Datasets:
kamaludeen
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Browse files- 2007-08-29-guidelines-for-colorectal-cancer-reporting.csv +1056 -0
- Dataset_for_Pathology_Reporting_of_Colorectal.35.csv +0 -0
- Dataset_for_Pathology_Reporting_of_Colorectal_Canc.csv +0 -0
- G049-Dataset-for-histopathological-reporting-of-colorectal-cancer (1).csv +0 -0
- GI-Colorectal-cancer-4th-Ed-2020-Protocol-v4-2.csv +0 -0
2007-08-29-guidelines-for-colorectal-cancer-reporting.csv
ADDED
@@ -0,0 +1,1056 @@
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1 |
+
|
2 |
+
,
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3 |
+
|
4 |
+
,
|
5 |
+
,
|
6 |
+
Minimum Dataset for
|
7 |
+
Colorectal Cancer
|
8 |
+
"1st Edition, August 2007 "
|
9 |
+
|
10 |
+
This document should be read in conjunction with the
|
11 |
+
minimum dataset proforma for colorectal cancer resection
|
12 |
+
developed by the NSW Oncology Group for Colorectal
|
13 |
+
Cancer. It is based on information contained within
|
14 |
+
multiple international publications and datasets and has
|
15 |
+
been developed in consultation with local practicing
|
16 |
+
"pathologists, oncologists, surgeons, radiologists and "
|
17 |
+
interested national bodies.
|
18 |
+
|
19 |
+
|
20 |
+
|
21 |
+
|
22 |
+
|
23 |
+
|
24 |
+
|
25 |
+
|
26 |
+
|
27 |
+
,
|
28 |
+
,
|
29 |
+
|
30 |
+
|
31 |
+
,
|
32 |
+
,
|
33 |
+
‐2 ‐
|
34 |
+
TABLE OF CONTENTS
|
35 |
+
,
|
36 |
+
SCOPE OF DOCUMENT .............................................................................................................. 5
|
37 |
+
How to use this document ........................................................................................................ 5
|
38 |
+
INTRODUCTION ......................................................................................................................... 6
|
39 |
+
Authors .................................................................................................................................. 6
|
40 |
+
MACROSCOPIC DESCRIPTION .................................................................................................... 7
|
41 |
+
Site of tumour ........................................................................................................................ 7
|
42 |
+
Definition of the rectum .................................................................................................... 7
|
43 |
+
Maximum tumour diameter .................................................................................................. 8
|
44 |
+
Distance of tumour to nearer cut end ................................................................................... 8
|
45 |
+
Presence of tumour perforation ........................................................................................... 8
|
46 |
+
Relationship of rectal tumours to the anterior peritoneal reflection ................................... 9
|
47 |
+
MICROSCOPIC DESCRIPTION ................................................................................................... 11
|
48 |
+
Tumour type ........................................................................................................................ 11
|
49 |
+
Differentiation by predominant area .................................................................................. 12
|
50 |
+
Local invasion ...................................................................................................................... 13
|
51 |
+
Non‐peritonealised circumferential margin in rectal tumours ........................................... 14
|
52 |
+
The non‐peritonealised margin in the colon ....................................................................... 15
|
53 |
+
Lymphocytic infiltration....................................................................................................... 15
|
54 |
+
Lymph nodes ....................................................................................................................... 16
|
55 |
+
Guidelines for small tumour deposits in lymph nodes .................................................... 16
|
56 |
+
A note on TNM 5th edition versus TNM 6th edition ......................................................... 17
|
57 |
+
Lymphovascular invasion .................................................................................................... 18
|
58 |
+
Perineural invasion .............................................................................................................. 18
|
59 |
+
Histologically confirmed distant metastases ....................................................................... 19
|
60 |
+
Background abnormalities................................................................................................... 19
|
61 |
+
Residual tumour status ....................................................................................................... 20
|
62 |
+
Summary – TNM staging ..................................................................................................... 20
|
63 |
+
Mismatch repair deficiency status ...................................................................................... 21
|
64 |
+
Appendix A – Minimum dataset proforma for colorectal cancer resections .......................... 22
|
65 |
+
Appendix B – Colorectal cancer surgical request .................................................................... 24
|
66 |
+
Useful Website ........................................................................................................................ 26
|
67 |
+
REFERENCES ............................................................................................................................ 26
|
68 |
+
,
|
69 |
+
,
|
70 |
+
‐3 ‐
|
71 |
+
|
72 |
+
,
|
73 |
+
|
74 |
+
,
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75 |
+
,
|
76 |
+
‐4 ‐
|
77 |
+
SCOPE OF DOCUMENT
|
78 |
+
,
|
79 |
+
This document should be read in conjunction with the minimum dataset proforma for
|
80 |
+
"colorectal cancer resections, which was developed by the NSW Oncology Group for "
|
81 |
+
Colorectal Cancer. It is based on information contained within multiple international
|
82 |
+
publications and datasets and has been developed in consultation with local practising
|
83 |
+
"pathologists, oncologists, surgeons, radiologists and interested national bodies. "
|
84 |
+
,
|
85 |
+
|
86 |
+
,
|
87 |
+
HOW TO USE THIS DOCUMENT
|
88 |
+
,
|
89 |
+
"To facilitate accurate and complete reporting of colorectal carcinomas, a proforma for "
|
90 |
+
the reporting of colorectal cancer resection specimens has been created from a set of
|
91 |
+
"minimum data items (Appendix A). To aid in the collection of all essential data items, a "
|
92 |
+
colorectal cancer surgical request form has also been prepared (Appendix B). This
|
93 |
+
document is a working guide to help in the accurate reporting of the dataset items
|
94 |
+
contained in the proforma. The data items are listed in the way that they would usually
|
95 |
+
be reported in current laboratory practice. These guidelines reference relevant
|
96 |
+
"literature for each data item, including their prognostic significance or relevance to case "
|
97 |
+
management.
|
98 |
+
,
|
99 |
+
It is important to highlight that the data items presented here form a “minimum”
|
100 |
+
dataset. The report is formatted with tick boxes for ease of presentation. Individual
|
101 |
+
"departments can alter the format to suit their working practices, add areas of free text, "
|
102 |
+
or incorporate the items into a free text document with the minimum dataset serving as
|
103 |
+
their template.
