Skip to main content

The role of the pathologist in rectal cancer diagnosis and staging and surgical quality assessment

Clinical and Translational Oncology volume 12, pages 339–345 (2010)Cite this article

Abstract

Since the introduction of the total mesorectal excision by Heald, many changes in the therapeutic management of rectal cancer have been incorporated. The multidisciplinary approach to colorectal cancer, integrated in a team of different specialists, ensures individualised treatment for each patient with rectal cancer. Therefore the role of the pathologist has acquired an important relevance, not only in diagnosing but also managing and evaluating the surgical specimen. The knowledge of preoperative staging, distance between tumour and anal verge or in patients subjected to a neoadjuvant treatment is necessary for the pathologist to make a detailed, accurate and good-quality report. Parameters such as the macroscopic quality of the mesorectum, the status of the circumferential resection margin and the lymph node harvest are considered basic criteria recommended by the current guidelines for the multidisciplinary team audit.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

References

  1. Heald RJ (1988) The ‘Holy Plane’ of rectal surgery. J R Soc Med 81:503–508

    CAS  PubMed  Google Scholar 

  2. Landheer ML, Therasse P, van de Velde CJ (2002) The importance of quality assurance in surgical oncology. Eur J Surg Oncol 28:571–602

    Article  CAS  PubMed  Google Scholar 

  3. Church JM, Gibbs P, Chao MW, Tjandra JJ (2003) Optimizing the outcome for patients with rectal cancer. Dis Colon Rectum 46:389–402

    Article  PubMed  Google Scholar 

  4. Radcliffe A, Brown G (2001) Will MRI provide maps of lines of excision for rectal cancer? Lancet 357:495–496

    Article  CAS  PubMed  Google Scholar 

  5. Nelson H, Sargent DJ (2001) Refining multimodal therapy for rectal cancer. N Engl J Med 345:690–692

    Article  CAS  PubMed  Google Scholar 

  6. Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1:1479–1482

    Article  CAS  PubMed  Google Scholar 

  7. Kelly MJ, Lloyd TD, Marshall D et al (2003) A snapshot of MDT working and patient mapping in the UK colorectal cancer centres in 2002. Colorectal Dis 5:577–581

    Article  CAS  PubMed  Google Scholar 

  8. Quirke P (1997) Limitations of existing systems of staging for rectal cancer: the forgotten margin. In: Soreide O, Norstein J; eds. Rectal cancer surgery: optimisation, standardisation, documentation. Springer Verlag, Berlin pp. 63–81

    Google Scholar 

  9. Williams GT, Shepherd NA on behalf of the RCPath Cancer Services Working Group (2007) Dataset for colorectal cancer (2nd edn). The Royal College of Pathologists. Available at www. rcpath.org

  10. Burton S, Brown G, Daniels IR et al (2006) MRI directed multidisciplinary team preoperative treatment strategy: the way to eliminate positive circumferential margins? Br J Cancer 94:351–357

    Article  CAS  PubMed  Google Scholar 

  11. Cervantes A, Rodriguez-Braun E, Navarro S et al (2007) Integrative decisions in rectal cancer. Ann Oncol 18(Suppl 9):ix127–ix131

    Article  PubMed  Google Scholar 

  12. Cervantes A, Rosello S, Rodriguez-Braun E et al (2008) Progress in the multidisciplinary treatment of gastrointestinal cancer and the impact on clinical practice: perioperative management of rectal cancer. Ann Oncol 19(Suppl 7):vii266–vii272

    Article  PubMed  Google Scholar 

  13. Salerno G, Daniels IR, Moran BJ et al (2006) Clarifying margins in the multidisciplinary management of rectal cancer: the MERCURY experience. Clin Radiol 61:916–923

    Article  CAS  PubMed  Google Scholar 

  14. Wiggers T (2003) Staging of rectal cancer. Br J Surg 90:895–896

    Article  CAS  PubMed  Google Scholar 

  15. MERCURY Study Group (2006) Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. BMJ 333:779

    Article  Google Scholar 

  16. Heald RJ, Moran BJ, Ryall RD et al (1998) Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997. Arch Surg 133:894–899

    Article  CAS  PubMed  Google Scholar 

  17. Goh V, Halligan S, Bartram CI (2004) Local radiological staging of rectal cancer. Clin Radiol 59:215–226

    Article  CAS  PubMed  Google Scholar 

  18. Hall NR, Finan PJ, al-Jaberi T et al (1998) Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent. Predictor of survival but not local recurrence? Dis Colon Rectum 41:979–983

    Article  CAS  PubMed  Google Scholar 

  19. Arbman G, Nilsson E, Hallbook O, Sjodahl R (1996) Local recurrence following total mesorectal excision for rectal cancer. Br J Surg 83:375–379

