ABSTRACT
Since Cuthbert Dukes fundamental work linking cancer stage to prognosis, the pathologist
has had an ever-expanding role in the multidisciplinary management of rectal cancer.
Gross dissection techniques and histologic evaluation are reviewed. The evolving tumor
size, node status, metastasis classification (TNM) staging system is outlined. The
pathologist's critical role in correctly assessing circumferential margins and establishing
resection adequacy and staging accuracy via lymph node assessment is emphasized.
KEYWORDS
Rectal cancer - total mesorectal excision - tumor size - node status - metastasis
(TNM) classification - pathological evaluation
REFERENCES
- 1
Dukes C.
The classification of cancer of the rectum.
J Pathol Bacteriol.
1932;
35
323-332
- 2 Breasalier R S, Kim Y S.
Malignant neoplasms of the large intestine. In: Feldman MF, Scharschmidt BF, Sleisenger MH Gastrointestinal and Liver Disease. Philadelphia;
WB Saunders 1998: 1923-1926
- 3 Sobin L H, Wittekind C H. TNM Classification of Malignant Tumours. 6th ed. Hoboken,
NJ; John Wiley & Sons 2002
- 4
Gospodarowicz M K, Miller D, Groome P A, Greene F L, Logan P A, Sobin L H.
The process for continuous improvement of the TNM classification.
Cancer.
2004;
100(1)
1-5
- 5
Goldstein N S, Soman A, Sacksner J.
Disparate surgical margin lengths of colorectal resection specimens between in vivo
and in vitro measurements. The effects of surgical resection and formalin fixation
on organ shrinkage.
Am J Clin Pathol.
1999;
111(3)
349-351
- 6
Weiss S W, Willis J, Jansen J, Goldblum J, Greenfield L.
Frozen section consultation. Utilization patterns and knowledge base of surgical faculty
at a university hospital.
Am J Clin Pathol.
1995;
104(3)
294-298
- 7
Henson D E, Hutter R V, Sobin L H, Bowman H E.
Protocol for the examination of specimens removed from patients with colorectal carcinoma.
A basis for checklists. Cancer Committee, College of American Pathologists. Task Force
for Protocols on the Examination of Specimens from Patients with Colorectal Cancer.
Arch Pathol Lab Med.
1994;
118(2)
122-125
- 8
Compton C C, Fielding L P, Burgart L J et al..
Prognostic factors in colorectal cancer. College of American Pathologists Consensus
Statement 1999.
Arch Pathol Lab Med.
2000;
124(7)
979-994
- 9
Prabhudesai A G, Dalton R, Kumar D, Finlayson C J.
Mechanised one-day fat clearance method to increase the lymph node yield in rectal
cancer specimens.
Br J Biomed Sci.
2005;
62(3)
120-123
- 10
Cawthorn S J, Gibbs N M, Marks C G.
Clearance technique for the detection of lymph nodes in colorectal cancer.
Br J Surg.
1986;
73(1)
58-60
- 11
Haboubi N Y, Clark P, Kaftan S M, Schofield P F.
The importance of combining xylene clearance and immunohistochemistry in the accurate
staging of colorectal carcinoma.
J R Soc Med.
1992;
85(7)
386-388
- 12
Blenkinsopp W K, Stewart-Brown S, Blesovsky L, Kearney G, Fielding L P.
Histopathology reporting in large bowel cancer.
J Clin Pathol.
1981;
34(5)
509-513
- 13
Compton C C.
Colorectal carcinoma: diagnostic, prognostic, and molecular features.
Mod Pathol.
2003;
16(4)
376-388
- 14
Jass J R, Love S B, Northover J M.
A new prognostic classification of rectal cancer.
Lancet.
1987;
1(8545)
1303-1306
- 15
Harrison J C, Dean P J, el-Zeky F, Vander Zwaag R.
From Dukes through Jass: pathological prognostic indicators in rectal cancer. [see
comments].
Hum Pathol.
1994;
25(5)
498-505
- 16 Hamilton S R, Rubio C A, Vogelstein B et al..
