Required clinical data

For optimal assessment of a resection specimen, it is necessary for the pathologist to have the following clinical information at his/her disposal:

• neoadjuvant therapy

• tumour localisation

• type of surgery

additional clinical data: obstruction, perforation, family history, IBD


Minimum reporting in conclusion

At a minimum, the pathology report should contain information about the following characteristics:

 

Macroscopy

• Tumour localisation

• Maximum tumour diameter

• Distance to the closest resection surface and state which resection surface that is

• Perforation

• Quality of surgery (completeness of mesorectal surface)

 

Microscopy

• Histological typing of the tumour

• Histological grading of the tumour

• Invasion depth (T-stage)

• Lymphatic invasion

• Resection margins

• Number of lymph nodes examined and affected (N-stage)

• Extramural vascular invasion

• Circumferential margin (positive, negative, distance in mm) for rectal carcinoma

• Presence of significant tumour regression (after neoadjuvant therapy)

• Histologically verified distant metastasis

 

Optional

• Perineural invasion

• Growth pattern/budding

• Tumour infiltrating lymphocytes

• Macroscopic description of the tumour

 

The use of a standard report for resection samples is compulsory.

 

The guideline development group is of the opinion that making and discussing photos of macroscopy of the resection samples forms part of standard care.

 

Other characteristics apply to resection samples from patients who have undergone neoadjuvant therapy; to this end, see the module ‘evaluation after neoadjuvant therapy”.

 

Minimum number of lymph nodes

To determine the lymph node status of the patient, as many lymph nodes as possible should be examined using conventional techniques (HE, without pretreatment). It is recommended that a minimum of 10 lymph nodes are examined to determine a negative lymph node status, starting with the lymph nodes surrounding the tumour.


TNM

The guideline development group is of the opinion that the TNM 5 (1997) should be used, noting that it is sensible to indicate separately if tumour deposits and their characteristics are (not) present.

 

It is recommended that the ASCO guidelines are followed in the identification of patients with a high rusk TNM stage II. In doing so, the following histopathological characteristics are considered unfavourable:

  • perforation
  • T4
  • EMVI (extramural vascular invasion)
  • poor to undifferentiated tumours
  • less than 10 lymph nodes

 

Surgery in an emergency situation, such as with obstruction, is seen as a high risk factor


CRM and surgery quality

As a standard with rectal carcinoma, the circumferential margin should be assessed. A margin of 1 mm or less is considered positive. The margin may be determined using the primary tumour as well as using a lymph node, and should be measured separately in such cases.

 

The guideline development group is of the opinion that the level of resection should be indicated in the assessment of both the rectal resection sample and colon resection sample. Photographic documentation is of great importance when discussing cases during multidisciplinary consultation.

 

The following levels are proposed for rectal carcinoma:

• Level of resection at the muscularis propria (previously incomplete)

• Level of resection in the mesorectal fat (previously virtually complete)

• Level of resection at the mesorectal fascia (previously incomplete)

 

When an abdominoperineal resection has been performed (anal region included in the resection), this area can be assessed as follows:

  • Level of the resection in the submucosa/perforation
  • Level of the resection in the area of the sphincters
  • Level of the resection outside the sphincters

 

With a colon resection, the following levels are assessed:

  • Level of the resection at the muscularis propria
  • Level of the resection in the mesocolic fat
  • Level of the resection at the mesocolon

 

Assessment after neoadjuvant therapy

After neoadjuvant therapy, the extent of tumour regression needs to be assessed and the circumferential margin should be determined. The type and differentiation grade do not need to be reported.


Molecular analyses

The RAS mutation status of the tumour should be determined in patients who are eligible for treatment with antibodies against EGFR.

 

In the case of liver metastases, the RAS determination can also be performed using material of the primary tumour. Lymph node metastases should not be used for the RAS test.

 

The RAS mutation status of the tumour should be determined by a laboratory equipped for this purpose and that participates in a quality assurance programme for this test.

 

Routine additional determinations (BRAF, PTEN, PIK3CA, MSI) is not recommended.

 

MSI research

Molecular MSI analysis, MMR-IHC or a combination of MSI analysis with immunohistochemistry of MMR proteins, should be performed in patients with colorectal carcinoma as documented in the guideline hereditary intestinal cancer.

 

MSI analysis should be performed by a laboratory that is equipped for this purpose and that participates in a quality assurance programme for the test(s) involved.

 

The guideline development group is of the opinion that standard texts should be used to report the results of an MSI analysis requested on the basis of the MIPA procedure by the pathologist.