|
104 |
+
,
|
105 |
+
This minimum dataset for colorectal cancer was developed after lengthy consultation
|
106 |
+
with interested parties and it is hoped that all those good ideas and comments have
|
107 |
+
"been taken on board. It may not please everyone and is a work in progress, but it is an "
|
108 |
+
important first step towards the objective of improving the way we report colorectal
|
109 |
+
cancer.
|
110 |
+
|
111 |
+
,
|
112 |
+
,
|
113 |
+
‐5 ‐
|
114 |
+
INTRODUCTION
|
115 |
+
,
|
116 |
+
Colorectal cancer is currently the most common cancer diagnosed in Australia and has
|
117 |
+
the second highest incidence of cancer related deaths [1]. Recent advances have been
|
118 |
+
"made with regard to the biological understanding of this disease and its treatment, with "
|
119 |
+
"new surgical, chemotherapeutic and radiotherapeutic strategies now available. "
|
120 |
+
,
|
121 |
+
Histopathological reporting of resection specimens for colorectal cancer provides
|
122 |
+
important information both for the clinical management of the affected patient and for
|
123 |
+
the evaluation of health care as a whole. For the patient it confirms the diagnosis and
|
124 |
+
"describes the variables that will affect prognosis, all of which will inform future clinical "
|
125 |
+
"management. For health care evaluation, pathology reports provide information for "
|
126 |
+
cancer registration and clinical audit for ensuring comparability of patient groups in
|
127 |
+
"clinical trials, and for assessing the accuracy of new diagnostic tests and preoperative "
|
128 |
+
"staging techniques. In order to fulfil all of these functions, the information contained "
|
129 |
+
within the pathology report must be accurate and complete.
|
130 |
+
,
|
131 |
+
"Guidelines, datasets and various documents on best practice in pathology are nothing "
|
132 |
+
"new. There are large differences however, between available versions. Within existing "
|
133 |
+
"datasets there is variability in the amount of information required, ranging from those "
|
134 |
+
"that encompass vast lists of every possible data item, many without proven relevance, to "
|
135 |
+
the more focussed and pragmatic evidence‐based minimum datasets.
|
136 |
+
,
|
137 |
+
Several studies have highlighted deficiencies in the content of colorectal cancer
|
138 |
+
"resection reports, including elements that are considered crucial for patient "
|
139 |
+
management [2]. Many studies have shown that adherence to a minimum dataset
|
140 |
+
proforma for colorectal cancer reporting significantly improves the rate of inclusion of
|
141 |
+
these crucial features [3].
|
142 |
+
,
|
143 |
+
|
144 |
+
,
|
145 |
+
AUTHORS
|
146 |
+
,
|
147 |
+
|
148 |
+
"This document was written by Dr Jill Farmer, Dr Sian Munro and Associate Professor "
|
149 |
+
Nicholas Hawkins from the Colorectal Cancer Research Consortium. The document
|
150 |
+
should be read in conjunction with the minimum dataset proforma for colorectal cancer
|
151 |
+
"resections, which was developed in collaboration with Dr Andrew Kneebone, the NSW "
|
152 |
+
Oncology Group for Colorectal Cancer and local pathologists. The Colorectal Cancer
|
153 |
+
Research Consortium is supported by a Strategic Research Partnership Grant from the
|
154 |
+
Cancer Council NSW.
|
155 |
+
,
|
156 |
+
,
|
157 |
+
‐6 ‐
|
158 |
+
MACROSCOPIC DESCRIPTION
|
159 |
+
,
|
160 |
+
All measurements should be made in millimetres
|
161 |
+
,
|
162 |
+
|
163 |
+
,
|
164 |
+
SITE OF TUMOUR
|
165 |
+
,
|
166 |
+
The site of the tumour should be recorded.
|
167 |
+
,
|
168 |
+
It is important to record the correct anatomical site of a tumour for the following
|
169 |
+
reasons:
|
170 |
+
,
|
171 |
+
It determines the appropriate staging system.
|
172 |
+
,
|
173 |
+
It indicates whether a non‐peritonealised (circumferential) margin is present.
|
174 |
+
,
|
175 |
+
It defines the presence of regional lymph nodes versus non‐regional lymph
|
176 |
+
nodes.
|
177 |
+
,
|
178 |
+
|
179 |
+
,
|
180 |
+
DEFINITION OF THE RECTUM
|
181 |
+
,
|
182 |
+
In 1999 representatives of the American Society of Colon and Rectal Surgeons and the
|
183 |
+
Association of Coloproctology of Great Britain and Ireland met with their Australian
|
184 |
+
counterparts to define the rectum and the procedures to treat cancer of the rectum [4].
|
185 |
+
,
|
186 |
+
The treatment of rectal cancer differs from the treatment of colonic cancer in some
|
187 |
+
"important respects, particularly in the areas of surgery and radiotherapy. It is thus "
|
188 |
+
essential to have a clear anatomical definition of the rectum.
|
189 |
+
,
|
190 |
+
Strictly the rectum is that part of the large bowel distal to the sigmoid colon and its
|
191 |
+
upper limit is indicated by the end of the sigmoid mesocolon. Standard anatomical texts
|
192 |
+
"put this at the level of the 3rd sacral vertebra [5], but it is generally agreed by surgeons "
|
193 |
+
that the rectum starts at the sacral promontory [6]. It was agreed by the Expert
|
194 |
+
Advisory Committee that any tumour whose distal margin is seen at 15cm or less from
|
195 |
+
"the anal verge using a rigid sigmoidoscope should be classified as rectal. Clearly, in the "
|
196 |
+
"excised specimen these anatomical landmarks are not available for the pathologist, "
|
197 |
+
hence the importance of the site of the tumour being stated by the surgeon on the
|
198 |
+
clinical request form.
|
199 |
+
,
|
200 |
+
|
201 |
+
,
|
202 |
+
,
|
203 |
+
‐7 ‐
|
204 |
+
MAXIMUM TUMOUR DIAMETER
|
205 |
+
,
|
206 |
+
The maximum tumour diameter should be recorded. The diameter is measured
|
207 |
+
from the luminal aspect of the bowel. The thickness of the tumour is ignored for
|
208 |
+
this measurement.
|
209 |
+
,
|
210 |
+
The definitive determination of tumour size is made on gross pathological examination.
|
211 |
+
,
|
212 |
+
Several studies have shown that tumour size is of no prognostic significance in
|
213 |
+
"colorectal cancer [7,8]. However, it is recorded for purposes of documentation and for "
|
214 |
+
correlation with measurements made by various imaging modalities.
