Approach to Cut Up Large Intestine. Prof Geraint Williams Wales College of Medicine Cardiff University

Transcription

1 Approach to Cut Up Large Intestine Prof Geraint Williams Wales College of Medicine Cardiff University

2 Inflammatory Conditions Neoplasia Resection Specimens Polyps and Local Resections

3 Before You Start Know your anatomy The peritoneum and its reflections The mesentery and omentum The blood vessels The adjacent structures Bladder, prostate, seminal vesicles, uterus, ovaries

4

5

6

7

8 Before You Start Know your anatomy Learn surgeon-speak Operations Hartmann s procedure Anterior resection, Abdominoperineal excision Right and left hemicolectomy Acronyms EMR, TEM, TART, TME Others Pouches, columnar cuffs Ostomies Curative vs palliative

9 Before You Start Know your anatomy Learn surgeon-speak Get to know the endoscopists, surgeons, and their support staff

10 Before You Start Know your anatomy Learn surgeon-speak Get to know the endoscopists, surgeons, and their support staff Insist on receiving the specimen fresh

11 Before You Start Know your anatomy Learn surgeon-speak Get to know the endoscopists, surgeons, and their support staff Insist on receiving the specimen fresh Find out as much as you can about the case Request form MDM records - diagnosis, stage, family history Pathology laboratory computer Previous treatment that might affect the pathology

12 Before You Start Know your anatomy Learn surgeon-speak Get to know the endoscopists, surgeons, and their support staff Insist on receiving the specimen fresh Find out as much as you can about the case Don t be coy about asking the surgeon to show you what she has done!

13 Before You Start Know your anatomy Learn surgeon-speak Get to know the endoscopists, surgeons, and their support staff Insist on receiving the specimen fresh Find out as much as you can about the case Don t be coy about asking the surgeon to show you what she has done! Ask yourself what does the clinician need to know?

14 Before You Start Know your anatomy Learn surgeon-speak Get to know the endoscopists, surgeons, and their support staff Insist on receiving the specimen fresh Find out as much as you can about the case Don t be coy about asking the surgeon to show you what she has done! Ask yourself what does the clinician need to know? Expect to report the histology yourself

15 The Specimen What is it? Request form, anatomical landmarks Where is the lesion? Look and feel before you cut! Mark subtle lesions with ink Should I mark margins first? With what? NEVER paint a serosal surface How should I open the specimen? End margins are generally of limited importance, so remove a doughnut containing the staples, fix and keep

16 The Specimen Wash out luminal contents carefully Think about taking fresh tissue Microbiology (esp TB), EM, cytogenetics Consider inflating with formalin and immersing in fixative Diverticular disease Crohn s disease Tight strictures Some tumours

17

18

19

20

21 Non-Neoplastic Conditions Look for fat wrapping

22 Non-Neoplastic Conditions Look for fat wrapping Look for sites of perforation, fistulae or strictures Open the whole specimen along its length Start from ileum and proceed distally Antimesenteric border usually Anterior wall of rectum Avoid focal lesions Pin onto cork board, maintaining anatomy Immerse in fixative

23 Non-Neoplastic Conditions Remove pins after overnight fixation LEAVE in fixative for another 24 hours Examine mucosal surface carefully for subtle lesions Aphthoid ulcers Potential dysplastic lesions (raised or velvet plaques) Photograph

24

25 Blocks in Inflammatory Conditions Is it chronic idiopathic inflammatory bowel disease? If yes, is it UC, Crohn s or indeterminate? And is there dysplasia or malignancy? If not CIBD, is it infective, ischaemic, druginduced or diverticulitis? Or is it something rare like Behcet s disease, pneumatosis, diversion proctocolitis or lymphoma

26 Blocks in Inflammatory Conditions Abnormal areas Junction between normal and abnormal areas Normal appearing mucosa between abnormal areas Strictures, perforations, fistulae Focal mucosal abnormalities Ileum and appendix if present Use the photo/diagram to identify areas sampled Generous blocks, perpendicular to mucosa Sample lymph nodes, mesenteric vessels Margins of relatively little value in CIBD

27

28

29

30

31

32 Indeterminate Colitis Diagnosis made in resection specimens 10-20% of colectomies, especially fulminant colitis Some features of UC and Crohn s Generally behave as UC Cautious approach to pouch surgery

33

34

35 Tumours Confirm the nature of the specimen and the site of the tumour Look for perforation through the TUMOUR (pt4) and record whether it is serosal or retro/infraperitoneal For rectal tumours, assess the plane of surgical excision

36

37 Quality of TME Specimens Mesorectal fascia Intramesorectal Muscularis propria

38 CR07 (1119 cases) Frequency Local Recurrence 3 yr 5 yr Mesorectal fascial plane 53% 4% 8% Intramesorectal plane 34% 8% 9% Muscularis propria plane 13% 15% 21% P=0.0019

39 Mesorectal fascial plane Smooth mesorectal surface or minor irregularities only; no defect deeper than 5mm. The mesorectum itself is of good bulk anteriorly and posteriorly No coning near the tumour

40 Intramesorectal plane Irregular mesorectal surface; muscularis propria not visible except at insertion of levators The mesorectum of moderate bulk anteriorly and posteriorly Significant coning distally

41 Muscularis propria plane Mesorectal surface irregular with deep cuts and tears Muscularis propria visible on surface The mesorectum itself is of little bulk Marked coning near the tumour

42

43 APR specimens

44 Tumours Paint the non-peritonealised circumferential margin, NOT the serosal surface

45

46

47

48 Tumours Decide whether to open the whole specimen along its length or to leave the tumour intact with a wick of foam sponge or absorptive paper Opening may be better in smaller, non-circumferential tumours Do so along normal-appearing anti-mesenteric border

49 Tumours In rectal tumours: Relation of tumour to peritoneal reflection Distance from dentate line (for APER specimens) Pin onto cork board, immerse in fixative for 48 hours ABOVE ASTRIDE BELOW Peritoneal reflection Lowest level of the peritoneal reflection anteriorly Bare area of mesorectum ANTERIOR

50 Tumours Identify vascular tie(s) and highest lymph node(s) - take two if uncertain!

51 Tumours Palpate mesentery adjacent to tumour for cords or worms that may represent large extramural veins plugged by tumour But beware atheromatous arteries!

