The prognostication of colorectal cancer (CRC) has traditionally relied on staging as defined by the Union for International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC) TNM staging classifications. However, clinically, there appears to be differences in survival patterns independent of stage, suggesting a complex interaction of stage, pathological features, and biomarkers playing a role in guiding prognosis, risk stratification, and guiding neoadjuvant and adjuvant therapies. Histological features such as tumour budding, perineural invasion, apical lymph node involvement, lymph node yield, lymph node ratio, and molecular features such as MSI, KRAS, BRAF, and CDX2 may assist in prognostication and optimising adjuvant treatment. This study provides a comprehensive review of the pathological features and biomarkers that are important in the prognostication and treatment of CRC. We review the importance of pathological features and biomarkers that may be important in colorectal cancer based on the current evidence in the literature.

There is not a clear consensus on which pathological features and biomarkers are important in guiding prognosis and adjuvant therapy in colon cancer. The Pathology in Colon Cancer, Prognosis and Uptake of Adjuvant Therapy (PiCC UP) Australia and New Zealand questionnaire was distributed to colorectal surgeons, medical oncologists and pathologists after institutional board approval. The aim of this study was to understand current specialist attitudes towards pathological features in the prognostication of colon cancer and adjuvant therapy in stage II disease. A 5-scale Likert score was used to assess attitudes towards 23 pathological features for prognosis and 18 features for adjuvant therapy. Data were analysed using a rating scale and graded response model in item response theory (IRT) on STATA (Stata MP, version 15; StataCorp LP). One hundred and sixty-four specialists (45 oncologists, 86 surgeons and 33 pathologists) participated. Based on IRT modelling, the most important pathological features for prognosis in colon cancer were distant metastases, lymph node metastases and liver metastases. Other features seen as important were tumour rupture, involved margin, radial margin, CRM, lymphovascular invasion and grade of differentiation. Size of tumour, location, lymph node ratio and EGFR status were considered less important. The most important features in decision making for adjuvant therapy in stage II colon cancer were tumour rupture, lymphovascular invasion and microsatellite instability. BRAF status, size of tumour, location, tumour budding and tumour infiltrating lymphocytes were factored as lesser importance. Biomarkers such as CDX2, EGFR, KRAS and BRAF status present areas for further research to improve precision oncology. This study provides the most current status on the importance of pathological features in prognostication and recommendations for adjuvant therapy in Australia and New Zealand. Results of this nationwide study may be useful to help in guiding prognosis and adjuvant treatment in colon cancer.

Introduction: Most fish bones ingested pass through the gastrointestinal tract without complications. Perforation occurs in less than 1% of cases but this rate increases up to 35% with ingestion of sharp pointed objects. There are only 14 cases of duodenal perforation from fish bone described in the literature thus far. In most of these cases there was no history of ingestion reported which makes diagnosis challenging. Complications from such perforation include hepatic abscess, pancreatic abscess, renal vein thrombus, duodenocaval fistula, and lodgement in common bile duct. 25% of these cases were managed with endoscopy alone without need for surgery. Case Report: We describe a case of a 70-year-old male with perforation involving the third part of the duodenum from a fish bone complicated by retroperitoneal collection. He presented with right-sided abdominal pain and raised inflammatory markers. Initial imaging revealed a foreign body lodged in the third portion of the duodenum with adjacent retroperitoneal fluid. Progress imaging showed new extraluminal gas and inflammation prompting urgent intervention. Endoscopic removal of the fish bone was successful with subsequent resolution of the abscess. Conclusion: In this case, endoscopic removal of the fish bone was successful resulting in early recovery. However, management of duodenal perforation by foreign body can be challenging due to its rarity and myriad of possible management options including conservative, percutaneous, endoscopic, and surgical approaches.