|
215 |
+
,
|
216 |
+
|
217 |
+
,
|
218 |
+
DISTANCE OF TUMOUR TO NEARER CUT END
|
219 |
+
,
|
220 |
+
This is the measurement from the nearer cut end of the specimen and not the non
|
221 |
+
"peritonealised (circumferential, radial) margin. "
|
222 |
+
,
|
223 |
+
Tumour at a longitudinal margin has always been considered a poor prognostic feature
|
224 |
+
"but it occurs very rarely [9,10]. The necessity of sampling this margin has therefore "
|
225 |
+
been questioned [11‐13]. It may be prudent to sample this margin if the tumour is close
|
226 |
+
"to the margin, or if the tumour is found by histology to have an exceptionally infiltrative "
|
227 |
+
"growth pattern, to show extensive vascular invasion or lymphatic permeation or to be a "
|
228 |
+
"pure signet ring, small cell or undifferentiated carcinoma [11]. "
|
229 |
+
,
|
230 |
+
NB. It is useful to have normal tissue for control purposes and uninvolved margins can
|
231 |
+
provide this.
|
232 |
+
,
|
233 |
+
|
234 |
+
,
|
235 |
+
PRESENCE OF TUMOUR PERFORATION
|
236 |
+
,
|
237 |
+
The presence or absence of tumour perforation should be recorded.
|
238 |
+
,
|
239 |
+
"Tumour perforation is defined as a macroscopically visible defect through the tumour, "
|
240 |
+
such that the bowel lumen is in communication with the external surface of the intact
|
241 |
+
resection specimen. Perforation through the tumour into the peritoneal cavity is a well
|
242 |
+
established adverse prognostic factor in colonic [14] and rectal cancer [15]. It is
|
243 |
+
suggested that a block be taken from the area of perforation for histological
|
244 |
+
confirmation. If perforation is present then this is regarded as pT4 in the TNM staging
|
245 |
+
"system, regardless of other factors [16]. "
|
246 |
+
,
|
247 |
+
Perforation of the proximal bowel as a result of a distal obstructing tumour should not
|
248 |
+
be recorded as tumour perforation.
|
249 |
+
,
|
250 |
+
|
251 |
+
,
|
252 |
+
|
253 |
+
,
|
254 |
+
,
|
255 |
+
‐8 ‐
|
256 |
+
RELATIONSHIP OF RECTAL TUMOURS TO THE ANTERIOR PERITONEAL
|
257 |
+
REFLECTION
|
258 |
+
,
|
259 |
+
The relationship of rectal tumours to the anterior peritoneal reflection should be
|
260 |
+
recorded.
|
261 |
+
,
|
262 |
+
Rectal tumours are classified according to whether they are
|
263 |
+
,
|
264 |
+
a. Entirely above the level of the peritoneal reflection anteriorly.
|
265 |
+
,
|
266 |
+
b. Astride (or at) the level of the peritoneal reflection anteriorly.
|
267 |
+
,
|
268 |
+
c. Entirely below the level of the peritoneal reflection anteriorly.
|
269 |
+
,
|
270 |
+
|
271 |
+
,
|
272 |
+
|
273 |
+
,
|
274 |
+
|
275 |
+
,
|
276 |
+
|
277 |
+
,
|
278 |
+
|
279 |
+
,
|
280 |
+
|
281 |
+
,
|
282 |
+
|
283 |
+
,
|
284 |
+
|
285 |
+
,
|
286 |
+
,
|
287 |
+
‐9 ‐
|
288 |
+
The non‐peritonealised margin is also known as the radial or circumferential resection
|
289 |
+
margin. It represents the “bare” area in the connective tissue at the surgical plane of
|
290 |
+
excision that is not covered by a serosal surface. Low rectal tumours will be completely
|
291 |
+
"surrounded by a non‐peritonealised margin (the circumferential margin), while upper "
|
292 |
+
rectal tumours have a non‐peritonealised margin posterolaterally and a peritonealised
|
293 |
+
(serosal) surface anteriorly. Tumours below the peritoneal reflection have the highest
|
294 |
+
"rates of local recurrence [15,17‐19]. "
|
295 |
+
,
|
296 |
+
,
|
297 |
+
|
298 |
+
,
|
299 |
+
Anteriorly the rectum is covered by peritoneum down to the peritoneal reflection.
|
300 |
+
Posteriorly the nonperitonealised margin extends upwards as a triangular shaped bare
|
301 |
+
"area containing the rectal arteries, which then continues up to the start of the sigmoid "
|
302 |
+
mesocolon.
|
303 |
+
,
|
304 |
+
,
|
305 |
+
‐10 ‐
|
306 |
+
MICROSCOPIC DESCRIPTION
|
307 |
+
,
|
308 |
+
TUMOUR TYPE
|
309 |
+
,
|
310 |
+
The tumour type should be described according to WHO International
|
311 |
+
Histological Classification of Tumours ICD10 (the “Blue Book”) [20].
|
312 |
+
,
|
313 |
+
Virtually all colorectal cancers are adenocarcinomas. The term “Adenocarcinoma NOS”
|
314 |
+
on the proforma is used in this instance to indicate conventional adenocarcinoma
|
315 |
+
without any of the special features of the tumour types listed below it.
|
316 |
+
,
|
317 |
+
For convenience the tumour types are summarised:
|
318 |
+
,
|
319 |
+
Adenocarcinoma
|
320 |
+
,
|
321 |
+
Mucinous adenocarcinoma
|
322 |
+
,
|
323 |
+
Signet‐ring carcinoma
|
324 |
+
,
|
325 |
+
Small cell carcinoma
|
326 |
+
,
|
327 |
+
Squamous cell carcinoma
|
328 |
+
,
|
329 |
+
Adenosquamous carcinoma
|
330 |
+
,
|
331 |
+
Medullary carcinoma
|
332 |
+
,
|
333 |
+
Undifferentiated carcinoma
|
334 |
+
,
|
335 |
+
"For most tumours, histologic type is not prognostically significant. Exceptions include "
|
336 |
+
"tumour types that are, by definition, high grade e.g. small cell carcinoma; and the "
|
337 |
+
"medullary subtype, which is invariably associated with high microsatellite instability "
|
338 |
+
(MSI‐H) and has a favourable prognosis when compared to other poorly differentiated
|
339 |
+
and undifferentiated colorectal carcinomas [20].
