Elsevier

Seminars in Oncology

Volume 38, Issue 4, August 2011, Pages 500-510
Seminars in Oncology

Colorectal cancer
Perspectives on Current Tumor-Node-Metastasis (TNM) Staging of Cancers of the Colon and Rectum

https://doi.org/10.1053/j.seminoncol.2011.05.004Get rights and content

Improvements in classifications of cancers based on discovery and validation of important histopathological parameters and new molecular markers continue unabated. Though still not perfect, recent updates of classification schemes in gastrointestinal oncology by the American Joint Commission on Cancer (tumor-node-metastasis [TNM] staging) and the World Health Organization further stratify patients and guide optimization of treatment strategies and better predict patient outcomes. These updates recognize the heterogeneity of patient populations with significant subgrouping of each tumor stage and use of tumor deposits to significantly ā€œup-stageā€ some cancers; change staging parameters for subsets of IIIB and IIIC cancers; and introduce of several new subtypes of colon carcinomas. By the nature of the process, recent discoveries that are important to improving even routine standards of patient care, especially new advances in molecular medicine, are not incorporated into these systems. Nonetheless, these classifications significantly advance clinical standards and are welcome enhancements to our current methods of cancer reporting.

Section snippets

TNM Stage in Colorectal Cancer

The TNM staging system is primarily based on the depth of invasion of the untreated primary tumor at the time of diagnosis (T), the presence of regional lymph nodes metastases (N), and the presence of distant metastasis (M). The TNM classification is applicable to both clinical (cTNM) and pathological staging (pTNM). Clinical staging is based on assessments including medical history and examination, imaging, and endoscopic studies. When pathological data on resected specimens are available,

Prognostic Features Outside of TNM Stage

A number of parameters have been identified in colorectal cancers that aid in risk stratification of cancer recurrence outside of TNM stage.

Specialized Challenges of Rectal Cancer

Total mesorectal excision (TME) is a surgical technique that achieves a sharp dissection within a plane outside the mesorectal fascia of the rectum. The plane constitutes Waldeyer's fascia, which encases the rectum, rectal mesentery, and regional lymph nodes.62 This ā€œholy planeā€ itself is the CRM after excision. TME surgery dramatically decreases the recurrence of rectal cancer from 30%ā€“40% to 2%ā€“15%.62, 63 Radiation therapy combined with TME further decreases local recurrence of rectal cancer.

Important General Concepts in TNM Staging

The AJCC 7th edition1 eliminated the MX designation to improve coding accuracy. Cancer resections with no evidence of an M1 lesion need to be correlated with clinical findings to give a final pathological stage. Thus the clinical status of cM0 or cM1 is grouped with pT and pN status to arrive at a final pathological stage.

Apart from clinical, pathological, and post-treatment staging, two other classifications are recognized. Re-treatment or recurrent TNM (rTNM) is used to classify recurrent

Future Directions for Colorectal Cancer Reporting

The primary mission of TNM staging is to reliably stratify an individual patient's risk of morbidity and mortality from a cancer and to allow for a rational set of decisions about the care of the patient to be made. Rapid progress in fields such as tumor biology, pharmaceutics, biomarker development, clinicopathological correlative sciences, and informatics provide opportunities to incorporate information from both traditional and nontraditional sources into standard pathology reports to help

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