2015 UCSF CURRENT ISSUES IN SURGICAL PATHOLOGY

2015 UCSF CURRENT ISSUES IN SURGICAL PATHOLOGY

Staging of colorectal and

appendiceal cancers

Staging of colorectal and

appendiceal cancers

Keeping the pathologists sane and the surgeons happy

Keeping the pathologists sane and the surgeons happy

Sanjay Kakar, MD

Sanjay Kakar, MD

Neils Bohr: Nobel Prize 1922 Einstein: Nobel Prize 1921

Prognostication is very difficult, God does not play dice with the
especially if it is about the future universe

Challenges in AJCC staging

Colorectal Adenocarcinoma
pT3 vs. pT4a
Satellite tumor deposits: pN1c
Tis vs. T1 tumor
CAP Protocol elements:
Tumor regression, mesorectal excision, sigmoid vs.
rectal location, peritoneal reflection

Appendiceal carcinoma
Low grade mucinous neoplasm
Goblet cell carcinoid

T4 staging
Widely underreported
Cytology from serosal surface of
pT3 tumors: 19% positive*
Review of pT3 cases: 20%
restaged as pT4**

pT3 and pT4

AJCC 7th edition
pT
Definition
classification
pT3
Tumor invades through the
muscularis propria into
pericolorectal tissues
pT4a
Tumor penetrates the visceral
peritoneum
pT4b
Tumor directly invades or is
adherent to other organs or
structures

Problems in pT4 staging

Varying terminology
Anatomic differences in subsites
Criteria used to define peritoneal
involvement
Challenges in interpretation

*Panarelli, AJSP 2013

**Hosseini/Kakar, USCAP 2014

T stage
pT3

pT4a

pT4b

Definition
Pericolorectal tissue
Subserosal connective tissue
Adventitia
Visceral peritoneum
Serosal surface
Peritoneal surface
Extramural involvement
Intramural extension: no change in T
Microscopically proven

Anatomic subsite

Relation to peritoneum

Cecum
Transverse colon
Sigmoid colon
Ascending colon

Peritoneal
Peritoneal
Peritoneal
Anterior, lateral: peritoneal
Posterior: retroperitoneal
Anterior, lateral: peritoneal
Posterior: retroperitoneal
Anterior, lateral: peritoneal
Posterior: retroperitoneal
Anterior: peritoneal
Posterior, lateral: retroperitoneal
Retroperitoneal

Descending colon
Rectum, upper 1/3
Rectum, middle 1/3
Rectum, lower 1/3

Margin: terminology
Commonly used terms
Radial margin
Deep margin
Circumferential margin
Nonperitonealized circumferential
margin
Positive margin: tumor <1 mm

CAP staging protocol

Cecum
Transverse
Sigmoid
Ant-lateral
Ascending
Descending

Posterior
Ascending
Descending
Rectum
Posterior
Lower 1/3

Rectum
Upper 1/3
Mid 1/3

pT3 vs. pT4

AJCC 7th edition
Site
Peritonealized
sites

Retroperitoneal
sites

pT classification
pT3: subserosa
pT4a: serosal surface
pT4b: directly into adjacent organ
Radial margin: not applicable
pT3: adventitia
pT4a: not applicable
pT4b: directly into adjacent organ
Radial margin: involved <1mm

Problems in pT4 staging

Varying terminology
Anatomic differences in subsites
Morphologic features of peritoneal
involvement
Challenges in interpretation

Rectum: posterior view

Non-peritonealized
CRM is inked

Criteria for serosal involvement

pT4a: CAP/AJCC staging

Tumor at serosal surface

Reaction: mesothelial hyperplasia,
inflammation, erosion/ulceration

Free tumor cells on serosal surface

Ulceration of visceral peritoneum

Tumor at serosal surface

Serosal involvement

Disrupted serosal surface with free floating tumor cells

Free floating tumor cells in clefts

Additional sections: obvious pT4a

Criteria for serosal involvement

pT4a: CAP/AJCC staging

Tumor at serosal surface

Free tumor cells on serosal surface
(esp. in clefts with tissue reaction)

