Evaluation of Venous Invasion by Elastica van Gieson Stain and Tumor Budding Predicts Local and Distant Metastases in Patients With T1 Stage Colorectal Cancer

Abstract

Evaluation of pathologic predictors of metastases in T1 stage colorectal cancer may be difficult with hematoxylin and eosin (HE) staining alone. The aim of this study was to clarify the role of pathologic predictors by using immunohistochemical staining and Elastica van Gieson (EVG) staining. One hundred and twenty-four patients who underwent bowel resection for single T1 stage colorectal cancer from 1990 to 2004 in 1 institution were studied. D2-40, EVG staining, and CAM5.2 were used to detect lymphatic invasion, venous invasion, and tumor budding, respectively. These 3 factors were separately evaluated based on HE staining. Histology was reviewed by 1 pathologist. Lymph node metastases in the surgical specimen were the standard reference, and distant metastases were identified by periodic computed tomography for 2 years or more after surgery. A logistic regression model was applied to analyze risk factors for lymph node metastases and a Cox regression model for distant metastases. In predicting lymph node metastases, univariate analysis demonstrated significance for all predictors except venous invasion by HE staining. Multivariate analysis showed that venous invasion by EVG and tumor budding by HE showed significance as predictors. In predicting distant metastases, univariate analysis showed significance for lymphatic invasion shown by D2-40, tumor budding shown by CAM5.2 and HE, and lymph node metastases. Multivariate analysis showed only venous invasion by EVG stain as being significantly associated with distant metastases (P=0.001). In conclusion, venous invasion evaluated shown by EVG staining is a useful pathologic predictor for metastases in T1 stage colorectal cancer.

Tumor budding in colorectal carcinoma: time to take notice

“…There is a strong association between budding and the presence of lymph node metastases and lymphovascular invasion, 11,12,[15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] defined by the presence of tumor cells within an endothelium-lined space, and it has been suggested that buds represent the part of the tumor that has gained the ability to invade lymphatics and vascular channels. This idea is supported by two intriguing morphological studies: Morodomi et al 33 examined serial sections of high-budding areas to demonstrate that budding nests are often found adjacent to areas of lymphovascular space invasion, and, in a more recent study, Ohtsuki et al 31 performed double staining for anti-cytokeratin antibodies and anti-lymphatic antibodies, finding that a number of 'buds' at the invasive edge of a tumor are in fact located in small lymphatic spaces.…”

“…Similarly, the presence of budding has been associated with increased risk of distant metastases, [34][35][36] suggesting that budding may also be associated with vascular invasion. A few tumor-budding studies have used vascular markers and/or elastic stains to assess vascular invasion, 11,12,19,22,26,32,37,38 but only four have analyzed the relationship between budding and vascular invasion: Kazama et al 22 found no relationship between budding and vascular invasion, whereas three other studies have reported a statistically significant correlation between budding and venous invasion, though the association was not as pronounced as the relationship with lymphatic invasion and lymph node metastases. 11,12,32 The tumor-host interaction at the invasive front may be of prognostic importance in the setting of tumor budding.…”

“…11,12,[15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] On multivariate analysis, budding has consistently emerged as an independent adverse prognostic factor, associated with local tumor recurrence and distant metastases, and significantly worse overall and disease-free survival. 12,15,16,21,27,28,31,32,[34][35][36]38,40,41 The adverse prognostic impact of high-grade tumor budding is seen in both early and advanced colorectal carcinoma, and there are several scenarios in which this feature might influence clinical decision making, particularly in early colorectal carcinoma.…”

“…12,13,22,23,31,32,38,40,43,44,48,51,54,55 The use of immunohistochemistry in the assessment of budding is somewhat controversial: some authors argue that the evaluation of budding should be limited to H&E-stained slides because of the cost and impracticality of performing immunohistochemistry in routine cases, while others argue that immunohistochemistry should be used routinely to improve the accuracy and reproducibility of bud counts. In addition to cost considerations, the use of immunohistochemistry may also require the establishment of a separate cutoff for defining positive budding.…”

“…A few studies on tumor budding have incorporated an assessment of interobserver variability, with reported kappa values ranging from 0.41 to 0.938. 15,27,32,34,38,41,48 Kappa values, a commonly used measure of interobserver agreement, can be interpreted as follows: o0.20, poor; 0.21-0.40, fair; 0.41-0.60, moderate; 0.61-0.80, good; and 40.80, very good. 56 Intuitively, one would expect the use of immunohistochemistry to improve interobserver variability, but studies assessing interobserver variability on immunohistochemically stained slides have reported kappa values ranging from 0.53 to 0.874, 32,38,48 similar to those reported by authors assessing tumour budding on H&E. 15,27,32,34,41 Only one study has directly compared interobserver variability between assessments performed on H&E and immunohistochemically stained slides among the same group of pathologists: when Suzuki et al 32 evaluated budding with both H&E and immunohistochemistry, they showed only a modest improvement in interobserver variability when anti-cytokeratin antibodies were used (k ¼ 0.41 with H&E, and k ¼ 0.53 with immunohistochemistry).…”