Pathology of liver resections

At a minimum, the pathology report should contain information about the following characteristics:

 

Macroscopy

  • Number of metastases
  • Maximum tumour diameter
  • Distance to the closest resection surface
  • Tumour perforation through the capsule

 

Microscopy

  • Histological typing of the tumour
  • Resection margins

 

Optional

  • Lymphatic invasion
  • Invasion in the bile duct
  • Vascular invasion
  • Possible tumour response

 

Use of a standard report is recommended. 

Authorization date and validity

Last review : 16-04-2014

Last authorization : 16-04-2014

The validity of this guideline and its associated modules is five years. For various reasons, it may be necessary to edit modules sooner than intended. The National Working Group on Gastrointestinal Cancers therefore annually assesses the content of the guideline and its associated modules. By 2016 it is decided whether a new multidisciplinary working group should be installed to revise the entire guideline.

Initiative and authorization

Initiative : Nederlandse Vereniging voor Radiotherapie en Oncologie

Authorized by:
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging van Maag-Darm-Leverartsen
  • Nederlandse Vereniging voor Heelkunde
  • Nederlandse Vereniging voor Klinische Geriatrie
  • Nederlandse Vereniging voor Nucleaire geneeskunde
  • Nederlandse Vereniging voor Pathologie
  • Nederlandse Vereniging voor Radiologie
  • Nederlandse Vereniging voor Radiotherapie en Oncologie
  • Vereniging Klinische Genetica Nederland

General details

All members were mandated by a scientific, professional or patient association. In the composition of the working group we tried to take national distribution, input from participants from both academic and general hospitals and representatives of various disciplines into account. Patients are also represented by delegation into the working group, as well as a focus group meeting.

Scope and target group

Goal

This guideline and its associated modules are - as much as possible - based on scientific research and / or consensus. It is a document with recommendations to support the daily practice of health care professionals involved in patients with (possible) colon cancer, rectal cancer or colorectal liver or lung metastases. It provides recommendations for diagnosis, treatment, follow-up and organization of care. The guideline and its associated modules are thus seeking to improve the quality of care, to increase transparency of choice for treatment and reduce diversity.

 

Target population

Each year colorectal cancer is identified in approximately 13,000 new patients. Rectal carcinoma occurs in about 1 in 3 patients of this. In the Netherlands, the colorectal cancer in both men and women rank third place in incidence of oncological diseases. The expected number of patients diagnosed with colorectal cancer are increased in 2020 to about 17,000, reflecting a slight increase in incidence (especially in men), population growth and aging.

Colorectal cancer is slightly more common in men than in women and ninety percent of patients 55 years or older. More information about the Dutch population can be found at the Netherlands Cancer Registry: www.cijfersoverkanker.nl

This guideline is applicable to all adult patients with (suspected) a primary colorectal carcinoma and patients with metastatic disease. Particular attention is given to the elderly. A separate guideline is available for adult patients with an increased risk of hereditary colon cancer.

Target Audience

This guideline and its associated modules are intended for all professionals involved in the diagnosis, treatment and rehabilitation of patients with (metastatic) colorectal cancer, such as surgeons, general practitioners, consultants, internists, gastroenterologists, (specialist) nurses, clinical geneticists, paramedics, pathologists, radiologists and radiotherapists. The complete guideline is used to develop a patient education text from the Dutch patients Consumer Federation (NPCF).

 

Member of workgroup

Name

Function

Hospital

Mandated

Mw. prof. dr. C.A.M. Marijnen chair

Radiotherapist

LUMC Leiden

NVRO

Mw. prof. dr. R.G.H. Beets-Tan

Radiologist

MUMC Maastricht

NVVR

Mw. S. de Bruijn

Specialist nurse

Renier de Graaf hospital Delft

V&VN

Mw. dr. A. Cats

Gastroenterologist

NKI-AVL Amsterdam

NVMDL

Prof. dr. E.F.I. Comans

Nuclear doctor

VUMC Amsterdam

NVNG

Dr. A.R. van Erkel

Intervention radiologist

LUMC Leiden

NVVR

Mw. dr. M.A.M. Frasa

Clinical chemist

Groene Hart hospitalGouda

NVKC

Mw. C. Gielen

Specialist nurse

MUMC Maastricht

V&VN

Dr. E.J.R. de Graaf

Surgeon

IJsselland hospital Capelle a/d IJssel

NVVH

Mw. dr. M. Hamaker

Geriatrician

Diakonessenhuis Utrecht

NVKG

Mw. dr. J.E. van Hooft

Gastroenterologist

AMC Amsterdam

NVMDL

Mw. H.J.A.M.. Kunneman

Researcher

LUMC Leiden

n.v.t.