Perforation: Tumor contiguous with serosal

surface through inflammation

Criteria for serosal involvement

pT4a: CAP/AJCC staging

Tumor at serosal surface

Free tumor cells on serosal surface
Tumor continuous with serosal surface
through perforation (inflammatory
reaction)
Cytology smears

Tumor <1 mm from serosal surface with

mesothelial reaction

Serosal hemorrhage, acute inflammation

Criteria for serosal involvement

Tumor <1mm with reaction

AJCC: tumor at or on serosal

surface
Tumor <1 mm: not T4a
Nonperitonealized radial margin:
Tumor <1 mm: positive

13 (46%) pT3 <1 mm from serosal

surface had +ve cytology
All had serosal reaction
Peritoneal recurrence same as
conventional pT4a tumors

Panarelli, AJSP 2013

pT4a: suspicious features

pT3 or pT4a: significance

Tumor <1 mm with reaction

Tumor >1 mm with reaction
Tumor <1 mm, no reaction
Acellular mucin at or <1mm from surface

Prognosis
Peritoneal recurrence
Choice of therapy

Not considered as pT4a

Deeper levels, additional sections

pT4a in practice
Margin vs. peritoneal involvement
Use AJCC criteria
Additional work-up for suspicious
cases

Additional radiotherapy for T4 disease

Challenges in AJCC staging

Colorectal Adenocarcinoma
pT3 vs. pT4a

pN
NX

Regional lymph nodes cannot be assessed

N1

N1a: metastasis in 1 LN
N1b: metastasis in 2-3 LNs
N1c: tumor deposit(s) in subserosa, mesentery,
or non-peritonealized pericolic/perirecal tissue,
without LN metastasis
N2a: metastasis in 4-6 LN
N2b: metastasis in >7 LNs

Satellite tumor deposits: pN1c

Tis vs. T1 tumor
CAP Protocol elements:
Tumor regression, mesorectal excision, sigmoid vs.
rectal location, peritoneal reflection

Definition

N2

Outline:
Round or irregular

Why N1c?
AJCC: prior editions
3 mm size cutoff
Venous invasion: irregular outline
Totally replaced LN: round outline

Worse prognosis than N0

disease

Outline:

Orphan artery sign

Round or irregular

Elastic stain highlights vein

10

Smooth muscle actin: venous invasion

11

CRC: Extramural venous invasion

Independent predictor of poor outcome
UK Royal College: 25% rate for audit

Recommendations:
Record separately from small vessel
invasion
4-5 sections of tumor
Elastic stain: routinely/suspicious areas

N1c: conflicting features

No positive nodes, 1 TD:
3 positive LN, no TD:

N1c
N1b

1 positive LN, no TD:

1 positive LN, 5 TD:
No positive nodes, 1 TD:
No positive nodes, 5 TDs:

N1a
N1a
N1c
N1c

AJCC, 7th edition, page 151: Discrete foci of tumor away

from leading edge of tumor without evidence of
residual LN tissue should be regarded as TD
AJCC, 7th edition, page 155: Replaced nodes should be
separately counted as positive nodes in the N category

Messenger, J Clin Pathol 2011

Kirsch, Human Pathol 2012

N1c in practice
Is it a tumor deposit

Challenges in AJCC staging

Helpful histologic features

Lymph node

Venous invasion
Tumor deposit

Thick capsule
Subcapsular sinus
Rim of lymphocytes
Accompanying artery
Elastic stain
Round outline, no remnant
lymph node or vein

Colorectal Adenocarcinoma
pT3 vs. pT4a
Satellite tumor deposits: pN1c
Tis vs. T1 tumor
CAP Protocol elements:
Tumor regression, mesorectal excision, sigmoid vs.
rectal location, peritoneal reflection

Do not add tumor deposits and lymph nodes for

- N stage
- Assessing adequacy of LN dissection
Rock, Arch Path Lab Med, 2014

12

AJCC: T definition

Intramucosal (Tis)

