Variation in the Thoroughness of Pathologic Assessment and Response Rates of Locally Advanced Rectal Cancers After Chemoradiation

  • Oliver S. Chow
  • Sujata Patil
  • Metin Keskin
  • J. Joshua Smith
  • Maria Widmar
  • David D. Smith
  • Karin Avila
  • Jinru Shia
  • Peiguo Chu
  • Julio Garcia-AguilarEmail author



Pathologic complete response (pCR) is associated with better prognosis and guides management for patients with advanced rectal cancer. Response rates vary between series for unclear reasons. We examine whether the thoroughness of pathologic assessment explains differences in pCR rates.


We retrospectively reviewed pathology reports from patients with stage II/III rectal cancer who underwent chemoradiation and resection in a prospective, multicenter trial. We utilized a novel measure for the thoroughness of pathologic assessment by dividing residual tumor size by the number of cassettes evaluated (tumor size to cassette ratio, TSCR), and evaluated whether TSCR is associated with pCR. We validated our findings using a separate cohort.


From the trial cohort, 71 of 247 (29%) patients achieved pCR. The pCR rate ranged from 0 to 45% and mean TSCR ranged 0.29 to 0.87 across 12 institutions. Within each institution, a lower TSCR was associated with pCR, demonstrating a higher degree of thoroughness used for tumors that achieved pCR. Moreover, across all samples, low TSCR was independently associated with pCR on multivariable analysis. This finding was corroborated in a separate cohort of 201 tumors evaluated by five pathologists; each pathologist had a lower mean TSCR for pCR calls compared with non-pCR calls. However, the mean TSCR for an institution was not associated with its overall pCR rate.


Pathologists assess rectal cancers that have responded significantly to neoadjuvant therapy more thoroughly. Thoroughness does not appear to explain differences in pCR rates between institutions. Our results suggest pCR is not a sampling artifact.


Rectal cancer Chemoradiotherapy RECIST Residual tumor Surgical pathology 


Statement of Author Contribution

Each of the authors included had a substantial contribution to the design, data acquisition, analysis, interpretation, and drafting and review of this manuscript and have agreed to the accuracy and the integrity of the work.


This study was supported by the National Institutes of Health (NIH) and National Cancer Institute (NCI) R01 Grant CA090559 (JGA) and Core Grant P30 CA008748 (JGA). No financial disclosures.


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© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  1. 1.Department of SurgeryBeth Israel Deaconess Medical CenterBostonUSA
  2. 2.Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkUSA
  3. 3.Division of BiostatisticsCity of HopeDuarteUSA
  4. 4.Department of PathologyCity of HopeDuarteUSA

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