Prognostic factors in colorectal cancer. College of American Pathologists Consensus Statement 1999.

BACKGROUND: Under the auspices of the College of American Pathologists, the current state of knowledge regarding pathologic prognostic factors (factors linked to outcome) and predictive factors (factors predicting response to therapy) in colorectal carcinoma was evaluated. A multidisciplinary group of clinical (including the disciplines of medical oncology, surgical oncology, and radiation oncology), pathologic, and statistical experts in colorectal cancer reviewed all relevant medical literature and stratified the reported prognostic factors into categories that reflected the strength of the published evidence demonstrating their prognostic value. Accordingly, the following categories of prognostic factors were defined. Category I includes factors definitively proven to be of prognostic import based on evidence from multiple statistically robust published trials and generally used in patient management. Category IIA includes factors extensively studied biologically and/or clinically and repeatedly shown to have prognostic value for outcome and/or predictive value for therapy that is of sufficient import to be included in the pathology report but that remains to be validated in statistically robust studies. Category IIB includes factors shown to be promising in multiple studies but lacking sufficient data for inclusion in category I or IIA. Category III includes factors not yet sufficiently studied to determine their prognostic value. Category IV includes factors well studied and shown to have no prognostic significance. MATERIALS AND METHODS: The medical literature was critically reviewed, and the analysis revealed specific points of variability in approach that prevented direct comparisons among published studies and compromised the quality of the collective data. Categories of variability recognized included the following: (1) methods of analysis, (2) interpretation of findings, (3) reporting of data, and (4) statistical evaluation. Additional points of variability within these categories were defined from the collective experience of the group. Reasons for the assignment of an individual prognostic factor to category I, II, III, or IV (categories defined by the level of scientific validation) were outlined with reference to the specific types of variability associated with the supportive data. For each factor and category of variability related to that factor, detailed recommendations for improvement were made. The recommendations were based on the following aims: (1) to increase the uniformity and completeness of pathologic evaluation of tumor specimens, (2) to enhance the quality of the data needed for definitive evaluation of the prognostic value of individual prognostic factors, and (3) ultimately, to improve patient care. RESULTS AND CONCLUSIONS: Factors that were determined to merit inclusion in category I were as follows: the local extent of tumor assessed pathologically (the pT category of the TNM staging system of the American Joint Committee on Cancer and the Union Internationale Contre le Cancer [AJCC/UICC]); regional lymph node metastasis (the pN category of the TNM staging system); blood or lymphatic vessel invasion; residual tumor following surgery with curative intent (the R classification of the AJCC/UICC staging system), especially as it relates to positive surgical margins; and preoperative elevation of carcinoembryonic antigen elevation (a factor established by laboratory medicine methods rather than anatomic pathology). Factors in category IIA included the following: tumor grade, radial margin status (for resection specimens with nonperitonealized surfaces), and residual tumor in the resection specimen following neoadjuvant therapy (the ypTNM category of the TNM staging system of the AJCC/UICC). (ABSTRACT TRUNCATED)

International Union Against Cancer. Classification of isolated tumor cells and micrometastasis.

BACKGROUND: Findings of isolated (disseminated or circulating) tumor cells (ITC) by immunocytochemistry and molecular pathology methods have led to varied interpretations and different applications of the TNM system. METHODS: An analysis of the relevant literature was undertaken. In addition, optional proposals for the classification of ITC, micrometastasis, and cytologic results in pleural and peritoneal washings are presented. RESULTS: Immunocytochemistry has a lower false-positive rate than nonmorphologic methods such as flow cytometry or the polymerase chain reaction; therefore the method(s) used always should be recorded. At the current time, the independent prognostic significance of ITC in regional lymph nodes and in the general circulation (blood, bone marrow, and other distant sites) is difficult to assess. To enable comparisons of treatment results and to avoid variation in staging, a finding of ITC should not be considered in the TNM and residual tumor (R) classifications, at least not at the current time. However, for future evaluation of their prognostic significance, the respective findings should be documented according to uniform criteria. CONCLUSIONS: ITC should be distinguished from micrometastasis. To investigate the independent prognostic significance of ITC and of positive lavage cytology, uniform data collection according to the proposed coding schema is recommended.