    Article  CAS  PubMed  Google Scholar 

  20. Lopez-Kostner F, Lavery IC, Hool GR et al (1998) Total mesorectal excision is not necessary for cancers of the upper rectum. Surgery 124:612–617

    Article  CAS  PubMed  Google Scholar 

  21. Heald RJ, Smedh RK, Kald A et al (1997) Abdominoperineal excision of the rectum—an endangered operation. Norman Nigro Lectureship. Dis Colon Rectum 40:747–751

    Article  CAS  PubMed  Google Scholar 

  22. Lavery IC, Lopez-Kostner F, Fazio VW et al (1997) Chances of cure are not compromised with sphincter-saving procedures for cancer of the lower third of the rectum. Surgery 122:779–784

    Article  CAS  PubMed  Google Scholar 

  23. Nagtegaal ID, van de Velde CJ, Marijnen CA et al (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 23:9257–9264

    Article  PubMed  Google Scholar 

  24. den Dulk M, Putter H, Collette L et al (2009) The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. Eur J Cancer 45:1175–1183

    Article  Google Scholar 

  25. Holm T, Ljung A, Haggmark T (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94:232–238

    Article  CAS  PubMed  Google Scholar 

  26. West NP, Finan PJ, Anderin C (2008) Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 26:3517–3522

    Article  PubMed  Google Scholar 

  27. Quirke P (2003) Training and quality assurance for rectal cancer: 20 years of data is enough. Lancet Oncol 4:695–702

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  29. Nagtegaal ID, van de Velde CJ, van der Worp E (2002) Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol 20:1729–1734

    Article  PubMed  Google Scholar 

  30. Nagtegaal ID, Marijnen CA, Kranenbarg EK (2002) 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 26:350–357

    Article  PubMed  Google Scholar 

  31. Hermanek P, Hohenberger W, Klimpfinger M (2003) The pathological assessment of mesorectal excision: implications for further treatment and quality management. Int J Colorectal Dis 18:335–341

    CAS  PubMed  Google Scholar 

  32. Enker WE, Levi GS (2009) Macroscopic assessment of mesorectal excision. Cancer 115:4890–4894

    Article  PubMed  Google Scholar 

  33. Garcia-Granero E, Faiz O, Munoz E et al (2009) Macroscopic assessment of mesorectal excision in rectal cancer: a useful tool for improving quality control in a multidisciplinary team. Cancer 115:3400–3411

    Article  PubMed  Google Scholar 

  34. Chan KW, Boey J, Wong SK (1985) A method of reporting radial invasion and surgical clearance of rectal carcinoma. Histopathology 9:1319–1327

    Article  CAS  PubMed  Google Scholar 

  35. de Haas-Kock DF, Baeten CG, Jager JJ et al (1996) Prognostic significance of radial margins of clearance in rectal cancer. Br J Surg 83:781–785

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  39. Ng IO, Luk IS, Yuen ST et al (1993) Surgical lateral clearance in resected rectal carcinomas. A multivariate analysis of clinicopathologic features. Cancer 71:1972–1976

    Article  CAS  PubMed  Google Scholar 

  40. Mekenkamp LJ, van Krieken JH, Marijnen CA et al (2009) Lymph node retrieval in rectal cancer is dependent on many factors-the role of the tumor, the patient, the surgeon, the radiotherapist, and the pathologist. Am J Surg Pathol 33(10):1547–1553

    Article  PubMed  Google Scholar 

  41. Cianchi F, Palomba A, Boddi V et al (2002) Lymph node recovery from colorectal tumor specimens: recommendation for a minimum number of lymph nodes to be examined. World J Surg 26:384–389

    Article  PubMed  Google Scholar 

  42. Kim YW, Kim NK, Min BS (2009) The influence of the number of retrieved lymph nodes on staging and survival in patients with stage II and III rectal cancer undergoing tumor-specific mesorectal excision. Ann Surg 249:965–972

    Article  PubMed  Google Scholar 

  43. Kim YW, Kim NK, Min BS et al (2009) The prognostic impact of the number of lymph nodes retrieved after neoadjuvant chemoradiotherapy with mesorectal excision for rectal cancer. J Surg Oncol 100:1–7

    Article  CAS  PubMed  Google Scholar 

  44. Kerwel TG, Spatz J, Anthuber M et al (2009) Injecting methylene blue into the inferior mesenteric artery assures an adequate lymph node harvest and eliminates pathologist variability in nodal staging for rectal cancer. Dis Colon Rectum 52:935–941

    PubMed  Google Scholar 

  45. Sobin LH, Fleming ID (1997) TNM classification of malignant tumors, fifth edition. Union Internationale Contre le Cancer and the American Joint Committee on Cancer. Cancer 80:1803–1804