Carcinoma of the colon and rectum. In: Hamilton SR, Aaltonen LA World Health Organization Classification of Tumors. Lyon,
France; IARC Press 2000: 101-119
- 17
Nissan A, Guillem J G, Paty P B, Wong W D, Cohen A M.
Signet-ring cell carcinoma of the colon and rectum: a matched control study.
Dis Colon Rectum.
1999;
42(9)
1176-1180
- 18
Kang H, O'Connell J B, Maggard M A, Sack J, Ko C Y.
A 10-year outcomes evaluation of mucinous and signet-ring cell carcinoma of the colon
and rectum.
Dis Colon Rectum.
2005;
48(6)
1161-1168
- 19
Vilor M, Tsutsumi Y, Osamura R Y et al..
Small cell neuroendocrine carcinoma of the rectum.
Pathol Int.
1995;
45(8)
605-609
- 20
Ihtiyar E, Algin C, Isiksoy S, Ates E.
Small cell carcinoma of rectum: a case report.
World J Gastroenterol.
2005;
11(20)
3156-3158
- 21
Cebrian J, Larach S W, Ferrara A et al..
Small-cell carcinoma of the rectum: report of two cases.
Dis Colon Rectum.
1999;
42(2)
274-277
- 22
Freedman L S, Macaskill P, Smith A N.
Multivariate analysis of prognostic factors for operable rectal cancer.
Lancet.
1984;
2(8405)
733-736
- 23
Jass J R, Atkin W S, Cuzick J et al..
The grading of rectal cancer: historical perspectives and a multivariate analysis
of 447 cases.
Histopathology.
1986;
10(5)
437-459
- 24
Compton C C.
Pathology report in colon cancer: what is prognostically important?.
Dig Dis.
1999;
17(2)
67-79
- 25
Hermanek P, Guggenmoos-Holzmann I, Gall F P.
Prognostic factors in rectal carcinoma. A contribution to the further development
of tumor classification.
Dis Colon Rectum.
1989;
32(7)
593-599
- 26
Schlemper R J, Riddell R H, Kato Y et al..
The Vienna classification of gastrointestinal epithelial neoplasia.
Gut.
2000;
47(2)
251-255
- 27
Goldstein N S, Hart J.
Histologic features associated with lymph node metastasis in stage T1 and superficial
T2 rectal adenocarcinomas in abdominoperineal resection specimens. Identifying a subset
of patients for whom treatment with adjuvant therapy or completion abdominoperineal
resection should be considered after local excision.
Am J Clin Pathol.
1999;
111(1)
51-58
- 28
Chapuis P H, Dent O F, Fisher R et al..
A multivariate analysis of clinical and pathological variables in prognosis after
resection of large bowel cancer.
Br J Surg.
1985;
72(9)
698-702
- 29
Newland R C, Dent O F, Lyttle M N, Chapuis P H, Bokey E L.
Pathologic determinants of survival associated with colorectal cancer with lymph node
metastases. A multivariate analysis of 579 patients.
Cancer.
1994;
73(8)
2076-2082
- 30
Deans G T, Patterson C C, Parks T G et al..
Colorectal carcinoma: importance of clinical and pathological factors in survival.
Ann R Coll Surg Engl.
1994;
76(1)
59-64
- 31
Michelassi F, Ayala J J, Balestracci T, Goldberg R, Chappell R, Block G E.
Verification of a new clinicopathologic staging system for colorectal adenocarcinoma.
Ann Surg.
1991;
214(1)
11-18
- 32 Hermanek P, Henson D E, Hutter R V, Sobin L H. TNM Supplement. New York, NY; Springer-Verlag
Inc. 1993
- 33
Shepherd N A, Baxter K J, Love S B.
The prognostic importance of peritoneal involvement in colonic cancer: a prospective
evaluation.
Gastroenterology.
1997;
112(4)
1096-1102
- 34
Knudsen J B, Nilsson T, Sprechler M, Johansen A, Christensen N.
Venous and nerve invasion as prognostic factors in postoperative survival of patients
with resectable cancer of the rectum.
Dis Colon Rectum.
