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Wider experience with and more data on curative local excision and endoscopic polypectomy for invasive rectal carcinoma are reported. Good results are achieved if strict selection criteria are observed. This treatment modality requires careful histopathologic diagnosis and regular follow-up examinations at short intervals. An international registry for locally treated rectal carcinoma is proposed for the collection of more data.

In esophageal carcinoma as well as in other malignant tumors, present-day oncology requires a standardized classification for planning treatment procedures, estimation of prognosis and evaluation of treatment results and, thus, quality assurance.

At present, staging of malignant tumors is based on the anatomical extent of disease defined by the T(umor) N(odes) M(etastasis) classification. The main objective of further efforts in classifying tumors is to identify additional independent prognostic factors and to create mathematical models that may predict disease progression by prognostic grouping. This article summarizes problems, methods and the design of coordinated studies on prognostic grouping.

Inadvertent perforation or incision into rectal carcinoma during surgery may lead to massive dissemination of tumor cells in the operative area. It was observed in 8.7 percent of 1360 radical resections for cure. In time, the incidence could be reduced from 11.0 to 5.2 percent. Intraoperative spillage of tumor cells influences the incidence of local recurrence. In the last period (1982 to 1985) in cases of spillage of tumor cells, local recurrence was seen in 39 percent as opposed to 12.9 percent in perforation or incision of the tumor. Intraoperative tumor-cell spillage has a negative effect on survival rates, reducing the relative five-year survival rate after resection for cure from 70 to 44 percent. It should be recorded in the surgical and pathologic reports and considered in the analysis of treatment results and in selection of patients for adjuvant radiotherapy.

The local recurrence rate is an important indicator in the quality management of rectal carcinoma. The data of the German Study Group for Colorectal Carcinoma (SGCRC) and the Erlangen Registry for Colorectal Carcinoma (ERCRC) were used to demonstrate the influence of different calculation methods on the level of local recurrence rates. The application of uniform definitions, rules and presentations is necessary to enable national and international comparisons. Only 5-year local recurrence rates allow treatment quality to be definitely judged, especially when multimodal treatment was applied.

The TNM/pTNM classification of anatomic extent before treatment is the strongest predictor of outcome in exocrine pancreatic carcinoma. Frequent changes in staging, published by the UICC in 1987, 1997, and 2002, lead to considerable problems.The data on 272 patients with resection of a pancreatic ductal adenocarcinoma between 1978 and 1997 were analyzed.Two hundred sixty-five tumors were assigned to a higher pT category in 1997. Of them, 70 were reassigned to a lower pT category in 2002. No patient fulfilled the criteria of pT4 in 2002. Eighty-seven tumors were assigned to a higher pathologic stage in 1997. In 2002, 151 tumors were assigned to a lower pathologic stage. No patient was assigned to pathologic stage III. The staging systems of 1987 and 1997 are able to identify subgroups of patients with superior prognosis. The staging system of 2002 includes the same 12 patients in stage I as the classification of 1997. However, stage II contains an inhomogeneous group of 193 patients with poor prognosis.Changes in the TNM classification require a conversion of the data. Analysis and comparison of published results are very difficult and sometimes impossible if classification systems change too often. The present classification is well qualified for treatment choice and gives good information on prognosis after resection. It should be unchanged for at least 10 years.

Die Klassifikation gilt nur fur Karzinome. Histologische Diagnosesicherung ist erforderlich. Der anatomische Unterbezirk sollte registriert, jedoch nicht in der Klassifikation berucksichtigt werden. Im Falle multipler simultaner Tumoren in einer Brust wird der Tumor mit der hochsten T-Kategorie klassifiziert. Simultane bilaterale Mammakarzinome sollten getrennt klassifiziert werden.

Even today, the prognosis of acrallentiginous melanoma (ALM) remains a controversial topic. We present a large case study including all known factors relevant for prognosis. 113 ALMs in 3616 melanoma patients were paired as precisely as possible with their twins, i.e. with 113 superficial spreading melanomas (SSM) from a group of 619 SSMs with high-risk location. The ALMs and SSMs were equivalent in tumor thickness, patient gender and mode of treatment. The follow-up period was for at least 5 years. The 5-year Kaplan-Meier survival curve in both groups are identical. The poor prognosis often ascribed to ALM results from the prognostic factor location. ALM should therefore be regarded as acral localized melanoma.