Invasive (T1)

pT Definition
Tis Carcinoma in situ, invasion of lamina
propria/ muscularis mucosa
(Intramucosal adenocarcinoma)
Virtually no chance of lymph node
metastasis
T1 Tumor invades submucosa
(Invasive adenocarcinoma)
Stromal desmoplasia

Pathology report

Invasive adenocarcinoma (T1) in polyp

Indications for colectomy

Intramucosal adenocarcinoma (pTis)

No desmoplasia
Single cell infiltration in lamina propria
AJCC 7th edition
Tis, not at risk for LN metastasis
No invasive adenocarcinoma (pT1)

Prognostic features
Grade: poor differentiation
Lymphovascular: present
Margin: <1 mm
Tumor budding
Depth of submucosal invasion

13

Tumor budding
Individual or small discrete cell
clusters (<5 cells) at the invasive edge
Independent adverse prognostic factor
Adjuvant therapy in stage II
Colectomy for malignant polyps
Recommended: UICC, ADASP
Not required by CAP

Tumor budding
2 grades: 20x
High: >10
Low <10
Use of keratin
stain

Mitrovic, Mod Pathol 2012

Invasive adenocarcinoma (T1) in polyp

Haggitt levels

Indications for colectomy

Prognostic features
Grade: poor differentiation
Lymphovascular: present
Margin: <1 mm
Tumor budding
Depth of submucosal invasion

14

Kikuchi levels

Tis and T1 in practice

SM1, SM2 and SM3

Clarify the term intramucosal

adenocarcinoma
T1 adenocarcinoma in polyp:
include prognostic features

CAP protocol 2015 (upcoming)

CAP colorectal cancer protocol

Frequently asked questions

Tumor regression score

Total mesorectal excision
Sigmoid vs. rectal location
Relationship to peritoneal
reflection

Description

Tumor regression score

No viable cancer cells

0 (complete response)

Single or rare groups of

cancer cells

1 (near complete response)

Residual cancer with

2 (partial response)
evident tumor regression,
but more than single or
rare groups of cancer cells
Extensive residual cancer 3 (minimal or no response)
with little or no evident
tumor regression
Ryan, Histopathol, 2005

15

Challenges in AJCC staging

Colorectal Adenocarcinoma
pT3 vs. pT4a
Satellite tumor deposits: pN1c
Tis vs. T1 tumor
CAP Protocol elements:
Tumor regression, mesorectal excision, sigmoid vs.
rectal location, peritoneal reflection

LAMN: staging challenges

Should LAMN be staged?

Appendiceal carcinoma
Low grade mucinous neoplasm
Goblet cell carcinoid

WHO 2010
.

Should LAMN be staged?

Appendiceal adenoma: intact muscularis mucosa

LAMN: rests on fibrous stroma, obliteration of MM
.

WHO 2010 classification

Low grade carcinoma

16

Should LAMN be staged?

WHO 2010 classification
Low grade carcinoma
AJCC: Yes
Most pathologists: No

Appendix: AJCC staging

T1
T2
T3
T4a
T4b
M1a
M1b

LAMN: staging problems

T stage is difficult to apply
Erroneous interpretation as
conventional adenocarcinoma
Acellular mucin

LAMN

Invasive adenocarcinoma

Tumor invades submucosa

Tumor invades muscularis propria
Tumor invades through muscularis propria into
subserosa or into mesoappendix
Tumor penetrates visceral peritoneum, including
mucinous peritoneal tumor within the right lower
quadrant
Tumor directly invades other organs or structures
Intraperitoneal metastasis beyond the right lower
quadrant, including pseudomyxoma peritonei
Nonperitoneal metastasis

Hemicolectomy not needed

Hemicolectomy for staging

17

Acellular mucin: T4a or T1

LAMN staging
T staging not useful
Assign best possible category
Emphasize diagnosis of LAMN

