MAJOR CHANGES IN THE STAGING OF COLORECTAL CANCER

Dongfeng Tan, MD

Adopted from the 7^th Edition of AJCC, please read the original book chapter for more detailed information

I.  Primary Tumor

Circumferential Resection Margins. It is essential that accurate pathologic evaluation of the CRM adjacent to the deepest point of the tumor invasion be performed. The CRM is the surgically dissected nonperitonealized surface of the specimen. It corresponds to any aspect of the colorectum that is not covered by a serosal layer of mesothelial cells and must be dissected from the retroperitoneum or sub-peritoneum in order to remove the viscus.

For resection cases, the resection (R) codes should be given for each procedure:

• R0 – Complete tumor resection with all margins histologically negative
• R1 – Incomplete tumor resection with microscopic surgical resection margin involvement (margins grossly uninvolved)
• R2 – Incomplete tumor resection with gross residual tumor that was not resected (primary tumor, regional nodes, macroscopic margin involvement)

Designation of Primary Tumor (T)

TX         Primary tumor cannot be assessed

T0         No evidence of primary tumor

Tis        Carcinoma in situ: intraepithelial or invasion of lamina propria*

T1         Tumor invades submucosa

T2         Tumor invades muscularis propria

T3         Tumor invades through the muscularis propria into pericolorectal tissues

T4a        Tumor penetrates to the surface of the visceral peritoneum

T4b        Tumor directly invades or is adherent to other organs or structures

*Note: The definition of in situ carcinoma – pTis – includes cancer cells confined within the glandular basement membrane (intraepithelial) or lamina propria (intramucosal) with no extension through the muscularis mucosae into the submucosa. Neither intraepithelial nor intramucosal carcinomas of the large intestine are associated with risk for metastasis.

Expanded data sets have shown differential prognosis within T4 lesions based on extent of disease. Accordingly, T4 lesions are subdivided as T4a (tumor penetrates the surface of the visceral peritoneum) and as T4b. (Tumor directly invades or is histologically adherent to other organs or structures)

II. Regional Lymph Nodes

It is essential that the total number of regional lymph nodes recovered from the resection specimen be described since that number is prognostically important.

It is recommended to obtain at least 10-14 lymph nodes in radical colon and rectum resections in patients without neoadjuvant therapy.  If the tumor is resected for palliation or in patients who have received preoperative radiation, fewer lymph nodes may be removed or present. A pN0 determination is assigned when these nodes are histologically negative, even though fewer than the recommended number of nodes has been analyzed. However, when fewer than the number of nodes recommended by the College of American Pathologists (CAP) have been found, it is important that the pathologist report the degree of diligence of their efforts to find lymph nodes in the specimen.

Designation of Regional Lymph Nodes (N)

NX      Regional lymph nodes cannot be assessed

N0       No regional lymph node metastasis*

N1       Metastasis in 1-3 regional lymph nodes

N1a     Metastasis in one regional lymph node

N1b     Metastasis in 2-3 regional lymph nodes

N1c     Tumor deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional nodal metastasis

N2       Metastasis in four or more regional lymph nodes

N2a     Metastasis in 4-6 regional lymph nodes

N2b     Metastasis in seven or more regional lymph nodes

• The interpretation of very small amounts of detected tumor in regional lymph nodes will continue to be classified as pN0. The prognostic significance of ITCs, defined as single malignant cells or a few tumor cells in microscopical clusters, identified in regional lymph nodes that otherwise would be considered to be negative is still unclear. It should be noted that isolated tumor cells identified on H&E stains alone are also classified as ITC and are annotated in the same fashion as ITC seen on immunohistochemical stains (i.e., pN0(i+);”i”= ”isolated tumor cells”).