1983;
26(9)
613-617
- 35
Talbot I C, Ritchie S, Leighton M H, Hughes A O, Bussey H J, Morson B C.
The clinical significance of invasion of veins by rectal cancer.
Br J Surg.
1980;
67(6)
439-442
- 36
Cooper H S, Deppisch L M, Gourley W K et al..
Endoscopically removed malignant colorectal polyps: clinicopathologic correlations.
Gastroenterology.
1995;
108(6)
1657-1665
- 37
Cranley J P, Petras R E, Carey W D, Paradis K, Sivak M V.
When is endoscopic polypectomy adequate therapy for colonic polyps containing invasive
carcinoma?.
Gastroenterology.
1986;
91(2)
419-427
- 38
Sitzler P J, Seow-Choen F, Ho Y H, Leong A P.
Lymph node involvement and tumor depth in rectal cancers: an analysis of 805 patients.
Dis Colon Rectum.
1997;
40(12)
1472-1476
- 39
Goldstein N S.
Lymph node recoveries from 2427 pT3 colorectal resection specimens spanning 45 years:
recommendations for a minimum number of recovered lymph nodes based on predictive
probabilities.
Am J Surg Pathol.
2002;
26(2)
179-189
- 40
Kikuchi R, Takano M, Takagi K et al..
Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines.
Dis Colon Rectum.
1995;
38(12)
1286-1295
- 41
Enker W E, Thaler H T, Cranor M L, Polyak T.
Total mesorectal excision in the operative treatment of carcinoma of the rectum.
J Am Coll Surg.
1995;
181(4)
335-346
- 42
Shirouzu K, Isomoto H, Kakegawa T.
Prognostic evaluation of perineural invasion in rectal cancer.
Am J Surg.
1993;
165(2)
233-237
- 43
Jass J R.
Lymphocytic infiltration and survival in rectal cancer.
J Clin Pathol.
1986;
39(6)
585-589
- 44
Benatti P, Gafa R, Barana D et al..
Microsatellite instability and colorectal cancer prognosis.
Clin Cancer Res.
2005;
11(23)
8332-8340
- 45
Shia J, Ellis N A, Paty P B et al..
Value of histopathology in predicting microsatellite instability in hereditary nonpolyposis
colorectal cancer and sporadic colorectal cancer.
Am J Surg Pathol.
2003;
27(11)
1407-1417
- 46
Hase K, Shatney C, Johnson D, Trollope M, Vierra M.
Prognostic value of tumor “budding” in patients with colorectal cancer.
Dis Colon Rectum.
1993;
36(7)
627-635
- 47
Adam I J, Mohamdee M O, Martin I G et al..
Role of circumferential margin involvement in the local recurrence of rectal cancer.
Lancet.
1994;
344(8924)
707-711
- 48
Hall N R, Finan P J, al-Jaberi T et al..
Circumferential margin involvement after mesorectal excision of rectal cancer with
curative intent. Predictor of survival but not local recurrence?.
Dis Colon Rectum.
1998;
41(8)
979-983
- 49
Astler V B, Coller F A.
The prognostic significance of direct extension of carcinoma of the colon and rectum.
Ann Surg.
1954;
139(6)
846-852
- 50
Quirke P, Durdey P, Dixon M F, Williams N S.
Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological
study of lateral tumour spread and surgical excision.
Lancet.
1986;
2(8514)
996-999
- 51
Heald R J, Ryall R D.
Recurrence and survival after total mesorectal excision for rectal cancer.
Lancet.
1986;
1(8496)
1479-1482
- 52
Kapiteijn E, Marijnen C A, Nagtegaal I D et al..
Preoperative radiotherapy combined with total mesorectal excision for resectable rectal
cancer.
N Engl J Med.
2001;
345(9)
638-646
- 53
Nagtegaal I D, Marijnen C A, Kranenbarg E K, van de Velde C J, van Krieken J H.
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(3)
350-357
- 54
Stocchi L, Nelson H, Sargent D J et al..
Impact of surgical and pathologic variables in rectal cancer: a United States community
and cooperative group report.
J Clin Oncol.
2001;
19(18)
3895-3902
- 55
Compton C C.
