Assessment of Margins in

Colorectal Cancer
Specimens
Holly Brunner, PA(ASCP)
Sibley Memorial Hospital
Washington, DC

3 factors in margin assessment

Knowing the margins
2. Handling the specimen correctly
3. Reporting of all the data related to the
margins (Minimal Pathology Data Set)
1.

Focus will be on rectal cases. They require

a little more TLC and the information is a
little newer.

Part 1: Knowing the Margins

1. Mucosal
2. Serosal
3. Mesenteric radial

4.Radial
5.CRM

Serosal Margin
Peritonealized surface near bowel wall
3 levels of involvement with different
prognoses

2 of those levels are micro level

Take more sections if close

Grave prognosis if involved

Some institutions doing intraoperative
serosal scrapings if tumor appears to
approach surface

Mesenteric Margin

aka mesenteric radial m.

Cecum, Transverse, Sigmoid

Point where the mesentary vessel root is cut by

the surgeon

Specimen should be surrounded by peritoneum

at the level of the tumor

Measure distance from deepest tumor

penetration to resection line usually > 5 cm

Mesenteric margin

Radial Margin

aka adventitial m., lateral m.

Retroperitoneal or perineal adventitial soft

tissue closest to deepest penetration of
tumor
Created by blunt dissection during
surgery
Ascending, Descending, Upper rectum
(partially encased by peritoneum) = radial
margin
Distal rectum (not encased) =
circumferential radial margin (CRM)

Part 2: Assessing and Measuring

Dr. Phil Quirke from Leeds University is leading

professor, researcher and honorary consultant on
colorectal cancer reporting and CRM data

Second interest is digital pathology

GI specialist + avid photographer = amazing
instruction on dissecting of colorectal specimens

Publication titles include:

Local recurrence of rectal adeno CA is caused by
inadequate surgical resection (1986)
Who to treat with adjuvent therapy in Stage II
colorectal CA? The need for high quality pathology
(2007)

Quirkes Protocol

http://www.ualberta.ca/~rmclean/crdiss.htm
http://philquirke.weebly.com/index.html

1.
2.
3.
4.

Grade the surgery quality of the specimen

Fix for 2 days minimum!
Serially section
Collect Minimal Data Pathology Set
(MPD)

1. Mesorectum Quality Assessment

Grades 3-1
Intact > Moderate > Incomplete
Great indicator of the patients prognosis

3-Good:

intact, bulky mesorectum

Grade 3

intact, smooth, complete

Grade 3

Grade 3 bulky up to levators

Grade 2 - Moderate
irregularity of the mesorectal surface w/
>5 mm defects. Moderate coning. No
visible m.propria

received is a 12 cm length segment of

recto sigmoid colon with a moderate
(ragged but no visible m.propria)
excision of the mesorectum

Grade 2

not intact

Is it possible for the entire

mesorectum to be removed
even though it has a ragged
appearance?
Yes, but it doesn't matter. Once the
mesorectum has been violated the risk
for spillage of tumor from lymphatics
exists. A ragged specimen without a
smooth surface must therefore be a
grade 2.

Grade 1: Poor
Little bulk with defects down onto
m.propria and/or very irregular CRM
The mesorectum is incomplete with
defects exposing m.propria.
TAKE PICTURES!

Grade 1

Quirkes Protocol
1.

Grade surgery quality

2. Ink, Partially cut, Fix for 2 days

minimum!
3. Serially section
4. Collect Minimal Data Pathology Set
(MPD)

2. Dont cut tumor area

3. Serially section 3-5 mm slices 2 cm

above and 2 cm below tumor area

Quirkes Protocol
1. Grade surgery quality
2. Fix for 2 days minimum!
3. Serially section

4. Collect Minimal Data Pathology Set

(MPD)

4. Measure limit of tumor extension

(yellow) and distance of tumor, deposit, or
node to CRM (red)

Minimal Pathology Data Set

1.
2.
3.
4.
5.
6.
7.

Extent of local invasion (w distance beyond

m. propria given)
# LNs retrieved
Nodal Stage
Extramural vascular invasion (EMVI)
Peritoneal or serosal involvement
CRM involvement (distance of tumor,
deposit, or +LN to margin)
Quality of mesorectum
Together the 7 bits help provide a more accurate
prognosis and make retrospective analysis better

Part 3: Reporting the Data

Sounds like the easy part but its actually

the most difficult to accomplish.

Part 3: Reporting the data

Updating the dynamic TNM system depends on

outcome studies and the collection of outcome
data by the NCDB (National Cancer Data Base).

3 parts of the MPD are being collected with the

TNM system and its been useful:

The first 5 ed. of the AJCC staging manual classified

stage III in a single group but now has subcategories in
the 6th ed. because of prognostic figures from NCDB
analysis from 87-93.
Subgroup survival rates were 59.8%, 42%, and 27.3%
,respectively when assessing both depth of penetration
and difference btwn <4 nodes or 4 nodes (+)

7th ed. comes out in June with changes going in

to effect Jan. 1, 2010

TNM system is good for staging and thus giving prognosis based on
studies already performed. But streamlined reporting often omits
data (MPD) needed for prognosis and treatment of the patients and
omits data needed to assess possible future staging changes.

