (tumor-node-metastasis [TNM] staging) and the World Health Organization further stratify patients and guide optimization of treatment strategies and better predict patient outcomes. These updates recognize the heterogeneity of patient populations with significant subgrouping of each tumor stage and use of tumor deposits to significantly "up-stage" some cancers; change staging parameters for subsets of IIIB and IIIC cancers; and introduce of several new subtypes of colon carcinomas. By the nature of the process, recent discoveries that are important to improving even routine standards of patient care, especially new advances in molecular medicine, are not incorporated into these systems. Nonetheless, these classifications significantly advance clinical standards and are welcome enhancements to our current methods of cancer reporting.

Expression of Transketolase like gene 1 (TKTL1) predicts disease-free survival in patients with locally advanced rectal cancer receiving neoadjuvant chemoradiotherapy

Background

For patients with locally advanced rectal cancer (LARC) neoadjuvant chemoradiotherapy is recommended as standard therapy. So far, no predictive or prognostic molecular factors for patients undergoing multimodal treatment are established. Increased angiogenesis and altered tumour metabolism as adaption to hypoxic conditions in cancers play an important role in tumour progression and metastasis. Enhanced expression of Vascular-endothelial-growth-factor-receptor (VEGF-R) and Transketolase-like-1 (TKTL1) are related to hypoxic conditions in tumours. In search for potential prognostic molecular markers we investigated the expression of VEGFR-1, VEGFR-2 and TKTL1 in patients with LARC treated with neoadjuvant chemoradiotherapy and cetuximab.

Methods

Tumour and corresponding normal tissue from pre-therapeutic biopsies of 33 patients (m: 23, f: 10; median age: 61 years) with LARC treated in phase-I and II trials with neoadjuvant chemoradiotherapy (cetuximab, irinotecan, capecitabine in combination with radiotherapy) were analysed by quantitative PCR.

Results

Significantly higher expression of VEGFR-1/2 was found in tumour tissue in pre-treatment biopsies as well as in resected specimen after neoadjuvant chemoradiotherapy compared to corresponding normal tissue. High TKTL1 expression significantly correlated with disease free survival. None of the markers had influence on early response parameters such as tumour regression grading. There was no correlation of gene expression between the investigated markers.

Conclusion

High TKTL-1 expression correlates with poor prognosis in terms of 3 year disease-free survival in patients with LARC treated with intensified neoadjuvant chemoradiotherapy and may therefore serve as a molecular prognostic marker which should be further evaluated in randomised clinical trials.

Evaluation of lymph node numbers for adequate staging of Stage II and III colon cancer

BACKGROUND

Although evaluation of at least 12 lymph nodes (LNs) is recommended as the minimum number of nodes required for accurate staging of colon cancer patients, there is disagreement on what constitutes an adequate identification of such LNs.

METHODS

To evaluate the minimum number of LNs for adequate staging of Stage II and III colon cancer, 490 patients were categorized into groups based on 1-6, 7-11, 12-19, and ≥ 20 LNs collected.

RESULTS

For patients with Stage II or III disease, examination of 12 LNs was not significantly associated with recurrence or mortality. For Stage II (HR = 0.33; 95% CI, 0.12-0.91), but not for Stage III patients (HR = 1.59; 95% CI, 0.54-4.64), examination of ≥20 LNs was associated with a reduced risk of recurrence within 2 years. However, examination of ≥20 LNs had a 55% (Stage II, HR = 0.45; 95% CI, 0.23-0.87) and a 31% (Stage III, HR = 0.69; 95% CI, 0.38-1.26) decreased risk of mortality, respectively. For each six additional LNs examined from Stage III patients, there was a 19% increased probability of finding a positive LN (parameter estimate = 0.18510, p < 0.0001). For Stage II and III colon cancers, there was improved survival and a decreased risk of recurrence with an increased number of LNs examined, regardless of the cutoff-points. Examination of ≥7 or ≥12 LNs had similar outcomes, but there were significant outcome benefits at the ≥20 cutoff-point only for Stage II patients. For Stage III patients, examination of 6 additional LNs detected one additional positive LN.

