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Has the new TNM classification for colorectal cancer improved care?

Nature Reviews Clinical Oncology volume 9, pages 119–123 (2012)Cite this article

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Abstract

In 2009, the Union for International Cancer Control issued the seventh edition of the well-used T (tumor), N (node), and M (metastasis) classification guidelines. There has been a continual refinement of the staging for colorectal cancer since this system for assessing tumor stage was initially adopted and it has been used to guide treatment decisions for over 50 years. However, the outcome after therapy for patients with colorectal cancer is very variable, even when patients are assigned to the same TNM category. This article assesses the changes that have been made since the sixth edition and discusses whether they are, in fact, informative improvements for a practicing clinician.

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Figure 1: Stage migration due to changes in staging systems with a pT2 colorectal cancer as an example.
Figure 2: The relationship between contour and lymph-node metastases.
Figure 3: Flow chart of the decision-making process applied to the guideline development for colorectal cancer screening in Europe.

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References

  1. Nagtegaal, I. D. & Quirke, P. Revised staging: is it really better, or do we not know? J. Clin. Oncol. 28, e397–e398 (2010).

    Article  Google Scholar 

  2. Sobin, L. H., Gospodarowicz, M. K. & Wittekind, C. (Eds). TNM Classification of Malignant Tumours 7th edn (Wiley–Blackwell, New York, 2009).

    Google Scholar 

  3. Benson, A. B. 3rd et al. American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. J. Clin. Oncol. 22, 3408–3419 (2004).

    Article  Google Scholar 

  4. Pollheimer, M. J. et al. Clinical significance of pT sub-classification in surgical pathology of colorectal cancer. Int. J. Colorectal Dis. 25, 187–196 (2010).

    Article  Google Scholar 

  5. Sobin, L. H. & Wittekind, C. (Eds). TNM Classification of Malignant Tumours 5th edn (Wiley–Blackwell, New York, 1997).

    Google Scholar 

  6. Sobin, L. H. TNM, sixth edition: new developments in general concepts and rules. Semin. Surg. Oncol. 21, 19–22 (2003).

    Article  Google Scholar 

  7. Sobin, L. H. & Wittekind, C. (Eds). TNM Classification of Malignant Tumours 6th edn (Wiley–Blackwell, New York, 2002).

    Google Scholar 

  8. Wünsch, K. et al. Shape is not associated with the origin of pericolonic tumor deposits. Am. J. Clin. Pathol. 133, 388–394 (2010).

    Article  Google Scholar 

  9. Nagtegaal, I. D. et al. Lymph nodes, tumor deposits and TNM: are we getting better? J. Clin. Oncol. 29, 2487–2492 (2011).

    Article  Google Scholar 

  10. Quirke, P. et al. The future of the TNM staging system in colorectal cancer: time for a debate? Lancet Oncol. 8, 651–657 (2007).

    Article  Google Scholar 

  11. Quirke, P. et al. Evidence-based medicine: the time has come to set standards for staging. J. Pathol. 221, 357–360 (2010).

    PubMed  Google Scholar 

  12. Gunderson, L. L., Jessup, J. M., Sargent, D. J., Greene, F. L. & Stewart, A. Revised tumor and node categorization for rectal cancer based on surveillance, epidemiology, and end results and rectal pooled analysis outcomes. J. Clin. Oncol. 28, 256–263 (2010).

    Article  Google Scholar 

  13. Gunderson, L. L., Jessup, J. M., Sargent, D. J., Greene, F. L. & Stewart, A. K. Revised TN categorization for colon cancer based on national survival outcomes data. J. Clin. Oncol. 28, 264–271 (2010).

    Article  Google Scholar 

  14. Sobin, L. H. et al. 'Evidence-based medicine: the time has come to set standards for staging'. Is a radical overhaul really needed? J. Pathol. 221, 361–362 (2010).

    PubMed  Google Scholar 

  15. Fleming, F. J., Påhlman, L. & Monson, J. R. Neoadjuvant therapy in rectal cancer. Dis. Colon Rectum 54, 901–912 (2011).

    Article  Google Scholar 

  16. Schmoll, H.-J. et al. The ESMO consensus guidelines for the management of colon and rectal cancer: personalized decision making. Ann. Oncol. (in press).

  17. Elferink, M. A. et al. Marked improvements in survival of patients with rectal cancer in the Netherlands following changes in therapy, 1989–2006 Eur. J. Cancer 46, 1421–1429 (2010).

    Article  CAS  Google Scholar 

  18. Valentini, V. et al. Multidisciplinary Rectal Cancer Management: 2nd European Rectal Cancer Consensus Conference (EURECA-CC2). Radiother. Oncol. 92, 148–163 (2009).

    Article  Google Scholar 

  19. Marijnen, C. A. et al. No downstaging after short-term preoperative radiotherapy in rectal cancer patients. J. Clin. Oncol. 19, 1976–1984 (2001).

    Article  CAS  Google Scholar 

  20. Astler, V. B. & Coller, F. A. The prognostic significance of direct extension of carcinoma of the colon and rectum. Ann. Surg. 139, 846–852 (1954).

