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Surgical Pathology

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Rectal Cancer

Part of the book series: Current Clinical Oncology ((CCO))

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Abstract

Pathologists play an important role in the treatment of rectal cancer, interacting closely with all members of the multidisciplinary team including surgeons, oncologists and radiologists. In particular, pathologists play a crucial feedback role to surgeons, allowing them to audit the quality of surgical dissection, as well as to radiologists, allowing them to audit the accuracy of pre-operative staging. It is vital that a comprehensive and accurate report is issued for rectal cancer resections, which identifies the key prognostic features oncologists require to guide adjuvant treatment. Rectal cancer resections need to be handled appropriately at the time of specimen dissection to ensure that all possible prognostic features are correctly identified and reported. Tissue blocks should be carefully selected to allow accurate staging of the disease and to identify key high-risk features such as circumferential resection margin (CRM) involvement, extra-mural vascular invasion (EMVI) and peritoneal involvement. Many rectal cancer patients, particularly those with locally advanced disease, are now offered neoadjuvant radiotherapy ± chemotherapy. Responses to therapy vary markedly, and the pathologist can indicate the degree of response using a qualitative tumour regression grade. Low rectal cancer treated by abdominoperineal excision (APE) continues to have poorer outcomes than higher rectal tumours treated by anterior resection. This is believed to be related to differences in the anatomy of the low rectum and the surgical approach utilised. Pathologists have played a crucial role in the study of this important area and have led the call for a change in surgical approach to such tumours.

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References

  1. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection: histopathological study of lateral tumour spread and surgical excision. Lancet. 1986;2:996–999.

    Article  PubMed  CAS  Google Scholar 

  2. Adam IJ, Mohamdee MO, Martin IG, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet. 1994;344:707–711.

    Article  PubMed  CAS  Google Scholar 

  3. Ng IOL, Luk ISC, Yuen ST. Surgical lateral clearance in resected rectal carcinomas. A multivariate analysis of clinicopathological features. Cancer. 1993;71:1972–1976.

    Article  PubMed  CAS  Google Scholar 

  4. Nagtegaal ID, Marijnen CA, Kranenbarg EK, van de Velde CJ, van Krieken JH. Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit. Am J Surg Pathol. 2002;26:350–357.

    Article  PubMed  Google Scholar 

  5. Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg. 2002;89:327–334.

    Article  PubMed  CAS  Google Scholar 

  6. Martling A, Singnomklao T, Holm T, Rutqvist LE, Cedermark B. Prognostic significance of both surgical and pathological assessment of curative resection for rectal cancer. Br J Surg. 2004;91: 1040–1045.

    Article  PubMed  CAS  Google Scholar 

  7. Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol. 2008;26:303–312.

    Article  PubMed  Google Scholar 

  8. Nagtegaal ID, van de Velde CJH, van der Worp E, et al. Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality. J Clin Oncol. 2002;20:1729–1734.

    Article  PubMed  Google Scholar 

  9. Quirke P, Sebag-Montefiore D, Steele R, et al. Local recurrence after rectal cancer resection is strongly related to the plane of surgical dissection and is further reduced by preoperative short course radiotherapy. Preliminary results of the MRC CR07 trial. J Clin Oncol. 2006;24s:A3512.

    Google Scholar 

  10. Rodel C, Martus P, Papadoupolos T, et al. Prognostic significance of tumour regression after preoperative chemoradiotherapy for rectal cancer. J Clin Oncol. 2005;23:8688–8696.

    Article  PubMed  Google Scholar 

  11. Thomas PR, Lindblad AS. Adjuvant postoperative radiotherapy and chemotherapy in rectal carcinoma: a review of the Gastrointestinal Tumour Study Group experience. Radiother Oncol. 1988;13:245–252.

    Article  PubMed  CAS  Google Scholar 

  12. Medical Research Council Rectal Cancer Working Party. Randomised trial of surgery alone versus surgery followed by radiotherapy for mobile cancer of the rectum. Lancet. 1996;348:1610–1614.

    Article  Google Scholar 

  13. Moertel CG, Fleming TR, MacDonald JS, et al. Fluorouracil plus levamisole as effective adjuvant therapy after resection of stage III colon carcinoma: a final report. Ann Intern Med. 1995;122:321–326.

    PubMed  CAS  Google Scholar 

  14. Andre T, Boni C, Mounedji-Boudiaf L, et al. Oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer. N Engl J Med. 2004;350:2343–2351.

