Transcript Reporting and Management of Early stage Colorectal Cancer

Reporting and Management of
Early stage Colorectal Cancer
Frank Carey
Dundee
First Principles
• Screening is about reducing diseasespecific mortality
• The best surrogate marker of success is
detection of a high proportion of cancers at
early stage
Stage Distribution of
Symptomatic Colorectal Cancer
A
D
8%
25%
B
C
34%
33%
Stage Distribution of Screen
-Detected Cancers
D
C
26%
1%
True A
26%
48%
B
Polyp Cancers
25%
22%
Early stage colorectal cancer
• Dukes A (T1, T2)
• Cancer confined to submucosa (T1)
We are concerned mainly with the latter
Pathology Reporting
• Early stage cancer in formal surgical
resections
• Cancer in local resections (polypectomy
and others)
• Together these make up 50% of screendetected cancers
• Add Dukes’B (T3/T4) and we have 75%
Early Cancer in Surgical
Resections
• RCPath dataset does not allow for
subdivision of T1 tumours apart from in
terms of tumour differentiation
• One effect of screening is that we may
detect biologically more aggressive lesions
at an early stage
• There may be a need to look more
carefully at these tumours
screen
Non-core data items
•
•
•
•
Nature of advancing margin
Tumour infiltrating lymphocytes
Tumour budding
Intramural venous invasion (Petersen et al
Gut 2002; 51:65)
• Immunohistochemical and/or molecular
data
Submucosal venous invasion
• Loses prognostic significance when all
stages are analysed
• Valid in Dukes’ B
• Indicator of bad prognosis in locally
resected cancer
• Need for study in screened population,
especially in Dukes’ A resections
“Jass” parameters
• Margin characteristics
• Lymphoid
reaction/tumour
infiltrating
lymphocytes
Early colorectal cancer
• Identification:
– Endoscopic
• Pedunculated
• Flat
• Depressed
– Pathological
Presentation to pathology
• Polypectomy for presumed adenoma
– Pedunculated
– Sessile
• Specialised resections for larger sessile
lesions
– Endoscopic mucosal resection (EMR)
– Transanal endoscopic microsurgical resection
(TEMS)
Macroscopic handling
• Measurement
• All should be handled as potential cancer
(all tissue submitted, preservation of the
stalk etc.)
• EMR/TEMS should
be received pinned on
cork
– Fixed “face down”
– Margins inked
Microscopy
• Often a difficult
problem…..
• How reproducible is
this diagnosis?
See Neil Shepherd…
• Help is at hand!
Microscopy
• Differentiation
– Even focal poor
differentiation is
reported and is an
indicator for further
surgical therapy
Microscopy
• Tumour budding
• Detached groups of
up to 5 cells at
invading front
– Not included in
reporting
recommendations
– Need for more
research
Microscopy
• Assessment of depth of invasion (if
completely excised)
– Direct measurement from muscularis
mucosae (Ueno et al)
• Depth >2mm
20% nodal mets (vs. 5%)
• Width of invasive front >4mm
20% node
positive (vs. 4%)
Measuring invasive tumour
• Accuracy of depth
measurement
questionable
Haggitt levels
• For polypoid
adenomas
• Often difficult in
practice
Depth of invasion….
• Haggitt system failings
– Study included high grade dysplasia (level 0)
– 1/3 of cases were surgical excisions
– Statistical comparison was between level 4
and combined levels 0-3 (no node mets in
levels 0-3)
Kikuchi levels
• Applicable to sessile adenomas
sm1
sm2
sm3
Depth of invasion…..
• Kikuchi system
– Refined
• sm1a – invading front < ¼ of width of lesion
• sm1b – invading front ¼ - ½ width of lesion
• sm1c – invading front > ½ width of lesion
– Not currently recommended
Microscopy
• Margins
– Involved by cancer
– Involved by adenoma
• Definition of margin
positivity
–
–
–
–
Direct involvement
1mm
2mm
5mm
Lymphatic or vascular invasion
• 3 categories allowed
– Not present
– Possibly present
– Present
• Problem of retraction
artefact
– Worse near cauterised
margin
APPENDIX D
PROFORMA FOR LOCAL EXCISION SPECIMENS
Surname: ………………………………… Forenames: ………………………………
Date of birth: …………….………………
Hospital………………… …………….….. Hospital no: ………………….……………
NHS no: ………………….……..…..…..
Date of receipt: ……………….…………. Date of reporting: ………………………..
Report no: ……………….………………
Pathologist: …………….……….……….. Surgeon: …………………………….…….
Sex: …………………….………….…….
Specimen type:
Polypectomy / Endoscopic mucosal resection / Transanal endoscopic microsurgical (TEM) excision / Other
Comments: …………………………………………………………………………………………………………..
Gross description
Site of tumour
……………………………………………………………………………………………………..…..
Maximum tumour diameter (if known) …………………… mm
Histology
Background adenoma:
Tumour type
Adenocarcinoma
Yes

No

If No, Other...................................................................
Yes

Margins
Not involved
Involved by adenoma only
Deep margin Involved by carcinoma
Differentiation
Well/moderate
Poor
Local invasion



Confined to submucosa (pT1)
Into muscularis propria (pT2)
Beyond muscularis propria (pT3)
For pT1 tumours:
Maximum thickness of invasive tumour from
muscularis mucosae
…….….mm
Haggitt level (polypoid tumours)
1/2/3/4
Kikuchi level (for sessile/flat tumours)
Peripheral margin Involved by carcinoma
No





Histological measurement from carcinoma
to nearest deep excision margin .............................mm
Pathological staging
Complete resection at carcinoma at all margins
Yes (R0)

No (R1 or R2)

sm1 / sm2 / sm3

Lymphatic or vascular invasion:

pT stage
Definite



Signature: ……………………………………….
Date …../…../……….
None
Possible
…….
SNOMED codes
T…….. / M…………
A real case
• Polyp was margin
clear
• Problem of ?vascular
invasion discussed at
MDT
• Surgery
– 1 positive node
Margin positivity
• Sigmoid polyp with a
lot of diathermy
artefact
• Called carcinoma R1
Resection after polypectomy
• Difficulty of finding
polypectomy site
• Reassuring for
endoscopist/surgeon!
Future developments
• Research studies looking at histological
parameters in early stage cancers
• Identification of poor-prognosis groups
• Interventional trials of therapy
• Ensuring consistency of pathological
reporting