Jibran Mohsin - Surgical Oncologist

Candidates for Preoperative Systemic Therapy in Breast Cancer

Reference: NCCN Guidelines Version 4.2023 (Invasive Breast Cancer)

visual abstract on impact of Anastomotic Leak on Long-Term Oncological Outcomes After Restorative Surgery for **alCancer

https://bit.ly/44MVcm3

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Enhanced Recovery After Colon and Re**al Surgery from ASCRS and SAGES

Caprini VTE risk assessment Tool: A Caprini score of 5 or more is a reliable criterion for identifying patients with an increased risk for VTE in CRC Surgery.
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In a prospective study of 148 patients undergoing laparoscopic colore**al cancer surgery, the overall screened VTE risk at postoperative day 6 was 24%; the highest risk was in patients with a Caprini score of 12 or more (40.5%) and between 9 and 12 (20.4%). [1]

An additional prospective study of 80 patients with colore**al cancer who received routine postoperative VTE prophylaxis (enoxaparin and compression stockings) found that a cutoff in the Caprini score of 11 resulted in a sensitivity of 76.2% and the specificity of 74.6% in predicting postoperative VTE. [2]

A retrospective population-based study of 17,774 surgical patients who received “standard prophylaxis” found a VTE rate of 0.8% and increased Caprini scores were found to be associated with VTE risk (score 0–1: 0.2%; score 2: 0.4%; score 3–4: 0.7%; score 5–6: 1.4%; score 7–8: 2.0%; score 9 or more: 3.3%). [3]
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[1] Lu X, Zeng W, Zhu L, Liu L, Du F, Yang Q. Application of the Caprini risk assessment model for deep vein thrombosis among patients undergoing laparoscopic surgery for colore**al cancer. Medicine (Baltimore). 2021;100:e24479.

[2] Lobastov K, Dementieva G, Sosh*tova N, et al. Utilization of the Caprini score in conjunction with thrombodynamic testing reduces the number of unpredicted postoperative venous thromboembolism events in patients with colore**al cancer. J Vasc Surg Venous Lymphat Disord. 2020;8:31–41.

[3] Bo H, Li Y, Liu G, et al. Assessing the risk for development of deep vein thrombosis among Chinese patients using the 2010 Caprini risk assessment model: a prospective multicenter study. J Atheroscler Thromb. 2020;27:801–808.

The American Society of Colon and Re**al Surgeons (ASCRS) Clinical Practice Guidelines for the Reduction of Venous Thromboembolic (VTE) Disease in Colore**al Surgery (2023)

Extended Right-Sided Colon Resection Does Not Reduce the Risk of (Right) Colon Cancer Local-Regional Recurrence: Nationwide Population-Based Study From Danish Colore**al Cancer Group Database

Large population-based study comparing extended right hemicolectomy & standard hemicoloectomy. Does extended resection reduce locoregional recurrence? Find out in : https://bit.ly/46ZPD5S

Parastomal Hernia Rates and Exercise Following Ostomy Surgery as shown in this visual abstract - what do you think?

https://bit.ly/3INMNGQ

Definition and Optimal surgical treatmemt for Splenic Flexure Colon Cancer

Standardization of the Definition and Surgical Management of the Splenic Flexure Carcinoma by an International Expert Consensus using the Delphi Technique: Room for Improvement? Find out in this visual abstract - reply with your thoughts. https://bit.ly/3qtrbJB

Role of ctDNA in surgery for CRC metastases

visual abstract on clinical validity of tumor-informed circulating tumor DNA analysis in patients undergoing surgery of colore**al metastases
https://bit.ly/3MF8olX

Lateral Lymph Node Size and Tumor Distance from A**l Verge Accurately Predict Positive Lateral Pelvic Lymph Nodes in Re**al Cancer: A Multi-Institutional Retrospective Cohort Study highlighted as a visual abstract: https://bit.ly/3OGZvuO

visual abstract discusses the Prognostic Factors of Bone Metastases From **alCancer in the Era of Targeted Therapy: https://bit.ly/3E98C1a

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2023 Advanced Coloproctology Course (ACC 2023) - the flagship educational course of the ACPGBI.

