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 Table of Contents  
Year : 2018  |  Volume : 25  |  Issue : 1  |  Page : 32-36

Histopathological report of colorectal carcinoma resections: A 5-year audit in Lagos

1 Department of Anatomic and Molecular Pathology, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Histopathology, St James's University Hospital, Leeds, United Kingdom
3 Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
4 Department of Radiodiagnosis and Radiotherapy, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria

Date of Web Publication17-Apr-2018

Correspondence Address:
Dr. Kabir Bolarinwa Badmos
Department of Anatomic and Molecular Pathology, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi-Araba, P.M.B 12003, Lagos
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_184_17

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Background: Complete and accurate pathology reporting of colorectal carcinoma (CRC) resection specimen is critical to clinical management of individual patients. The study aims to audit colorectal cancer histopathology reporting in Lagos between 2011 and 2015 before the adoption of the Society for Gastroenterology and Hepatology in Nigeria pro forma in 2016. Materials and Methods: All resected CRC cases were identified from the Histopathology record of our Department and that of a private Laboratory in Lagos over a 5-year from 2011 to 2015. The dataset as contained in the pro forma was extracted from the reports and analysed using SPSS version 16 software. Results: A total of 92 colorectal resections were received during the 5-year period consisting of 90 colonic and 2 rectal tumours. Data inclusiveness on tumour differentiation, extent of primary tumour, total lymph node and lymph node involvement were 96.7%, 91.3%, 83.7% and 92.4%, respectively. Tumour perforation, level of venous involvement and distant metastasis were reported in 73.9%, 21.7% and 96.7% respectively. The circumferential resection margin (CRM) in the 2 rectal tumours had 100% inclusiveness. Tumour node metastasis staging was complete in 87% of cases while Dukes staging was documented in 8.7% of the reports. Conclusion: None of the data items was 100% complete except the CRM for rectal carcinoma. Free text reporting results in incomplete data resulting in improper staging, especially the lymph node status. This highlights the need for pro forma reporting to ensure and maintain consistent reporting of important parameters required for proper staging and management of patients with colorectal cancer.

Keywords: Audit, colorectal cancer, histopathology, pro forma, staging

How to cite this article:
Badmos KB, Rotimi O, Lawal AO, Osinowo AO, Habeebu MY, Abdulkareem FB. Histopathological report of colorectal carcinoma resections: A 5-year audit in Lagos. Niger Postgrad Med J 2018;25:32-6

How to cite this URL:
Badmos KB, Rotimi O, Lawal AO, Osinowo AO, Habeebu MY, Abdulkareem FB. Histopathological report of colorectal carcinoma resections: A 5-year audit in Lagos. Niger Postgrad Med J [serial online] 2018 [cited 2020 May 27];25:32-6. Available from: http://www.npmj.org/text.asp?2018/25/1/32/230192

  Introduction Top

Colorectal carcinoma (CRC) is the third most commonly reported cancer in our hospital and accounts for 59% of all gastrointestinal malignancies in an earlier study.[1] Even though the reported incidence rates in Nigeria is 3.4 cases per 100,000 which is about a tenth of what is seen in the developed countries, CRC constitutes a significant proportion of cancer cases in our hospital.[2] Treatment plan, as well as prognosis of patients with CRC, is dependent on the stage of the disease, completeness of tumour excision among other factors. The quality of histopathology report on resection specimens for colorectal cancer is critical to assessing the quality of surgery, determining the stage, need for adjuvant chemotherapy and/or radiotherapy and prognosis.[3]

In countries with high burden of colorectal cancer, series of interventions on the informational content of pathology report on CRC in many hospitals and regions were observed not to have produced results in terms of desirable minimum standards over a long period.[4],[5] In the United Kingdom, for example, protocols for reporting CRC were developed and updated periodically based on audit reports. This has led to a national pro forma reporting system by the Royal College of Pathologists and has been shown to have improved the inclusiveness of minimum dataset of CRC reporting.[5],[6],[7]

In 2012, the Society for Gastroenterology and Hepatology in Nigeria (SOGHIN) taking a cue from the Royal College of Pathologists (RCP) and the American College of Pathologist developed a pro forma containing minimum dataset for reporting CRC in Nigeria based on the submission of a working committee that was earlier set up.[8] The reporting format is to ensure completeness of histopathology report of resection samples of colorectal cancer and to promote uniformity of colorectal cancer reporting nationally. In our department, free text reporting style for colorectal cancer was in use until 2016 when the SOGHIN pro foma reporting was adopted. This study aims to review the completeness of histopathology reports before the adoption of pro forma reporting method between 2011 and 2015.