CONCLUSIONS

Thus, the 12 LN cut-off point cannot be supported as requisite in determining adequate staging of colon cancer based on current data. However, a minimum of 6 LNs should be examined for adequate staging of Stage II and III colon cancer patients.

Standard protocol for assessment of colon cancer improves the quality of pathology

AIM

Tumour stage is the most important prognostic factor in colon cancer. The aim of this study was to examine the impact on the quality of pathology of the use of a standardized pathological and anatomical (PAD) protocol.

METHOD

A standardized PAD protocol for colorectal cancer was developed and all patients subjected to colon resection due to adenocarcinomas between 2004 and 2006 were analysed regarding lymph node status, circumferential resection margin (CRM), and intravascular and perineural growth. Moreover, usage of the PAD protocol and whether a pathologist or biomedicine analytical technician (BMA) performed the lymph node dissection was noted, and also whether the surgical procedure was elective or acute.

RESULTS

During the study period 302 colon resections were carried out. The standard protocol was employed in 68% of the cases, varying from 0% to 100% between pathologists. The median number of investigated lymph nodes was 16 ± 11. When the lymph node dissection was performed by a BMA, significantly more lymph nodes were examined; 22 ± 15 and 14 ± 9, respectively (P < 0.01). There was a positive correlation between application of the standard protocol and the number of analysed lymph nodes (< 0.05). Comments on CRM, perineural growth and intravascular growth were also significantly more frequent when the protocol was used. Emergency surgery did not influence the handling of the specimens.

CONCLUSION

Minor changes in procedure in terms of a standard protocol for pathology and specimen dissection by BMAs, leading to an increased quality of the PAD-report, may also improve the long-term outcome for patients.

Assessment of Serosal Invasion and Criteria for the Classification of Pathological (p) T4 Staging in Colorectal Carcinoma: Confusions, Controversies and Criticisms

Transmural spread by colorectal carcinoma can result in tumor invasion of the serosal surface and, hence, more likely dissemination within the peritoneal cavity and potentially to additional metastatic sites. The adverse prognostic significance of serosal invasion is widely accepted and its presence may be considered an indication for chemotherapy in patients with node negative disease. However, controversy persists regarding the most appropriate criteria for diagnosis and there are also practical difficulties associated with histological assessment in some cases. Therefore, serosal invasion may be under-diagnosed in a significant proportion of tumors, potentially leading to sub-optimal treatment of high-risk patients. The examination of multiple microscopic sections combined with ancillary studies such as cytology preparations, elastin stains, and immunohistochemistry may prove beneficial in selected problematic cases, but these are not used routinely. The relative prognostic significance of serosal invasion and of direct tumor spread to other organs, both of which are incorporated within the pT4 category of the AJCC/UICC TNM staging system, remains unclear. Further studies are required to demonstrate whether recent adjustments to the TNM staging of pT4 tumors are appropriate.

Clinicopathological staging of colorectal cancer: Evolution and consensus-an Australian perspective

In 1991 this journal published the report of an international working party to the World Congress of Gastroenterology regarding the clinicopathological staging of colorectal cancer. Since that time staging has continued to evolve as further prognostic factors in colorectal cancer have been elucidated in studies of increasingly large databases in several countries. This review summarizes several of the key issues that have arisen during this evolutionary process and raises matters which still remain controversial in staging at the present time.

Surgical quality and nodal ultrastaging is associated with long-term disease-free survival in early colorectal cancer: an analysis of 2 international multicenter prospective trials

BACKGROUND

The National Quality Forum has endorsed a minimum of 12 lymph node (LN) as a surrogate measure of quality in colorectal cancer (CRC). The prognostic value of ultrastaging hematoxylin and eosin (H&E) negative LNs (N0) using pan-cytokeratin immunohistochemistry (pan-CK-IHC) is unknown.

PURPOSE

To assess the effect on survival of surgical quality and focused pathologic analysis.

