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Letters to the Editor serosal surface, which had become or GIACOMO PUPPA, MD For the Sake of Clarity would later become immediately ad- PhD Programme in About pT4 Category of herent to adjacent structures because Experimental Medicine and of inﬂammation.6 In other words, the Oncology Colorectal Cancer involvement of the visceral peritone- University of Insubria um may be ‘‘covered’’ by adhesion to Varese, Italy To the Editor.—We read with great in- adjacent structures or organs associ- terest the latest guidelines for report- ANGELICA SONZOGNI, MD ated with ﬂorid inﬂammation and ﬁ- ing the relevant features resulting GIUSEPPE PELOSI, MD brosis in pT4a tumors. Division of Pathology and from colorectal surgical specimen ex- In this setting, the frequency of amination.1,2 We noticed, however, Laboratory Medicine distant metastasis has been shown to European Institute of major differences in comparison with be higher in cases with perforation of the previous guidelines,3,4 and there- Oncology the visceral peritoneum compared Milan, Italy fore, we would like to point out some with cases with direct invasion of ad- observations about the subclassiﬁca- jacent organs or structures, and the GIUSEPPE PELOSI, MD tion of pT4 category in colorectal can- median survival time after curative University of Milan School of cer. surgery is shorter for patients with Medicine In 2000, the T4 category, which is pT4b tumors than for those with Milan, Italy the highest one for local extent of co- pT4a tumors.4,7 lorectal tumor and includes both ex- In the latest protocol for the ex- tension into an adjacent structure or 1. Washington MK, Berlin J, Branton PA, et al. amination of specimens from patients Protocol for the examination of specimens from pa- organ and tumor involving the vis- with primary carcinomas of the colon tients with primary carcinomas of the colon and rec- ceral peritoneum, was subdivided and rectum, however, the deﬁnitions tum. Arch Pathol Lab Med. 2008;132:1182–1193. into T4a and T4b.3 Taking into ac- 2. Washington K, Berlin J, Branton P, et al. Pro- of pT4a and pT4b are inverted, be- tocol for the Examination of Specimens from count the general rule that, in TNM cause T4a is applied when tumor Patients with Primary Carcinomas of the Colon classiﬁcation, the categories with and Rectum. College of American Pathologists; penetrates the visceral peritoneum 2008. http://www.cap.org/apps/docs/committees/ higher numbers and letters describe and pT4b is applied when the tumor cancer/cancer protocols/2008/colonrectum08 the most advanced cancers that result pw.pdf. Accessed September 5, 2008. directly invades other organs or in the poorest prognosis, it was rec- 3. Compton C, Fenoglio-Preiser CM, Pettigrew N, structures.1,2 To the best of our Fielding LP. American Joint Committee on Cancer ommended that the T4 category be knowledge, no warning has thus far Prognostic Factors Consensus Conference: Colorec- modiﬁed as follows: T4a, tumor in- tal Working Group. Cancer. 2000;88:1739–1757. been put forward to point out these vades adjacent structures or organs; 4. Compton CC, for the Members of the Can- contradictory presentations for the cer Committee, College of American Pathologists. and T4b, tumor involves the visceral TNM pT4 category. Colon and Rectum. College of American Pathol- peritoneum.3,4 ogists. http://www.cap.org/apps/docs/cancer The identiﬁcation of patients with This statement reﬂected the fact protocols/2005/colonrectum05 ckw.pdf. Updated a high risk for local recurrence and/ January 2005. Accessed September 30, 2005. that several studies demonstrated the or distant metastases, who can ben- 5. Shepherd NA, Baxter KJ, Love SB. The prog- adverse effect on outcome of serosal nostic importance of peritoneal involvement in co- eﬁt from further treatment, especially invasion by tumor.3 I
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