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Macroscopic Evaluation of Rectal Cancer Resection Specimen: Clinical Significance of the Pathologist in Quality Control

From the Departments of Pathology and Surgery, Leiden University Medical Center, Leiden, and Department of Pathology, University Medical Center St Radboud, Nijmegen, the Netherlands; and Department of Pathology, University of Leeds, Leeds, United Kingdom.

Address reprint requests to Iris D. Nagtegaal, MD, Department of Pathology, University Medical Center St Radboud, PO Box 9101, 6500 HB Nijmegen, the Netherlands; email: i.nagtegaal{at}pathol.azn.nl

PURPOSE: Quality assessment and assurance are important issues in modern health care. For the evaluation of surgical procedures, there are indirect parameters such as complication, recurrence, and survival rates. These parameters are of limited value for the individual surgeon, and there is an obvious need for direct parameters. We have evaluated criteria by which pathologists can judge the quality or completeness of the resection specimen in a randomized trial for rectal cancer.

PATIENTS AND METHODS: The pathology reports of all patients entered onto a Dutch multicenter randomized trial were reviewed. All participating pathologists had been instructed by workshops and videos in order to obtain standardized pathology work-up. A three-tiered classification was applied to assess completeness of the total mesorectal excision (TME). Prognostic value of this classification was tested using log-rank analysis of Kaplan-Meier survival curves using the data of all patients who did not receive any adjuvant treatment.

RESULTS: Included were 180 patients. In 24% (n = 43), the mesorectum was incomplete. Patients in this group had an increased risk for local and distant recurrence, 36.1% v 20.3% recurrence in the group with a complete mesorectum (P = .02). Follow-up is too short to observe an effect on survival rates.

CONCLUSION: A patient’s prognosis is predicted by applying a classification of macroscopic completeness on a rectal resection specimen. We conclude that pathologists are able to judge the quality of TME for rectal cancer. With this direct interdisciplinary assessment instrument, we establish a new role of the pathologist in quality control.

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