AN AUDIT OF COLORECTAL CANCER HISTOPATHOLOGY REPORTS IN A TERTIARY HEALTH CARE CENTER IN NIGERIA

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1 Nigerian Journal of Gastroenterology and Hepatology Vol. 7 No. 1 June, AN AUDIT OF COLORECTAL CANCER HISTOPATHOLOGY REPORTS IN A TERTIARY HEALTH CARE CENTER IN NIGERIA Obaseki DE*, Rotimi O **, Mekoma DF * and Obahiagbon I* *Dept. of Pathology, University of Benin Teaching Hospital, Benin City,Nigeria. **Department of Histopathology, St James s University Hospital, Leeds, United Kingdom Correspondence Address: Dr D. Obaseki Dept. of Pathology,University of Benin Teaching Hospital, Benin City,Nigeria. .- darlobaseki@yahoo.co.uk ABSTRACT Objective: To audit the completeness of histopathologic reports of Colorectal Cancer for prognostic information in a tertiary care hospital in the light of the minimum reporting standards for colorectal cancer resections recently proposed for use in Nigeria. Material and Methods: Twenty five histopathology reports of colorectal cancer from January 2012 to December 2014 were reviewed. Results: Some of data items were mentioned in the histopathology reports, however gross description of resection specimens was inadequate, degree of differentiation of tumour, stage of tumour, lympho-vascular invasion and status of the surgical margins were poorly mentioned. The mean number of lymph nodes isolated were three and this was done in only ten cases. Conclusion: The quality of histopathology reports is unsatisfactory. Action should be taken to improve the histopathologic reports by adopting in full the proposed proforma for reporting colorectal cancer resection specimens in Nigeria. INTRODUCTION Histopathologic examination and reporting of colorectal cancer specimen is indispensable in the management of affected patients. 1 It confirms diagnosis with accurate typing of cancer and describes the factors that affect prognosis, such as pathologic stage and completeness of local excision, lymph node status, lympho-vascular invasion and marginst hat affect the overall management of the patient. 2 It also provides an assessment of the effect of new adjuvant therapy 19

2 Audit of colorectal cancer histopathology (if this has been given) and a guide to the need of post-operative adjuvanttherapy if preoperative treatment has not beenadministered. 3 Histopathological reports also provide infor mation for cancer registration, clinical audits, and assessment of the accuracy of new diagnostic and preoperative staging techniques and ensuring comparability of patient groups in clinical trials. 4 For these reasons, therefore, histopathology reports have to be of a high quality as much as possible. Histopathologic reports are in reality often extremely variable in form, content and quality but ideally should be made up of standard language, structured format and consistent content. 5 It has been evident for decades that pathologic reports are variable even within a single institution. There is a spectrum of cancer pathology reporting which ranges from a simple narrative report using a single text field of data, which is still being used in our center to sophisticated proforma reporting. 6 Missing information in thehistopathologic reports results in inappropriatetreatment. It is therefore necessary to audit the histopathology reports for the quality and completeness. Audit not only point out the shortcoming but appropriate remedial measures can also be made. 7 Several guidelines on reporting of colorectal cancer have been published by various working groups and experts. 8, 9 Several audits have demonstrated that the use of proforma reporting has improved the quality of pathology reports and their contents at various cancer sites but especially colorectal, breast, 15,16 uterine cervix, 17 pancreas 18 and upper GI. 19 These audits are varied in their quality with some simply comparing historical narrative reports with proformas, 11,19 others comparing the use of proformas alongside narrative reports and one randomised controlled trial of the use of proforma; all showed a significant improvement in the quality of pathology reports using a proforma in comparison to narrative reports by providing more than 90% of data items in the reports in contrast to the less than 77% rate previously found with use of narrative reports only. 20,21 In Nigeria, a proforma for the minimum reporting standards for colorectal cancer resections drafted by Obaseki et al, and subsequently adopted by the Society of Gastroenterology and Hepatology in Nigeria at a preconference workshop held in Calabar Nigeria in 2012 has been strongly recommended to all practicing pathologists in Nigeria. 22 This proforma aims to improve the quality and consistency of results generated in Nigeria. The purpose of this study is to look at the quality and completeness of histopathologic reports on the basis of the minimum reporting standards for colorectal cancer resections in Nigeria guidelines in the last 3 years. MATERIALS AND METHOD This is a retrospective evaluation of histopathology reports of postoperative specimen of twenty five (25) colorectal cancer resections in the Department of Pathology at the university of Benin teaching hospital Benin City, Edo state, Nigeria from January 2012 to December Result and data were assessed and checked for completeness of data items as proposed in the recommended the minimum reporting standards for colorectal cancer resections in Nigeria guidelines. Data items such as the biodata, number of lymph nodes and status, gross description, margins and other parameters were assessed. Only the information contents of reports were audited and not the diagnostic precision. Resection colectomy specimens from other causes like ulcerative colitis, diverticulosis, granulomatous inflammation, trauma and perforation other than that due to malignancy were excluded from the study. RESULTS Patitent biodata, biopsy specimen type, site of tumour and histologic diagnosis were stated in all reports. The margins (cut end) was stated in 80 % of the reports. Maximum tumour diameter on gross examination was written in 68% of the reports. This was followed by local invasion/ staging that was stated in 56% of reports. Lymphnodes were isolated in twelve cases (48%) with a mean isolated number of three lymphnodes and a maximum number of nine lymphnodes. Differentiation of tumour by predominant area and distance of tumour to nearer cut end was only stated in 36% and 20% of reports respectively. Vascular invasion was mentioned in just two reports while only one report had mention of tumour perforation on gross examination. Gross description for rectal tumours, gross description for abdominopelvic resection, response to neoadjuvant 20

