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Reporting and Management of Early stage Colorectal Cancer. Frank Carey Dundee. First Principles. Screening is about reducing disease-specific mortality The best surrogate marker of success is detection of a high proportion of cancers at early stage.

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Presentation Transcript
first principles
First Principles
  • Screening is about reducing disease-specific mortality
  • The best surrogate marker of success is detection of a high proportion of cancers at early stage
stage distribution of screen detected cancers
Stage Distribution of Screen -Detected Cancers

D

1%

True A

26%

C

26%

48%

B

25%

Polyp Cancers

22%

early stage colorectal cancer
Early stage colorectal cancer
  • Dukes A (T1, T2)
  • Cancer confined to submucosa (T1)

We are concerned mainly with the latter

pathology reporting
Pathology Reporting
  • Early stage cancer in formal surgical resections
  • Cancer in local resections (polypectomy and others)
  • Together these make up 50% of screen-detected cancers
  • Add Dukes’B (T3/T4) and we have 75%
early cancer in surgical resections
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
non core data items
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
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
“Jass” parameters
  • Margin characteristics
  • Lymphoid reaction/tumour infiltrating lymphocytes
early colorectal cancer
Early colorectal cancer
  • Identification:
    • Endoscopic
      • Pedunculated
      • Flat
      • Depressed
    • Pathological
presentation to pathology
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
Macroscopic handling
  • Measurement
  • All should be handled as potential cancer (all tissue submitted, preservation of the stalk etc.)
slide15
EMR/TEMS should be received pinned on cork
    • Fixed “face down”
    • Margins inked
microscopy
Microscopy
  • Often a difficult problem…..
  • How reproducible is this diagnosis?

See Neil Shepherd…

microscopy18
Microscopy
  • Differentiation
    • Even focal poor differentiation is reported and is an indicator for further surgical therapy
microscopy19
Microscopy
  • Tumour budding
  • Detached groups of up to 5 cells at invading front
    • Not included in reporting recommendations
    • Need for more research
microscopy20
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
Measuring invasive tumour
  • Accuracy of depth measurement questionable
haggitt levels
Haggitt levels
  • For polypoid adenomas
  • Often difficult in practice
depth of invasion
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
Kikuchi levels
  • Applicable to sessile adenomas

sm3

sm1

sm2

depth of invasion25
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
microscopy26
Microscopy
  • Margins
    • Involved by cancer
    • Involved by adenoma
  • Definition of margin positivity
    • Direct involvement
    • 1mm
    • 2mm
    • 5mm
lymphatic or vascular invasion
Lymphatic or vascular invasion
  • 3 categories allowed
    • Not present
    • Possibly present
    • Present
  • Problem of retraction artefact
    • Worse near cauterised margin
a real case
A real case
  • Polyp was margin clear
  • Problem of ?vascular invasion discussed at MDT
  • Surgery
    • 1 positive node
margin positivity
Margin positivity
  • Sigmoid polyp with a lot of diathermy artefact
  • Called carcinoma R1
resection after polypectomy
Resection after polypectomy
  • Difficulty of finding polypectomy site
  • Reassuring for endoscopist/surgeon!
future developments
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