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Table 3. Dworak regression grade. 20Grade 0 no regressionGrade 1 dominant tumor mass with obvious fibrosis and/or vasculopathyGrade 2 dominantly fibrotic changes with few tumor cells or groups (easy to find)Grade 3 very few (difficult to find microscopically) tumor cells in fibrotic tissue with or without mucous substanceGrade 4 no tumor cells, only fibrotic mass (total regression or response)Table 4. Pathological subclassification of the extent of invasion in superficial cancer.pTis - Primary tumor: invasion of lamina propriam1 superficial third of the mucosam2 middle third of the mucosam3 deepest third of the mucosapT1 - Primary tumor: invasion of submucosasm1 superficial third of the submucosa or invasion depth of less than 0.5 mmsm2 middle third of the submucosa or invasion depth of between 0.5 and 1 mmsm3 deepest third of the submucosa or invasion depth of more than 1 mmpathology, treatment modalities, and prognosticfactors of this disease. In this context, visiting thepathologist in the cut-up room, assisting in theevaluation of the circumferential resection margin,and studying pathological cross-sections can be useful,especially for both the training surgeon and theradiologist. Also digital imaging of the exterior surfaceprior to cutting and of whole transverse slideswill provide feedback to other medical disciplinesof the team.Careful analysis of the rectal cancer resection specimenwith grading and staging of the tumor needto be performed. 21 In particular, a high motivationto find as many lymph nodes as possible must bemaintained, as node-positive patients may benefitfrom chemotherapy. Also, several studies supportthe concept that the more nodes are examined, themore accurate is the staging. 6 It is also advised toreport the degree of tumor regression after neoadjuvantradiochemotherapy. 20,30,32,33 For regressiongrading to mean anything, it is however necessaryto standardize the assessment. Before concludingthat there is complete response with no viable tumoridentified, embedding of the whole suspicious areaand cutting of 3 levels through each tissue block issuggested. 20,34Use of pathology report forms for reporting rectumcancer resection specimens is highly recommended,as it ensures the completeness and consistency ofdata reporting.The next challenge now is the search for immunohistochemicalor molecular markers, that will identifypatients who respond favourably to preoperativetreatment to shrink or destroy the tumor preoperativelyand further increase the percentage of curativesurgery.References1. Quirke P. Training and quality assurance for rectal cancer:20 years of data is enough. Lancet 2003;4:695-701.2. PROCARE: multidisciplinary <strong>Belgian</strong> PROject on CAncer ofthe Rectum. Multidisciplinary guidelines for the treatment ofrectal cancer can be downloaded from www.kankerregister.be(menu: procare) or www.registreducancer.be (menu: procare).3. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectalcancer surgery-the clue to pelvic recurrence? Br J Surg1982;69:613-6.4. Law WL, Chu KW. Anterior resection for rectal cancer withmesorectal excision. A prospective evaluation of 622 patients.Ann Surg 2004;240:260-8.5. Nagtegaal ID, Van de Velde CJ, Van der Worp E, Kapiteijn E,Quirke P, Van Krieken JH, et al. Macroscopic evaluation ofrectal cancer resection specimen: clinical significance of thepathologist in quality control. J Clin Oncol 2002;20:1729-34.6. Maugham NJ, Quirke P. Modern management of colorectalcancer - a pathologist's view. Scand J Surg 2003;92:11-9.7. Parfitt JR, Driman DK. The total mesrorectal excision specimenfor rectal cancer. A review of its pathological assessment.J Clin Pathol 2007;60:849-55.B E L G I A N J O U R N A L O F M E D I C A L O N C O L O G Y v o l . 3 i s s u e 6 - 2 0 0 9 258
