How Many Nodes Have to Be Detected/Examined After Preoperative Radio(chemo) Therapy?
In patients with colonic and rectal cancer treated with surgery alone, prognosis depends primarily on the pathological stage of the tumour according to the tumour, node, metastasis (TNM) system, based on the extent of the primary tumour (pT) and its relat
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David Tan, Iris D. Nagtegaal, and Rob Glynne-Jones
65.1 Introduction Total mesorectal excision (TME) using meticulous dissection along surgical planes remains the mainstay of curative treatment options for rectal carcinoma. In patients treated with surgery alone, prognosis depends primarily on the pathological stage of the tumour. Cuthbert Dukes originally proposed a classification system for colorectal cancer in 1935, which recognised the importance of pathological nodal status. Till now, this remains one of the most important factors in predicting future outcome both in terms of local recurrence and disease-free survival (DFS) and overall survival (OS), although the Dukes’ classification has been superseded by more precise tumour, node, metastasis (TNM) systems, which are used by the American Joint Committee on Cancer (AJCC) and the Union for International
D. Tan Department of Radiation Oncology, National Cancer Centre, Singapore, 11 Hospital Drive, Singapore, 169610, Singapore I.D. Nagtegaal Department of Pathology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands R. Glynne-Jones (*) Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex, UK e-mail: [email protected]
Cancer Control(UICC) for rectal cancer [1–3] (see Table 65.1). TNM staging in rectal cancer is based on the extent of the primary tumour (pT) and its relationship to the muscularis propria, the absence or extent of nodal involvement (pN0), the number of the involved regional lymph nodes (pN1 and pN2) and the presence or absence of distant metastases (M). Patients with histologically node-positive rectal cancer tend to be those with more advanced T sub-stage [4] and more frequently involved circumferential resection margins. Population data suggest that approximately 18–20% of patients with pT3 tumours have four or more involved lymph nodes (pN2) [5]. Hence, the various combinations of T-stage, N-stage and M-stage have been combined into stage groupings (stage I to IV) that give a more defined risk stratification and determine prognosis. However, a staging system is only valuable if the results can reliably reproduce an accurate prediction of outcomes (in terms of local and distant metastases). This prediction can then guide postoperative treatment decisions regarding the need for additional adjuvant treatment, and direct the type and intensity of follow-up surveillance. In this chapter, we will discuss the conflicting findings regarding lymph nodes (LNs) in rectal cancer when surgery alone is performed and neoadjuvant treatments are delivered. We also examine the issues surrounding the importance of
© Springer-Verlag Berlin Heidelberg 2018 V. Valentini et al. (eds.), Multidisciplinary Management of Rectal Cancer, https://doi.org/10.1007/978-3-319-43217-5_65
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554 Table 65.1 TNM classification (version 8, 2017) with sub-classifications
Primary Tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ: intraepithelial or invasion of la
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