What Is the Prognostic Value of EMVI?
Vascular invasion has long been established as a poor prognostic feature in colorectal cancer. Over the past 80 years, experience in gastrointestinal pathology has led to the subclassification of vascular invasion into extramural and intramural venous inv
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Timothy G. Palmer and Nicholas P. West
66.1 Introduction The presence of vascular invasion is, almost universally, a poor prognostic feature within solid neoplasms, and in colorectal cancer (CRC), it has also been identified as such for 80 years [11]. Vascular invasion is generally defined as tumour cells within an endothelial-lined space; however, in CRC, vascular invasion is further subclassified by its location within the colorectal wall with regard to the outer layer of the muscularis propria, i.e. intramural or extramural, and also by the type of vessel involved, i.e. lymphatic space or blood vessel. This distinction is important as a large body of evidence exists to suggest that extramural venous invasion (EMVI) is of prognostic significance, whereas as the impact of lymphatic
T.G. Palmer, BSc, MB ChB N.P. West, PhD, FRCPath (*) Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK e-mail: [email protected]
vessel invasion (LVI) or intramural venous invasion (IMVI) is less clear, although recently this has been suggested to be of importance [10]. Due to new insights, gained partly from experience with early CRC [2], it is now likely that IMVI is has a significant degree of prognostic significance.
66.2 Extramural Venous Invasion Although vascular invasion had been felt to be of prognostic significance since the 1920s [11], the retrospective study published by Talbot et al. [16] was the first large study to establish that the presence of EMVI reduces 5-year survival by up to 40%; this trend was most pronounced when the involved vessels had thick muscular walls and it was suggested that EMVI reduced survival in stage II, III and IV tumours. This initial work did not demonstrate any impact of IMVI. Although isolated papers dispute the impact of vascular invasion on survival and disease recurrence [12] in CRC, the majority of published work supports the prognostic impact of vascular invasion. The most recent available data shows that patients with vascular invasion display a higher rate of overall recurrence (42.7% vs. 17.4%) and a lower 5-year disease-free survival (57.0% vs 82.7%) compared to those without vascular invasion [7]. This study also suggests that vascular invasion has a significant impact on 5-year survival and
© 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_66
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recurrence in stage II, III and IV tumours, although unfortunately the authors did not differentiate between IMVI and EMVI. Gibson et al. [5] examined a cohort of a similar size (approximately 2000 patients) with a 10-year follow-up period and identified vascular invasion as EMVI, IMVI or both. Within this cohort it was observed that, although stage II patients showed a reduced 5-year overall survival, over the entire 10-year follow-up period, there was no survival impact of either EMVI or IMVI. Both EMVI and IMVI had a significant impact on overall survival in st
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