|
340 |
+
,
|
341 |
+
|
342 |
+
,
|
343 |
+
|
344 |
+
,
|
345 |
+
|
346 |
+
,
|
347 |
+
|
348 |
+
,
|
349 |
+
,
|
350 |
+
‐11 ‐
|
351 |
+
DIFFERENTIATION BY PREDOMINANT AREA
|
352 |
+
,
|
353 |
+
The assessment of differentiation should be based on the predominant degree of
|
354 |
+
differentiation present in the primary tumour [21].
|
355 |
+
,
|
356 |
+
Assessment of differentiation should be based on the percentage of tumour showing the
|
357 |
+
"formation of glands, as described in WHO International Histological Classification of "
|
358 |
+
Tumours [20]:
|
359 |
+
,
|
360 |
+
Well differentiated adenocarcinoma shows glands in 95% of the tumour.
|
361 |
+
,
|
362 |
+
Moderately differentiated adenocarcinoma shows 50‐95% glands.
|
363 |
+
,
|
364 |
+
Poorly differentiated adenocarcinoma shows 5‐50% glands.
|
365 |
+
,
|
366 |
+
Undifferentiated carcinoma shows <5% glands.
|
367 |
+
,
|
368 |
+
"Histologic grade is a stage independent prognostic factor [17,22]. Multiple grading "
|
369 |
+
systems with variation in the number of strata within them have been suggested over
|
370 |
+
the past few years. The distinction between well and moderately differentiated
|
371 |
+
adenocarcinoma (low grade) versus poorly differentiated or undifferentiated carcinoma
|
372 |
+
"(high grade) has been shown to be prognostically useful [23]. The terms well, moderate "
|
373 |
+
and poor differentiation are equivalent to Grades 1‐3 in the TNM staging system [16].
|
374 |
+
,
|
375 |
+
For the most part the pathological distinction between moderately and poorly
|
376 |
+
differentiated or undifferentiated tumours is consistent and interobserver variability is
|
377 |
+
small. Distinction between well and moderately differentiated carcinomas is less
|
378 |
+
"reproducible and associated with significant interobserver variability. Thus, a two tiered "
|
379 |
+
grading system that eliminates this distinction is recommended:
|
380 |
+
,
|
381 |
+
Well differentiated and moderately differentiated – low grade
|
382 |
+
,
|
383 |
+
Poorly differentiated and undifferentiated – high grade
|
384 |
+
,
|
385 |
+
Small foci of apparent poor differentiation are not uncommon at the advancing edge of
|
386 |
+
tumours but these are insufficient to classify the tumour as poorly differentiated [21].
|
387 |
+
,
|
388 |
+
There is recent interest in the phenomenon of tumour budding at the advancing margin
|
389 |
+
of colorectal cancers with accumulating evidence that it might have prognostic
|
390 |
+
"significance [24]. However, this is not yet considered sufficient to justify the inclusion of "
|
391 |
+
this item the minimum dataset.
|
392 |
+
,
|
393 |
+
|
394 |
+
,
|
395 |
+
,
|
396 |
+
‐12 ‐
|
397 |
+
LOCAL INVASION
|
398 |
+
,
|
399 |
+
The maximum degree of local invasion into or through the bowel wall should be
|
400 |
+
recorded. This is based on the T component of the TNM staging system.
|
401 |
+
,
|
402 |
+
pTis Carcinoma insitu: intraepithelial or invasion of lamina propria.
|
403 |
+
pT1 Tumour invades submucosa.
|
404 |
+
pT2 Tumour invades muscularis propria.
|
405 |
+
pT3 Tumour invades through muscularis propria into subserosa or into non
|
406 |
+
peritonealised pericolic or perirectal tissues.
|
407 |
+
pT4 Tumour directly invades other organs or structures (pT4a) and/or
|
408 |
+
perforates visceral peritoneum (pT4b).
|
409 |
+
|
410 |
+
pTis: The TNM classification includes a level pTis to represent either in‐situ carcinoma
|
411 |
+
or carcinoma showing invasion of the lamina propria (intramucosal carcinoma).
|
412 |
+
This practice is based primarily on the aim of achieving a uniform staging system
|
413 |
+
across all organ systems. Colorectal neoplasia has not been shown to have
|
414 |
+
metastatic potential until it has invaded through the muscularis mucosae. The
|
415 |
+
term pTis is thus avoided in the lower gastrointestinal tract and the term high
|
416 |
+
grade dysplasia is preferred. pTis tumours should be regarded as adenomas and
|
417 |
+
not as carcinomas for the purpose of diagnosis and cancer registration.
|
418 |
+
pT1: Tumour invades submucosa but not muscularis propria.
|
419 |
+
"pT2: Tumour invades into, but not through muscularis propria. "
|
420 |
+
pT3: Tumour invades through muscularis propria into subserosa or into non‐
|
421 |
+
peritonealised pericolic or perirectal tissues.
|
422 |
+
pT3 indicates spread in continuity beyond the bowel wall. The microscopic
|
423 |
+
presence of tumour cells confined within the lumen of lymph vessels or veins
|
424 |
+
does not qualify as local spread in the T classification [16]. Occasionally cancer
|
425 |
+
has spread as far as the outer edge of the muscularis propria but not beyond. If
|
426 |
+
no muscle separates the cancer from the mesenteric tissue then the muscle coat
|
427 |
+
should be interpreted as breached (pT3) [25].
|
428 |
+
pT4a: Tumour directly invades other organs or structures AND/OR
|
429 |
+
pT4b: Tumour invades through serosa with tumour cells on the peritoneal surface or
|
430 |
+
free in the peritoneal cavity. Cases showing perforation should be classified as
|
431 |
+
pT4b.
|
432 |
+
Direct invasion in pT4 includes invasion of other segments of the colorectum by
|
433 |
+
" way of the serosa, e.g. invasion of sigmoid colon by a carcinoma of the caecum "
|
434 |
+
" [16,26]. Intramural or longitudinal extension of tumour into an adjacent part of "
|
435 |
+
the bowel e.g. extension of a caecal tumour into the terminal ileum does not
|
436 |
+
affect the pT stage.
|
437 |
+
Serosal involvement through direct continuity with the primary tumour (pT4) is
|
438 |
+
recorded differently from peritoneal tumour deposits that are separate from the
|
439 |
+
primary. These latter deposits are regarded as distant metastases (pM1).
