Arq Bras Cir Dig abcd ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) ABCD, arq. bras. cir. dig. 0102-6720 2317-6326 Colégio Brasileiro de Cirurgia Digestiva RESUMO RACIONAL: A análise microscópica de brotamento peri-tumoral (BT) pode ser uma importante ferramenta preditiva de metástases linfonodais regionais em casos de câncer colorretal, principalmente entre pacientes em estágios intermediários, os quais apresentam marcante variabilidade prognóstica. OBJETIVOS: Avaliar o poder preditivo do BT em relação à presença de metástases linfonodais, bem como sua associação com outras características relacionadas à progressão do carcinoma colorretal. MÉTODOS: Trata-se de estudo transversal, retrospectivo com abordagem quantitativa, com revisão de prontuários médicos e laudos anatomopatológicos de pacientes submetidos a cirurgia oncológica por câncer colorretal. RESULTADOS: Foram analisados 153 prontuários de pacientes, predominando a faixa etária de 61-70 anos, com uma maioria masculina (50,98%). O adenocarcinoma sem especificação foi o tipo histológico mais comum (60,78%), com a maioria mostrando moderada diferenciação (87,58%). Da amostra total, 97 casos (63,39%) apresentaram BT, com 51,55% classificados como alto escore de brotamento. A invasão em tecido adiposo/subserosa foi a mais prevalente, ocorrendo em 46,41% dos casos. Metástases em linfonodos regionais e embolização angiolinfática foram observadas em 66 e 101 pacientes, respectivamente. A análise cruzada indicou uma associação estatisticamente significativa entre BT e metástase linfonodal (p<0,05). CONCLUSÕES: A relação entre BT e metástase linfonodal destaca a importância deste fator histológico na estratificação de risco e prognóstico em pacientes com câncer colorretal, complementando o estadiamento TNM. Portanto, a avaliação do brotamento tumoral é crucial em laudos anatomopatológicos, podendo influenciar decisões terapêuticas adicionais. Peritumoral budding as a predictor for lymph node metastases in colorectal carcinomas: what is its significance? Central Message Colorectal cancer (CRC) is the second-most prevalent cancer in both sexes in Brazil, excluding non-melanoma skin cancer, and is associated with significant morbidity and mortality. The prognosis of CRC is based on the disease stage according to the TNM classification. However, there is considerable variability in outcomes and prognosis among patients at identical stages, especially in intermediate stages (II and III). Thus, additional strategies for stratifying the risk of recurrence and metastasis, designed to enhance the treatment of CRC patients, present a favorable alternative by utilizing the tumor budding (TB) marker. Perspectives This study highlights the significant relationship between the presence of TB and lymph node metastasis, emphasizing the importance of tumor budding as a detectable histological prognostic factor in patients with colorectal cancer. TNM staging remains the primary stratification method; however, assessing other prognostic predictors in CRC patients is crucial for oncological treatment decisions. INTRODUCTION Colorectal cancer (CRC) is the second-most prevalent cancer in both sexes in Brazil, excluding non-melanoma skin cancer, and is associated with significant morbidity and mortality11. The prognosis of CRC is largely based on the disease stage according to the TNM classification12. However, there is significant variability in outcomes and prognosis among patients at identical stages, especially in intermediate stages (II and III)16. Therefore, additional strategies to stratify the risk of recurrence and metastasis, aiming to enhance the treatment of CRC patients, may provide beneficial alternatives through the utilization of the tumor budding (TB) marker14. TB is a phenomenon where single isolated cells or small clusters of up to four cells are present at the invasive front of the tumor, indicating the tumor’s capacity to infiltrate the extracellular matrix and lymphatic vessels to reach regional lymph nodes19. This process has been associated with worse prognosis, including higher local recurrence, distant metastases, and reduced survival in CRC patients16. In 2016, the International Tumor Budding Consensus Conference (ITBCC) standardized TB assessment in CRC patients into three distinct groups based on the number of buds identified under microscopy: Low TB group: a maximum of four buds in the assessment field (hotspot area); Intermediate TB group: between five and nine buds; High TB group: 10 or more buds8. The aim of this study was to assess the predictive power of TB regarding the presence of lymph node metastases, and other characteristics of tumor progression in CRC, in a Brazilian university hospital. METHODS This is an observational, retrospective study with a quantitative approach, conducted in Curitiba (PR), Brazil. Medical records from the Mackenzie Evangelical University Hospital (HUEM) were examined, along with histopathological results of resected surgical specimens from patients who underwent oncological surgery for CRC between November 2019 and June 2022. Patients with missing data in medical records and/or incomplete histopathological analyses were excluded. Multiple variables, such as sex, age, type/grade of histological neoplasia, depth of invasion, angiolymphatic embolization, lymph node metastases, and TB assessment, were considered. For analysis, the data were exported to a Microsoft Office Excel spreadsheet, where descriptive statistics were used, including absolute numbers and percentages. The