tion, the subclassification of T1 and T2 was introduced as proposed by the UICC TNM Supplement 1993 [4], i.e., T1a 5 T1M (mucosa, muscularis mucosae), T1b 5 T1SM (submucosa), T2a 5 T2MP (muscularis propria), and T2b 5 T2SS (subserosa). According to the new Japanese edition, in patients treated by mucosal resection, submucosal carcinomas should be further subdivided into SM 1 (submucosal invasion less than 0.5 mm) and SM 2 (submucosal invasion 0.5mm or more), predominantly because longterm outcome data after endoscopic mucosal resections are not yet available. Regional lymph nodes (N). Now, as before, there are considerable differences in the classification of regional lymph nodes. First of all, in the Japanese classification the definition of regional lymph nodes is different according to the tumor localization, while in the UICC system no respective differentiation is provided. Secondly, some lymph node stations considered as regional at least for some tumor localizations by the Japanese rules (13, retropancreatic; 14v, superior mesenteric vein; 16a2 and 16b1, paraaortic middle) are always classified as distant by the UICC. In consequence, there are patients with lymph node metastases who are assigned to M0 in the Japanese system and to M1 in the UICC system. Furthermore, the subclassification of node-positive patients into N1, N2, and N3 follows different principles: in the UICC system, it is based on the number, and in the Japanese system, on the localization of the involved nodes. A translation of the UICC N classification into the Japanese system is not possible because documentation of the site of involved regional lymph nodes is not provided. On the other hand, translation of the Japanese system into the UICC N classification is possible, if for the individual lymph node stations, the number of involved nodes is documented as required in the Japanese rules. Letter to the editor

The American Joint Committee on Cancer (AJCC) recently proposed a new staging system for cutaneous melanoma. We tested its practicability and its prognostic value was compared with the currently used TNM classification. The data of 1976 melanoma patients were used for the testing. 1218 patients (61.6%) could be assigned to the proposed pT classification, 136 patients (90.1%) with lymph node metastases and/or in-transit metastases to the proposed pN classification and all 14 patients with distant metastases to the proposed pM classification. Proposed pathological staging was possible for 971 patients (49%). The number of pT1 patients (399 versus 230) and stage I patients (544 versus 393) was distinctly higher in the proposed classification. In proposed stage II and III groups, subgroups with different prognosis could be identified. The new staging system includes more detailed information on clinical and pathohistological findings. Nevertheless, it is practicable and enables more patients with excellent prognosis to be identified.

BACKGROUND It is unclear whether patients with Stage II colon carcinoma should be offered adjuvant chemotherapy. Therefore, the authors analyzed the risk factors of these patients to identify high-risk subgroups who may benefit from such treatment. METHODS The data from 305 patients with Stage II colon carcinoma documented in the Erlangen Registry of Colorectal Carcinoma were analyzed to identify risk factors for distant metastasis and disease-related survival. The patients were divided into two subgroups: those in a low-risk group and those in a high-risk group. The data were then compared with those from 306 patients with Stage II colon carcinoma from the German Study Group for Colorectal Carcinoma (SGCRC). RESULTS Emergency presentation, a primary tumor site in the left colon, pT3 tumors with a depth of invasion of > 15 mm beyond the outer border of the muscularis propria, and pT4 lesions were identified as the major risk factors for Stage II colon carcinoma. On dividing patients into subgroups according to these risk factors, it was found that patients in the high-risk group had a significantly higher risk of distant metastases and a significantly lower disease-related survival rate compared with patients in the low-risk group. On analyzing the SGCRC data, the authors also found a significantly higher rate of distant metastases in the high-risk group, but the disease-related survival rate differed only marginally. CONCLUSIONS Among patients with Stage II colon carcinoma, it is possible to identify a high-risk group of patients who may be candidates for adjuvant chemotherapy. Stratification by the risk factors emergency presentation, tumor site, depth of tumor invasion, and surgical department should be employed in further clinical studies. Cancer 2001;92:1435–43. © 2001 American Cancer Society.

Tumoren (Neoplasmen) zeigen eine grose Vielfalt in Klinik, Pathologie und Biologie. Gutartige (benigne) und bosartige (maligne) Tumoren sind zu unterscheiden, aber auch innerhalb der Tumoren der einzelnen Organe gibt es eine grose Zahl unterschiedlicher Tumortypen. Maligne Tumoren treten bei bestimmten Personengruppen bevorzugt auf und entwickeln sich oft auf dem Boden von Vorerkrankungen (prakanzerose Bedingungen und Lasionen). Daher werden Krebsfruherken-nungsuntersuchungen vorgenommen, um Vorerkrankungen und fruhe Tumorstadien mit guter Prognose zu diagnostizieren und adaquat zu therapieren.

