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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

Survival analysis of 260 patients with pT4 colorectal carcinoma. Note that the pT4a and pT4b cases have similar outcomes (pT4a - direct invasion of other structures, pT4b - serosal invasion).
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f8-cancers-03-00164: Survival analysis of 260 patients with pT4 colorectal carcinoma. Note that the pT4a and pT4b cases have similar outcomes (pT4a - direct invasion of other structures, pT4b - serosal invasion).

Mentions: The basis for the pT4 subdivision has also been called into question. We have argued previously that the evidence supporting the initial pT4a/4b split was limited in that it appeared to be based upon unpublished data and the purported differences in patient outcomes were stated to be statistically not significant [52]. Furthermore, analysis of pT4 CRC cases in our own department has shown very similar survival curves for these subgroups (Figure 8). Nevertheless, the earlier staging classification was at least consistent with multiple studies identifying serosal invasion as an adverse prognostic factor in CRC, provisionally meriting its designation as the more advanced tumor stage (T4b). In the 7th edition of the AJCC/TNM classification there has been an alteration to the substaging of pT4 tumors with reversal of the previously recommended T4a and T4b categories [6,7]. In other words, pT4a now defines tumors that involve or penetrate the visceral peritoneum whereas direct invasion of other organs or structures is classified as pT4b. Surprisingly, this staging alteration was made without any initial comment or explanation [52,53]. Subsequently, the basis for these changes was stated to be a study (at that time available only in Abstract form) that demonstrated a 10-20% worse outcome for tumors showing direct invasion of other organs compared to serosal invasion in both lymph node negative and positive CRC categories [54].


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)

Survival analysis of 260 patients with pT4 colorectal carcinoma. Note that the pT4a and pT4b cases have similar outcomes (pT4a - direct invasion of other structures, pT4b - serosal invasion).
© Copyright Policy
Related In: Results  -  Collection

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

f8-cancers-03-00164: Survival analysis of 260 patients with pT4 colorectal carcinoma. Note that the pT4a and pT4b cases have similar outcomes (pT4a - direct invasion of other structures, pT4b - serosal invasion).
Mentions: The basis for the pT4 subdivision has also been called into question. We have argued previously that the evidence supporting the initial pT4a/4b split was limited in that it appeared to be based upon unpublished data and the purported differences in patient outcomes were stated to be statistically not significant [52]. Furthermore, analysis of pT4 CRC cases in our own department has shown very similar survival curves for these subgroups (Figure 8). Nevertheless, the earlier staging classification was at least consistent with multiple studies identifying serosal invasion as an adverse prognostic factor in CRC, provisionally meriting its designation as the more advanced tumor stage (T4b). In the 7th edition of the AJCC/TNM classification there has been an alteration to the substaging of pT4 tumors with reversal of the previously recommended T4a and T4b categories [6,7]. In other words, pT4a now defines tumors that involve or penetrate the visceral peritoneum whereas direct invasion of other organs or structures is classified as pT4b. Surprisingly, this staging alteration was made without any initial comment or explanation [52,53]. Subsequently, the basis for these changes was stated to be a study (at that time available only in Abstract form) that demonstrated a 10-20% worse outcome for tumors showing direct invasion of other organs compared to serosal invasion in both lymph node negative and positive CRC categories [54].

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