    Article  PubMed  CAS  Google Scholar 

  15. Twelves C, Wong A, Nowacki MP, et al. Capecitabine as adjuvant treatment for stage III colon cancer. N Engl J Med. 2005;352:2696–2704.

    Article  PubMed  CAS  Google Scholar 

  16. QUASAR Collaborative Group. Adjuvant chemotherapy versus observation in patients with colorectal cancer: a randomised study. Lancet. 2007;370:2020–2029.

    Article  Google Scholar 

  17. Quirke P, Morris E. Reporting colorectal cancer. Histopathology. 2007;50:103–112.

    Article  PubMed  CAS  Google Scholar 

  18. Amado RG, Wolf M, Peeters M, et al. Wild-type KRAS is required for panitumumab efficacy in patients with metastatic colorectal cancer. J Clin Oncol. 2008;26:1626–1634.

    Article  PubMed  CAS  Google Scholar 

  19. Di Nicolantonio F, Martini M, Molinari F, et al. Wild-type BRAF is required for response to panitumumab or cetuximab in metastatic colorectal cancer. J Clin Oncol. 2008;26(35):5705–5712; published online Nov 10th.

    Article  PubMed  Google Scholar 

  20. Group MS. Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. Br Med J. 2006;333:779–784.

    Article  Google Scholar 

  21. Purkayastha S, Tekkis PP, Athanasiou T, Tilney HS, Darzi AW, Heriot AG. Diagnostic precision of magnetic resonance imaging for preoperative prediction of the circumferential margin involvement in patients with rectal cancer. Colorectal Dis. 2006;9:402–411.

    Article  Google Scholar 

  22. Brown G, Richards CJ, Newcombe RG, et al. Rectal carcinoma: thin-section MR imaging for staging in 28 patients. Radiology. 1999;211:215–222.

    PubMed  CAS  Google Scholar 

  23. Mercury Study Group. Extramural depth of tumor invasion at thin-section MR in patients with rectal cancer: results of the MERCURY study. Radiology. 2007;243:132–139.

    Article  Google Scholar 

  24. Brown G, Richards CJ, Bourne MW, et al. Morphologic predictors of lymph node status in rectal cancer with use of high-spatial-resolution MR imaging with histopathologic comparison. Radiology. 2003;227:371–377.

    Article  PubMed  Google Scholar 

  25. Brown G, Radcliffe AG, Newcombe RG, Dallimore NS, Bourne MW, Williams GT. Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging. Br J Surg. 2003;90:355–364.

    Article  PubMed  CAS  Google Scholar 

  26. Smith NJ, Barbachano Y, Norman AR, Swift RI, Abulafi AM, Brown G. Prognostic significance of magnetic resonance imaging-detected extramural vascular invasion in rectal cancer. Br J Surg. 2008;95:229–236.

    Article  PubMed  CAS  Google Scholar 

  27. Martling A, Holm T, Bremmer S, Lindholm J, Cedermark B, Blomqvist L. Prognostic value of preoperative magnetic resonance imaging of the pelvis in rectal cancer. Br J Surg. 2003;90:1422–1428.

    Article  PubMed  CAS  Google Scholar 

  28. Cross SS, Feeley KM, Angel CA. The effect of four interventions on the informational content of histopathology reports of resected colorectal carcinomas. J Clin Pathol. 1998;51:481–482.

    Article  PubMed  CAS  Google Scholar 

  29. Rigby K, Brown SR, Lakin G, Balsitis M, Hosie KB. The use of a proforma improves colorectal cancer pathology reporting. Ann R Coll Surg Engl. 1999;81:401–402.

    PubMed  CAS  Google Scholar 

  30. Branston LK, Greening S, Newcombe RG, et al. The implementation of guidelines and computerised forms improves the completeness of cancer pathology reporting. The CROPS project: a randomised controlled trial in pathology. Eur J Cancer. 2002;38:764–772.

    Article  PubMed  CAS  Google Scholar 

  31. Beattie GC, McAdam TK, Elliott S, Sloan JM, Irwin ST. Improvement in quality of colorectal cancer pathology reporting with a standardized proforma – a comparative study. Colorectal Dis. 2003;5:558–562.