The classifications apply to carcinomas of the lung and malignant mesothelioma of the pleura.

Hintergrund: In den Leitlinien fur das Kolonkarzinom wird fur Patienten im UICC-Sta-dium III (pN1 oder pN2, Mo) eine adjuvante Chemotherapie empfohlen.

Aims. To recognize possible advantages of the 5th edition of TNM of gastric carcinoma in comparison to the former edition. Methods. Data from Erlangen Cancer Center for 898 patients with gastric carcinoma treated surgically by total or subtotal gastrectomy with en bloc lymphadenectomy were analysed. Results. The prognostic significance of TNM has been improved by the new edition as demonstrated by the likelihood ratio test. In addition, uncertainties of method in the pathological classification of regional lymph-node metastasis inherent in the 4th edition can now be avoided. Conclusion. The changes in the TNM classification introduced by the 5th edition are justified by data from the Erlangen Cancer Center, have methodic advantages in determining the N classification, and lead to an improvement in estimation of outcome.

Introduction: Ductal adenocarcinoma of the pancreas is a highly aggressive tumor with early local spread beyond the pancreas, predominantly to the retroperitoneum, but also with invasion of adjacent great vessels and adjacent organs. Discussion: Anterior extension may lead to perforation of the visceral peritoneum and spread within the peritoneal cavity. Cytology in peritoneal lavage can be positive before any peritoneal metastasis is seen. Invasion of lymphatics and veins as well as perineural invasion are common. The lymph drainage of the pancreas is multidirectional to superior, inferior, anterior, posterior and left lymph nodes. In node-negative cases, isolated tumor cells in the sinus of regional lymph nodes may be found by immunocytochemistry; such findings must be distinguished from micrometastasis. The same applies to isolated tumor cells in bone marrow. Prognosis: The independent prognostic significance of isolated tumor cells in the regional lymph nodes and in the bone marrow remains to be proven. For classification of anatomic extent the new, fifth edition (1997) of the UICC TNM classification should be used. The complex Japanese classification cannot be directly compared with the UICC system. Conclusion: Tumor size and histologic grade influence the extent of spread. Anatomic extent and histologic grade are the strongest predictors of outcome.

Tumoren (Neoplasmen) zeigen eine grose Vielfalt in Klinik, Pathologie und Biologie. Gutartige (benigne) und bosartige (maligne) Tumoren sind zu unterscheiden, aber auch innerhalb der Tumoren der einzelnen Organe gibt es eine grose Zahl unterschiedlicher Tumortypen. Maligne Tumoren treten bei bestimmten Personengruppen bevorzugt auf und entwickeln sich oft auf dem Boden von Vorerkrankungen (prakanzerose Bedingungen und Lasionen). Daher werden Krebsfruherkennungsuntersuchungen vorgenommen, um Vorerkrankungen und fruhe Tumorstadien mit guter Prognose zu diagnostizieren und adaquat zu therapieren.

526 Background: Preoperative chemoradiation adds functional impairment to patients undergoing total mesorectal excision (TME). Surgical quality is of paramount importance to achieve low local recurrence rates in patients operated without preoperative chemoradiation when a negative circumferential margin was shown by preoperative magnetic resonance imaging (MRI). We aimed to determine surgical quality in a prospective multicenter cohort study (OCUM) in patients selected by MRI for surgery without neoadjuvant chemoradiation. Methods: Quality of TME was assessed in three categories for 282 patients from 12 hospitals enrolled for surgery without preoperative chemoradiation (Nagtegaal et al. 2005, Quirke and Morris 2007). Tumor perforation, local tumor cell dissemination and number of lymph nodes were assessed. Further, negative predictive value of MRI for histopathological involvement of the circumferential margin was determined. Results: In patients undergoing TME the muscularis propria plane (category III) was reached in 1/282 patients (0,4 %). Intraoperative tumor cell dissemination was observed in 3/282 patients (1,1 %). Total number of lymph nodes was 25 (median, range 10-79) and 79/282 patients had positive lymph nodes (28 %). The number of 12 lymph nodes recommended by UICC was not reached in one patient. Preoperative MRI correctly predicted a negative circumferential margin involvement as determined by histopathological workup in 98,9 % of patients. Conclusions: Excellent results in terms of surgical quality are possible justifying surgery without pretreatment in patients with MRI-negative circumferental margin tumors. This concept avoids additional functional impairment and reduced quality of life following preoperative chemoradiation in selected patients. Clinical trial information: NCT01325649.

