Transcript Assessment of Margins in Colorectal Cancer Specimens

Assessment of Margins in
Colorectal Cancer
Specimens
Holly Brunner, PA(ASCP)
Sibley Memorial Hospital
Washington, DC
3 factors in margin assessment
Knowing the margins
2. Handling the specimen correctly
3. Reporting of all the data related to the
margins (Minimal Pathology Data Set)
1.
Focus will be on rectal cases. They require
a little more TLC and the information is a
little newer.
Part 1: Knowing the Margins
1. Mucosal
2. Serosal
3. Mesenteric radial
4.Radial
5.CRM
Serosal Margin
Peritonealized surface near bowel wall
 3 levels of involvement with different
prognoses

◦ 2 of those levels are micro level
◦ Take more sections if close
Grave prognosis if involved
 Some institutions doing intraoperative
serosal scrapings if tumor appears to
approach surface
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Mesenteric Margin
aka mesenteric radial m.
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Cecum, Transverse, Sigmoid
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Point where the mesentary vessel root is cut by
the surgeon
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Specimen should be surrounded by peritoneum
at the level of the tumor
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Measure distance from deepest tumor
penetration to resection line – usually > 5 cm
Mesenteric margin
Radial Margin
aka adventitial m., lateral m.
Retroperitoneal or perineal adventitial soft
tissue closest to deepest penetration of
tumor
 Created by blunt dissection during
surgery
 Ascending, Descending, Upper rectum
(partially encased by peritoneum) = radial
margin
 Distal rectum (not encased) =
circumferential radial margin (CRM)

Part 2: Assessing and Measuring

Dr. Phil Quirke from Leeds University is leading
professor, researcher and honorary consultant on
colorectal cancer reporting and CRM data

Second interest is digital pathology
◦ GI specialist + avid photographer = amazing
instruction on dissecting of colorectal specimens

Publication titles include:
◦ Local recurrence of rectal adeno CA is caused by
inadequate surgical resection (1986)
◦ Who to treat with adjuvent therapy in Stage II
colorectal CA? The need for high quality pathology
(2007)
Quirke’s Protocol
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http://www.ualberta.ca/~rmclean/crdiss.htm
http://philquirke.weebly.com/index.html
1.
2.
3.
4.
Grade the surgery quality of the specimen
Fix for 2 days minimum!
Serially section
Collect Minimal Data Pathology Set
(MPD)
1. Mesorectum Quality Assessment
Grades 3-1
 Intact > Moderate > Incomplete
 Great indicator of the patient’s prognosis

3-Good:
“intact, bulky mesorectum”
Grade 3
intact, smooth, complete
Grade 3
Grade 3 bulky up to levators
Grade 2 - Moderate
irregularity of the mesorectal surface w/
>5 mm defects. Moderate coning. No
visible m.propria
“received is a 12 cm length segment of
recto sigmoid colon with a moderate
(ragged but no visible m.propria)
excision of the mesorectum”
Grade 2
not intact
Is it possible for the entire
mesorectum to be removed
even though it has a ragged
appearance?
Yes, but it doesn't matter. Once the
mesorectum has been violated the risk
for spillage of tumor from lymphatics
exists. A ragged specimen without a
smooth surface must therefore be a
grade 2.
Grade 1: Poor
Little bulk with defects down onto
m.propria and/or very irregular CRM
“The mesorectum is incomplete with
defects exposing m.propria.”
TAKE PICTURES!
Grade 1
Quirke’s Protocol
1.
Grade surgery quality
2. Ink, Partially cut, Fix for 2 days
minimum!
3. Serially section
4. Collect Minimal Data Pathology Set
(MPD)
2. Don’t cut tumor area
3. Serially section 3-5 mm slices 2 cm
above and 2 cm below tumor area
Quirke’s Protocol
1. Grade surgery quality
2. Fix for 2 days minimum!
3. Serially section
4. Collect Minimal Data Pathology Set
(MPD)
4. Measure limit of tumor extension
(yellow) and distance of tumor, deposit, or
node to CRM (red)
Minimal Pathology Data Set
1.
2.
3.
4.
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6.
7.
Extent of local invasion (w distance beyond
m. propria given)
# LNs retrieved
Nodal Stage
Extramural vascular invasion (EMVI)
Peritoneal or serosal involvement
CRM involvement (distance of tumor,
deposit, or +LN to margin)
Quality of mesorectum
Together the 7 bits help provide a more accurate
prognosis and make retrospective analysis better
Part 3: Reporting the Data

Sounds like the easy part but it’s actually
the most difficult to accomplish.
Part 3: Reporting the data

Updating the dynamic TNM system depends on
outcome studies and the collection of outcome
data by the NCDB (National Cancer Data Base).