The potential importance of satellite tumor deposits is now defined by the new site-specific factor Tumor Deposits (TD) that describes their texture and number. T1-2 lesions that lack regional lymph node metastasis but have tumor deposit(s) will be classified in addition as N1c

• The number of nodes involved with metastasis influences prognosis within both N1 and N2 groups. Accordingly N1 will be subdivided as N1a (metastasis in 1 regional node) and N1b (metastasis in 2-3 nodes), and N2 will be subdivided as N2a (metastasis in 4-6 nodes) and N2b (metastasis in 7 or more nodes)

 III.  Metastatic sites.

Carcinomas of the colon and rectum can metastasize to almost any organ, with the liver and lungs being most commonly involved. Tumor can also spread to other segments of the colon, small intestine, or peritoneum.

Designation of Distant Metastasis (M)

M0       No distant metastasis

M1       Distant metastasis

M1a     Metastasis confined to one organ or site (e.g., liver, lung, ovary, and nonregional node)

M1b     Metastases in more than one organ/site or the peritoneum

 IV.    SUMMARY OF ANTATOMIC STAGE/PROGNOSTIC GROUPS

Stage                  

T                      N                     M                   

0

Tis                    N0                   M0                  

I                      

T1                     N0                   M0                  

T2                     N0                   M0                  

IIA                     

 T3                    N0                   M0                  

IIB                      

  T4a                  N0                   M0                  

IIC                     

  T4b                  N0                   M0                  

IIIA                    

   T1-T2              N1/N1c                M0    

   T1                   N2a                 M0                  

IIIB                   

   T3-T4a               N1/N1c              M0                  

    T2-T3               N2a                 M0                  

    T1-T2               N2b                 M0                  

IIIC                   

    T4a                 N2a                 M0                  

    T3-T4a              N2b                 M0                  

    T4b                 N1-N2               M0                  

IVA                

         Any T               Any N              M1a   

IVB                 

         Any T               Any N              M1b                

__________________________________________________________

.           The y prefix is used for those cancers that are classified after Neoadjuvant pretreatment (e.g., ypTNM). Patients who have a complete pathologic response are ypT0N0cM0 that may be similar to Stage Group 0 or I. The r prefix is to be used for those cancers that have recurred after a disease-free interval (rTNM).

• In the seventh edition of AJCC Staging Manual, further substaging of Stage II and III has been accomplished, based on new survival and relapse data.

• Stage Group II is subdivided into IIA (T3N0), IIB (T4aN0) and IIC (T4bN0)

• Stage Group III:
• A category of N1 lesions, T4bN1, that was formerly classified as IIIB was found to have outcomes more akin to IIIC and has been reclassified from IIIB to IIIC
• Similarly, several categories of N2 lesions formerly classified as IIIC have outcomes more akin to other stage groups; therefore, T1N2a has been reclassified as IIIA and T1N2b, T2N2a-b, and T3N2a have all been reclassified as IIIB

Tumor Regression Grade.

The pathologic response to preoperative adjuvant treatment should be recorded according to the CAP Protocol for the examination of Specimens from Patients with Carcinomas of the Colon and Rectum), since  neoadjuvant chemoradiation in rectal cancer is  associated with significant treatment effect and often down-staging.

 老师讲得好，厉害，你们翻译得也厉害

好

II. 局部淋巴结

 从切除的标本中寻找全部局部淋巴结是必需的，因为淋巴结数目对预后非常重要。

 对根治性结肠和直肠切除而未行新辅助治疗的病人建议至少检测10-14个淋巴结。如果肿瘤因姑息性或接受术前放疗，那么切除的标本中检出的淋巴结少。pN0是指检出的淋巴结组织学检查均为阴性，即使检出的淋巴结数目少于推荐的检出数目。然而，当检出的淋巴结少于美国病理学会（CAP）推荐的检出淋巴结数目时，病理报告中应注明寻找标本中淋巴结努力的程度。