Eg. TNM (+) radial margin definition: 0mm

A pt with tumor at the CRM has a 22% chance of local recurrence.
But its the same prognosis if distance from CRM to tumor is 1mm.
Chance of local recurrence doesnt significantly drop til distance is
greater than 2 mm (5%).
Europe reports CRM as positive if tumor is 1mm or less from the
inked radial margin. Places in the US fail to even report on CRM
distance.

And there are more issues

Problem:
According to several journals on the staging and prognosis of
colorectal cancer, many centers, especially the US, are
omitting data (MPD) pertinent to prognosis and data analysis!

1. Poor assessment of specimen

(informed PAs can fix that issue!)
2. No comprehensive report of data set
(pull out the easy button for the pathologists)

Example comments about specimen assessment:

Frequency of margin involvement is related to the interest of the
pathologist. [Dept.] with high LN yields, a good indicator of high
quality pathology, are more likely to reflect the true incidence of
CRM involvement.
Examination

of additional slides has led to an increase in CRM (+)

pts from 6% to 27%.

And they keep going

Centers not having a special interest in GI

pathology reported extramural vascular invasion
findings in 17.8% of cases.
In centers with special GI interest, EMVI rates of
30% are seen.
If the oncologist is not aware that a pt. is
potentially at risk then treatment could be withheld
with a concomitant increase in the risk of death.

..and going

In North America, the clinical importance of the

CRM has not been widely recognized by
pathologists and routine pathological evaluation of
the CRM has been lacking. Assessment of data
from 3 treatment protocols conducted between
79-92 by North Central Cancer Treatment Group
shows the CRM was evaluated pathologically in
only 21% of cases.

Get the picture?

One pathologist said that NAACLS trained

PAs perform gross pathology and
dissection duties better than most
pathologists. It is doubtful that any path
dept. where dissections are performed by
pathologists can match [their] quality of
work. But the use of PAs is not universal.

(Dr. Goldstien of William Beaumont Hospt., Royal Oaks MI)

Shout out to the PAs

Solution

Incorporate all necessary data in to the gross report.

Talk with your pathologists about including all the data. The
report reflects on your skills, the pathologists, the depts and
the hospital. Most importantly, it affects the patient!
Patients have been refused into a trial based on lack of
information.
Become

Magnum G.I.

Take all the necessary measurements

Comment on the serosa and mesocolon and
back up assessment with photos
Take extra sections if necessary
Fix the specimen for best cutting and
measurements
Find all the lymph nodes (12-15+)
Talk to your pathologists about getting the
data in to the report
Go to tumor board so the surgeons are
familiar with you

Conclusion

PS.

Positive node AT mesenteric margin: no

research on it yet. But Dr. Quirke says its
similar to a Dukes C2 (+ln at high tie). So
margin now is reported (-) but note
should be included in the report stating
that a + LN was at the margin.

References
1.

2.
3.

4.
5.
6.
7.

8.
9.
10.

11.

Anderson C, Uman G, Pigazzi A. Oncological outcomes of laparoscopic surgery for rectal

cancer: A systematic review and meta-analysis of the literature. EJSO 34 (2008) 11351142.
Compton, C. Colorectal Carcinoma: Diagnostic, Prognostic, and Molecular Features. Mod
Pathol 2003; 16(4): 376-388.
Compton C, Greene F. The staging of colorectal cancer: 2004 and beyond. Cancer J Clin
2004; 54;295-308.
Fleshman Jr, J. The effect of the surgeon and the pathologist on patient survival after
resection of colon and rectal cancer. Annals of Surgery 2002. V235N4, 464-465.
Goldstein N.S. Recent pathology related advances in colorectal adenocarcinomas. EJSO
2001. 27:446-450.
Greene, F. Current TNM staging of colorectal cancer. The Lancet Oncology, 2007. V8I7.
572-573.
Maughan NJ, Morris E, Forman D, Quirke P. The validity of the Royal College of
Pathologists colorectal cancer minimum dataset within a population. British J of Cancer
2007. 97,1393-1398.
Nagtegaal I, Quirke P. What is the role for the circumferential margin in the modern
treatment of rectal cancer. J Clin Onc 2008. 26:303-312.
Parfitt J, Driman D. The total mesorectal excision specimen for rectal cancer: a review of
its pathological assessment. J Clin Pathol 2007; 60:849-855.
West N, Morris E, Rotimi O, Cairns A, Finan P, Quirke P. Pathology grading of colon
cancer surgical resection and its association with survival: a retrospective study. The
Lancel Oncology 2008. V9I9:
Wibe A, Rendedal PR, Svensson E, Norstein J, Eide TJ, Myrvold HE, Prognostic
significance of the CRM folowing TME for rectal cancer. British Journal of Surg 2002, 89,
327-334.