Updated protocol for the examination of specimens from patients with carcinomas of
the colon and rectum, excluding carcinoid tumors, lymphomas, sarcomas, and tumors
of the vermiform appendix: a basis for checklists. Cancer Committee.
Arch Pathol Lab Med.
2000;
124(7)
1016-1025
- 56
Schofield J B, Mounter N A, Mallett R, Haboubi N Y.
The importance of accurate pathological assessment of lymph node involvement in colorectal
cancer.
Colorectal Dis.
2006;
8(6)
460-470
- 57
Wright F C, Law C H, Last L et al..
Lymph node retrieval and assessment in stage II colorectal cancer: a population-based
study.
Ann Surg Oncol.
2003;
10(8)
903-909
- 58
Schrag D, Gelfand S E, Bach P B, Guillem J, Minsky B D, Begg C B.
Who gets adjuvant treatment for stage II and III rectal cancer? Insight from surveillance,
epidemiology, and end results-Medicare.
J Clin Oncol.
2001;
19(17)
3712-3718
- 59
Cianchi F, Palomba A, Boddi V et al..
Lymph node recovery from colorectal tumor specimens: recommendation for a minimum
number of lymph nodes to be examined.
World J Surg.
2002;
26(3)
384-389
- 60
Caplin S, Cerottini J P, Bosman F T, Constanda M T, Givel J C.
For patients with Dukes' B (TNM Stage II) colorectal carcinoma, examination of six
or fewer lymph nodes is related to poor prognosis.
Cancer.
1998;
83(4)
666-672
- 61
Esser S, Reilly W T, Riley L B, Eyvazzadeh C, Arcona S.
The role of sentinel lymph node mapping in staging of colon and rectal cancer.
Dis Colon Rectum.
2001;
44(6)
850-854
discussion 4-6
- 62
Berberoglu U.
Prognostic significance of total lymph node number in patients with T1-4N0M0 colorectal
cancer.
Hepatogastroenterology.
2004;
51(60)
1689-1693
- 63
Wong J H, Severino R, Honnebier M B, Tom P, Namiki T S.
Number of nodes examined and staging accuracy in colorectal carcinoma.
J Clin Oncol.
1999;
17(9)
2896-2900
- 64
Hernanz F, Revuelta S, Redondo C, Madrazo C, Castillo J, Gomez-Fleitas M.
Colorectal adenocarcinoma: quality of the assessment of lymph node metastases.
Dis Colon Rectum.
1994;
37(4)
373-376
discussion 6-7
- 65
Goldstein N S, Sanford W, Coffey M, Layfield L J.
Lymph node recovery from colorectal resection specimens removed for adenocarcinoma.
Trends over time and a recommendation for a minimum number of lymph nodes to be recovered.
[see comments].
Am J Clin Pathol.
1996;
106(2)
209-216
- 66 Sobin L H, Wittekind C. TNM-Classification of Malignant Tumors. New York, NY; Springer
1997
- 67
Sobin L H, Greene F L.
TNM classification: clarification of number of regional lymph nodes for pNo.
Cancer.
2001;
92(2)
452
- 68
Nelson H, Petrelli N, Carlin A et al..
Guidelines 2000 for colon and rectal cancer surgery.
J Natl Cancer Inst.
2001;
93(8)
583-596
- 69
Baxter N N, Virnig D J, Rothenberger D A, Morris A M, Jessurun J, Virnig B A.
Lymph node evaluation in colorectal cancer patients: a population-based study.
J Natl Cancer Inst.
2005;
97(3)
219-225
- 70
Monig S P, Baldus S E, Zirbes T K et al..
Lymph node size and metastatic infiltration in colon cancer.
Ann Surg Oncol.
1999;
6(6)
579-581
- 71
Wijesuriya R E, Deen K I, Hewavisenthi J, Balawardana J, Perera M.
Neoadjuvant therapy for rectal cancer down-stages the tumor but reduces lymph node
harvest significantly.
Surg Today.
2005;
35(6)
442-445
- 72
Wichmann M W, Muller C, Meyer G et al..