Mw. dr. M.E. van Leerdam

Gastroenterologist

NKI-AVL Amsterdam

NVMDL

Dr. H. Martijn

Radiotherapist

Catharina-hospital Eindhoven

NVRO

Mw. dr. A.M. Mendez

Romero

Radiotherapist

EMC Cancer Insititute Rotterdam

NVRO

Mw. prof. dr. I.D. Nagtegaal

Pathologist

UMCN St Radboud Nijmegen

NVVP

Dr. L.A. Noorduyn

Pathologist

Lab. Voor Pathologie Dordrecht e.o.

NVVP

Mw. A. Ormeling

Patient

Stomavereniging

NFK

Drs. T.A.M. van Os

Klinisch Geneticus

AMC Amsterdam

VKGN

Dr. F.T.M. Peters

Gastroenterologist

UMCG Groningen

NVMDL

Mw. J. Pon

Patient

NFK/SPKS

NFK

Mw. dr. J.E.A. Portielje

Medical oncologist

Haga hospital Den Haag

Gerionne

Prof. dr. C.J.A. Punt

Medical oncologist

AMC Amsterdam

NIV

Mw. dr. H. Rütten

Radiotherapist

UMCN Radboud Nijmegen

NVRO

Prof. dr. H.J.T. Rutten

Surgeon

Catharina-hospitalEindhoven

NVVH

Prof. dr. J. Stoker

Radiologist

AMC Amsterdam

NVVR

Dr. P.J. Tanis

Surgeon

AMC Amsterdam

NVVH

Dr. J.H. von der Thüsen

Pathologist

MC Haaglanden Den Haag

NVVP

Prof. dr. H.M.W. Verheul

Medical oncologist

VUMC Amsterdam

NIV

Prof. dr. C. Verhoef

Surgeon

EMC Cancer Insititute Rotterdam

NVVH

Dr. Tj. Wiersma

General practitioner

NHG

NHG

 

 

Name

Function

Location

Mw. drs. A.Y. Steutel

process manager

Utrecht

Drs. T. van Vegchel

process manager

Amsterdam

Mw. S. Janssen-van Dijk

secretary

Rotterdam

M.P.  van den Berg

Researcher

Bilthoven

P.F. van Gils

Researcher

Bilthoven

Mw. J. Robays

Methodologist

Brussels

Mw. drs. Y Smit

Methodologist

Germany

Mw. A. Suijkerbuijk

Researcher

Bilthoven

Mw. dr. L. Veerbeek

Methodologist

Groningen

Mw. dr. L. Verheye

Methodologist

Brussels

Mw. dr. G.A. de Wit

Researcher

Bilthoven

 

Patient involvement

Two patient experts have been part of the guideline development group. One on behalf of the Dutch Ostomy Association and on behalf of SPKS/NFK. Based on a focus group meeting experiences of patients regarding care were collected. The guideline also has been used to develop a patient education text for the Dutch patients Consumer Federation (NPCF).

Method of development

Evidence based

Implementation

Promoting the use of recommendations begins with a broad (digital) distribution of the guideline, using direct mailing and an article published in the Dutch Journal of Oncology. In other journals or training sessions, for example, the guideline is brought to the attention. An implementation plan for this guideline contains the key recommendations and an overview of barriers and facilitators for implementation.

Methods and proces

The working group met in July 2012 for the first time. Based on an initial list of problems by working group members a survey among professionals involved in patients with colorectal carcinoma was held. Through this survey, sixty professionals supplied and prioritized possible subjects for revision. Also, a focus group meeting was held, collection patients' experiences. The eleven most relevant questions were answered, and translated into English. Also, alle recommendations were translated into English.

 

Each clinical question was andwered by a subgroup within the development group. External methodologists provided the literature search, review, critical assessment, evidence tables and a draft literature review. Workgroup members suggested other considerations and recommendations.

Responsibility

The Comprehensive Cancer Organisation the Netherlands (IKNL) promotes that people with cancer and their families have access to a consistent and qualitatively adequate care as close to home as possible. IKNL was established to improve treatment, care and clinical research in oncology. It also has a role in setting up and supporting networks for palliative care. IKNL supports multidisciplinary guideline development for oncology and palliative care and facilitates the maintenance, management, implementation and evaluation of these guidelines.

AGREE was used to check the methodological quality of the guideline.

Search strategy

Searches are available upon request. Please contact the Richtlijnendatabase.