    Article  PubMed  CAS  Google Scholar 

  32. Williams GT, Quirke P, Shepherd N. Standards and datasets for reporting cancers: Dataset for colorectal cancer. 2nd ed. London: The Royal College of Pathologists; 2007.

    Google Scholar 

  33. Maughan NJ, Morris E, Forman D, Quirke P. The validity of the Royal College of Pathologists’ colorectal cancer minimum dataset within a population. Br J Cancer. 2007;97:1393–1398.

    Article  PubMed  CAS  Google Scholar 

  34. Quirke P, Dixon MF. The prediction of local recurrence in rectal adenocarcinoma by histopathological examination. Int J Colorectal Dis. 1988;3:127–131.

    Article  PubMed  CAS  Google Scholar 

  35. Quirke P, Williams GT. Minimum dataset for colorectal cancer histopathology reports. London: The Royal College of Pathologists; 1998.

    Google Scholar 

  36. West NP, Morris EJA, Rotimi O, Cairns A, Finan PJ, Quirke P. Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol. 2008;9:857–865.

    Article  PubMed  Google Scholar 

  37. Eriksen MT, Wibe A, Syse A, Haffner J, Wiig JN, on behalf of the Norwegian Rectal Cancer Group and the Norwegian Gastrointestinal Cancer Group. Inadvertent perforation during rectal cancer resection in Norway. Br J Surg. 2004;91:210–216.

    Article  PubMed  CAS  Google Scholar 

  38. Nagtegaal ID, Van de Velde CJH, Marijnen CAM, van Krieken JHJM, Quirke P. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23:9257–9264.

    Article  PubMed  Google Scholar 

  39. Quirke P, Williams GT, Ectors N, Ensari A, Piard F, Nagtegaal I. The future of the TNM staging system in colorectal cancer: time for a debate? Lancet Oncol. 2007;8:651–657.

    Article  PubMed  Google Scholar 

  40. Gabriel WB, Dukes C, Bussey HJR. Lymphatic spread in cancer of the rectum. Br J Surg. 1935;23:395–413.

    Article  Google Scholar 

  41. Sobin LH, Wittekind C. UICC TNM classification on malignant tumours. 5th ed. New York: Wiley Liss; 1997.

    Google Scholar 

  42. Sobin LH, Wittekind C. UICC TNM classification on malignant tumours. 6th ed. New York: Wiley Liss; 2002.

    Google Scholar 

  43. Howarth SM, Morgan JM, Williams GT. The new (6th edition) TNM classification of colorectal cancer – a stage too far. Gut. 2004;53:a21-a22.

    Article  Google Scholar 

  44. Birbeck K, Macklin CP, Tiffin NJ, et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery. Ann Surg. 2002;235:449–457.

    Article  PubMed  Google Scholar 

  45. Talbot IC, Ritchie S, Leighton MH, Hughes AO, Bussey HJ, Morson BC. The clinical significance of invasion of veins by rectal cancer. Br J Surg. 1980;67:439–442.

    Article  PubMed  CAS  Google Scholar 

  46. Shepherd NA, Baxter KJ, Love SB. The prognostic importance of peritoneal involvement in colonic cancer: a prospective evaluation. Gastroenterology. 1997;112:1096–1102.

    Article  PubMed  CAS  Google Scholar 

  47. Mandard AM, Dalibard F, Mandard JC, et al. Pathologic assessment of tumor regression after preoperative chemoradiotherapy of esophageal carcinoma. Clinicopathologic correlations. Cancer. 1994;73:2680–2686.

    Article  PubMed  CAS  Google Scholar 

  48. Dworak O, Keilholz L, Hoffmann A. Pathological features of rectal cancer after preoperative radiochemotherapy. Int J Colorectal Dis. 1997;12:19–23.

    Article  PubMed  CAS  Google Scholar 

  49. Bouzourene H, Bosman FT, Seelentag W, Matter M, Coucke P. Importance of tumor regression assessment in predicting the outcome in patients with locally advanced rectal carcinoma who are treated with preoperative radiotherapy. Cancer. 2002;94:1121–1130.

    Article  PubMed  Google Scholar 

  50. Wheeler JMD, Warren BF, Mortensen Mc NJ, et al. Quantification of histologic regression of rectal cancer after irradiation: a proposal for a modified staging system. Dis Colon Rectum. 2002;45:1051–1056.

