Tumour Periphery Growth Pattern

The growth pattern at the advancing edge of the tumour [41] has been shown to have prognostic significance independent of stage and may predict liver metastasis [42,43].

1) Pushing borders: the advancing edge of the tumour is regular, well demarcated or only slightly irregular.

2) Infiltrating borders: by either "streaming dissection" of muscularis propria or dissection of adipose tissue by small glands or irregular clusters of

Fig. 3. Extramural venous invasion with neoplastic thrombosis cells, most often in perivascular of perineural areas.

Infiltrative borders are associated with a poorer prognosis [41].

Some studies, however, revealed problems with the reproducibility of Jass' grading system based on the nature of the advancing tumour margin, which divided rectal tumours into expanding type and infil-trative type [44, 45]. Several investigators have highlighted the histological phenomenon that represents the first step in invasion and metastasis, using the term tumour "budding" [46,47]. Tumour "budding" is defined as an isolated single cancer cell and a cluster composed of fewer than five cancer cells, observed in the stroma of the actively invasive frontal region. Tumour "budding" intensity (<10; >10) has a strong correlation with the pathological characteristics that define tumour aggressiveness. Ueno et al. [48] have demonstrated that patients with expanding

Table 3. Macroscopic pathologic assessment of the completeness of the mesorectum

Incomplete

Little bulk to the mesorectum

Defects in the mesorectum down to the muscularis propria

After transverse sectioning, the circumferential margin appears very irregular

Nearly complete

Moderate bulk to the mesorectum

Irregularity of the mesorectal surface with defect greater than 5 mm, but none extending to

the muscularis propria

No area of visibility of the muscularis propria except at the insertion site of the elevator ani

muscles

Complete

Intact bulk mesorectum with a smooth surface

Only minor irregularities of the mesorectal surface

No surface defects greater than 5 mm in depth

No coning towards the distal margin of the specimen

After transverse sectioning, the circumferential margin appears smooth

tumours (Jass' criteria) that had a tumour "budding" intensity >10 showed much poorer survival than patients with expanding tumours that had a "budding" intensity <10. In the same way, patients belonging to the infiltrating group by Jass' criteria could be divided into two groups with different outcomes based on the intensity of tumour "budding". Multivariate analysis selected tumour "budding" as a significant independent variable, together with number of nodes involved, extramural spread, lymphocyte infiltration, apical nodal involvement and tumour differentiation. The evaluation of tumour "budding" could improve the grading system with particular reference to potential aggressiveness as a marker of prognostic significance and furthermore is simple and reproducible [48].

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