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Assessment of Serosal Invasion and Criteria for the Classification of Pathological (p) T4 Staging in Colorectal Carcinoma: Confusions, Controversies and Criticisms.

Stewart CJ, Hillery S, Platell C, Puppa G - Cancers (Basel) (2011)

Bottom Line: However, controversy persists regarding the most appropriate criteria for diagnosis and there are also practical difficulties associated with histological assessment in some cases.The examination of multiple microscopic sections combined with ancillary studies such as cytology preparations, elastin stains, and immunohistochemistry may prove beneficial in selected problematic cases, but these are not used routinely.Further studies are required to demonstrate whether recent adjustments to the TNM staging of pT4 tumors are appropriate.

View Article: PubMed Central - PubMed

Affiliation: Department of Histopathology, SJOG Hospital, Perth, Western Australia. colin.stewart@health.wa.gov.au.

ABSTRACT
Transmural spread by colorectal carcinoma can result in tumor invasion of the serosal surface and, hence, more likely dissemination within the peritoneal cavity and potentially to additional metastatic sites. The adverse prognostic significance of serosal invasion is widely accepted and its presence may be considered an indication for chemotherapy in patients with node negative disease. However, controversy persists regarding the most appropriate criteria for diagnosis and there are also practical difficulties associated with histological assessment in some cases. Therefore, serosal invasion may be under-diagnosed in a significant proportion of tumors, potentially leading to sub-optimal treatment of high-risk patients. The examination of multiple microscopic sections combined with ancillary studies such as cytology preparations, elastin stains, and immunohistochemistry may prove beneficial in selected problematic cases, but these are not used routinely. The relative prognostic significance of serosal invasion and of direct tumor spread to other organs, both of which are incorporated within the pT4 category of the AJCC/UICC TNM staging system, remains unclear. Further studies are required to demonstrate whether recent adjustments to the TNM staging of pT4 tumors are appropriate.

No MeSH data available.


Related in: MedlinePlus

Histological image of colorectal carcinoma invading the subserosal fat. (A) The conventional hematoxylin and eosin stain shows tumor glands (upper field) with a marked reactive stroma towards the serosal surface (lower field). The relationship of the tumor to the native serosa is not clear. (×40) (B) Elastin stain shows an intact peritoneal elastic lamina (arrows) deep to the malignant glands suggesting that the tumor has not penetrated the serosal surface (×40).
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f6-cancers-03-00164: Histological image of colorectal carcinoma invading the subserosal fat. (A) The conventional hematoxylin and eosin stain shows tumor glands (upper field) with a marked reactive stroma towards the serosal surface (lower field). The relationship of the tumor to the native serosa is not clear. (×40) (B) Elastin stain shows an intact peritoneal elastic lamina (arrows) deep to the malignant glands suggesting that the tumor has not penetrated the serosal surface (×40).

Mentions: A second approach to the diagnosis of serosal invasion utilizes elastin stains to highlight the peritoneal elastic lamina (PEL). Normally, the PEL comprises a relatively delicate layer of elastic fibers that lie just deep to the mesothelium [41], shown schematically in Figures 1 and 2. The importance of the PEL in pathological situations such as neoplasia is that it could provide a surrogate anatomical marker in those cases where tumor destruction or prominent fibro-inflammatory changes have distorted and effaced the native serosa (Figure 6) [16]. It should be noted that since the PEL is not considered to represent part of the normal serosa, the presence of tumor cells close to (or even penetrating) this structure does not necessarily equate with serosal invasion. Nevertheless, tumor extension beyond the PEL does provide indirect evidence of possible serosal invasion. This interpretation is supported by two studies in which CRC exhibiting extra-mural invasion were examined using elastin stains. Shinto et al. subdivided a series of pT3 CRC (that is cases considered negative for serosal invasion on routine histologic examination) into those with ‘shallow’ invasion and those with ‘deep’ invasion corresponding to malignant infiltration superficial to, or beyond, the PEL, respectively [42]. Deep invasion was an independent adverse prognostic factor. More recently, Kojima and colleagues studied peritoneal elastic lamina invasion in 564 pT3 and pT4 cancers [43]. Elastic lamina invasion correlated with other adverse histologic parameters and was an independent risk factor for recurrence in patients with stage II colonic malignancies.