    Article  PubMed  CAS  Google Scholar 

  51. Ryan R, Gibbons D, Hyland JMP, et al. Pathological response following long-course neoadjuvant chemoradiotherapy for locally advanced rectal cancer. Histopathology. 2005;47:141–146.

    Article  PubMed  CAS  Google Scholar 

  52. Sebag-Montefiore D, Brown G, Rutten H, et al. An international phase II study of capcitabine, oxaliplatin, radiotherapy and excision (CORE) in patients with MRI-defined locally advanced rectal adenocarcinoma. Interim results. Eur J Cancer. 2005;3s:170.

    Google Scholar 

  53. Rutten H, Sebag-Montefiore D, Glynne-Jones R, et al. Capecitabine, oxaliplatin, radiotherapy, and excision (CORE) in patients with MRI-defined locally advanced rectal adenocarcinoma: results of an international multicenter phase II study. J Clin Oncol. 2006;24s:A3528.

    Google Scholar 

  54. Tilney HS, Heriot AG, Purkayastha S, et al. A national perspective on the decline of abdominoperineal resection for rectal cancer. Ann Surg. 2008;247:77–84.

    Article  PubMed  Google Scholar 

  55. Morris E, Quirke P, Thomas JD, Fairley L, Cottier B, Forman D. Unacceptable variation in abdominoperineal excision rates for rectal cancer – time to intervene? Gut. 2008;57:1690–1697; published online June 5th.

    Article  PubMed  CAS  Google Scholar 

  56. Wibe A, Syse A, Anderson E, et al. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum. 2004;47:48–58.

    Article  PubMed  Google Scholar 

  57. Marr R, Birbeck K, Garvican J, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg. 2005;242:74–82.

    Article  PubMed  Google Scholar 

  58. West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol. 2008;26:3517–3522.

    Article  PubMed  Google Scholar 

  59. Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg. 2007;94:232–238.

    Article  PubMed  CAS  Google Scholar 

  60. Bebenek M, Pudelko M, Cisarz K, et al. Therapeutic results in low-rectal cancer patients treated with abdominosacral resection are similar to those obtained by means of anterior resection in mid- and upper-rectal cancer cases. Eur J Surg Oncol. 2007;33:320–323.

    Article  PubMed  CAS  Google Scholar 

  61. Miles WE. A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet. 1908;2:1812–1813.

    Article  Google Scholar 

  62. Salerno G, Chandler I, Wotherspoon A, Thomas K, Moran B, Brown G. Sites of surgical wasting in the abdominoperineal specimen. Br J Surg. 2008;95:1147–1154.

    Article  PubMed  CAS  Google Scholar 

  63. Treanor D, Waterhouse M, Lewis F, Quirke P. A virtual slide library for histopathology. J Pathol. 2007;213(S1):27A.

    Google Scholar 

  64. Wright A, Magee D, Quirke P, Treanor D. Automated scoring of tissue microarrays using virtual slides. J Pathol. 2008;216(S1):S33.

    Google Scholar 

  65. Treanor D, Quirke P. The virtual slide and conventional microscope – a direct comparison of their diagnostic efficiency J Pathol. 2007;213(S1):7A.

    Google Scholar 

  66. Treanor D, Jordan-Owers N, Hodrien J, Wood J, Ruddle R, Quirke P. A virtual reality powerwall compared to the conventional light microscope: results of a pilot study. J Pathol. 2008;216(S1):S43.

    Google Scholar 

  67. West N, Quirke P. An evaluation of mesorectal tissue volume using three dimensional digital imaging. J Pathol. 2007;213(S1):31A.

    Google Scholar 

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Authors and Affiliations

  1. Department of Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK

    Nicholas P. West MB, ChB & Philip Quirke PhD

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  1. Nicholas P. West MB, ChB
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  2. Philip Quirke PhD
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Editors and Affiliations

  1. Dept. Radiation Oncology, Duke University Medical Center, Durham, USA

    Brian G. Czito

  2. Dept. Radiation Oncology, Duke University Medical Center, Durham, USA

    Christopher G. Willett

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© 2010 Humana Press

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West, N.P., Quirke, P. (2010). Surgical Pathology. In: Czito, B., Willett, C. (eds) Rectal Cancer. Current Clinical Oncology. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-60761-567-5_9

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  • DOI: https://doi.org/10.1007/978-1-60761-567-5_9

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  • Publisher Name: Humana Press, Totowa, NJ

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