Clinical Practice Guidelines - National Health and Medical Research ...

CHAPTER 14 STAGING AND REPORTING
Staging of Colorectal Cancer refers to the classification of the tumour according to the extent of
spread in a manner that has a clinically useful correlation with prognosis.
Applications of staging include patient management, quality assurance and research.
A number of imaging techniques, including endorectal ultrasound, will define the extent of tumour
spread at the time of diagnosis. There is, however, no known, reliable, preoperative staging system
that correlates accurately with patient survival.
14.1 Development of postsurgical staging
The first well-documented and tested staging system was that of Dukes. 1 This system was based
entirely on the extent of direct tumour spread and the presence or absence of lymph node metastases
in the resected specimen of bowel. Although Dukes staging was originally described for rectal cancer,
it has also been shown to also be applicable to colonic cancer. Dukes stages A, B and C correlated
well with patient survival, and they were easy to recall and apply. For these reasons the system was
widely adopted. However, the Dukes system did not seek to address the issue of residual tumour,
either local, due to tumour transection, or due to known distant metastases.
The Dukes A, B, C system was broadened by Turnbull, who added a stage D for cases with known
distant metastases and locally advanced tumour. 2 Thus, Turnbull introduced the concept of
clinicopathological staging in which distant metastases, found by the surgeon at the time of bowel
resection, could determine the assigned stage. Clinicopathological staging has now gained wide
acceptance as the preferred method of staging.
14.2 Selection of a clinicopathological staging system
The two main clinicopathological staging systems available, the Australian clinicopathological
staging (ACPS) system and pathological staging (pTNM — tumour, node, metastasis), may both be
seen as extensions of the original Dukes staging method.
The ACPS system was recommended for use in Australia following two workshops on staging held in
Brisbane in 1981. 3 The system was validated using prospectively collected data from the Concord
Hospital Colorectal Cancer Project. The ACPS is essentially a simplified version of the system used at
Concord Hospital since 1971. 4,5 The ACPS and Concord systems are shown in Table 14.1.
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