Appendiceal tumors: significant factors

Appendix: AJCC staging

T1
T2
T3
T4a
T4b
M1a
M1b

Tumor invades submucosa

Tumor invades muscularis propria
Tumor invades through muscularis propria into
subserosa or into mesoappendix
Tumor penetrates visceral peritoneum, including
mucinous peritoneal tumor within the right lower
quadrant
Tumor directly invades other organs or structures

Extrappendiceal mucin/epithelium
High grade features
Destructive invasion
Resection margin

Goblet cell carcinoid

Staged as
adenocarcinoma
Right hemicolectomy
with LN dissection

Intraperitoneal metastasis beyond the right lower

quadrant, including pseudomyxoma peritonei
Nonperitoneal metastasis

18

CAP colorectal cancer checklist

14 required elements
4 optional elements
Pathology report
AJCC: T3N1cV1R1B0
Molecular:
KRAS exon 13 mutation
NRAS, BRAF, PIK3CA: wild type
PTEN absent
P53 mutation present
Microsatellite stable
Consensus molecular subtype 4 (CMS4)
Next generation sequencing.

Good checklists are precise, to the point, and easy to

use. They do not try to spell out everything.

19

CAP colorectal cancer protocol

Protocol elements
Tumor regression score (for cases with
neoadjuvant therapy)
Completeness of mesorectal envelope
Relationship of tumor to peritoneal
reflection
the volume and complexity of what we know has
exceeded our individual ability to deliver its
benefits correctly, safely or reliably.

Total mesorectal excision (TME)

The mesorectal fascia (fascia propria or the pelvic
visceral fascia) surrounds the rectum and is
separated from the presacral fascia (Waldeyer
fascia) by an avascular plane. The two fascia merge
inferiorly at the level of levator ani muscles. During
rectal surgery, dissection is performed along this
avascular plane. The intactness of the mesorectal
excision is one of the most important features
determining local recurrence.

Sigmoid vs. rectal location

Rectal cancer: surgery

Local recurrence: quality of surgery
Anterior resection
Without TME: 20-30%
With TME: 8-10%
Adjuvant therapy: 2-3%
Pathologic evaluation for quality of TME

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Descriptor
Complete

Status of mesorectal excision

Intact bulky mesorectum with smooth surface,
only minor irregularities, defects <5 mm
No coning
Smooth circumferential margin

Nearly complete

Moderate bulk
Defects >5 mm, not extending to muscularis

Incomplete

Little bulk
Defects >5 mm extending to muscularis
Irregular circumferential margin

Mesorectal excision
Assess completeness
Ink the non-peritonealized
circumferential resection margin
Distinguish margin from serosal
surface in submitted sections

Parfitt, J Clin Pathol 2006

Avascular plane
between
mesorectal fascia
and presacral
fascia
Fascia propria,
pelvic visceral,
fascia recti
Waldeyer fascia
(presacral fascia)

Complete

Incomplete

TME: tumors of middle and lower third of rectum

Partial mesorectal excision: upper rectum
Parfitt, J Clin Pathol 2006

21

Tumor regression: problems

Poor reproducibility
Lack of standardized scoring scheme

Tumor regression scoring

Issues under consideration
Possible two point grading system
Complete/near complete response
Partial or no response

Sampling
4-5 sections or entire tumor bed
Level sections

CAP protocol 2015 (draft)

Description

Tumor regression score

Sigmoid vs. rectal location

CAP protocol 2015 (draft):

No viable cancer cells

0 (complete response)

Single or rare groups of

cancer cells

1 (near complete response)

Residual cancer with

2 (partial response)
evident tumor regression,
but more than single or
rare groups of cancer cells
Extensive residual cancer 3 (minimal or no response)
with little or no evident
tumor regression

A tumor is classified as rectal if its lower margin is within 16

cm of the anal verge or if any part of the tumor is located
within the supply of the superior rectal artery. The rectum
commences at the sacral promontory and the junction of
sigmoid colon and rectum is anatomically marked by fusion of
tenia coli to form the circumferential longitudinal muscle of
the rectal wall. Intraoperatively, the rectosigmoid junction
corresponds to the sacral promontory. The location is
classified as rectosigmoid when differentiation between
rectum and sigmoid sites cannot be reliably determined.
Reference: Wittekind C, Henson DE, Hutter RVP, Sobin LH, eds. TNM
Supplement: A Commentary on Uniform Use. 2nd ed. New York, NY:
Wiley-Liss; 2001.