  Materials and Methods Top

Histopathology reports of colorectal resection specimens between 2011 and 2015 from our Department and a private laboratory in Lagos constituted the materials for the study. Data items (type of specimen, extent of primary tumour (pT), total number of lymph nodes, lymph node involvement and others highlighted in [Table 1]) based on the SOGHIN pro forma reporting for CRC were extracted from the surgical request forms complemented by the duplicate copy of histopathology reports. The data extracted were entered and analysed using Statistical Package for Social Sciences (version 16.0, SPSS Inc, Chicago, III., USA).
Table 1: Completeness of the dataset items for colorectal carcinoma resection samples

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  Results Top

Out of the 173 patients who had initial diagnosis of CRC, 92 cases of colorectal resections were reviewed during the 5-year study period. The remaining cases included those who do not have surgery due to advanced disease or those who defaulted on account of financial constraints or other socio-cultural reasons. Of the 92 cases, 53 were males and 39 were females with M:F ratio of 1.4:1. The age was not recorded for 3 cases while the mean for the rest was 49.5 ± 14.7 years (median = 49 years, range 13–79 years).

The minimum dataset audited in the pathology reports are shown in [Table 1]. Surgical specimen types and tumour sites were unstated in 12 (13.1%) and 13 cases (14.1%), respectively. The maximum tumour diameter ranges from 20 to 140 mm (mean = 53 mm) in 82 reports while it was unstated in 10 cases (10.9%). Measurements indicating tumour distance to the nearest longitudinal resection margin was not stated in 16 cases (17.4%), the margin was involved in 10 cases (10.9%) while in the remaining 66 cases (71.7%), the longitudinal distance ranges from 10 to 400 mm. In tumour differentiation categorisation, the data were complete in 89 cases (96.7%) and unstated in 3 cases (3.3%). In 64 cases, the total lymph node harvested ranges from 1 to 23 lymph nodes (mean = 7, median = 6) while in 13 cases, no lymph node was seen [Table 2].
Table 2: Tumour differentiation, stage and lymph node status in colorectal carcinoma resected samples

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  Discussion Top

Complete and accurate pathology reporting of CRC resection specimen is critical to the clinical management of these patients and a means of evaluation of the health care system. It confirms diagnosis in the individual patient, gives estimates of prognosis and guides further treatment plan.[9] For health-care evaluation, pathology reports provide information for cancer registries and clinical audit, ensuring comparability of patient groups in clinical trials, and for assessing the accuracy of new diagnostic tests and pre-operative staging techniques.[10] To fulfil these obligations, a periodic evaluation of pathologic report is mandatory and this has been shown to improve the informational content. A published report on the effects of four interventions on the informational contents of CRC reporting in Sheffield showed improvement in the inclusion of data items with each intervention but only with the introduction of template pro formas did these rates approach 100% for all the data items.[5]

Tumour differentiation (Grade) is one of the data items that can predict how aggressive a tumour will behave and it is a stage-independent prognostic factor.[11],[12] Inclusiveness of data on tumour differentiation in this study is among the highest recorded (96.7%). Majority of these cases were well-moderately differentiated carcinoma, 69.5%, while the signet-ring and poorly differentiated carcinoma were 4.3% and 3.3% respectively and are associated with poorer prognosis.[11] Inclusiveness of histologic type and grade is a prominent feature of most histology report and an audit report of 17 laboratories from Wales in the early 1990s showed that these items were reported 100% by all laboratories.[3]

The extent (or depth) of the pT is an important data item in the staging of CRC that influences disease outcomes. In this audit, eight cases (8.7%) do not have data inclusion on the extent of the pT. This omission is similar albeit lower compared to 14 cases (56%) non-inclusiveness of pT in the audit of CRC report in Benin, Nigeria.[13] However, our 91.3% inclusiveness of depth of invasion was much lower compared to earlier audit reports from other countries where 100% or nearly 100% was reported for such data item.[3],[14],[15] Out of the cases with data on the extent of pT, pT3 and pT4 accounted for 79.4% of the total, an indication of advanced stage at presentation by our patients. pT3 tumours (particularly when extramural extension >5 mm) and pT4 tumours are associated with adverse prognostic effect whether or not regional lymph node metastasis is present.[16] It is noteworthy that only 6 cases out of the 54 cases with pT3 tumour in this audit had information about maximum distance beyond the muscularis propria. Thus, stratification of this group in terms of prognosis correlating with the extent of pT may not be feasible.