Staging is defined as the assessment and description of the anatomical extent of cancer at certain points in its natural history, as a rule at diagnosis or first treatment. Its significance is based on the fact that, for most solid tumours, anatomical extent is the best predictor of outcome. The purposes of staging are to assist in the planning of treatment, to estimate prognosis and to enable meaningful evaluation of treatment results.

The classification applies only to carcinomas. There should be histological confirmation of the disease. The anatomical subsite of origin should be recorded but is not considered in classification.

Knowledge of a possible correlation between distal polyps found at screening sigmoidoscopy and proximal colonic lesions is important for deciding whether to perform total colonoscopy or not.A prospective analysis of 2439 consecutive patients with colorectal polyps. Of these, 304 were asymptomatic subjects who underwent complete colonoscopy for screening and were found to have adenomatous or hyperplastic polyps in the distal colorectum.Ten (15%) out of 65 patients with distal hyperplastic polyps only and 86 (36%) out of 239 with distal adenomatous polyps were found to have adenomatous polyps in the proximal colon as well (P0.001). The frequency of synchronous proximal adenomas in patients with small (or = 5 mm) or large distal adenomas (5 mm) was comparable (37% and 35%, respectively). However, patients with small distal adenomas had significantly smaller proximal adenomas (P = 0.004) containing less villous component (P = 0.017) than those with large distal adenomas. Neither the patient's age nor the presence of multiple distal adenomas increased the prevalence of proximal adenomas.Hyperplastic polyps found on rectosigmoidoscopy do not indicate a need for a complete colorectal examination, as 15% of patients with distal hyperplastic polyps will have proximal adenomatous polyps, a figure that is comparable with that of asymptomatic patients having no distal polyps, either hyperplastic or adenomatous. When only small distal adenomas are found at screening sigmoidoscopy in asymptomatic persons the decision to do a total colonoscopy should be based on individual considerations, as in such cases only small polyps are to be expected in the proximal colon.

Tumor classification is associated with two inherent problems: (1) to find a compromise between the simplicity needed for a wide application by the medical community and sufficient differentiation and specification required for the presently high differentiation in treatment options and for detailed analysis of treatment results; and (2) to achieve an agreement between the stability necessary for data collection over long periods and the needed continuous inclusion of new proposals that arise by advances in diagnostic and therapeutic methods and the increasing knowledge of prognostic factors. The aim of this report is to inform on the changes and expansions of the international classification of gastric carcinoma during the last few years, to refer to new developments, to point out the relations between established classifications and molecular biology, and to show the future trend in tumor classification.

The anatomic extent of tumor (TNM, pTNM) and, in case of treatment, the residual tumor status following treatment (residual tumor, or R classification) are the strongest predictors for outcome of patients with gastrointestinal cancer. The results of the pTNM and the R classifications depend on the methods used. In particular, the pN classification correlates with the number of nodes examined. The findings of micrometastases or isolated tumor cells in bone marrow should be indicated, and such cases must be analyzed separately from other metastatic cases. The same applies to patients with positive cytology in ascites fluid or peritoneal washings without gross involvement of the peritoneum. For the R classification the additional descriptors (conv), for conventional methods used, and (soph), for sophisticated, are recommended to indicate the methods used for classification. In general, long-term survival can be expected only after R0 resection (resection without residual tumor). The observed 5-year survival after R0 resection is 15% to 40% for esophageal carcinoma. 40% to 75% for gastric carcinoma, and 55% to 60% for colorectal carcinoma; the respective figures for R1 and R2 resections are only about 5% each. In R1 and R2 cases prognosis is determined primarily by the absence or presence of distant metastases, and pT and pN are of minor significance. After R0 resection there is a wide spectrum of prognoses. Careful pTNM classification allows a good estimation of the prognosis and can be considered the gold standard for any analysis of treatment results.

Das Kollektiv der retrospektiven Studie zum Prognoseeffekt der elektiven Lymphknotendissektion (ELND) umfast die Daten von 3616 Patienten mit primarem malignen Melanom der Risikokategorien pT2 bis pT4a, NO, MO aus 9 deutschen Melanomzentren mit unterschiedlicher ELND-Indikation, aber sonst vergleichbaren Standards in Diagnostik, Therapie und Nachsorge.