chi-squared test was performed when applicable with a significance level of <0.05. The study was approved by the HUEM Research Ethics Committee (nº 70071623.7.0000.0103), in accordance with Resolution no. 466/12 of the National Research Council, which regulates scientific research in human subjects. The data obtained were compared with the literature on the subject. RESULTS From November 2019 to June 2022, 153 CRC cases were recorded at the hospital’s high-complexity center that met the inclusion criteria for this study. The distribution between sexes was similar, with a slight predominance of males, accounting for 50.98% of the cases. Age ranged from 35 to 94 years, as shown in Figure 1, with a mean of 62.76±12.02 and with 30.07% predominantly in the age group of 61-70 years. Figure 1 shows the distribution of CRC patients by age group (n=153). Figure 1 Distribution of patients with colorectal cancer by age groups (n=153). Adenocarcinoma not otherwise specified (NOS) was the most prevalent histological type, present in 93 patients (60.78%) of the cases. Table 1 shows the degree of tumor differentiation, with the majority classified as moderately differentiated, totaling 134 cases (87.58%). Table 1 Distribution of colorectal cancer differentiation degree (n=153). Differentiation degree n % Moderately differentiated 134 87.58 Poorly differentiated 16 10.45 Well-differentiated 3 1.96 Total 153 100 Table 2 shows that in 66 patients (43.13%), at least one metastasis in regional lymph nodes was detected in the surgical specimen. Table 2 Distribution of colorectal cancer patients according to lymph node involvement (n=153). Lymph node involvement n % Not involved 87 57.14 Involved 66 42.86 Total 153 100 The analysis of tumor invasion depth (pathological staging T) of the samples showed a significant number of cases classified as pT3 (46.41%), characterized by tumor cell invasion into the pericolic adipose tissue, followed by pT4a (30.07%), which includes infiltration to the serosal surface. Additionally, the presence of pT2 (16.69%), characterized by the infiltration of the muscularis propria, was also particularly noteworthy. The relationship between tumor depth and lymph node metastasis presence was analyzed and presented in Table 3. There was a statistically significant association between tumor invasiveness and the probability of lymph node involvement (p<0.05). Table 3 Tissue invasion depth (T) in colorectal cancer (n=153). Tissue infiltration pT n % Lymph node metastasis (n) p-value Mucosa pTis 1 0.65 0 Submucosa pT1 4 2.6 0 Muscularis propria pT2 24 16.69 3 Adipose tissue pT3 71 46.41 33 Serosa pT4a 46 30.07 27 Adjacent organs pT4b 7 4.58 3 Total - 153 100 66 0.0032 Angiolymphatic embolization was examined and found in 101 patients (66.01%). However, in 53 cases (34.64%), it was not identified. TB identification was described in 97 cases (63.39%), classified into low, intermediate, and high scores, as shown in Table 4. Over half of these cases had the highest score. Table 4 Distribution of budding score according to classification into high, intermediate, or low (n=97). Budding score n % High 50 51.55 Intermediate 26 26.80 Low 21 21.65 Total 97 100 The association between TB and lymph node metastasis was considered significant (p<0.05) since 51 of the 66 patients with lymph node metastasis had TB. Conversely, most patients without lymph node involvement had positive TB (Figure 2). Furthermore, the sensitivity and specificity of peritumoral budding for regional lymph node involvement were 77.27% and 47.13%, respectively, with a positive predictive value of 52.58%. Figure 2 Relationship between lymph node involvement and tumor budding. ROC: receiver operating characteristic; AUC: area under the curve. Additionally, the ROC (receiver operating characteristic) curve analysis for TB on lymph node involvement in CRC patients revealed an area under the curve (AUC) of 0.622, as shown in Figure 3. This value indicates moderate accuracy of TB in distinguishing between cases with and without lymph node involvement. Moreover, likelihood ratios were calculated, with a positive likelihood ratio of approximately 1.46 suggesting that a positive TB test result increases the probability of lymph node involvement by approximately 46%. In contrast, a negative likelihood ratio of approximately 0.46 indicates that a negative result reduces the probability of lymph node involvement by approximately 46%. Figure 3 The blue curve shows the test performance; the dashed gray line shows a test with no discriminative ability. The area under the curve of 0.622 indicates moderate test accuracy. Finally, TB was associated with lymph node metastasis, histological grade, invasion depth, and angiolymphatic embolization. However, the latter exhibited no statistical significance, as shown in Table 5. Table 5 Age, sex, lymph node involvement, angiolymphatic invasion, histological grade, and invasion depth in CRC patients with and without tumor budding (n=153). Tumor budding p-value Present (n) Absent (n) 97 56 Age (mean) 62.65 62.86 0.877* Sex (n) Male 52 27 Female 45 30 Lymph node metastasis (n) Present 51 15 0.0034† Absent 46 41 Angiolymphatic invasion (n) Present 68 33 0.2192† Absent 29 23 Histological grade (n) Well-differentiated 0 3 0.0131† Moderately differentiated 90 44 Poorly differentiated 7 9 Invasion depth Mucosa 0 1 0.068† Submucosa 0 4 Muscularis propria 15 9 Adipose tissue 45 26 Serosa 32 14 Adjacent organs 5 2 *Student’s t-test; †χ2 test. DISCUSSION Most of the 153 patients with CRC surgically treated