Benign breast changes and the risk for subsequent breast cancer: an update of the 1985 consensus statement. Cancer Committee of the College of American Pathologists.

The Cancer Committee of the College of American Pathologists has prepared an update of the consensus statement on premalignant breast lesions and breast cancer risk that was originally published in the Archives of Pathology & Laboratory Medicine in 1986. The objective of this publication is to better define the relative breast cancer risk associated with specific histologic abnormalities by incorporating data derived from recent case-control studies. Explanatory notes are used to document and explain specific risk classifications. In addition to refining the degree of risk associated with individual lesions, such as fibroadenoma and atypical hyperplasia, this update includes a discussion of age-specific breast cancer risk and provides examples that can be used when counseling patients.

History and international developments in cancer staging.

OBJECTIVE: To inform the reader of the objectives of staging classification, and review history of the development of modern staging classifications in cancer. DESIGN: Review of the literature documenting the development of modern cancer staging systems with the emphasis on the history of the development of the TNM classification by the UICC and the history of the Canadian Committee on Cancer Staging. The underlying principles of the TNM system have been reviewed in the context of modern cancer practice. CONCLUSION: In the era of the multidisciplinary approach to cancer management, staging allows precision in documenting disease extent, thereby enhancing the quality of patient care. The recording of cancer stage at diagnosis is necessary to optimise patient care and provides a valuable means for recording patterns of disease presentation and monitoring advances in diagnosis and therapy. The objectives of staging described in the TNM staging system are as valid today as when implemented almost 50 years ago.

Stereotactic core-needle biopsy of the breast: a report of the Joint Task Force of the American College of Radiology, American College of Surgeons, and College of American Pathologists.

A national task force consisting of members from the American College of Radiology, the American College of Surgeons, and the College of American Pathologists examined the issues surrounding stereotactic core-needle biopsy for occult breast lesions. Their report includes indications and contraindications, informed consent, specimen handling, and management of indeterminate, atypical, or discordant lesions.

Updated protocol for the examination of specimens removed from patients with colorectal carcinoma. A basis for checklists.

The Cancer Committee of the College of American Pathologists has updated and expanded their protocol for the pathologic examination and reporting of specimens from patients with colorectal carcinoma, which was originally developed in 1989. The updated protocol incorporates all basic pathology data of diagnostic and prognostic significance appropriate for the treatment of patients with colorectal carcinoma. The purpose of the protocol is to serve as a basis for the development of checklists, as an outline for full narrative reporting, as a basis for research protocols, or as a guide for other types of synoptic or reporting formats. The protocol is stratified to accommodate the surgical procedures usually employed for colorectal carcinomas, including incisional endoscopic biopsy, polypectomy, local excision (transanal disc excision), and colon/colorectal resection (eg, segmental resection, total colectomy, abdominoperoneal resection). Explanatory notes detailing specific procedures and rationales for documentation of specific pathologic data are included in the protocol. The protocol uses the recently revised TNM staging system for colorectal carcinoma defined by the American Joint Committee on Cancer and the International Union Against Cancer.

Predictors of recurrence for patients with small (one centimeter or less) localized breast cancer (T1a,b N0 M0).