The R classification, adopted in 1987 by the UICC, denotes absence or presence of residual tumor after treatment. Residual tumor may be localized in the area of the primary tumor and/or as distant metastases. R0 corresponds to resection for cure or complete remission. R1 to microscopic residual tumor, R2 to macroscopic residual tumor. The R classification takes into account clinical and pathological findings. A reliable classification requires the pathological examination of resection margins. The R classification has considerable clinical significance, particularly being a strong predictor of prognosis. General and specific procedures for performing pathological R classification on resection specimens of different organs will be described. New methods in R classification comprise imprint cytology, cytolocial examination of ascites, examination of bone marrow biopsy. The importance of these methods will have to be established in the future.

The tumor status following treatment is described by the residual tumor (R) classification: R0, no residual tumor; R1, microscopic residual tumor; R2, macroscopic residual tumor. Residual tumor may be found in the area of primary tumor and its regional lymph nodes and/or at distant sites. The R classification reflects the effects of treatment and influences further treatment planning. Furthermore, the R classification is a strong predictor of prognosis. An acceptable long-term prognosis can be expected only in R0 patients. Although there exist clear correlations between stage and R classification the differences in prognosis of R0 versus R1,2 cannot be explained by differences in stage alone. The prognostic significance of R classification is demonstrated by respective data for non-small cell lung carcinoma, squamous cell carcinoma of oesophagus, gastric carcinoma, ductal adenocarcinoma of the pancreas, colorectal carcinoma, lung and liver metastases.

Between 1984 and 1986 2347 patients with invasive colorectal carcinoma were registered in a prospective multicenter observation study in which seven German institutions participated. The 5-year survival following tumor resection primarily is influenced by the residual tumor (R) classification. Within the RO patients prognosis can be well estimated by pTNM and pTNM based stage grouping. Stage III is inhomogeneous and should be subdivided into pNl and pN2,3. The 5-year survival rates for the individual institutions showed significant differences for the total, but also for the individual stages. This reflects the importance of the surgeon as “prognostic factor”.

The aim of a tumor classification is to arrange tumors into specifically defined groups and subgroups. The tumors comprising one group are not usually replicas of each other, but resemble one another more closely than they resemble those in other groups. Such a system is convenient, but has inherent limitations which must be clearly recognized. The pathologist must be aware of the difficulties in the classification of tumors, including gastric carcinomas. Individual tumors exhibit a wide range of structures and behavior, so that subdivisions within groups are largely arbitrary.

The purpose of tumour staging for colorectal cancer (CRC) is to help define clinical management, facilitate communication between physicians, provide a basis for stratification and analysis of treatment results in prospective studies, and provide some prognostic information for patients and their families. The World Congresses of Gastroenterology, Digestive Endoscopy, and Coloproctology, Working Party on staging for CRC studied six commonly used systems to review their strengths and weaknesses. Although it was concluded that defining a new staging system was unnecessary, it was recognized that there is a need to define a terminology to describe the full anatomic extent of spread of CRC. Furthermore, we note that there are several additional features, derived from both clinical and pathology information, which have had prognostic significance shown by appropriately constructed multivariate analyses and which can be used to formulate a more accurate prognostic index than that provided by a description of anatomical tumour spread. Thus the Working Party came to two principal conclusions. First, a standard format should be adopted for the collection of the essential data required for prospective studies, and we recommend the 'International Documentation System (IDS) for CRC' for this purpose. Second, a nomenclature which describes the full anatomical extent of tumour spread and residual tumour status in CRC has been defined and should be adopted, from which all currently used staging systems can be derived. We have called this nomenclature the 'International Comprehensive Anatomical Terminology (ICAT) for CRC'. In the event that these recommendations are adopted, we envision that there will be improved clarity in the documentation of treatment outcome for patients with CRC and improved communication of results derived from prospective studies. Furthermore, an acceptance of IDS and ICAT would set the scene to develop a prognostic index for individual patients with CRC by the expansion of anatomical clinicopathology staging information to include additional factors which have independent prognostic significance.

Different classification systems for pancreatic cancer have evolved in western countries as compared to Japan. While the UICC classification which is focused on tumour size and distant metastasis has achieved widespread acceptance, the more complicated Japanese system seems to be superior in the estimation of local growth. The major drawback of the JPS system, however, is the complex structure and difficult handling. To overcome both the international barriers in classification systems and to achieve a universal prospective data acquisition, a uniform international Documentation System for Exocrine Pancreatic Cancer (IDS for EPC) has been developed by an international group of pancreatologists. The present form of IDS is supported by a software program (based on Microsoft Access®) which allows simplified data acquisition and statistical analysis as well as automated stage grouping for the UICC and JPS classifications. From the first contact with the patient, through all diagnostic and therapeutic measures including follow-up, IDS enables a compact and easy-to-use tool for prospective data acquisition and exchange on an international basis.