reporting and management of early stage colorectal cancer l.
Skip this Video
Loading SlideShow in 5 Seconds..
Reporting and Management of Early stage Colorectal Cancer PowerPoint Presentation
Download Presentation
Reporting and Management of Early stage Colorectal Cancer

Loading in 2 Seconds...

play fullscreen
1 / 33

Reporting and Management of Early stage Colorectal Cancer - PowerPoint PPT Presentation

  • Uploaded on

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.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Reporting and Management of Early stage Colorectal Cancer' - oshin

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
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



True A







Polyp Cancers


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.)
EMR/TEMS should be received pinned on cork
    • Fixed “face down”
    • Margins inked
  • Often a difficult problem…..
  • How reproducible is this diagnosis?

See Neil Shepherd…

  • Differentiation
    • Even focal poor differentiation is reported and is an indicator for further surgical therapy
  • Tumour budding
  • Detached groups of up to 5 cells at invading front
    • Not included in reporting recommendations
    • Need for more research
  • 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




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
  • 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