Integrating Staging of

Colorectal Cancer

Paul Finan

John Goligher Colorectal Unit

Leeds General Infirmary

Staging of Colorectal Cancer

• Prediction of survival

• Allows appropriate international comparisons of

outcome

• Determination of treatment

• Entry into trials

• Response to different therapeutic modalities

Staging of Colorectal Cancer

Staging of Colorectal Cancer

• Confusion for nearly 80 years

• Some attempt at uniformity

• Opportunity to standardise staging

Dukes‟ Classification

A

B

C

Staging of Colorectal Cancer

• 1932 Dukes‟ classification

• 1949 Kirklin‟s classification

• 1954 Astler-Coller system

• 1988 TNM (now version 7)

• (not to mention SEER, Stage I-IV etc)

Staging of Colorectal CancerDukes‟ Stage

Staging of Colorectal CancerAstler-Coller

Evolution of Dukes‟ Classification

Dukes‟ ClassificationC1

• Dukes 1929 – extension into perirectal tissues withoutnodal involvement

• Dukes 1932 – metastases present within lymph nodes

• Dukes 1935 – lymph node involvement but excludingthe apical node

• Astler 1954 – limited to bowel wall and positive nodes

• GITSG 1975 – less than or equal to four involved nodes

Fitzgerald 1982

“Modified” Dukes‟ Classification

• Introduction of stage D

• “extensive local spread or with distant

metastases”

• Some discussion over “incomplete

removal of the primary tumour”

Whittaker and Goligher 1976

Staging of Colorectal CancerTNM Staging

Staging of Colorectal Cancer

Stage T N M

0 Tis N0 M0

I T1-2 N0 M0

II T3-4 N0 M0

III Any T N1-2 M0

IV Any T Any N M1

Staging of Colorectal Cancer

Stage T N M

I T1-2 N0 M0

IIA T3 N0 M0

IIB T4 N0 M0

III A T1-2 N1 M0

IIIB T3-4 N1 M0

IIIC Any T N2 M0

Staging of Colorectal CancerTNM Staging

• Clinical TNM

• Pathological TNM

• Integrated (clinico-pathological) TNM

Staging of Colorectal CancerClinical T-stage

•Major

advances with

rectal cancer

•Less accuracy

with colonic

cancers

Submucosa intact but loss part deep mucosal layer

SM

DM

uT1

uT2

Submucosal reflection lost- outer border MP intact

MR Imaging for Rectal Cancer

Accurate analysis of depth of invasion, relationship to mesorectal

fascia and selection for pre-operative therapy

Staging of Colorectal CancerClinical N-stage

• Certainly operator dependent

• Loose relationship with size

• Some relationship with contour

• Loose relationship with sonographic

appearances

• Hope for lymph node specific agents

Staging of Colorectal CancerClinical M-stage

Solitary hepatic

metastasis

Staging of Colorectal CancerProblems with Clinical TNM

• Accurate assessment of T-stage pre-

operatively

• Always difficulty with nodal disease

• Refined scanning with MR, CT and PET

• Involvement of RCR

Staging of Colorectal CancerProblems with Pathological TNM

• Poor clinical evidence for change

• Classification of mesorectal deposits

• Influence of pre-operative therapy

• Stage migration and influence on

treatment

• Settling on an agreed version (5,6 or 7)

Quirke et al 2007

Staging of Colorectal CancerProblems with Pathological TNM

• Define and agree R0, R1 and R2 status

• Attempt to resolve issues around

mesorectal deposits (N or T) including size

and contour

• Ensure that “y” prefix is used

• Work with agreed proformas from R.C.