Ryan, Histopathol, 2005

22

Tumor in relation to the peritoneal reflection

Anteriorly, the peritoneal reflection is located at the junction of middle and lower third
of the rectum, while laterally, it is located at the junction of upper and middle third of
the rectum. Posteriorly, the reflection is located higher and most of the posterior
rectum does not have a serosal covering.
(a) Whether an adenocarcinoma located in the rectum has a circumferential resection
(radial) margin (CRM) or a peritoneal (serosal) surface (with no true circumferential
resection margin), depends on its location in relation to the peritoneal reflections.
Tumors below the anterior peritoneal reflection will have a 360-degree CRM, while
those above it may have (CRM) or a peritoneal (serosal) surface, or both, depending on
the precise location.
(b) Neoadjuvant therapy and total mesorectal excision are considered standard of care
for rectal adenocarcinomas 'below the anterior peritoneal reflection', while the
opinions about use of these modalities vary about rectal adenocarcinomas located
above the anterior peritoneal reflection. Conservative options like transanal disc
excisions are often considered for location 'below the anterior peritoneal reflection'. In
these contexts, the peritoneal reflection refers to the junction of upper and middle
third of the rectum.
(c) If information about tumor location with respect to the peritoneal reflection is
included in the report, the aspect of rectum in question (posterior, lateral,
anterior) should also be noted.
Reference:
Kenig J, Richter P. Definition of the rectum and level of the peritoneal reflection - still a
matter of debate? Wideochir Inne Tech Malo Inwazyjne. 2013;8:183-186.

23

LAMN: T stage is difficult to apply

24

25

Is pTis with poor differentiation

at higher risk?

Tis or T1
Poor differentiation: word of caution
Ensure complete resection/followup/colectomy

CAP/AJCC protocol
pT3 vs. pT4
Satellite tumor deposits: pN1c
Adenocarcinoma in polyp: TIS vs. T1

Mesorectal excision
Tumor regression grading

26

CAP/AJCC protocol

pT3 vs. pT4

Satellite tumor deposits: pN1c
Adenocarcinoma in polyp: TIS vs. T1
Mesorectal excision

Tumor regression grading

Neoadjuvant therapy and TME
Assess response to treatment

Tumor regression grading

Grade 0: no residual tumor

Grade 2 (minimal): tumor outgrown by fibrosis

27

CAP colorectal cancer protocol

Essential elements
Site, procedure
Size

Optional elements
MSI-related features
Type of polyp

Perforation
Mesorectal envelope
Histologic type, grade
Additional
Lymphovascular, perineural
Treatment effect
Tumor extension (pT)
Margin
Lymph node
Tumor deposits
Stage

Acellular mucin pools

Tumor regression grading

Possible two point grading system
Complete/near complete response
Partial or no response

Sampling
4-5 sections or entire tumor bed
Level sections

Fibrosis
Tumor regression, necrosis of normal
Desmoplasia

28

Mandard tumor regressive grade

Description

Total mesorectal excision

Tumor regression grade

No viable cancer cells

Rare cancer cells

Residual cancer outgrown

by fibrosis

Minimal or no tumor kill;