|
440 |
+
,
|
441 |
+
,
|
442 |
+
‐13 ‐
|
443 |
+
NON‐PERITONEALISED CIRCUMFERENTIAL MARGIN IN RECTAL
|
444 |
+
TUMOURS
|
445 |
+
,
|
446 |
+
In rectal tumours the minimum distance in millimetres between the tumour and
|
447 |
+
"the nonperitonealised, (circumferential, radial) margin should be recorded from "
|
448 |
+
the histological slides.
|
449 |
+
,
|
450 |
+
Tumour frequently (5‐36%) involves the non‐peritonealised surgical circumferential
|
451 |
+
resection margin (CRM) in the rectum and is associated with significantly higher rates of
|
452 |
+
local recurrence and cancer‐related death [27‐34].
|
453 |
+
,
|
454 |
+
"The frequency of involvement of the CRM depends on the quality of surgery, advancing "
|
455 |
+
TNM stage and whether the patient has undergone preoperative neoadjuvant therapy.
|
456 |
+
The closer the tumour is to the CRM the worse the prognosis [35]. The vast majority of
|
457 |
+
"studies, including clinical trials and population studies, have used a cut off of 1mm or "
|
458 |
+
less to define margin involvement. The Dutch total mesorectal excision (TME) study
|
459 |
+
suggests this measurement should be 2mm [31].
|
460 |
+
,
|
461 |
+
"CRM involvement may be through direct continuity with the main tumour, by tumour "
|
462 |
+
"deposits discontinuous from the main tumour or by tumour in veins, lymphatics or "
|
463 |
+
"lymph nodes. All types of involvement confer a poor prognosis [28,31]. "
|
464 |
+
,
|
465 |
+
|
466 |
+
,
|
467 |
+
|
468 |
+
,
|
469 |
+
|
470 |
+
|
471 |
+
|
472 |
+
|
473 |
+
|
474 |
+
|
475 |
+
|
476 |
+
|
477 |
+
|
478 |
+
|
479 |
+
|
480 |
+
|
481 |
+
|
482 |
+
|
483 |
+
" x = minimum clearance in mm of primary tumour, extramural or "
|
484 |
+
" nodal deposit or tumour in vessel etc, whichever is the closest. "
|
485 |
+
|
486 |
+
|
487 |
+
|
488 |
+
"Confusingly, the residual tumour status (R) used in the TNM staging system requires "
|
489 |
+
that tumour be identified at the resection margin for the margin to be considered
|
490 |
+
"involved [16]. Thus, in TNM staging if tumour is not actually seen at this margin it is "
|
491 |
+
"coded as R0. Therefore, recording the distance between the tumour and the CRM will "
|
492 |
+
alert the clinician to those patients who may benefit from being treated as though they
|
493 |
+
were margin positive.
|
494 |
+
|
495 |
+
,
|
496 |
+
|
497 |
+
,
|
498 |
+
‐14 ‐
|
499 |
+
THE NON‐PERITONEALISED MARGIN IN THE COLON
|
500 |
+
,
|
501 |
+
"The importance of non‐peritonealised margin involvement in colonic tumours, "
|
502 |
+
"particularly those of caecum and ascending colon has recently been recognised [14,36]. "
|
503 |
+
Studies indicate the frequency of margin involvement is 7‐10% [36]. It is recommended
|
504 |
+
that tumour involvement of the non‐peritonealised resection margin in colonic tumours
|
505 |
+
should be recorded when this is present as this may facilitate the selection of patients
|
506 |
+
with colonic tumours for postoperative adjuvant therapy [11].
|
507 |
+
,
|
508 |
+
|
509 |
+
,
|
510 |
+
LYMPHOCYTIC INFILTRATION
|
511 |
+
,
|
512 |
+
Intraepithelial lymphocytes (IEL) are those that are in direct contact with tumour
|
513 |
+
cells or are located directly between tumour cell clusters. For standardised
|
514 |
+
"detection, routine histological methods should be used. Only a high density of "
|
515 |
+
lymphocytes (≥5 IEL per hpf) should be considered significant. It has been
|
516 |
+
suggested that a minimum of 10 standard fields including both the centre and
|
517 |
+
periphery of the tumour should be included in the count [37].
|
518 |
+
,
|
519 |
+
Intraepithelial lymphocytes are thought to be indicative of a host immune response
|
520 |
+
against cancer cells. They are also associated with a favourable outcome in terms of
|
521 |
+
both recurrence and overall survival [38‐40].
|
522 |
+
,
|
523 |
+
While the extent of lymphocytic infiltrates at the margins of the tumour
|
524 |
+
(peritumoural lymphocytes) and the prominence of lymphoid follicles (Crohn’s‐like
|
525 |
+
"reaction) in adjacent tissues are also features of MMR deficient tumours, most "
|
526 |
+
studies have found the strongest correlation between IELs and MMR deficiency
|
527 |
+
"[41,42]. IEL counts are therefore not necessary if MMR deficiency status is to be "
|
528 |
+
"assessed formally, by MMR immunohistochemistry or MSI testing. "
|
529 |
+
,
|
530 |
+
,
|
531 |
+
‐15 ‐
|
532 |
+
LYMPH NODES
|
533 |
+
,
|
534 |
+
All lymph nodes should be harvested from the specimen and examined
|
535 |
+
histologically.
|
536 |
+
,
|
537 |
+
The finding of positive lymph nodes is a major determinant of whether the patient
|
538 |
+
receives adjuvant therapy. The probability of finding a positive node increases with the
|
539 |
+
number of nodes found although this probability curve flattens out after finding 12‐15
|
540 |
+
"nodes [43,44]. However, for practical purposes all lymph nodes present should be "
|
541 |
+
harvested from the specimen.
|
542 |
+
,
|
543 |
+
"The AJCC recommendations state that if the examined lymph nodes are negative, but "
|
544 |
+
"only a small number of nodes has been found, then the case should be classified as pN0 "
|
545 |
+
rather than pNX [16].
|
546 |
+
,
|
547 |
+
"The N3 staging category, which described cases with a positive apical node, has been "
|
548 |
+
shown not to be prognostic [45] and so has been removed from the 6th edition of the
|
549 |
+
AJCC guidelines.
|
550 |
+
,
|
551 |
+
Direct extension of a colorectal tumour into a lymph node is considered nodal
|
552 |
+
metastasis. Metastasis in any lymph nodes other than regional nodes is classified as
|
553 |
+
distant metastasis [16].
