colorectal margin presentation

8/10/2019 Colorectal Margin Presentation

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Assessment of Margins inColorectal Cancer

SpecimensHolly Brunner, PA(ASCP)Sibley Memorial Hospital

Washington, DC


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3 factors in margin assessment

1. Knowing the margins

2. Handling the specimen correctly

3. Reporting of all the data related to the

margins (Minimal Pathology Data Set)

Focus will be on rectal cases. They require

a little more TLC and the information is alittle newer.


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Part 1: Knowing the Margins

1. Mucosal

2. Serosal

3. Mesenteric radial

4.Radial5.CRM


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Serosal Margin

Peritonealized surface near bowel wall

3 levels of involvement with differentprognoses

2 of those levels are micro level

Take more sections if close

Grave prognosis if involved

Some institutions doing intraoperativeserosal scrapings if tumor appears toapproach surface


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Mesenteric Margin aka mesenteric radial m.

Cecum, Transverse, Sigmoid

Point where the mesentary vessel root is cut by

the surgeon

Specimen should be surrounded by peritoneumat the level of the tumor

Measure distance from deepest tumorpenetration to resection line usually > 5 cm


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Mesenteric margin


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Radial Margin aka adventitial m., lateral m.

Retroperitoneal or perineal adventitial softtissue closest to deepest penetration oftumor

Created by blunt dissection duringsurgery Ascending, Descending, Upper rectum

(partially encased by peritoneum) = radial

margin Distal rectum (not encased) =

circumferential radial margin (CRM)


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Part 2: Assessing and Measuring

Dr. Phil Quirke from Leeds University is leadingprofessor, researcher and honorary consultant oncolorectal cancer reporting and CRM data

Second interest is digital pathology

GI specialist + avid photographer = amazinginstruction on dissecting of colorectal specimens

Publication titles include: Local recurrence of rectal adeno CA is caused by

inadequate surgical resection (1986) Who to treat with adjuvent therapy in Stage II

colorectal CA? The need for high quality pathology(2007)


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Quirkes Protocol

http://www.ualberta.ca/~rmclean/crdiss.htm

http://philquirke.weebly.com/index.html

1. Grade the surgery quality of the specimen2. Fix for 2 days minimum!

3. Serially section

4. Collect Minimal Data Pathology Set

(MPD)
http://www.ualberta.ca/~rmclean/crdiss.htmhttp://philquirke.weebly.com/index.htmlhttp://philquirke.weebly.com/index.htmlhttp://www.ualberta.ca/~rmclean/crdiss.htm


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1. Mesorectum Quality Assessment

Grades 3-1 Intact > Moderate > Incomplete

Great indicator of the patients prognosis

3-Good:

intact, bulky mesorectum


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Grade 3 intact, smooth, complete


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Grade 3


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Grade 3 bulky up to levators


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Grade 2 - Moderateirregularity of themesorectal surface w/

>5 mm defects. Moderate coning. No

visible m.propria

received is a 12 cm length segment ofrecto sigmoid colon with a moderate(ragged but no visible m.propria)excision of the mesorectum


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Grade 2 not intact


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Is it possible for the entire

mesorectum to be removedeven though it has a raggedappearance?

Yes, but it doesn't matter. Once themesorectum has been violated the riskfor spillage of tumor from lymphatics

exists. A ragged specimen without asmooth surface must therefore be agrade 2.


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Grade 1: Poor

Little bulk with defects down ontom.propria and/orvery irregular CRM

The mesorectum is incomplete withdefects exposing m.propria.

TAKE PICTURES!


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Grade 1


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Quirkes Protocol1. Grade surgery quality

2. Ink, Partially cut, Fix for 2 daysminimum!

3. Serially section

4. Collect Minimal Data Pathology Set(MPD)


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3. Serially section 3-5 mm slices 2 cmabove and 2 cm below tumor area


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Quirkes Protocol

1. Grade surgery quality

2. Fix for 2 days minimum!

3. Serially section

4. Collect Minimal Data Pathology Set(MPD)


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4. Measure limit of tumor extension(yellow) and distance of tumor, deposit, ornode to CRM (red)


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Minimal Pathology Data Set

1. Extent of local invasion (w distance beyondm. propria given)

2. # LNs retrieved3. Nodal Stage4. Extramural vascular invasion (EMVI)5. Peritoneal or serosal involvement6. CRM involvement (distance of tumor,

deposit, or +LN to margin)7. Quality of mesorectum

Together the 7 bits help provide a more accurateprognosis and make retrospective analysis better


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Part 3: Reporting the Data

Sounds like the easy part but its actuallythe most difficult to accomplish.