BACKGROUND: The frequency of small (< or = 1 cm) axillary lymph node negative invasive breast cancers (T1a,b N0 M0) is increasing because of wider implementation of breast cancer screening. Identification of prognostic factors for these patients has been based largely on retrospective pathology review. The authors analyzed histologic factors recorded in the original pathology reports to determine predictors of recurrence for patients with T1a,b N0 M0 breast cancer. METHODS: Two hundred eighteen patients were studied. Potential prognostic factors including measured millimeter tumor size in three dimensions, histologic grade, nuclear grade, and presence or absence of lymphatic vessel invasion were documented prospectively in routine surgical pathology reports of a large community (nonuniversity based) hospital. Follow-up was performed annually by the tumor registry. RESULTS: With a median follow-up of 6.9 years (range, 3-15.8 years), overall recurrence free survival was 93%. Poor nuclear grade (hazard ratio, 5.8; 95% confidence interval, 1.70-19.82; P = 0.004) and lymphatic vessel invasion (hazard ratio, 4.6; 95% confidence interval, 1.34-15.61; P = 0.01) were independent predictors of recurrence. Only 10% of patients had cancers with both poor nuclear grade and lymphatic vessel invasion and their 67% 7-year recurrence free survival (RFS) rate was significantly lower than the 92% RFS rate observed for patients with one of these two factors (P = 0.007) and the 99% RFS for patients with neither poor risk factor (P = 0.0001). CONCLUSIONS: The combination of poor nuclear grade and lymphatic vessel invasion identifies a very small subset (10%) of patients with T1a,b N0 M0 breast cancer with a significant relapse risk that warrants consideration of adjuvant systemic therapy. However, the majority of patients with T1a,b N0 M0 breast cancer have an exceptionally good prognosis.

Breast cancer.

BACKGROUND: Breast cancer is the most common cancer and the second leading cause of cancer death among women in the United States; annual breast cancer deaths are exceeded only by those for lung cancer. METHODS: Data from the Surveillance, Epidemiology, and End Results (SEER) program registry of the National Cancer Institute comprising 158,621 invasive and 10,639 in situ cases of microscopically confirmed breast carcinomas registered for the years 1973-1987 have been analyzed. Relative frequencies, incidence rates, and 5-year relative survival rates were examined by selected variables of interest. Invasive and in situ breast carcinomas and sarcomas were analyzed separately. RESULTS: Infiltrating duct carcinoma was the largest group of female breast cancer, constituting 67.9% of the total with a 5-year relative survival of 79%. All other invasive carcinomas were compared with this group. Lobular carcinoma was the second largest group, only 6.3%, and a 5-year relative survival of 84%. Medullary carcinoma was the third most common with 2.8% and a 5-year relative survival of 82%. Other types included mucinous (colloid) adenocarcinoma, 2.2%, 5-year relative survival of 95%; comedocarcinoma, 1.4%, 5-year relative survival of 87%; Paget's disease (nipple and other breast), 1.1%, 5-year relative survival of 79%; papillary carcinoma, 0.9%, 5-year relative survival of 95%; tubular adenocarcinoma, 0.7%, 5-year relative survival of 96% and inflammatory carcinoma, 0.5%, 5-year relative survival of 18%. Carcinoma in situ was registered as intraductal, lobular, combined ductal and lobular, papillary, and carcinoma in situ, not otherwise specified. The relative survival for all forms of carcinomas in situ was approximately 100%. Sarcomas and malignant tumors not further classified are also considered. CONCLUSIONS: The various histologic types of breast cancer exhibit differences in regard to relative frequency, site pattern within the breast, and patient survival. The SEER program data base of breast cancer is the largest single population-based reference source for breast cancer in the United States. This program is a valuable resource for information on frequency, percentage, and incidence rates by histologic type as well as survival rates of patients with breast cancer.

Intraepidermal squamous carcinoma (Bowen's disease) of the nipple.

A case of Bowen's disease of the nipple clinically resembling Paget's disease is reported. This lesion was differentiated from other pagetoid lesions by negative histochemical stains for mucin and melanin, positive immunohistochemical preparation for high-molecular weight cytokeratin 66 kd (904) using adequate controls, and electron microscopic findings of squamous cell features. The therapeutic implications of such a pagetoid nipple lesion in the absence of an underlying breast carcinoma are discussed.