P R A C T I C E G U I D E L I N E SKey messages for clinical practice1. A multidisciplinary team approach significantly improves the outcome of rectal cancer patients.The pathologist has a crucial role in this process, by assessment of the quality of themesorectal excision and the completeness of tumor resection.2. The proximity of the tumor to the circumferential resection margin (CRM) is the most importantfactor for predicting the risk of local recurrence in rectal cancer patients. Tumor involvement ofthe CRM strongly correlates with local recurrence, distant metastasis and poor survival.3. Macroscopic evaluation of the completeness of mesorectal excision has additional value in patientswithout CRM involvement. Incomplete mesorectal resection in patients with a negativeCRM leads to a higher recurrence rate and lower survival.4. The number of tumor-positive lymph nodes should be established with a yield as high as possible.Several studies support the concept that the more nodes are examined, the more accurateis the staging.5. Assessment of tumor regression post neoadjuvant treatment needs standardization. Beforeconcluding that there is complete response with no viable tumor identified, embedding of thewhole suspicious area and cutting of 3 levels through each tissue block is suggested.8. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrenceof rectal adenocarcinoma due to inadequate surgical resection.Histopathological study of lateral tumor spread and surgicalexcision. Lancet 1986;2:996-9.9. Adam IJ, Mohamdee MO, Martin IG, Scott N, Finan PJ, JohnstonD, et al. Role of circumferential margin involvement inthe local recurrence of rectal cancer. Lancet 1994;344:707-11.10. Wibe A, Rendedal PR, Svensson E, Norstein J, Eide TJ, MyrvoldHE, et al. Prognostic significance of the circumferentialresection margin following total mesorectal excision for rectalcancer. Br J Surg 2002;89:327-34.11. Nagtegaal ID, Marijnen CA, Kranenbarg EK, Van de VeldeCJ, Van Krieken JH, for the pathology review committee andthe cooperative clinical investigators. Circumferential margininvolvement is still an important predictor of local recurrencein rectal carcinoma: not one millimetre but two millimetres isthe limit. Am J Surg Pathol 2002;26:350-7.12. Birbeck KF, Macklin CP, Tiffin NJ, Parsons W, Dixon MF,Mapstone NP, et al. Rates of circumferential resection margininvolvement vary between surgeons and predict outcomes inrectal cancer surgery. Ann Surg 2002;235:449-57.13. Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, ParsonsWJ, et al. The modern abdominoperineal excision. The next challengeafter total mesorectal excision. Ann Surg 2005;242:74-82.14. Nagtegaal ID, Van de Velde CJ, Marijnen CA, Van KriekenJH, Quirke P. Low rectal cancer: a call for a change of approachin abdominoperineal resection. J Clin Oncol 2005;23:9257-64.15. Nagtegaal ID, Van Krieken JH. The role of pathologists inthe quality control of diagnosis and treatment of rectal cancer-anoverview. Eur J <strong>Cancer</strong> 2002;38:964-72.16. Torkzad MR, Blomqvist L. The mesorectum: morphometricassessment with magnetic resonance imaging. Eur Radiol2005;15:1184-91.17. Quirke P, Dixon MF. The prediction of local recurrence inrectal adenocarcinoma by histopathological examination. IntJ Colorect Dis 1988;3:127-31.18. Williams N, Dixon M, Johnston D. Reappraisal of the 5 centimeterrule of distal excision for carcinoma of the rectum: astudy of distal intramural spread and patient' survival. Br JSurg 1983;70:150-4.19. Halvorsen TB. Tissue sampling and histological grading incolorectal cancer. Are routine sections representative? AP-MIS 1989;97:261-6.20. Dworak O, Keilholz L, Hoffmann A. Pathological featuresof rectal cancer after preoperative radiochemotherapy. Int JColorect Dis 1997;12:19-23.21. Compton CC; Updated protocol for the examination ofspecimens from patients with carcinomas of the colon andrectum, excluding carcinoid tumors, lymphomas, sarcomas,and tumors of the vermiform appendix. A basis for checklists.Arch Pathol Lab Med 2000;124:1016-25.22. TNM classification of malignant tumors. 5th ed. NewYork: Wiley; 1997.23. TNM classification of malignant tumors. 6th ed. NewYork: Wiley; 2002.24. Marijnen CA, Nagtegaal ID, Kranenbarg EK, Hermans J,Van de Velde CJ, Leer JW, et al. No downstaging after shorttermpreoperative radiotherapy in rectal cancer patients.J Clin Oncol 2001;19:1976-84.25. Rullier A, Laurent C, Capdepont M, Vendrely V, Bellean-259v o l . 3 i s s u e 6 - 2 0 0 9B E L G I A N J O U R N A L O F M E D I C A L O N C O L O G Y
Page 2 and 3: ABFigure 1. Anterior (A) and poster
Page 4 and 5: Table 1. Grading of the quality of
Page 6 and 7: Table 2. Pathological TNM classific

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