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Part 3: Reporting the data Updating the dynamic TNM system depends on

outcome studies and the collection of outcomedata by the NCDB (National Cancer Data Base).

3 parts of the MPD are being collected with theTNM system and its been useful:

The first 5 ed. of the AJCC staging manual classifiedstage III in a single group but now has subcategories inthe 6thed. because of prognostic figures from NCDBanalysis from 87-93.

Subgroup survival rates were 59.8%, 42%, and 27.3%,respectively when assessing both depth of penetrationand difference btwn


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And there are more issues

TNM system is good for staging and thus giving prognosis based onstudies alreadyperformed. But streamlined reporting often omitsdata (MPD) needed for prognosis and treatment of the patients and

omits data needed to assess possible future staging changes.

Eg. TNM (+) radial margin definition: 0mm

A pt with tumor at the CRM has a 22% chance of local recurrence.But its the same prognosis if distance from CRM to tumor is 1mm.Chance of local recurrence doesnt significantly drop til distance isgreater than 2 mm (5%).

Europe reports CRM as positive if tumor is 1mm or less from theinked radial margin. Places in the US fail to even report on CRMdistance.


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Problem:According to several journals on the staging and prognosis of

colorectal cancer, many centers, especially the US, areomitting data (MPD) pertinent to prognosis and data analysis!

1. Poor assessment of specimen

(informed PAs can fix that issue!)

2. No comprehensive report of data set(pull out the easy button for the pathologists)


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Example comments about specimen assessment:

Frequency of margin involvement is related to the interest of thepathologist. [Dept.] with high LN yields, a good indicator of highquality pathology, are more likely to reflect the true incidence ofCRM involvement.

Examination of additional slides has led to an increase in CRM (+)pts from 6% to 27%.

And they keep going


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..and going

Centers nothaving a special interest in GIpathology reported extramural vascular invasionfindings in 17.8% of cases.In centers with special GI interest, EMVI rates of30% are seen.

If the oncologist is not aware that a pt. ispotentially at risk then treatment could be withheldwith a concomitant increase in the risk of death.


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Get the picture?

In North America, the clinical importance of theCRM has not been widely recognized bypathologists and routine pathological evaluation ofthe CRM has been lacking. Assessment of data

from 3 treatment protocols conducted between79-92 by North Central Cancer Treatment Groupshows the CRM was evaluated pathologically inonly 21% of cases.


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Shout out to the PAs

One pathologist said that NAACLS trainedPAs perform gross pathology and

dissection duties better than mostpathologists. It is doubtful that any pathdept. where dissections are performed bypathologists can match [their] quality of

work. But the use of PAs is not universal.(Dr. Goldstien of William Beaumont Hospt., Royal Oaks MI)


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SolutionIncorporate all necessary data in to the gross report.

Talk with your pathologists about including all the data. Thereport reflects on your skills, the pathologists, the depts andthe hospital. Most importantly, it affects the patient!Patients have been refused into a trial based on lack of

information.

Become


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Magnum G.I.


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Conclusion

Take all the necessary measurements Comment on the serosa and mesocolon and

back up assessment with photos Take extra sections if necessary Fix the specimen for best cutting and

measurements Find all the lymph nodes (12-15+)

Talk to your pathologists about getting thedata in to the report Go to tumor board so the surgeons are

familiar with you


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PS.

Positive node AT mesenteric margin: no

research on it yet. But Dr. Quirke says itssimilar to a Dukes C2 (+ln at high tie). Somargin now is reported (-) but note

should be included in the report statingthat a + LN was at the margin.


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