Assessment of Serosal Invasion and Criteria for the Classification of Pathological (p) T4 Staging in Colorectal Carcinoma: Confusions, Controversies and Criticisms.

Stewart CJ, Hillery S, Platell C, Puppa G - Cancers (Basel) (2011)

Histological image of colorectal carcinoma invading the subserosal fat. (A) The conventional hematoxylin and eosin stain shows tumor glands (upper field) with a marked reactive stroma towards the serosal surface (lower field). The relationship of the tumor to the native serosa is not clear. (×40) (B) Elastin stain shows an intact peritoneal elastic lamina (arrows) deep to the malignant glands suggesting that the tumor has not penetrated the serosal surface (×40).
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3756354&req=5

f6-cancers-03-00164: Histological image of colorectal carcinoma invading the subserosal fat. (A) The conventional hematoxylin and eosin stain shows tumor glands (upper field) with a marked reactive stroma towards the serosal surface (lower field). The relationship of the tumor to the native serosa is not clear. (×40) (B) Elastin stain shows an intact peritoneal elastic lamina (arrows) deep to the malignant glands suggesting that the tumor has not penetrated the serosal surface (×40).
Mentions: A second approach to the diagnosis of serosal invasion utilizes elastin stains to highlight the peritoneal elastic lamina (PEL). Normally, the PEL comprises a relatively delicate layer of elastic fibers that lie just deep to the mesothelium [41], shown schematically in Figures 1 and 2. The importance of the PEL in pathological situations such as neoplasia is that it could provide a surrogate anatomical marker in those cases where tumor destruction or prominent fibro-inflammatory changes have distorted and effaced the native serosa (Figure 6) [16]. It should be noted that since the PEL is not considered to represent part of the normal serosa, the presence of tumor cells close to (or even penetrating) this structure does not necessarily equate with serosal invasion. Nevertheless, tumor extension beyond the PEL does provide indirect evidence of possible serosal invasion. This interpretation is supported by two studies in which CRC exhibiting extra-mural invasion were examined using elastin stains. Shinto et al. subdivided a series of pT3 CRC (that is cases considered negative for serosal invasion on routine histologic examination) into those with ‘shallow’ invasion and those with ‘deep’ invasion corresponding to malignant infiltration superficial to, or beyond, the PEL, respectively [42]. Deep invasion was an independent adverse prognostic factor. More recently, Kojima and colleagues studied peritoneal elastic lamina invasion in 564 pT3 and pT4 cancers [43]. Elastic lamina invasion correlated with other adverse histologic parameters and was an independent risk factor for recurrence in patients with stage II colonic malignancies.

Bottom Line: However, controversy persists regarding the most appropriate criteria for diagnosis and there are also practical difficulties associated with histological assessment in some cases.The examination of multiple microscopic sections combined with ancillary studies such as cytology preparations, elastin stains, and immunohistochemistry may prove beneficial in selected problematic cases, but these are not used routinely.Further studies are required to demonstrate whether recent adjustments to the TNM staging of pT4 tumors are appropriate.

View Article: PubMed Central - PubMed

Affiliation: Department of Histopathology, SJOG Hospital, Perth, Western Australia. colin.stewart@health.wa.gov.au.

ABSTRACT
Transmural spread by colorectal carcinoma can result in tumor invasion of the serosal surface and, hence, more likely dissemination within the peritoneal cavity and potentially to additional metastatic sites. The adverse prognostic significance of serosal invasion is widely accepted and its presence may be considered an indication for chemotherapy in patients with node negative disease. However, controversy persists regarding the most appropriate criteria for diagnosis and there are also practical difficulties associated with histological assessment in some cases. Therefore, serosal invasion may be under-diagnosed in a significant proportion of tumors, potentially leading to sub-optimal treatment of high-risk patients. The examination of multiple microscopic sections combined with ancillary studies such as cytology preparations, elastin stains, and immunohistochemistry may prove beneficial in selected problematic cases, but these are not used routinely. The relative prognostic significance of serosal invasion and of direct tumor spread to other organs, both of which are incorporated within the pT4 category of the AJCC/UICC TNM staging system, remains unclear. Further studies are required to demonstrate whether recent adjustments to the TNM staging of pT4 tumors are appropriate.

No MeSH data available.


Related in: MedlinePlus