Effect of preoperative radiochemotherapy on lymph node retrieval after resection of
rectal cancer.
Arch Surg.
2002;
137(2)
206-210
- 73
Bernini A, Spencer M, Frizelle S et al..
Evidence for colorectal cancer micrometastases using reverse transcriptase-polymerase
chain reaction analysis of MUC2 in lymph nodes.
Cancer Detect Prev.
2000;
24(1)
72-79
- 74
NIH consensus conference .
Adjuvant therapy for patients with colon and rectal cancer.
JAMA.
1990;
264(11)
1444-1450
- 75
Camma C, Giunta M, Fiorica F, Pagliaro L, Craxi A, Cottone M.
Preoperative radiotherapy for resectable rectal cancer: A meta-analysis.
JAMA.
2000;
284(8)
1008-1015
- 76
Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish
Rectal Cancer Trial.
N Engl J Med.
1997;
336(14)
980-987
- 77
Bouzourene H, Bosman F T, 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(4)
1121-1130
- 78
Kaminsky-Forrett M C, Conroy T, Luporsi E et al..
Prognostic implications of downstaging following preoperative radiation therapy for
operable T3-T4 rectal cancer.
Int J Radiat Oncol Biol Phys.
1998;
42(5)
935-941
- 79
Janjan N A, Abbruzzese J, Pazdur R et al..
Prognostic implications of response to preoperative infusional chemoradiation in locally
advanced rectal cancer.
Radiother Oncol.
1999;
51(2)
153-160
- 80
Wheeler J M, Warren B F, Mortensen N J et al..
Quantification of histologic regression of rectal cancer after irradiation: a proposal
for a modified staging system.
Dis Colon Rectum.
2002;
45(8)
1051-1056
- 81
Minsky B D, Cohen A M, Kemeny N et al..
Enhancement of radiation-induced downstaging of rectal cancer by fluorouracil and
high-dose leucovorin chemotherapy.
J Clin Oncol.
1992;
10(1)
79-84
- 82
Ryan R, Gibbons D, Hyland J M et al..
Pathological response following long-course neoadjuvant chemoradiotherapy for locally
advanced rectal cancer.
Histopathology.
2005;
47(2)
141-146
- 83
Shia J, Guillem J G, Moore H G et al..
Patterns of morphologic alteration in residual rectal carcinoma following preoperative
chemoradiation and their association with long-term outcome.
Am J Surg Pathol.
2004;
28(2)
215-223
- 84
Rodel C, Martus P, Papadoupolos T et al..
Prognostic significance of tumor regression after preoperative chemoradiotherapy for
rectal cancer.
J Clin Oncol.
2005;
23(34)
8688-8696
- 85
Pucciarelli S, Toppan P, Friso M L et al..
Complete pathologic response following preoperative chemoradiation therapy for middle
to lower rectal cancer is not a prognostic factor for a better outcome.
Dis Colon Rectum.
2004;
47(11)
1798-1807
- 86
Machiels J P, Aydin S, Bonny M A, Hammouch F, Sempoux C.
What is the best way to predict disease-free survival after preoperative radiochemotherapy
for rectal cancer patients: tumor regression grading, nodal status, or circumferential
resection margin invasion?.
J Clin Oncol.
2006;
24(8)
1319
, author reply 1320-1321
- 87
Ruo L, Tickoo S, Klimstra D S et al..
Long-term prognostic significance of extent of rectal cancer response to preoperative
radiation and chemotherapy.
Ann Surg.
2002;
236(1)
75-81
- 88
Hemmings C, Jeffery M, Frizelle F.
Changes in the pathology reporting of rectal cancer: is it time to adopt synoptic
reporting?.
N Z Med J.
2003;
116(1178)
U513
- 89
Murari M, Pandey R.
A synoptic reporting system for bone marrow aspiration and core biopsy specimens.
Arch Pathol Lab Med.
2006;
130(12)
1825-1829
Joseph WillisM.D.
Department of Pathology, Case Western Reserve University, University Hospitals Case
Medical Center
11100 Euclid Ave., Cleveland, OH 44106
Email: josephe.willis@uhhospitals.org