|
554 |
+
,
|
555 |
+
There is no consensus that occult metastatic disease detected by immunohistochemistry
|
556 |
+
or other methods discriminates between high‐ and low‐risk groups of patients. Data are
|
557 |
+
thus insufficient to recommend routine use of tissue levels or ancillary special
|
558 |
+
"techniques [23,25]. "
|
559 |
+
,
|
560 |
+
|
561 |
+
,
|
562 |
+
GUIDELINES FOR SMALL TUMOUR DEPOSITS IN LYMPH NODES
|
563 |
+
,
|
564 |
+
"Isolated tumour deposits are single tumour cells or small cell clusters, generally less "
|
565 |
+
"than 0.2mm in diameter, present within a lymph node. They may be visible in H&E "
|
566 |
+
stained sections or detected by immunohistochemistry. The literature suggests that the
|
567 |
+
finding of su ch cells is not a marker of an adverse prognosis for the patient [46‐48].
|
568 |
+
,
|
569 |
+
The TNM 6th edition recommends that cases in which isolated tumour cells are the only
|
570 |
+
"form of nodal involvement should be classified as pN0, although the presence of the "
|
571 |
+
isolated tumour cells should be noted. Optional designation as pN0(i+) is suggested for
|
572 |
+
"this situation [26], although a free‐text description might provide clearer "
|
573 |
+
communication.
|
574 |
+
,
|
575 |
+
Micrometastasis refers to nodal metastatic deposits less than 2 mm in diameter. Such
|
576 |
+
"deposits differ from isolated tumour cells not only in size, but also in that they show "
|
577 |
+
"evidence of growth, for example glandular differentiation, distension of the sinus or a "
|
578 |
+
stromal desm oplastic reaction [25].
|
579 |
+
,
|
580 |
+
The TNM 6th edition suggests that cases where micrometastasis is the only form of
|
581 |
+
"metastatic spread, be classified as pN1(mi), although again some explanatory free text "
|
582 |
+
would be advisable in this situation.
|
583 |
+
,
|
584 |
+
|
585 |
+
,
|
586 |
+
‐16 ‐
|
587 |
+
A NOTE ON TNM 5TH EDITION VERSUS TNM 6TH EDITION
|
588 |
+
,
|
589 |
+
"Isolated tumour deposits in the pericolic or perirectal fat, separate from the main "
|
590 |
+
"tumour and lacking evidence of pre‐existing lymph node or vessel, are common. TNM 5th "
|
591 |
+
edition classified such deposits as involved lymph nodes if they were >3mm in diameter.
|
592 |
+
"TNM 6th edition replaced this criterion with another, namely that such deposits were "
|
593 |
+
"classified as involved lymph nodes if they showed a rounded contour, regardless of size. "
|
594 |
+
Deposits of irregular shape are to be coded as T3 and recorded as vascular invasion.
|
595 |
+
"This change has been the subject of some criticism, as it has replaced a relatively "
|
596 |
+
objective criterion (a measurement) with a subjective one (assessment of shape). The
|
597 |
+
assessment of the nodal contour has been shown to be poorly reproducible [49] and it
|
598 |
+
has therefore been suggested that the 5th edition criteria should be adhered to.
|
599 |
+
,
|
600 |
+
"Other commentators [50] have pointed out that, reproducible or not, both criteria are "
|
601 |
+
"essentially arbitrary and that such deposits may derive from nodes, vascular invasion, "
|
602 |
+
perineural invasion or a combination of these within a single case. Most examples occur
|
603 |
+
in situations where there are unequivocally involved nodes anyway (in only 8% of cases
|
604 |
+
"were they the only form of deposit) and, where present, are in themselves associated "
|
605 |
+
with an adverse prognosis. It would therefore seem reasonable to adhere to the TNM 6th
|
606 |
+
"edition criteria, stating in free‐text if isolated tumour deposits are the only form of nodal "
|
607 |
+
deposits identified.
|
608 |
+
,
|
609 |
+
|
610 |
+
,
|
611 |
+
|
612 |
+
|
613 |
+
,
|
614 |
+
|
615 |
+
,
|
616 |
+
|
617 |
+
,
|
618 |
+
,
|
619 |
+
‐17 ‐
|
620 |
+
LYMPHOVASCULAR INVASION
|
621 |
+
,
|
622 |
+
"For all tumours, including malignant polyps, venous and lymphatic invasion "
|
623 |
+
should be reported as present or absent and its anatomic location specified as
|
624 |
+
mural or extramural.
|
625 |
+
,
|
626 |
+
"Venous invasion by tumour has been repeatedly shown by multivariate [17,51,52] and "
|
627 |
+
univariate analyses to be a stage independent adverse prognostic factor. However some
|
628 |
+
studies identifying venous invasion as an adverse factor on univariate analysis have
|
629 |
+
failed to confirm its independent impact on prognosis on multivariate breakdown [52‐
|
630 |
+
54]. Similar disparate results have also been reported for lymphatic invasion [54]. In
|
631 |
+
"other reports vascular invasion as a general feature was prognostically significant, but "
|
632 |
+
no distinction between lymphatic and venous vessels was made. In a few studies the
|
633 |
+
location as well as the type of the involved vessels (e.g. extramural veins) were both
|
634 |
+
"considered strong determinants of prognostic impact [23,55]. Data from existing "
|
635 |
+
"studies are difficult to amalgamate but nevertheless, the importance of venous and "
|
636 |
+
lymphatic invasion by tumour is strongly suggested and largely confirmed.
|
637 |
+
,
|
638 |
+
Some groups have recommended that only extramural vascular invasion be recorded
|
639 |
+
"[11], while others have recommended that the site of any vascular invasion should be "
|
640 |
+
"recorded, along with its location, intra or extramural [23]. Both intramural and "
|
641 |
+
extramural vascular invasion have been shown to have similar prognostic value [14].
|
642 |
+
Evidence is also lacking or is inconclusive for preferential recording of vascular versus
|
643 |
+
lymphatic invasion. It is thus recommended that both items are combined as
|
644 |
+
lymphovascular invasion and a comment made on its location.
|
645 |
+
,
|
646 |
+
"It is debatable whether special techniques, such as histochemical and "
|
647 |
+
"immunohistochemical stains, to identify elastic tissue or endothelium increase the ease "
|
648 |
+
or accuracy of evaluation. Because these techniques are also labour intensive and time
|
649 |
+
"consuming they are not performed routinely. Accordingly, special stains are not "
|
650 |
+
recommended.
