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 C

B
 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 Cancer
Dukes‟ Stage
Staging of Colorectal Cancer
Astler-Coller
Evolution of Dukes‟ Classification
 Dukes‟ Classification
C1
• Dukes 1929 – extension into perirectal tissues without
nodal involvement

• Dukes 1932 – metastases present within lymph nodes

• Dukes 1935 – lymph node involvement but excluding

the 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 Cancer
TNM 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 Cancer
TNM Staging

• Clinical TNM

• Pathological TNM

• Integrated (clinico-pathological) TNM

Staging of Colorectal Cancer
Clinical T-stage

•Major
advances with
rectal cancer

•Less accuracy
with colonic
cancers
 uT1
SM
DM

Submucosa intact but loss part deep mucosal layer

 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 Cancer
Clinical 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 Cancer
Clinical M-stage

Solitary hepatic
metastasis
 Staging of Colorectal Cancer
Problems 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 Cancer
Problems 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 Cancer
Problems 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 Cancer
TNM 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

De-duplication
English cancer
registry information
A B

A
Linked national
dataset

Hospital
Episode C
Statistics
C D
De-duplication
 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 Clinical Pathological Integrated Dukes‟

Registry TNM TNM TNM

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 Dukes‟ Stage
Registry 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 Dukes‟ Stage
Registry 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 Cancer
Proposal 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 Cancer
Issues 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