extensive cancer
No regressive change

The Waldeyer's fascia is synonymous with the presacral fascia and is more commonly described in surgery
textbooks, rather than in anatomy textbooks. Although Waldeyer himself did not actually describe this exact
anatomy, it is credited to him as he was the first to describe the anatomy of pelvic fascia in detail.[1][2]
The presacral fascia lines the anterior aspect of the sacrum, enclosing the sacral vessels and nerves. It
continues anteriorly as the pelvic parietal fascia, covering the entire pelvic cavity.[3] It has been erroneously
described as the posterior aspect of the mesorectal fascia.[4] These two fascias are in fact, separate
anatomical entities. During rectal surgery and mesorectum excision, dissection along the avascular aveolar
plane between these two fascias, facilitates a straightforward dissection and preserves the sacral vessels
and hypogastric nerves.
The presacral fascia is limited postero-inferiorly, as it fuses with the mesorectal fascia, lying above the
levator ani muscle, at the level of the anorectal junction.[5] The colloquial term, among colo-rectal surgeons,
for this inter-fascial plane, is known as the "holy plane" of dissection first coined by Heald RJ.[6]
The mesorectal fascia, also known as the fascia propria or the pelvic visceral fascia, has been originally
described as the fascia recti in Waldeyer's publication, Das Becken. Fascia recti is also a term commonly
used among French surgeons to describe the mesorectal fascia.[7] Confusingly, fascia recti is described in
some anatomy books, referring to the fascia of the rectus abdominis muscle.
Identification and preservation of the Waldeyers fascia is of fundamental importance in preventing
complications and reducing local recurrences of rectal cancer.[8] Hence attention to this anatomy is essential
in contemporary rectal surgery.

Mandard, Cancer, 1994

Background
Total mesorectal excision is a common procedure used in the treatment of colorectal cancer in which a significant
length of the bowel around the tumor is removed. Total mesorectal excision addresses earlier treatment concerns
regarding adequate local control of rectal cancer while performing an anterior resection.
The term total mesorectal excision strictly applies when performing a low anterior resection for tumors of the
middle and the lower rectum, wherein it is essential to remove the rectum along with the mesorectum up to the
level of the levators. The principles of total mesorectal excision (sharp mesorectal excision) are also applied
during an abdominoperineal excision of the rectum and for tumors of the upper rectum, although these are
considered distinct from standard total mesorectal excision. In an abdominoperineal excision of the rectum where
the tumor exists below the level of the levators, the lateral margins of the tumor are inferior to the mesorectum
and the benefits of total mesorectal excision do not apply. Anterior resections involving the upper rectum may be
completed with mobilization of the rectum to beyond 5 cm of the lower margin of the tumor, and which is often
above the level of the levator and is sometimes referred to as partial mesorectal excision.
The treatment of rectal cancers is multimodal with adjuvant radiotherapy and chemotherapy having benefits in
some settings. In addition, accurate preoperative staging is dependent on good radiological support. It is
therefore necessary to subject all rectal cancers to multidepartment conference and to design individualized
treatment plans based on a well-defined protocol. This serves the dual purpose of maintaining a consistent
evidence-based approach as well as creating a dataset for prospective analysis and feedback.
Indications
Total mesorectal excision is indicated as a part of low anterior resection for patients with adenocarcinoma of the
middle and lower rectum. Total mesorectal excision is now considered the gold standard for tumors of the middle
and the lower rectum.
Outcomes
Circumferential resection margin positivity rate is about 5% or less for low anterior resections with total
mesorectal excision, whereas it is between 10% and 25% for abdominoperineal excision of the rectum. There is
understandably a higher local recurrence rate following abdominoperineal excision of the rectum. Five-year
survival and disease-free survival rates are significantly lower with total mesorectal excision.
Evidence suggests that a circumferential resection margin of 1 mm or less adversely affects cancer-specific
survival, local recurrence, and distant metastasis.[1]

13 (46%) pT3 <1 mm from

serosal surface had +ve cytology
All had serosal reaction
Fibroinflammatory: 12
Vascular: 8, abscess:1
Rx mesothelial:6, Hem/fibrin: 11
Hemorrhage/fibrin on serosa

http://emedicine.medscape.com/article/1893507-overview

29

High risk features

Elastic stain
Shinto: recurrence 35% in
tumors that involved elastic
lamina vs. 21% that did not
5-yr survival 57% vs. 79%
Kojima: 34% with elastic
involvement but not serosa vs
23% with serosal involvement

Microsatellite stable tumors

Poorly differentiated
Lymphatic/vascular invasion
Perineural invasion
Bowel obstruction, perforation
<12 lymph nodes
Close, indeterminate, positive margin
NCCN guidelines
NCCN.org