|
651 |
+
,
|
652 |
+
"The prognostic importance of involvement of small (thin‐walled, presumably lymphatic) "
|
653 |
+
vessels in the submucosa has been well documented with respect to polypectomies of
|
654 |
+
malignant polyps. Such involvement has been shown to be associated with an increased
|
655 |
+
risk of regional lymph node metastasis [56].
|
656 |
+
,
|
657 |
+
|
658 |
+
,
|
659 |
+
PERINEURAL INVASION
|
660 |
+
,
|
661 |
+
Perineural invasion should be reported as present or absent.
|
662 |
+
,
|
663 |
+
There is some evidence that perineural infiltration by tumour is an important indicator
|
664 |
+
"of spread, particularly in rectal tumours where it may involve the sacral plexus and this "
|
665 |
+
may be an indication for radiotherapy [57].
|
666 |
+
,
|
667 |
+
The presence or absence of perineural invasion should be assessed using routine
|
668 |
+
histology alone.
|
669 |
+
,
|
670 |
+
,
|
671 |
+
‐18 ‐
|
672 |
+
HISTOLOGICALLY CONFIRMED DISTANT METASTASES
|
673 |
+
,
|
674 |
+
The presence of histologically confirmed distant metastases and their site should
|
675 |
+
be recorded.
|
676 |
+
,
|
677 |
+
Pathological M staging can only be based on distant metastases that are submitted for
|
678 |
+
histological assessment by the surgeon and will therefore tend to underestimate the
|
679 |
+
true (clinical) M stage. Pathologists will only be able to use pM1 (distant metastases
|
680 |
+
present) or pMX (distant metastases unknown). However at the request of the
|
681 |
+
"oncologists, a box marked cM has been included in the staging summary to record the "
|
682 |
+
presence of clinically diagnosed metastases as stated by the submitting surgeon and
|
683 |
+
captured by the clinical request form.
|
684 |
+
,
|
685 |
+
Disease classifiable as distant metastasis may sometimes be present within the primary
|
686 |
+
"tumour resection specimen, e.g. a serosal or mesenteric deposit that is distant from the "
|
687 |
+
primary tumour mass.
|
688 |
+
,
|
689 |
+
Metastatic deposits in lymph nodes distant from those surrounding the main tumour or
|
690 |
+
its main artery in the specimen will usually be submitted separately by the surgeon (e.g.
|
691 |
+
deposits in para‐aortic nodes or nodes surrounding the external iliac or common iliac
|
692 |
+
arteries). Metastatic deposits in lymph nodes distant from those surrounding the main
|
693 |
+
tumour or its main artery in the specimen are regarded as distant metastases (pM1)
|
694 |
+
[26].
|
695 |
+
,
|
696 |
+
|
697 |
+
,
|
698 |
+
BACKGROUND ABNORMALITIES
|
699 |
+
,
|
700 |
+
The presence of any pathological abnormalities in the background bowel should
|
701 |
+
be recorded. Those listed are particularly of note.
|
702 |
+
,
|
703 |
+
If the resection specimen contains two or more carcinomas (as indicated by the term
|
704 |
+
“synchronous carcinomas” on the minimum dataset proforma) then a separate
|
705 |
+
minimum dataset should be completed for each primary carcinoma. Where possible
|
706 |
+
"lymph nodes should be assigned and assessed for each cancer separately, based on "
|
707 |
+
topographical distribution.
|
708 |
+
,
|
709 |
+
|
710 |
+
,
|
711 |
+
|
712 |
+
,
|
713 |
+
,
|
714 |
+
‐19 ‐
|
715 |
+
RESIDUAL TUMOUR STATUS
|
716 |
+
,
|
717 |
+
The completeness of resection should be recorded.
|
718 |
+
,
|
719 |
+
R0 No margin involvement (or residual disease).
|
720 |
+
,
|
721 |
+
R1 Microscopic but not macroscopic margin involvement.
|
722 |
+
,
|
723 |
+
R2 Macroscopic margin involvement.
|
724 |
+
,
|
725 |
+
|
726 |
+
Residual tumour classification (R status) is not limited to the primary tumour. The R
|
727 |
+
"classification not only considers locoregional residual tumour, but also distant residual "
|
728 |
+
tumour in the form of unresected or incompletely resected metastases (R2) [58].
|
729 |
+
,
|
730 |
+
"For example, a metastasis in the liver from a primary colorectal carcinoma would be M1 "
|
731 |
+
and R0 if the metastasis was solitary and resected with tumour‐free margins. This case
|
732 |
+
would be M1 and R2 if the metastasis was not resected.
|
733 |
+
,
|
734 |
+
The resection status rule also applies to lymph nodes. If a clinically positive lymph node
|
735 |
+
is left behind it is classified as R2.
|
736 |
+
,
|
737 |
+
Tumour cells that are confined to the lumen of blood vessels or lymphatics at the
|
738 |
+
resection margin are classified as R0 [58].
|
739 |
+
,
|
740 |
+
Peritoneal involvement alone is not a reason to categorise the tumour as incompletely
|
741 |
+
excised.
|
742 |
+
,
|
743 |
+
With regard to the presence of residual disease in areas which have not been resected
|
744 |
+
"(e.g. involvement of other organs by trans‐coelomic spread), it is the responsibility of "
|
745 |
+
the surgeon to recognise and report these deposits. Such information will be collected
|
746 |
+
by the surgical request form.
|
747 |
+
,
|
748 |
+
|
749 |
+
,
|
750 |
+
SUMMARY - TNM STAGING
|
751 |
+
,
|
752 |
+
TNM 6th edition is used.
|
753 |
+
,
|
754 |
+
The prefix “p” is used to indicate pathological staging.
|
755 |
+
,
|
756 |
+
"If neoadjuvant chemotherapy or radiotherapy has been given, the prefix “yp” should be "
|
757 |
+
used to indicate that the original p stage may have been modified by therapy. Tumour
|
758 |
+
remaining in a resection specimen following neoadjuvant therapy should always be
|
759 |
+
classified by ypTNM to distinguish it from untreated tumour [26].
|
760 |
+
,
|
761 |
+
,
|
762 |
+
‐20 ‐
|
763 |
+
MISMATCH REPAIR DEFICIENCY STATUS
|
764 |
+
,
|
765 |
+
"A mutation in mismatch repair genes (mainly MLH1, PMS2, MSH2 and MSH6) can "
|
766 |
+
cause an accumulation of DNA mutations that result in the initiation of cancer.