52 Tumours Look carefully for sites of potential serosal involvement - pallor, dulling, granularity

53

54

55 Serosal Involvement Defined by tumour cells on serosal surface Independent prognostic factor Do not paint serosa. it can cause artefact and the overcalling of true serosal involvement. it can lead reviewing or even reporting pathologists to misidentify tumour adjacent to the painted aspect as representing surgical margin involvement.

56 Slice transversely through tumour and adjacent mesocolon or mesorectum at 3mm intervals Photograph Examine each slice carefully before block taking Tumours

57

58

59 Adam et al Lancet 1994; 344:

60 Rectal CRM Involvement Anterior 74% Lateral 13% Posterior 13% Direct spread 73.6% Nodes 20.8% Vascular 5.6% Boyle et al 2004

61 Non-peritonealised circumferential margin involvement in colon cancer Regions of the colon where a significant proportion of the circumference is retroperitoneal caecum ascending colon descending colon distal sigmoid

62

63 Blocks Tumour - blocks (4-6) to allow assessment of Histological type and differentiation Extramural spread and its extent in mm Tumour closest to serosal surface (NB crevices) Tumour in relation to non-peritonealised CRM (esp anteriorly in the rectum) Extramural venous invasion Involvement of adjacent organs

64 Blocks Tumour and adjacent mucosa End margins only if tumour <30mm away highly infiltrative or angioinvasive signet ring, small cell, undifferentiated carcinomas ALL lymph nodes (+ CRM if close) Fat clearance not recommended routinely Whole nodes blocked unless huge and obviously involved Any background abnormalities, especially Large or Multiple polyps IBD

65 Proportion population surviving CRC Survival by pn stage p< pn0 pn1 pn Time (yrs)

66 Proportion population surviving Dukes B CRC Survival by Number Lymph Nodes Retrieved p< nodes 7-12 nodes >12 nodes Years

67 Indications for Adjuvant Therapy Dukes C (pn1, pn2) Tumour perforation Two of Serosal involvement Extramural vascular invasion Non peritonealised margin involvement

68 Audit and Standards The mean number of lymph nodes examined is 12 The frequency of serosal involvement is at least 20% for colonic cancers and 10% for rectal cancers The frequency of extramural venous invasion is at least 25%

69 ACPGBI Lymph Node Harvest Model Predicts lymph node harvest from Age ASA grade Operative urgency Dukes stage Type of surgery Preoperative radiotherapy

70 ACPGBI Lymph Node Harvest Model Predicts lymph node harvest from Age 92yrs 40yrs ASA grade V I Operative urgency Emergency Elective Dukes stage A C1 Type of surgery APR Ant Res Preoperative radiotherapy Yes No Predicted nodes 4 14

71 Neoadjuvant Therapy If no obvious tumour at least 5 blocks of thickened area at tumour site Block whole tumour site if nothing in these Look hard for lymph nodes

72 Local Excisions Polypectomy Endoscopic mucosal resections Transanal endoscopic microsurgical excision of rectal tumours

73

74 National Dataset for Colorectal Cancer Local Excision Histopathology Reports Surname: É É ÉÉ É É É ÉÉ É ÉÉ É Forenames: É ÉÉ É ÉÉ É ÉÉ É É É Date of Birth: É ÉÉ É É É É HospitalÉ É ÉÉ É É..: ÉÉ É ÉÉ.É.. Hospital No: É ÉÉ É ÉÉ É.É É É É É NHS No: ÉÉ É ÉÉÉ É ÉÉ..É É.. Date of receipt: É É É É ÉÉ.ÉÉ É É. Date of reporting: É É ÉÉ É ÉÉ É É.. Report No: É É ÉÉ É É É É..É ÉÉ Pathologist: É É ÉÉ É.É ÉÉ É É Surgeon: É É ÉÉ É ÉÉ É ÉÉ É.É É. Sex: ÉÉ É ÉÉ É ÉÉ É ÉÉ É.É É. Specimen Type: Polypectomy / Endoscopic Mucosal Resection / Transanal Endoscopic Microsurgical (TEM) Excision / Other Comments: ÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ.. Gross Description Site of Tumour É ÉÉ É ÉÉ É ÉÉ É ÉÉ É ÉÉ É ÉÉ É ÉÉ É ÉÉ É ÉÉ É ÉÉ É ÉÉ É ÉÉ É É..É.. Maximum tumour diameter (if known) É É É ÉÉ É É É m m

75

76 Indications for Further Resection in T1 Cancers Incomplete excision including tumours <1 mm from margin Poor differentiation Deep submucosal invasion (Haggitt 4, Kikuchi Sm3) Lymphovascular invasion

77 Haggitt staging of Cancer in Polyps

78 sm1 sm2 sm3 Kikuchi staging of Cancer in Sessile Lesions

79

80 Local Excisions Orientation is vital Embed the whole of the lesion to allow assessment of margins Work with endoscopist and surgical colleagues and their staff to obtain properly presented specimens

81 Nightmare!

82

83

84

85

86

87

88 Acknowledgements Ray McMahon Phil Quirke Neil Shepherd Bryan Warren Axel von Herbay Royal College of Pathologists