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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 disease-specific mortality The best surrogate marker of success is detection of a high proportion of cancers at early stage.

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Reporting and Management of Early stage Colorectal Cancer

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  1. Reporting and Management of Early stage Colorectal Cancer Frank Carey Dundee

  2. 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

  3. Stage Distribution of Symptomatic Colorectal Cancer A 8% D 25% B 33% C 34%

  4. Stage Distribution of Screen -Detected Cancers D 1% True A 26% C 26% 48% B 25% Polyp Cancers 22%

  5. Early stage colorectal cancer • Dukes A (T1, T2) • Cancer confined to submucosa (T1) We are concerned mainly with the latter

  6. 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%

  7. 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

  8. screen

  9. 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

  10. 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

  11. “Jass” parameters • Margin characteristics • Lymphoid reaction/tumour infiltrating lymphocytes

  12. Early colorectal cancer • Identification: • Endoscopic • Pedunculated • Flat • Depressed • Pathological

  13. Presentation to pathology • Polypectomy for presumed adenoma • Pedunculated • Sessile • Specialised resections for larger sessile lesions • Endoscopic mucosal resection (EMR) • Transanal endoscopic microsurgical resection (TEMS)

  14. Macroscopic handling • Measurement • All should be handled as potential cancer (all tissue submitted, preservation of the stalk etc.)

  15. EMR/TEMS should be received pinned on cork • Fixed “face down” • Margins inked

  16. Microscopy • Often a difficult problem….. • How reproducible is this diagnosis? See Neil Shepherd…

  17. Help is at hand!

  18. Microscopy • Differentiation • Even focal poor differentiation is reported and is an indicator for further surgical therapy

  19. Microscopy • Tumour budding • Detached groups of up to 5 cells at invading front • Not included in reporting recommendations • Need for more research

  20. 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%)

  21. Measuring invasive tumour • Accuracy of depth measurement questionable

  22. Haggitt levels • For polypoid adenomas • Often difficult in practice

  23. 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)

  24. Kikuchi levels • Applicable to sessile adenomas sm3 sm1 sm2

  25. 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

  26. Microscopy • Margins • Involved by cancer • Involved by adenoma • Definition of margin positivity • Direct involvement • 1mm • 2mm • 5mm

  27. Lymphatic or vascular invasion • 3 categories allowed • Not present • Possibly present • Present • Problem of retraction artefact • Worse near cauterised margin

  28. A real case • Polyp was margin clear • Problem of ?vascular invasion discussed at MDT • Surgery • 1 positive node

  29. Margin positivity • Sigmoid polyp with a lot of diathermy artefact • Called carcinoma R1

  30. Resection after polypectomy • Difficulty of finding polypectomy site • Reassuring for endoscopist/surgeon!

  31. 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

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