    Article  CAS  PubMed  Google Scholar 

  46. Sobin LH (2003) TNM, sixth edition: new developments in general concepts and rules. Semin Surg Oncol 21:19–22

    Article  PubMed  Google Scholar 

  47. Goldstein NS, Turner JR (2000) Pericolonic tumor deposits in patients with T3N+MO colon adenocarcinomas: markers of reduced disease free survival and intra-abdominal metastases and their implications for TNM classification. Cancer 88:2228–2238

    Article  CAS  PubMed  Google Scholar 

  48. Kapiteijn E, Marijnen CA, Nagtegaal ID et al (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345:638–646

    Article  CAS  PubMed  Google Scholar 

  49. Stockholm Rectal Cancer Study Group (1990) Preoperative short-term radiation therapy in operable rectal carcinoma. A prospective randomized trial. Cancer 66:49–55

    Article  Google Scholar 

  50. Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740

    Article  CAS  PubMed  Google Scholar 

  51. Sebag-Montefiore D (2006) Developments in the use of chemoradiotherapy in rectal cancer. Colorectal Dis 8(Suppl)3:14–17

    Article  PubMed  Google Scholar 

  52. Marijnen CA, Nagtegaal ID, Klein Kranenbarg E et al (2001) No downstaging after short-term preoperative radiotherapy in rectal cancer patients. J Clin Oncol 19:1976–1984

    CAS  PubMed  Google Scholar 

  53. Nagtegaal ID, Marijnen CA, Kranenbarg EK et al (2002) Short-term preoperative radiotherapy interferes with the determination of pathological parameters in rectal cancer. J Pathol 197:20–27

    Article  PubMed  Google Scholar 

  54. Wheeler JM, Warren BF, Jones AC, Mortensen NJ (1999) Preoperative radiotherapy for rectal cancer: implications for surgeons, pathologists and radiologists. Br J Surg 86:1108–1120

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  56. Quirke P, Morris E (2007) Reporting colorectal cancer. Histopathology 50:103–112

    Article  CAS  PubMed  Google Scholar 

  57. Newland RC, Dent OF, Chapuis PH, Bokey L (1995) Survival after curative resection of lymph node negative colorectal carcinoma. A prospective study of 910 patients. Cancer 76:564–571

    Article  CAS  PubMed  Google Scholar 

  58. Jass JR, Atkin WS, Cuzick J et al (1986) The grading of rectal cancer: historical perspectives and a multivariate analysis of 447 cases. Histopathology 10:437–459

    Article  CAS  PubMed  Google Scholar 

  59. Tsai HL, Chu KS, Huang YH et al (2009) Predictive factors of early relapse in UICC stage I-III colorectal cancer patients after curative resection. J Surg Oncol 100:736–743

    Article  PubMed  Google Scholar 

  60. Georgescu SO, Neacsu CN, Vintila D et al (2007) [Long-term results after surgery for colorectal adenocarcinoma, stage I–III. Problems of prognosis]. Rev Med Chir Soc Med Nat Iasi 111:932–939.

    PubMed  Google Scholar 

  61. Fitzgerald RH Jr (1982) What is the Dukes’ system for carcinoma of the rectum? Dis Colon Rectum 25:474–477

    Article  PubMed  Google Scholar 

  62. Hase K, Shatney C, Johnson D et al (1993) Prognostic value of tumor “budding” in patients with colorectal cancer. Dis Colon Rectum 36:627–635

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Affiliations

  1. Department of Pathology, Hospital Clínico Universitario University of Valencia. INCLIVA, Av. Blasco Ibáñez, 17, ES-46010, Valencia, Spain

    Carmen Faus & Samuel Navarro

  2. Department of Haemathology and Oncology, Hospital Clínico Universitario University of Valencia. INCLIVA, Valencia, Spain

    Desamparados Roda & Susana Roselló

  3. Department of Surgery, Hospital Clínico Universitario University of Valencia. INCLIVA, Valencia, Spain

    Matteo Frasson, Eduardo García-Granero & Blas Flor-Lorente

Authors
  1. Carmen Faus
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Desamparados Roda
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Matteo Frasson
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Susana Roselló
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Eduardo García-Granero
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Blas Flor-Lorente
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Samuel Navarro
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Carmen Faus.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Faus, C., Roda, D., Frasson, M. et al. The role of the pathologist in rectal cancer diagnosis and staging and surgical quality assessment. Clin Transl Oncol 12, 339–345 (2010). https://doi.org/10.1007/s12094-010-0515-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12094-010-0515-7

Keywords

  • Rectal cancer
  • Diagnosis
  • Pathologic assessment
  • Circumferential radial margin