Path

Staging of Colorectal CancerTNM Staging

• Pre-op MDT – clinical TNM stage

• Post-op MDT – pathological TNM stage

• Pre-op treatment – “y” prefix

• Overall integrated TNM stage(e.g. pT2, pN1, cM1, R0, V1)

Staging of Colorectal Cancer

National Colorectal Cancer Dataset

Hospital

Episode

Statistics

Linked national

dataset

English cancer

registry information

De-duplication

A B

A

De-duplication

C D

C

Staging fields requested in the NCDR

• Clinical T stage

• Clinical N stage

• Clinical M stage

• Combined clinical TNM stage

• Pathological T stage

• Pathological N stage

• Pathological M stage

• Combined pathological TNM

stage

• Integrated T stage

• Integrated; N stage

• Integrated M stage

• Combined integrated TNM

stage

• Dukes‟ stage

• Metastases at diagnosis

• Number of nodes examined

• Number of positive nodes

• Tumour size

• TNM version

• Neo-adjuvant treatment flag

• Nottingham prognostic index

• Breslow thickness

• Gleason score

• FIGO score

Rules used to derive stage across the multiple

staging fields in the NCDR

• The information in each staging field was „cleaned‟ to ensure only valid staging information was present

• For each TNM class (i.e. clinical, pathological or integrated) the individual T, N and M information were combined to give an overall TNM stage of 1 to 4. If information conflicted between the combined form of a TNM stage and the individual component the highest overall stage was retained.

• All the TNM stage categories were then converted to Dukes‟ stage. If both a Dukes and a pathological or integrated TNM were provided for an individual but the information conflicted then the highest stage was taken

Rules used to derive stage across the multiple

staging fields in the NCDR

• If no Dukes‟ stage or pathological/integrated stage was available for an individual but a clinical TNM stage was provided then the clinical stage was used.

• If the presence of positive nodes was recorded in the dataset then empty or lower stages were upgraded to Dukes‟ C

• If the presence of metastases was recorded in the dataset then empty of lower stages were upgraded to Dukes D

Staging information submitted into the NCDR

Cancer

Registry

Clinical

TNM

Pathological

TNM

Integrated

TNM

Dukes‟

ECRIC X X

NWCIS X X X

NYCRIS X

OCIU X X X

SWCIS X X X

ThCR X X X

TrCR X X

WMCIU x x x X

Percentage distribution of Dukes Stage

between 1995 - 2008

Cancer

Registry

Dukes‟ Stage

A B C D Unknown

ECRIC 9.1 20.0 22.4 12.1 36.3

NWCIS 6.6 20.7 22.4 2.2 48.1

NYCRIS 9.6 22.8 20.4 21.1 26.1

OCIU 9.2 24.1 24.3 12.0 30.4

SWCIS 7.9 21.8 21.1 6.5 42.7

ThCR 6.7 21.0 19.4 20.2 32.7

TrCR 6.8 16.3 16.6 5.7 54.5

WMCIU 9.2 26.2 24.6 14.5 25.6

Total 8.0 21.5 21.1 12.2 37.2

Percentage distribution of Dukes Stage in

2008

Cancer

Registry

Dukes‟ Stage

A B C D Unknown

ECRIC 12.6 22.7 21.6 15.8 27.3

NWCIS 9.0 20.5 25.0 4.1 41.4

NYCRIS 8.9 20.6 19.6 22.2 28.6

OCIU 9.1 21.4 22.3 5.0 42.1

SWCIS 11.2 22.6 22.5 15.5 28.2

ThCR 9.1 23.0 22.0 19.6 26.3

TrCR 12.7 21.4 22.3 7.6 36.0

WMCIU 11.1 25.6 24.4 15.9 23.0

Total 10.4 22.3 22.5 14.3 30.6

Staging of Colorectal CancerProposal from NYCRIS

• Continue with 5th edition of TNM

• Modify databases to record clinical,

pathological and integrated TNM stage

• A need for pre-treatment AND post-

treatment stage

• Advice needed on position of stage after

pre-operative (“y”) treatment

• Links with NBOCAP audit and NCIN

Staging of Colorectal CancerIssues for Discussion

• Agree on an integrated clinico-pathological

stage

• Confirm version of TNM

• Particular problems with very early lesions

and those that have no resection

• Standardise pre-operative stage requiring

non-surgical treatment

• Agree the lines of responsibility