Rectal cancer and the pathologist

Minerva Chir. 2018 Dec;73(6):534-547. doi: 10.23736/S0026-4733.18.07739-8. Epub 2018 Apr 13.


Examination of the rectum by pathologists is instrumental in the management of patients affected by rectal carcinoma. That role includes evaluation of multiple gross and microscopic features that convey prognostic implications. The analysis is based on the authors' experience handling rectal specimens along with review of the pertinent literature in these areas: margins of excision, quality of the mesorectum, diligence and techniques to sample lymph nodes, tumor budding, grading of residual amount of carcinoma after preoperative therapy, vascular/perineural invasion, and staging the tumor. Pathologists must communicate the findings in a clear manner. Evaluation of margins and completeness of mesorectum are markers of the quality of surgical excision. The number of lymph nodes obtained and examined is dependent in great part on the diligence of the pathologist finding them in the mesenteric adipose tissue. There are grades for budding and response to prior chemoradiation therapy. The location of vascular invasion (extramural vs. intramural) may predict aggressive behavior. Pathologists proactively are to choose sections of tumor for molecular testing. Meticulous macro- and microscopic evaluation of specimens for rectal carcinoma by pathologist is needed to determine an accurate assessment of staging and other prognostic factors. The modern pathologists play a pivotal part in the care and management of patients suffering from rectal adenocarcinoma. That role goes from the initial histological diagnosis to the gross and microscopic examination of the excised specimens. Based on that examination pathologists issue statements that not only evaluate the quality of the surgical procedure, but also through the application of molecular tests they give light on prognostic factors and information for therapeutic purposes.

Publication types

  • Review

MeSH terms

  • Adenocarcinoma / blood supply
  • Adenocarcinoma / pathology*
  • Adenocarcinoma / surgery
  • Adenocarcinoma / therapy
  • Biomarkers, Tumor / analysis
  • Biopsy / methods
  • Cell Differentiation
  • Combined Modality Therapy
  • DNA Mismatch Repair
  • Frozen Sections
  • Humans
  • Lymph Node Excision
  • Lymphatic Metastasis
  • Margins of Excision
  • Microsatellite Instability
  • Neoadjuvant Therapy
  • Neoplasm Invasiveness
  • Neoplasm Proteins / analysis
  • Neoplasm Staging
  • Neoplasm, Residual
  • Prognosis
  • Rectal Neoplasms / blood supply
  • Rectal Neoplasms / pathology*
  • Rectal Neoplasms / surgery
  • Rectal Neoplasms / therapy
  • Specimen Handling


  • Biomarkers, Tumor
  • Neoplasm Proteins