PATIENTS AND METHODS

Between 2001 and 2007, 253 evaluable patients with resectable CRC were enrolled. Multiple sectioning and pan-CK-IHC were performed on N0 LNs (American Joint Commission on Cancer Stage II). Follow-up was performed at 6-month intervals with a 4-year disease-free survival (DFS) primary end-point.

RESULTS

There were 253 patients, 177 N0 and 76 N1/N2 patients, staged conventionally. Thirty-six (20%) N0 patients were upstaged using ultrastaging (N0-->N0i+ [n = 27] and N0-->N1mi [n = 9]). At a mean follow-up of 3.4 +/- 1.6 years, 38 (15%) have recurred. Only 3% (3/108) of patients with > or =12 LNs, negative by H&E and pan-CK-IHC (N0i-), compared with 18% (6/33) with <12 LNs/N0i- (6/33; P = 0.0015) have recurred. Four-year DFS differed significantly according to surgical quality (<12 vs. > or =12 LNs) among Stage II patients only (DFS, <12 vs. > or =12 LNs: Stage I, 90.5% vs. 97.7%, P = 0.22; Stage II, 67.5% vs. 94.7%, P = 0.0036; Stage III, 61% vs. 61%, P = 0.61).

CONCLUSION

This represents the first prospective report demonstrating that both surgical quality and nodal ultrastaging impacts survival in Stage II CRC. Patients with Stage II CRC having > or =12 LNs negative for micrometastases (N0i-) are likely cured by surgery alone. Both surgical and pathologic quality measures are imperative in early CRC to improve patient selection for adjuvant chemotherapy.

Negative prognostic factors in colorectal carcinoma: An analysis of 448 patients

BACKGROUND AND AIMS

Colorectal carcinoma (CRC) is the most frequent malignancy of the gastrointestinal tract. Prognostic researches are carried out for choosing the optimum therapy, evaluating therapy results and comparing multicentre results for better qualification in the therapy of the disease.

PATIENTS AND METHODS

In this study, 448 patients, whose surgery and follow-up was performed by the same correspondent surgeon between the years 1995 and 2003, were retrospectively analyzed.

RESULTS

Age, presence of comorbidity, weight loss, emergency admission, high serum CEA and CA 19-9 levels, neighboring organ invasion, operation type, major morbidity, tumor size and type, lymph node metastases, venous and perineural invasion, Dukes' classification and local recurrence and distant metastasis during follow-up are found to be significant negative factors affecting prognosis of the CRC patient.

CONCLUSION

Therapy results of the CRC are evaluated by survival times regardless of the therapy method selected for each individual. In our study we tried to find out negative prognostic factors by researching possible factors affecting disease free survival time for CRC. Since our understanding of factors that have an impact on prognosis increases, we are hoping to improve survival.

Practical and molecular evaluation of colorectal cancer: new roles for the pathologist in the era of targeted therapy

CONTEXT

Colorectal cancer is the third most common cancer and the fourth most common cause of cancer death worldwide. Patient cases are discussed in multidisciplinary meetings to decide on the best management on an individual basis. Until recently, the main task of the pathologist in such teams was to provide clinically useful reports comprising staging of colorectal cancer in surgical specimens. The advent of total mesorectal excision and the application of anti-epidermal growth factor receptor (EGFR)-targeted therapies for selected patients with metastasized colorectal cancer have changed the role of the pathologist.

OBJECTIVES

To present the traditional role of the pathologist in the multidisciplinary team treating patients with colorectal cancer, to address the technique of total mesorectal excision and its implications for the evaluation of surgical specimens, to offer background information on the various EGFR-targeted therapies, and to review the currently investigated tissue biomarkers assumed to be predictive for efficacy of such therapies, with a focus on the role of the pathologist in determining the status of such biomarkers in individual tumors.

DATA SOURCES

This article is based on selected articles pertaining to biopsy evaluation of colorectal carcinoma and reviews of EGFR-targeted therapies for this cancer. All references are accessible via the PubMed database (US National Library of Medicine and the National Institutes of Health).

CONCLUSIONS

Pathologists play an increasingly important role in the diagnosis and management of colorectal cancer because of the advent of new surgical techniques and of targeted therapies. It is expected that this role will increase further in the near future.