Focal desmoplasia and submucosal extension

N1c staging

I've been asked this question several times. The AJCC stage designations on page 155 clearly
indicate that N1c can be used with any T. However, the text on page 151 is confusing. The message
being conveyed on page 151 is that when a satellite tumor deposit occurs with a T1 or T2 tumor
(with negative lymph nodes), it should not be interpreted as discontinuous spread and hence
should not be classified as T3, but rather as T1/T2 N1c. The way it is written can lead to the
mistaken impression that N1c should be used only with T1 or T2 tumors.

why PN1c of colon cancer was put under N stage and not under T stage since it describes the
presence of tumor. pN1c: Tumor deposit(s) in the subserosa, or non-peritonealized pericolic or
perirectal tissues without regional lymph node metastasis
Kay: The criteria for tumor deposits are more fully elucidated in the text of the AJCC chapter. These
deposits are discontinuous, but must be within the lymph node draining basin for the primary
tumor and are not clearly entirely replaced lymph nodes. pN1c was chosen as a unique category for
these discontinuous tumor deposits because of studies identifying these deposits as having an
adverse outcome on prognosis beyond that seen in pT3 or pT4 node-negative colon cancers. Prior
to the 7th edition designating these as N1c, some pathologists regarded tumor deposits as pT3 or
pT4 tumor, others as positive lymph nodes. At the same time, many oncologists regarded them as
equivalent to positive lymph nodes when making decisions regarding adjuvant therapy for nodenegative tumors.

30

Tumor extending into submucosa: true invasion?

2 high grade TIS cases

(1) recurrence (2) lymphatic invasion. Both desmoplasia

Tumor extending into submucosa: true invasion?

Intramucosal adenocarcinoma-high grade

31

Colon: any subsite

T4b

pT4a and pT4b

CAP/AJCC
7th edition
pT4a
pT4b

CAP/AJCC
6th edition
pT4a
pT4b

N1c: impact on final stage

Definition
Tumor penetrates visceral peritoneum
Tumor directly invades or is adherent to
other organs or structures

Stage
IIIA
IIIB

Definition
IIIC
Tumor directly invades or is adherent to
other organs or structures
Tumor penetrates visceral peritoneum

T
T1-T2
T1
T3-T4a
T2-T3
T1-T2
T4a
T3-T4a
T4b

N
N1 or N1c
N2a
N1 or N1c
N2a
N2b
N2a
N2b
N1-2

32

TA with high grade dysplasia

33

Colon: peritonealized areas

T3

T4a

Peritonealized region

Peritoneal reflection

Non-peritonealized circumferential margin

Parfitt, J Clin Pathol 2006

34

Why do TDs affect N?

Adverse outcome similar to
node-positive disease
Some TDs are irregular and are
not LN metastasis

Should N1c be used only for T1

and T2 tumors?
AJCC, 7th edition, page 151:
If tumor deposits are seen in lesions that
would otherwise be classified as T1 or T2, the
T classification is not changed, but nodule is
recorded as TD and staged as N1c
Page 155:
Stage group table clearly indicates that N1c
can be used with any T

35

Pathology diagnosis

I have nothing to disclose

Tubular adenoma with high grade

dysplasia and intramucosal
adenocarcinoma

36

Tumor contiguous with serosal surface

through inflammation

Tumor >1 mm, serosal reaction

37

Additional sections: tumor cells on serosal surface

Tumor <1 mm, no reaction

Mucinous carcinoma <1 mm

Muc CA involving peritoneal cleft: pT4a

38

AJCC: T definitions
pT Definition
Tis Carcinoma in situ, intraepithelial, no
invasion of lamina propria
(High grade dysplasia)
Tis Carcinoma in situ, invasion of lamina
propria/ muscularis mucosa
(Intramucosal adenocarcinoma)
T1 Tumor invades submucosa
(Invasive adenocarcinoma)

39

Venous invasion

IM carcinoma (Tis): Tumor involvement of lamina propria

40