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Colorectal carcinoma, extramural spread and TNM staging

Tissue dissection

Case notes:

80y.o. male with abdominal pain and obstructive symptoms. Right hemicolectomy.

Macroscopic assessment:

Ulcerated tumour,  110 x 70mm, in the ascending colon/hepatic flexure,  with extensive invasion into pericolic fat and subserosa and multiple separate pericolic tumour nodules.

Microscopic:

Poorly differentiated adenocarcinoma, multifocal lymphovascular invasion including extramural venous invasion, extension to free serosal surface, metastatic carcinoma in ‘at least’ 7 pericolic lymph nodes. Pathological stage – pT4a N2b Mx

Discussion:

This case raises one of the difficulties regarding TNM staging in colorectal carcinoma; in particular, the interpretation of pericolic tumour as it relates to the T (tumour) and N (node) categories.

The specimen photograph demonstrates colorectal carcinoma with extensive pericolic fat involvement. There is direct tumour invasion into pericolic fat, consistent with at least T3 (in this case the histology showed extension to the free serosal surface so it was classified as T4). For us (I speak as a Pathologists) this is the easy bit.

The difficult part can arise with the classification of separate tumour nodules in the perinephric fat. Tumour nodules in pericolic fat can be seen in several settings;

  • Tangential cutting of direct tumour extension – this can occur when irregular ‘tongues’ of the main tumour are sliced tangentially, giving the impression of separate nodules
  • Metastatic lymph node involvement
  • Extramural vascular invasion

Nodules in the setting of direct tumour extension should be identified, and therefore avoided, at macroscopic ‘cut-up’. Identification of lymph node metastases is easy when there is residual lymph node present. When there is no residual lymph node, by convention the nodule is regarded as completely replaced lymph node metastasis if the nodule is rounded and circumscribed (N category), and as extramural vascular invasion (under T category) if the nodule is irregular; the latter situation can be additionally designated with a V prefix (V1 if seen microscopically and V2 if seen macroscopically) but in practice it rarely is, instead being describe descriptively as extramural venous/vascular invasion.

My take home message is that the exact cause of pericolic tumour involvement is sometimes difficult, often requiring histological assessment for accurate classification.

Dr Andrew Ryan

This case is de-identified and intended for education purposes only.

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