3 parts of the MPD are being collected with the
TNM system and it’s been useful:
◦ The first 5 ed. of the AJCC staging manual classified
stage III in a single group but now has subcategories in
the 6th ed. because of prognostic figures from NCDB
analysis from ‘87-’93.
◦ Subgroup survival rates were 59.8%, 42%, and 27.3%
,respectively when assessing both depth of penetration
and difference btwn <4 nodes or ≥4 nodes (+)

7th ed. comes out in June with changes going in
to effect Jan. 1, 2010
TNM system is good for staging and thus giving prognosis based on
studies already performed. But streamlined reporting often omits
data (MPD) needed for prognosis and treatment of the patients and
omits data needed to assess possible future staging changes.
Eg. TNM (+) radial margin definition: 0mm
A pt with tumor at the CRM has a 22% chance of local recurrence.
But it’s the same prognosis if distance from CRM to tumor is 1mm.
Chance of local recurrence doesn’t significantly drop til distance is
greater than 2 mm (5%).
Europe reports CRM as positive if tumor is 1mm or less from the
inked radial margin. Places in the US fail to even report on CRM
distance.
And there are more issues…
Problem:
According to several journals on the staging and prognosis of
colorectal cancer, many centers, especially the US, are
omitting data (MPD) pertinent to prognosis and data analysis!
1. Poor assessment of specimen
(informed PAs can fix that issue!)
2. No comprehensive report of data set
(pull out the easy button for the pathologists)
‘
Example comments about specimen assessment:
“Frequency of margin involvement is related to the interest of the
pathologist. [Dept.] with high LN yields, a good indicator of high
quality pathology, are more likely to reflect the true incidence of
CRM involvement.”
•Examination
of additional slides has led to an increase in CRM (+)
pts from 6% to 27%.
And they keep going…
Centers not having a special interest in GI
pathology reported extramural vascular invasion
findings in 17.8% of cases.
In centers with special GI interest, EMVI rates of
30% are seen.
If the oncologist is not aware that a pt. is
potentially at risk then treatment could be withheld
with a concomitant increase in the risk of death.
..and going…
“In North America, the clinical importance of the
CRM has not been widely recognized by
pathologists and routine pathological evaluation of
the CRM has been lacking. Assessment of data
from 3 treatment protocols conducted between
‘79-’92 by North Central Cancer Treatment Group
shows the CRM was evaluated pathologically in
only 21% of cases.”
Get the picture?

One pathologist said that NAACLS trained
PAs perform gross pathology and
dissection duties better than most
pathologists. “It is doubtful that any path
dept. where dissections are performed by
pathologists can match [their] quality of
work. But the use of PAs is not universal.”
(Dr. Goldstien of William Beaumont Hospt., Royal Oaks MI)
Shout out to the PAs
Solution
Incorporate all necessary data in to the gross report.
Talk with your pathologists about including all the data. The
report reflects on your skills, the pathologist’s, the dept’s and
the hospital. Most importantly, it affects the patient!
Patients have been refused into a trial based on lack of
information.
Become…
Magnum G.I.
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Take all the necessary measurements
Comment on the serosa and mesocolon and
back up assessment with photos
Take extra sections if necessary
Fix the specimen for best cutting and
measurements
Find all the lymph nodes (12-15+)
Talk to your pathologists about getting the
data in to the report
Go to tumor board so the surgeons are
familiar with you
Conclusion
PS.
Positive node AT mesenteric margin: no
research on it yet. But Dr. Quirke says it’s
similar to a Dukes C2 (+ln at high tie). So
margin now is reported (-) but note
should be included in the report stating
that a + LN was at the margin.
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