|
767 |
+
Mismatch repair deficient (MMRD) cancers occur either sporadically (~12%) or less
|
768 |
+
commonly (~2%) because the individual suffers from hereditary non‐polyposis
|
769 |
+
colorectal cancer (HNPCC). Tumours which show loss of MMR proteins by
|
770 |
+
immunohistochemistry are almost always characterised by microsatellite instability
|
771 |
+
"(MSI), which is determined by analysis of tumour DNA. This finding is important "
|
772 |
+
for the following reasons:
|
773 |
+
,
|
774 |
+
"MMRD has been shown to be a favourable prognostic factor in colorectal cancer, in "
|
775 |
+
"terms of both recurrence‐free survival and overall survival [41,59,60]. "
|
776 |
+
,
|
777 |
+
MMRD tumours may be less responsive to adjuvant chemotherapy compared to
|
778 |
+
other colorectal cancers [61‐63] although this has not been shown conclusively in
|
779 |
+
all studies [64‐66].
|
780 |
+
,
|
781 |
+
In 2% of cases MMRD is associated with underlying HNPCC which raises cancer
|
782 |
+
issues for all family members.
|
783 |
+
,
|
784 |
+
Immunohistochemical (IHC) analysis of mismatch repair proteins is used to detect
|
785 |
+
"MMRD in colorectal cancer, with an absence of one or more of the mismatch repair "
|
786 |
+
"proteins considered an abnormal result [67,68]. MMRD can also be determined by "
|
787 |
+
"microsatellite analysis, which is the amplification and analysis of selected "
|
788 |
+
"microsatellite loci within the genome of the tumour cells. However, this later "
|
789 |
+
technique is not used routinely in diagnostic pathology settings. MMR testing is
|
790 |
+
currently recommended for all cases of colorectal cancer arising in individuals less
|
791 |
+
"than 50 years of age, although this cut off is arbitrary. "
|
792 |
+
,
|
793 |
+
|
794 |
+
,
|
795 |
+
,
|
796 |
+
‐21 ‐
|
797 |
+
APPENDIX A - MINIMUM DATASET PROFORMA FOR
|
798 |
+
COLORECTAL CANCER RESECTIONS
|
799 |
+
,
|
800 |
+
,
|
801 |
+
‐22 ‐
|
802 |
+
|
803 |
+
‐23 ‐‐23 ‐
|
804 |
+
APPENDIX B – COLORECTAL CANCER SURGICAL REQUEST
|
805 |
+
,
|
806 |
+
,
|
807 |
+
‐24 ‐
|
808 |
+
|
809 |
+
,
|
810 |
+
|
811 |
+
,
|
812 |
+
,
|
813 |
+
‐25 ‐
|
814 |
+
USEFUL WEBSITE
|
815 |
+
,
|
816 |
+
http://www.uicc.org/
|
817 |
+
,
|
818 |
+
"The UICC website has a dedicated TNM page, which includes a frequently asked "
|
819 |
+
"questions (FAQ) section and a link to a helpdesk, for questions not covered by the FAQ. "
|
820 |
+
,
|
821 |
+
|
822 |
+
,
|
823 |
+
REFERENCES
|
824 |
+
,
|
825 |
+
|
826 |
+
1. Australian Institute of Health and Welfare and the Australasian Association of
|
827 |
+
" Cancer Registries: Cancer in Australia. In 2004 AIoHaWAAAoCRA (ed), AIHW "
|
828 |
+
" Canberra, Australia, 2004. "
|
829 |
+
"2. Bull AD, Biffin AH, Mella J, Radcliffe AG, Stamatakis JD, Steele RJ, Williams GT: "
|
830 |
+
Colorectal cancer pathology reporting: a regional audit. Journal of Clinical
|
831 |
+
Pathology 1997;50:138‐142.
|
832 |
+
"3. Cross SS, Feeley KM, Angel CA: The effect of four interventions on the "
|
833 |
+
informational content of histopathology reports of resected colorectal
|
834 |
+
carcinomas. Journal of Clinical Pathology 1998;51:481‐482.
|
835 |
+
4. The association of Coloproctology of Great Britian and Ireland (ed): Guidelines
|
836 |
+
" for the management of colorectal cancer. London, The association of "
|
837 |
+
" Coloproctology of Great Britian and Ireland, 2001. "
|
838 |
+
"5. Williams PL, Warwick R (eds): Gray’s anatomy. London [England], Churchill "
|
839 |
+
" Livingstone, 1980. "
|
840 |
+
6. UKCCCR (ed): Handbook for the clinicopathological assessment and staging of
|
841 |
+
" colorectal cancer. London, UKCCCR, 1989. "
|
842 |
+
"7. Miller W, Ota D, Giacco G, Guinee V, Irimura T, Nicolson G, Cleary K: Absence of a "
|
843 |
+
relationship of size of primary colon carcinoma with metastasis and survival.
|
844 |
+
Clinical & Experimental Metastasis 1985;3:189‐196.
|
845 |
+
"8. Morris M, Platell C, de Boer B, McCaul K, Iacopetta B: Population‐based study of "
|
846 |
+
prognostic factors in stage II colonic cancer. British Journal of Surgery
|
847 |
+
2006;93:866‐871.
|
848 |
+
"9. Guillou PJ, Quirke P, Bosanquet N, Smith A, Thorpe H, Walker J, Bell SE, Brown "
|
849 |
+
JM: The MRC CLASICC trial: results of short term endpoints. British Journal of
|
850 |
+
Cancer 2003;88(Suppl 1):S11 ‐ S24.
|
851 |
+
"10. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AMH, Heath RM, Brown "
|
852 |
+
" JM, group MCt: Short‐term endpoints of conventional versus laparoscopic‐"
|
853 |
+
assisted surgery in patients with colorectal cancer (MRC CLASICC trial):
|
854 |
+
" multicentre, randomised controlled trial. Lancet 2005;365:1718‐1726. "
|
855 |
+
11. The Royal College of Pathologists Working Group on Cancer Services: UK
|
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Dataset_for_Pathology_Reporting_of_Colorectal.35.csv
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Dataset_for_Pathology_Reporting_of_Colorectal_Canc.csv
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G049-Dataset-for-histopathological-reporting-of-colorectal-cancer (1).csv
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GI-Colorectal-cancer-4th-Ed-2020-Protocol-v4-2.csv
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