Plane of excision of the levators/sphincters (APE specimens only)
1- Extralevator
2 - Sphincteric
3 - Intrasphincteris / submucosal / perforation

Evaluation/Grading of Macroscopic Completeness/intactness of Mesorectum
1 - Mesore**al Plane (Complete)
2 - Intramesore**al Plane (Nearly Complete)
3 - Muscularis Propria Plane (Incomplete)

LVI vs EMVI - CRC

Treatment Effect - Post Neoadjuvant Therapy - CRC

A modified Ryan scheme is suggested for scoring of tumor response, and has been shown to provide good interobserver reproducibility provide prognostic significance.

Several other systems have been studied and can be chosen to report the tumor regression score.
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Note:
1. Tumor regression should be assessed only in the primary tumor; lymph node metastases should not be included in the assessment.

2. Acellular pools of mucin in specimens following neoadjuvant therapy are considered to represent completely eradicated tumor and are not used to assign pT stage or counted as positive lymph nodes.
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Reference: College of American Pathologists (CAP) / NCCN / AJCC 8th edition

American Joint Committee on Cancer (AJCC)
TNM Staging System for CRC. 8th ed., 2017

Prognostic Groups

Lymph Node Evaluation – CRC

AJCC / CAP - examination of a minimum of 12 lymph nodes to accurately stage CRC.
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Stage II CRC

Lack of consensus in the literature on a minimal number of LN for accurate staging.

Reported as >7, >9, >13, >20, and >30 (CRC)
Reported as 14 and >10 (minimal number to accurately identify stage II re**al cancer)

Stage II (pN0) --> < 12 LN initially identified --> resubmit more tissue of potential LNs --> still < 12 LN --> comment in report = extensive search for LN undertaken.
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Factors affecting LN retrieval.
o Age,
o Gender,
o Tumor grade,
o Tumor site, and
o Preoperative Chemotherapy.
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Effect on Preoperative Chemotherapy

1. Sampling of 12 lymph nodes may not be achievable in patients who received preoperative chemotherapy.

2. The mean number of lymph nodes retrieved from re**al cancers treated with neoadjuvant therapy is significantly less than those treated by surgery alone (13 vs. 19, P < .05; 7 vs. 10, P < .001).

3. Only 20% of cases treated with neoadjuvant therapy had adequate lymph node sampling (Reference 12 LN).

4. Number of lymph nodes needed to accurately stage neoadjuvant-treated cases is unknown.
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Attempt to retrieve as many lymph nodes as possible as a number of negative lymph nodes is an independent prognostic factor for patients with stage IIIB and IIIC CRC.

Isolated Tumor Cells (ITC) , Micrometastases, and Macrometastases in CRC (AJCC 8th edition).
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Isolated Tumor Cells (ITC) = Single cell or clumps of cells < 0.2 mm (IHC, H&E) = pN0

[multicenter prospective study of stage I or II disease (via H&E) = 10% decrease in survival for IHC-detected ITC in those with pT3–pT4 disease]
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Micrometastases = clumps of tumor cells ≥0.2 mm but ≤2 mm in diameter = clusters of 10 to 20 tumor cells = pN+

[meta-analysis , significant poor prognostic factor]

Components of Post resection CRC Surgical Pathology Report (College of American Pathologists)

1. Procedure
2. Tumor site and location
3. Tumor size
4. Macroscopic Tumor Perforation
5. Macroscopic Intactness of Mesorectum
6. Histologic Type
7. Histologic Grade
8. Tumor extension (T stage)
9. Margins
10. Treatment Effect
11. LVI and EMVI
12. PNI
13. Tumor Budding
14. Tumor Deposits
15. Regional Lymph Nodes examined / involved.
16. Pathologic Stage Classification (pTNM, AJCC 8th Edition)

Circumferential (Radial) Resection Margin - CRM - evaluation in Colon Cancer

Tumor Deposits vs Tumor Budding

Significance - Important Prognostic Factors
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1. Tumor Deposits - associated with reduced disease-free (DFS) and overall survival (OS) especially stage III.
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2. Tumor budding

a. Independent prognostic factor for stage II colon cancer – making it high risk (ASCO).
b. High-tier tumor budding in pT1 CRC and malignant polyps - increased risk of LN metastasis.
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SURGICAL PATHOLOGY REPORT

1. Numbers of tumor deposits should be recorded.
2. Total number of buds should be reported from a selected hot spot measuring 0.785 mm (20x ocular in most microscopes/via a conversion factor).