局部淋巴结的命名（N）

NX      局部淋巴结不能评价

N0       无局部淋巴结转移*

N1       1-3个局部淋巴结转移

N1a     1个局部淋巴结转移

N1b     2-3个局部淋巴结转移

N1c     浆膜下、肠系膜或非腹膜覆盖的结肠周围或直肠周围组织中有肿瘤但无局部淋巴结转移

N2      4个或以上局部淋巴结转移

N2a     4-6个局部淋巴结转移

N2b     7个或以上局部淋巴结转移

局部淋巴结内检出非常少的肿瘤将继续归类为pN0。ITCs定义为单个的恶性细胞或少量镜下群集的肿瘤细胞，其在局部淋巴结的预后意义以及是否可认为是阴性仍不清楚。应指出的是在单个HE染色切片中发现的孤立的肿瘤细胞也归类为ITC，应根据免疫组化染色中见到的ITC同样形式进行注解（如pN0(i+);”i”= “孤立的肿瘤细胞”）

 肿瘤卫星灶的潜在意义现已定义为新的部位特异性肿瘤灶，应描述其质地和数量。缺乏局部淋巴结转移但有肿瘤灶的T1-2病变将另外归类为N1c。

 N1和N2组中转移的淋巴结数目影响病人的预后。相应地N1将分为N1a（1个局部淋巴结转移）和N1b（2-3个局部淋巴结转移），N2分为N2a（4-6个淋巴结转移）和N2b（7个或以上淋巴结转移）

 结直肠癌分期的主要改变

谈东风

引自AJCC第7版，请阅读原著章节以获得详细信息

I.  原发肿瘤

Tis  原位癌：上皮内或黏膜固有层浸润*

T1     肿瘤侵犯黏膜下层

T2     肿瘤侵犯肌层

T3     肿瘤侵犯穿透肌层进入结肠周围组织   

T4a       肿瘤穿透到脏层腹膜的表面

T4b     肿瘤直接侵犯或粘附到其他器官或结构

较大范围的资料显示在T4病变内病人的预后基于疾病的范围。相应地可将T4病变分为T4a（肿瘤侵犯脏层腹膜表面）和T4b（肿瘤直接侵犯或组织学上与其他器官或组织黏连）