Meeting the 12 lymph node (LN) benchmark in colon cancer

BACKGROUND

Examining >or=12 LN in colon cancer has been suggested as a quality metric. The purpose of this study was to determine whether the 12 LN benchmark is achieved at NCCN centers compared to a US population-based sample.

METHODS

Patients with stage I-III disease resected at NCCN centers were identified from a prospective database (n = 718) and were compared to 12,845 stage I-III patients diagnosed in a SEER region. Age, gender, location, stage, number of positive nodes were compared for NCCN and SEER data in regards to number of nodes evaluated. Multivariate logistic regression models were developed to identify factors associated with evaluating 12 LNs.

RESULTS

92% of NCCN and 58% of SEER patients had >or=12 LN evaluated. For patients treated at NCCN centers, factors associated with not meeting the 12 LN target were left-sided tumors, stage I disease and BMI >30.

CONCLUSIONS

>or=12 LN are almost always evaluated in NCCN patients. In contrast, this target is achieved in 58% of SEER patients. With longer follow-up of the NCCN cohort we will be able to link this quality metric to patterns of recurrence and survival and thereby better understand whether increasing the number of nodes evaluated is a priority for cancer control.

The pathologist's role in rectal cancer patient assessments

Since Cuthbert Dukes fundamental work linking cancer stage to prognosis, the pathologist has had an ever-expanding role in the multidisciplinary management of rectal cancer. Gross dissection techniques and histologic evaluation are reviewed. The evolving tumor size, node status, metastasis classification (TNM) staging system is outlined. The pathologist's critical role in correctly assessing circumferential margins and establishing resection adequacy and staging accuracy via lymph node assessment is emphasized.

[Oncological data elements in histopathology]

In order to cope with increasing demands to supply information to a variety of documentation systems outside pathology, pathologists need to set standards both for the content and the use of the information they generate. Oncological datasets based on a set vocabulary are urgently required for use both in pathology and in further processing. Data elements were defined according to German pathology report guidelines for colorectal cancers in line with ISO 11179 requirements for the relations between data element concepts and value domains, as well as for further formal conditions, which can be exported in XML together with metadata information. Tests on 100 conventionally written diagnoses showed their principal usability and an increasing degree of guideline conformity in diagnoses commensurate with training time. This set of oncological data elements is a valuable checklist tool for pathologists, enabling formatted information export for further use and saving documentation effort.

Prognostic significance of the number of lymph nodes examined in colon cancer surgery: clinical application beyond simple measurement

OBJECTIVE

To identify an optimal cutoff value for the number of lymph node examined (NLNE) to distinguish the prognoses in patients following a curative resection for advanced colon cancer, to clarify the mechanism of the difference, and to suggest the integration of NLNE to colon cancer staging.

PATIENTS AND METHODS

A total of 859 patients who had undergone surgical treatment for localized colon cancer from 1980 to 2000 were reviewed. This was a cohort from a single institution with mean NLNE of 20.7 and more than 12 NLNE in 77% of the patients. The optimal breakpoint for NLNE was calculated by a receiver operating characteristic curve (ROC) analysis. The patients were stratified into groups based on various parameters and underwent univariate and multivariate analyses with respect to survival.

RESULTS

The ROC analysis identified NLNE as a significant prognostic factor with cutoff value of 18 for node-negative and 20 for node-positive patients. A multivariate analysis with these cutoff values identified NLNE as a significant prognostic factor independent of tumor depth and the number of lymph nodes involved. The 5-year cause-specific survival of stage IIB patients was 96.5% with 18 or more NLNE and 67.5% with NLNE less than 18 (P[r]=0.0067). Similarly, a cutoff value of 20 NLNE for node-positive patients separated the 5-year cause-specific survival of stage IIIB patients into 79.3% with 20 or more NLNE and 63.3% with less than 20 NLNE (P=0.0052).

CONCLUSIONS

The clinical significance of NLNE is not limited to being a benchmark for quality care, but has a definite benefit as a prognostic indicator across the stages. Patients could be stratified more efficiently by the integration of NLNE to TNM staging.