3 Obaseki DE, Rotimi O, Mekoma DF and Obahiagbon I therapy, doughnuts and non-peritonealised margins were not stated in the reports at all. Our results show that histopathologic diagnosis was documented in all cases. However the degree of tumour differentiation and the TNM staging Table 1: Audited data items documented in the reports Data Item Documented in report (n=25) % Biodata Specimen Type Site of tumour Maximum tumour diameter Distance of tumour to nearer cut end 5 20 Tumour perforation 1 4 Gross description for rectal tumours 0 0 Gross description for APR 0 0 Histologicdiagnosis Differentiation by predominant area 9 36 Local invasion/staging Response to neo adjuvant therapy 0 0 Doughnuts 0 0 Margins (cut end) Non-peritonealised circumferential margin 0 0 Lymph nodes Perineural and LymphoVascular invasion 2 8 DISCUSSION Audit is a systemic and independent examination to determine whether quality activities and related results comply with the planned arrangementsand whether these arrangements are implemented effectively and are suitable to achieve the objective. 23 It is an integral part of clinical governance, with links to both risk management program and evidence based practice. As part of their risk management strategy Histopathology Departments should use audit to minimize the chances of an incorrect/misleading report. 24 We audited the information content of our histopathology reports of colorectal cancer. We have not investigated the diagnostic precision, the way that the specimens have been handled and the samples of the specimen for microscopic examination. was documented in only 36% and 56% respectively of the reports. These are recognized histopathologic prognostic factors in colorectal cancer which add value to the quality of the report. 25 TNM staging for colorectal cancer provides more details and has better inter-observer correlation and should be included in all histopathology reports. 26 Provided with a complete set of data, the clinician can stage the patient, however a concluding statement in the pathologic stage will greatly facilitate cancer registration. Although the margins of resection are mention in 80% of cases, dough nuts and circumferential margins are poorly documented. Involvement of both types of margins, have prognostic implications in colorectal cancer management and complement the 27, 28 report. Other important data that were poorly documented include the presence and absence of lymph node metastasis (48%) and the apical lymph 21

4 Audit of colorectal cancer histopathology node involvement. Apical lymph node metastasis is a strong independent negative prognostic factor of poor survival in colorectal cancer. 29 In the majority of cases, the apical lymph node status can be assumed to be negative if the overall nodal status was reported as negative. Nevertheless apical lymph node may not have been identified and this could have implications in patient management. 1 In the present study tbe maximum number of lymph node reported with any sample was nine (9), with a mean of 3 lymphnodes. This is insufficient and below the standard range mentioned by International Union against Cancer and National Cancer Institute (NCI) consensus panel. 30, 31 The College of American Pathologists also recommends the examination of at least 12 nodes in order to accurately predict node negativity. 32 If fewer than 12 nodes were found after thorough gross examination, additional visual enhancement techniques are recommended. 33 Lymph node retrieval has been shown to be intimately linked with rates of circumferential margin status, peritoneal involvement and extramural vascular invasion because the more diligently the pathologist looks for lymph nodes, the better the examination of the specimen and the reporting of important factors. 34 The total number of lymph nodes retrieved therefore appears a good measure of the quality of pathology. Under sampling lymph nodes in cancer specimens can lead to under-staging and mis-utilization of adjuvant chemotherapy. 35 Perineural and Lympho-vascular invasion are poorly documented in our reports (8%). The presence and absence of perineural and lympho-vascular invasion gives reliable prediction of recurrences after resection and better selection of patient for adjuvant systemic chemotherapy. 36,37 Intestinal perforation an important complication in colorectal cancer and is associated with advance disease. Perforated tumor causes peritonitis, sheds malignant cells into the peritoneal cavity and is regarded as pt4 irrespective of other factors. 8 The presence or absence of perforation was documented in only one report. Regarding rectal tumor, relationship of tumor to peritoneal reflection and involving circumferential resections margin were not documented. Both these are important prognostic factors and have high 27, 38 predictive value for both survival andrecurrence. Therefore it is vital that both factors are properly documented in the reports. Audit reports done in other countries also poorly represented these factors. In a study done by Beattie et al in 1996, relationship of tumor below peritoneal reflection wasmentioned in only 1% of the reports. 39 CONCLUSION Overall, the histopathology reports of colorectal cancer was unsatisfactory. Staging, resection margin (goughnuts), apical lymph node involvement, lymphovascular invasion, perineural invasion, background pathologic abnormalities, circumferential resection margin involvement and relationship to peritoneal reflection in rectal tumor were poorly documented. RECOMMENDATION It is strongly recommended that template-based proforma should be implemented for improving the quality of histopathologic reports. REFERENCES 1. Rigby K, Brown R. Steven, Gill L, Margaret B and Hosie BK. The use of proforma improves colorectal cancer patholog y reporting. Ann R Coll Surg Engl 1999; 81: Hermanek P, Gospodarowicz MK, Hensen DE, Hunter RVP and Sobin LH. Prognostic factors in Cancer. Berlin: Spinger 1995: Keating J, Lolohea S and Kenwright D. Pathology reporting of rectal cancer: a National Audit. NZMJ;2003: 116 (1178). Available from: URL:// journal/ / Nagtegaal ID and Van Krieken JH. The Role of Pathologists in the quality control of diagnosis and treatment of Rectal Cancer an Overview. European Journal of Cancer, 2002; 38: Goldsmith JD,Siegal GP, susters,wheeler TM and Brown RW. Reporting Guidelines for Clinical Laboratory Reports in Surgical Patholog y. Archives of Patholog y and Laboratory Medicine; 2008;132:

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