Lymph node assessment is another key data item that determines stage-related outcome in CRC. Many studies over the past 15 years have demonstrated the importance of an adequate nodal harvest in colorectal cancer, and specifically that node positivity rates increase with increased nodal harvest.[17] Data items such as total lymph node harvested and lymph node status were complete in 77 (83.7%) and 80 (87%) cases, respectively. The total lymph node harvested ranged from 0 to 23 (mean = 7) and only 18 cases (19.7%) had 12 or more lymph nodes harvested. Majority of our cases had lymph node harvest below the minimum of 12 recommended in most guidelines including SOGHIN, RCP (UK) and American Joint Committee on Cancer.[8],[18],[19] Several factors have been identified affecting the number of lymph nodes recovered from resection specimens, and it includes patient factors such as age and anatomic variation, surgical technique and diligence of the pathologist in harvesting all existing nodes.[11] One of the probable reasons for low lymph node yields in this study is surgical techniques with too small mesentery particularly in those cases resected by surgeons with little experience in colorectal surgery. The second is lack of meticulous search by the residents/pathologists that grossed the samples and these will require further research. It was also observed that even though in 15 cases the total number lymph node harvested was unstated, in 10 of these cases the lymph node status was reported as positive or negative. The drawback of lymph node being reported as positive or negative without stating the absolute number is the resultant difficulty in proper lymph node staging as experienced with these cases. A 5-year population-based study of patients undergoing resection for primary CRC in Nova Scotia established that there was a significant increase in lymph node harvest of audited health district when compared to non-audited health district.[17] The relevance of careful lymph node dissection is reflected in the differences observed in lymph node positivity between low and higher lymph node total counts. Low lymph node yield could inadvertently results to understaging of the disease and hence depriving such patients the benefits of adjuvant therapy. It is well established that node-negative diseases have a 5-year survival rates of 70%–80% in contrast to 30%–60% in node-positive disease.[20] However, survival is improved in the latter group by adjuvant chemotherapy hence the need for thorough lymph node dissection.

Another data item from the SOGHIN guidelines is the maximum tumour diameter which was unstated in 10.9% of cases in this study. The relevance of measuring tumour diameter in terms of prognosis is not well established, but it can be used as a quality indicator for assessment of the accuracy of pre-operative imaging results.[21] The distance of tumour to the nearest longitudinal margin was omitted in 17.4% of our cases. It has been suggested from previous studies that any specimen with the presence of tumour at >30 mm from the margin do not need sampling as the margin in unlikely to be involved.[18] However, the presence of tumour at <30 mm from the margin and gross appearance of mucinous tumour should necessitate submission from such longitudinal margin to exclude tumour involvement.[22] For low anterior rectal resection specimen of rectal cancer, a margin of 20 mm is accepted as adequate.[16] In this study, 10 cases (10.9%) had longitudinal margin involvement, and this is a poor prognostic indication. Another important data item considered in this study is the circumferential resection margin (CRM) which is a very important margin particularly in rectal cancers and right-sided colonic cancers because it predicts risk of local recurrence, which is itself a strong predictor of survival.[23],[24] Due to advanced disease at the presentation of rectal cancer in many of our patients, only two patients had curative primary surgical resections and CRM was reported in both cases. However, none of the right hemicolectomy reports contains information on CRM.

The other data items that are of prognostic significance include venous invasion, perineural invasion and tumour perforation.[11],[25] Data inclusiveness for the level of venous invasion and tumour perforation are 21% and 73.9%, respectively. Venous invasion by tumour has been shown to be a stage-independent adverse prognostic factor associated with visceral metastasis and may affect the decision to treat with adjuvant therapy.[26] Morphologic clues of venous invasion should be sought and the level of invasion should be stated. Colorectal tumour perforation had poorer progression-free survival, a higher local recurrence rate and a higher distant metastasis rate.[27] Tumour perforation including intraoperative tumour perforation in colon cancer upstage the tumour to pT4, is associated with statistically significant reduced long-term survival and increased post-operative mortality.[28] Pathologically confirmed distant metastatic disease data inclusiveness in this study is 96.7%. It is one of those parameters needed for tumour node metastasis staging whose inclusiveness is 87% in this study. Majority of these cases are late-stage tumour by virtue of the tumour depth and lymph node metastasis. Dukes staging is rarely used obviously due to non-inclusiveness of the apical lymph nodes in most of the reports with only eight cases (8.7%) reported. None of the reported cases contain information on the residual tumour (R) data item. The R classification not only has prognostic significance but also is important with regard to quality assurance in oncologic treatment and for additional treatment planning when the first treatment course does not achieve complete tumour clearance.[29]

  Conclusion Top

None of the data items in this audit except the CRM for rectal carcinoma recorded 100% inclusiveness. Even though there were set guidelines in our department regarding colorectal cancer reporting; strict adherence is not complied with by the different reporting pathologist as evidenced by the low percentages in inclusion rate of many data items. The use of freestyle reporting may probably contribute to the omission of these data items and therefore, routine use of pro forma reporting is advocated. There is a need for regular education of practicing pathologists in reporting the important parameters needed for adequate staging of resected colorectal specimens. Regular multidisciplinary team comprising of surgeon, oncologist and pathologist will assist in the delivery of quality cancer care and result to improved data inclusiveness for colorectal cancer patients.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2]


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