Adequate lymph node assessment for extrahepatic bile duct adenocarcinoma

OBJECTIVE

To examine the importance of adequate lymph node sampling in staging of extrahepatic bile duct cancer (EHBDCA).

SUMMARY OF BACKGROUND DATA

The American Joint Committee on Cancer staging manual (sixth edition) states that histologic examination of at least 3 lymph nodes is required for adequate N stage determination for EHBDCA. This recommendation has not been validated; however, there has been no comparative assessment of the proximal versus distal bile duct cancer.

METHODS

A total of 257 patients (144 hilar cholangiocarcinoma [HCCA] and 113 distal bile duct adenocarcinoma [DBDCA]) who underwent curative intent resection (1987-2007) were analyzed; patients with gallbladder cancer were excluded. Final disease staging, including lymph node status and total number of nodes examined (total lymph node count), was obtained from the final pathology report. Differences in disease-specific survival, according to nodal status, were compared using the log-rank test. R1 resections (n = 51) were excluded from this analysis.

RESULTS

Metastasis to regional lymph nodes was noted in 89 patients (34.6%) and was an independent prognostic factor of poor survival (median disease-specific survival N0 vs. N1: 53.5 vs. 19.3 months, P < 0.0001, hazard ratio = 2.1 [95% CI: 1.4-3.2]). The median total lymph node count was 6 (range: 0-42), and was significantly lower for HCCA compared with DBDCA (median = 3 [range: 0-16] vs. 12 [range: 1-42], P < 0.001, respectively). For the entire cohort, patients who underwent R0 resection and were classified as N0, based on total lymph node count <11, had a disease-specific survival that was significantly worse than that of patients classified as N0 based on total lymph node count >or=11 (52.6 +/- 9.8 months vs. not reached, P = 0.008). The estimated optimal total lymph node count for HCCA differed from that of DBDCA (n = 7 vs. n = 11, respectively).

CONCLUSIONS

Adequate lymph nodes assessment of EHBDCA, based on the current AJCC recommendations, results in understaging of these tumors. With respect to the optimal total lymph node count, HCCA, and DBDCA should be considered separately.

Impacto do uso da solução reveladora de linfonodos no estadiamento do câncer colorretal

INTRODUÇÃO: A avaliação anátomo-patológica do câncer colorretal (CCR) em relação ao acometimento linfonodal é fundamental para o prognóstico da doença e para a indicação de terapias adjuvantes. Tem sido considerado um número mínimo de 12 linfonodos na peça cirúrgica para que se obtenha adequado estadiamento linfonodal, embora se admita que quanto maior o número de linfonodos dissecados, maior é a probabilidade de se encontrar linfonodos metastáticos. OBJETIVOS: avaliar o número de linfonodos obtidos em peças cirúrgicas de CCR antes e após a utilização rotineira de solução reveladora de linfonodos na gordura mesocólica. MATERIAL E MÉTODOS: Foram avaliados 706 laudos anátomo-patológicos de CCR, sendo 582 sem tratamento do espécime cirúrgico com solução reveladora e 124 após uso de solução reveladora. Resultados: Houve predominância do sexo feminino (57,6%) e a média de idade foi de 61,36 anos. A maioria dos tumores localizava-se distalmente à flexura esplênica (60%). A média de linfonodos dissecados após uso da solução reveladora foi igual a 28,97, enquanto que no período anterior ao uso desta solução esta média foi de 16,73 (p < 0,001). A porcentagem de peças com 11 linfonodos dissecados ou menos (pNx) diminuiu significativamente após a utilização da solução reveladora (32,7 para 3,2%, com p < 0,0001). Ao contrário, houve aumento significativo do número de casos estadiados como pN0, pN1, pN2 e pN3 após o uso da solução reveladora. CONCLUSÃO: O uso da solução reveladora de linfonodos causa grande impacto no estudo anátomo-patológico das peças cirúrgicas do CCR, sendo altamente aconselhável sua introdução na rotina dos serviços de patologia cirúrgica.