    Article  CAS  Google Scholar 

  21. Wittekind, C., Greene, F., Hutter, R. V. P., Sobin, L. H. & Henson, D. E. (Eds). TNM Supplement: a Commentary on Uniform Use 3rd edn (Wiley–Blackwell, New York, 2003).

    Book  Google Scholar 

  22. Nagtegaal, I. D. & Marijnen, C. A. M. The future of TNM in rectal cancer: the era of neoadjuvant therapy. Cur. Colorectal Cancer Rep. 4, 147–154 (2008).

    Article  Google Scholar 

  23. Vuong, T. et al. Conformal preoperative endorectal brachytherapy treatment for locally advanced rectal cancer: early results of a phase I/II study. Dis. Colon Rectum 45, 1486–1493 (2002).

    Article  Google Scholar 

  24. Allen, D. C., Fon, L. J., McAleer, J. J. & Irwin, S. T. Pathology of rectal adenocarcinoma following preoperative adjuvant radiotherapy and chemotherapy. Ulster Med. J. 68, 17–21 (1999).

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Stein, D. E. et al. Longer time interval between completion of neoadjuvant chemoradiation and surgical resection does not improve downstaging of rectal carcinoma. Dis. Colon Rectum 46, 448–453 (2003).

    Article  Google Scholar 

  26. Chau, I. et al. Neoadjuvant capecitabine and oxaliplatin followed by synchronous chemoradiation and total mesorectal excision in magnetic resonance imaging-defined poor-risk rectal cancer. J Clin Oncol. 24, 668–674 (2006).

    Article  CAS  Google Scholar 

  27. Gosens, M. J. et al. Preoperative radiochemotherapy is successful also in patients with locally advanced rectal cancer who have intrinsically high apoptotic tumours. Ann. Oncol. 19, 2026–2032 (2008).

    Article  CAS  Google Scholar 

  28. Nagtegaal, I. D. & Quirke, P. Colorectal tumour deposits in the mesorectum and pericolon; a critical review. Histopathology 51, 141–149 (2007).

    Article  CAS  Google Scholar 

  29. Song, J. S. et al. Is the N1c category of the new American Joint Committee on Cancer staging system applicable to patients with rectal cancer who receive preoperative chemoradiotherapy? Cancer 117, 3917–3924 (2011).

    Article  Google Scholar 

  30. Wittekind, C., Henson, D. E., Hutter, R. V. P. & Sobin, L. H. (Eds). TNM supplement: a commentary on uniform use (Wiley–Blackwell, New York, 2001).

    Google Scholar 

  31. Giroux, D. J. et al. The IASLC Lung Cancer Staging Project: data elements for the prospective project. J. Thorac. Oncol. 4, 679–683 (2009).

    Article  Google Scholar 

  32. Rami-Porta, R., Bolejack, V. & Goldstraw, P. The new tumor, node, and metastasis staging system. Semin. Respir. Crit Care Med. 32, 44–51 (2011).

    Article  Google Scholar 

  33. Rusch, V. W. et al. The seventh edition of the American Joint Committee on Cancer/International Union Against Cancer Staging Manuals: the new era of data-driven revisions. J. Thorac. Cardiovasc. Surg. 139, 819–821 (2010).

    Article  Google Scholar 

  34. Vallières, E. et al. The IASLC Lung Cancer Staging Project: proposals regarding the relevance of TNM in the pathologic staging of small cell lung cancer in the forthcoming (seventh) edition of the TNM classification for lung cancer. J. Thorac. Oncol. 4, 1049–1059 (2009).

    Article  Google Scholar 

  35. Segnan, N., Patnick, J. & von Karsa, L. (Eds). European Guidelines for Quality Assurance in Colorectal Cancer Screening and Diagnosis 1st edn (Publication Office of the European Union, Luxembourg, 2010).

    Google Scholar 

  36. Allegra, C. J. et al. Phase III trial assessing bevacizumab in stages II and III carcinoma of the colon: results of NSABP protocol C-08. J. Clin. Oncol. 29, 11–16 (2011).

    Article  CAS  Google Scholar 

  37. Leeds Institute of Molecular Medicine. Virtual Pathology at the University of Leeds [online], (2011).

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Author information

Authors and Affiliations

  1. Department of Pathology, Radboud University Nijmegen Medical Center, Geert Grooteplein 2, Nijmegen, 6500 HB, The Netherlands

    Iris D. Nagtegaal

  2. Pathology and Tumor Biology, Leeds Institute of Molecular Medicine, St. James's University Hospital, University of Leeds, Beckett Street, Leeds, LS9 7TF, UK

    Phil Quirke

  3. Department of Oncology, University Hospital Halle, Ernst-Grube-Straße 40, Halle, D-06120, Germany

    Hans-Joachim Schmoll

Authors
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Contributions

I. D. Nagtegaal and P. Quirke researched the data for the article. All authors made a substantial contribution to the discussion of the content, writing and editing the manuscript prior to submission.

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Correspondence to Iris D. Nagtegaal.

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The authors declare no competing financial interests.

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Nagtegaal, I., Quirke, P. & Schmoll, HJ. Has the new TNM classification for colorectal cancer improved care?. Nat Rev Clin Oncol 9, 119–123 (2012). https://doi.org/10.1038/nrclinonc.2011.157

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