in a high-complexity center were male (50.98%). These findings align with current data from the World Health Organization (WHO) for Brazil, where CRC exhibits an almost equal distribution between sexes, with males accounting for 49.6% of the total CRC cases6,18. The American Cancer Society (ACS) estimates that in 2022, there were 80,690 new cases among males, compared to 70,340 new cases among females1. The predominant age group in this study was between 61 and 70 years, with a mean age of 62 years. Age assessment is crucial as it is a risk factor for CRC development, with cases being more common in patients over 50 years and significantly increasing with each decade. The average age at diagnosis is 72 years for women and 68 years for men10. A Brazilian study of 521 cases found an average age of 63 years, with an affected range between the fifth and the eighth decades of life3. The most widely used and gold-standard pathological staging system for CRC evaluation is the TNM system, recommended by the American Joint Committee on Cancer (AJCC), which considers tumor invasion depth (T); the number of compromised lymph nodes (N); and the presence or absence of distant metastases (M)12,20. Our study showed a prevalence of 71 (46.41%) cases with infiltration into the pericolic adipose tissue, corresponding to pT3, which is also described as predominant in the global literature3,4,17. Additionally, at least one lymph node metastasis was identified in 66 patients (42.86%). A similar value has been described in the literature13. TB was identified in 97 (63.39%) cases, with the majority classified as high scores, corresponding to 51.55% of the results. Furthermore, a statistically significant association was found between peritumoral budding and the presence of lymph node metastasis (p<0.05), with 77.27% sensitivity. Although the mechanism of TB formation in colorectal cancer is not yet fully understood, the predominant theory suggests that at least some types of budding represent an example of epithelial-mesenchymal transition. It suggests that during the epithelial-mesenchymal transition, tumor cells undergo changes that include the loss of cell adhesion molecules, cytoskeletal modifications, increased production of extracellular matrix components, resistance to apoptosis, and the ability to degrade the basement membrane7. These described changes result in a cellular phenotype with greater migratory and invasive capacity, allowing tumor cells to detach from the primary tumor mass and disseminate to adjacent tissues, lymph nodes, and distant organs7. Therefore, TB is considered an early step in the neoplasm’s ability to invade lymphovascular spaces and metastasize. Additionally, TB can currently be used as an auxiliary in CRC risk stratification2,15,19. In 46 (30.06%) patients, the presence of TB was detected without lymph node involvement; yet, this finding suggests increased tumor aggressiveness, being associated with infiltration depth and substantial loss of cellular differentiation. Histopathological detection is crucial in assessing patients with early stage CRC due to its association with the presence of lymph node metastases, indicating the need for additional resections or association with other complementary therapeutic approaches, such as adjuvant oncological therapy, and in metastatic cases, it is associated with a worse prognosis5,15. Marx et al. have shown a statistically significant association between TB and lymphovascular invasion9. However, in this study, this association was not confirmed. Several factors may justify this outcome, including imprecise histological assessment, technical difficulties in histotechnical processing, insufficient macroscopic sampling, or the fact that these were initial cases and TB had not yet resulted in subsequent embolization. The ITBCC recommends the assessment of TB using hematoxylin and eosin-stained histological slides, and a hotspot at the invasive tumor front (standard field size of 0.785 mm2). To assist this analysis, the consensus provides a table for standardizing this count across various microscopes8. According to ITBCC, TB should be included in CRC protocols and described in patients’ pathology reports due to its prognostic, clinical, and therapeutic value. Thus, this histopathological evaluation should always be described. In the present study, information was sourced from radical surgical specimens; nonetheless, TB identification is particularly important in endoscopic resections of early cases, such as polypectomies and mucosectomies8. In recent years, there has been a growing increase in CRC diagnosis, with local resection surgery considered curative in the absence of metastases5. TNM classification remains the primary staging stratification method. However, evaluating other new prognostic predictors in CRC patients is uniquely important in therapeutic decision-making in oncology. 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Ann Surg Oncol. 2018;25(6):1454-5. https://doi.org/10.1245/s10434-018-6462-1 Weiser MR AJCC 8th edition: colorectal cancer Ann Surg Oncol 2018 25 6 1454 1455 10.1245/s10434-018-6462-1 1 How to cite this article: Santos EKAN, Triches BG, Silva GP, Linhares JC, Mehanna SH, Cavalcanti MS. Peritumoral budding as a predictor for lymph node metastases in colorectal carcinomas: what is the importance? ABCD Arq Bras Cir Dig. 2025;38e1875. https://doi.org/10.1590/0102-6720202500006e1875. Financial source: None 4 Editorial Support: National Council for Scientific and Technological Development (CNPq).