 重大改变的结肠直肠癌分期
　　
　　　
　　从第7版,请阅读AJCC原书一章更详细的信息
　　
　　　即原发性肿瘤
　　环状切除的利润。它是必要的,精确的病理诊断价值CRM邻近的肿瘤侵犯的最深的地方。CRM是外科nonperitonealized表面的解剖标本。它符合任何方面的colorectum那不是覆盖著一层mesothelial细胞浆膜,必须从后腹膜解剖或sub-peritoneum为了拆卸viscus。
　
　　手术切除术病例,(R)代码应该给每个步骤:
　　
　　R0 -完全切除肿瘤,与所有的利润在组织学上负面
　　R1 -完全切除肿瘤切除和微观关联(利润过分局外)。
　　R2 -完全切除肿瘤残留与未切除肿瘤原发肿瘤、区域淋巴结(宏观关联),
　　
　　指定原发性肿瘤(T)。
　　
　　德克萨斯州的原发性肿瘤无法评定
　　
　　没有证据表明,每原发肿瘤
　　
　　说明:这原位癌或侵略的固有层
　　
　　粘膜下肿瘤侵入T1
　　
　　此例中肿瘤侵入层是
　　
　　T3肿瘤侵入到pericolorectal固有肌组织
　　
　　T4a肿瘤渗透到表面的内脏手术
　　
　　T4b肿瘤直接侵入或附着到其他器官或结构
　　
注:* *的定义——pTis原位癌肿瘤细胞——包括局限在腺体基底膜(说明)或固有层采用)没有肌到黏膜下层。既不采用的上皮癌与大肠癌的风险转移。
　　扩展的数据集内所显示的微分预后情况的基础上的疾病病变程度。因此,T4病变分为作为T4a(肿瘤渗透表面的内脏腹膜)和T4b。(肿瘤直接侵入或组织学附着到其他器官或结构)。
　　二。区域淋巴结
　　这是最基本的总数量的区域淋巴结切除标本中描述的号码是prognostically以来最重要的。
　　这是推荐获得至少10-14淋巴结结肠和直肠重建激进病人没有新辅助治疗。如果肿瘤切除患者得到缓解或收到术前放疗,更少的淋巴结可以拆卸或礼物。一个pN0时确定这些节点分配组织学消极,虽然少于推荐的节点进行了分析。然而,当少于这个数量的节点推荐的美国病理学家协会(CAP)已经被发现,但重要的是,在病理报告了他们的努力程度勤奋发现淋巴结标本。
　　指定区域淋巴结(N)。
　　NX淋巴结无法评定
　　没有任何区域淋巴结转移
　  在1-3 N1转移的淋巴结
　　N1a在一个区域淋巴结转移
　　N1b 2-3区域淋巴结转移
　　N1c肿瘤存款(s)在subserosa、输卵管、或nonperitonealized pericolic或直肠周组织没有区域淋巴结转移
　　在四个或更多N2转移的淋巴结
　　N2a 4-6区域淋巴结转移
　　N2b转移七个以上的淋巴结
　　解释很少量的探测局部淋巴结切除仍将继续为pN0。ITCs的预后意义,定义为单一的恶性细胞或几肿瘤细胞,在微观集群区域淋巴结,否则会被认为是消极的,尚不清楚。应该注意的是孤立的肿瘤细胞中H&E污渍也列为ITC仅在相同,诠释时尚为国贸看到免疫组织化学污渍(例如,pN0(+);“我”= "孤立的肿瘤细胞”)。
　　潜在的重要性是现在的卫星肿瘤存款所定义的新地点的因素(TD),肿瘤描述他们的纹理和电话号码。T1-2病灶局部淋巴结转移的缺乏,但有肿瘤存款(s)将被归类为N1c除
　　节点内影响预后涉及转移双方N1及N2期的团体。因此N1将细分为N1a区域淋巴结转移(1)和N1b(转移),N2期2-3节点将作为N2a(转移)和N2b 4-6节点(转移7或更多的节点)。
　　结肠和直肠的癌转移到几乎任何机关可以与肝、肺,是最常见的参与。肿瘤也可以扩展到其他部分肠癌、小肠,或手术。
　　指定远处转移(M)。
　　M0无远处转移
　　M1远处转移
　　M1a局限于一个器官或转移(例如肝、肺、卵巢和nonregional节点)。
　　M1b转移在多个机构/网站或手术
　四。总结ANTATOMIC阶段/预后组
　　T0　
　　T1　　
　　T2

    IIA
    T3　　
　　IIB

    T4a

　　IIC

    T4b　　
　　IIIA
　　N1c t1 - t2 N1(M0)
　　T1 N2a M0)
　　化疗

    T3-T4a N1 / N1c M0)
　　T2-T3 N2a M0)
　　t1 - t2 N2b M0)
　　IIIC
　　T4a N2a M0)
　　T3-T4a N2b M0)
　　T4b N1-N2 M0)
　　M1a
　　IVB
　　任何一个M1b
　　
　　。y前缀是用于癌症,分类预处理后(例如,ypTNM新辅助)。病人有完整的病理反应是ypT0N0cM0相似,可能是0或一组的r前缀用于癌症复发后,便选择了健康的间隔(rTNM)。
　　在第七版的AJCC分期手册,进一步substaging的第二和第三阶段已经完成,基于新的生存和复发的数据。
　　被细分为ⅱIIA(T3N0)件,国际投资(T4aN0)和IIC(T4bN0)。
　　III族阶段。
　　一个类,T4bN1,N1病变以前列为化疗被发现结果更类似于IIIC和被重新来IIIC从用户
　　同样,几个类别划分N2病变分为IIIC从前有结果更类似于其他阶段,因此,T1N2a团体已经重新定为IIIA和T1N2b,T2N2a-b,T3N2a都被重新定为化疗
　　肿瘤退缩的品位。
　　手术病理反应辅助治疗应记录根据帽协议的患者标本的结肠和直肠),因为新辅助放化疗在直肠癌是明显疗效,经常的治疗。

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 学习了，谢谢谈教授