ArticleJMIR formative research2021
e-Learning for Instruction and to Improve Reproducibility of Scoring Tumor-Stroma Ratio in Colon Carcinoma: Performance and Reproducibility Assessment in the UNITED Study.
Article in JMIR formative research, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 12 papers, 2 of them syntheses that pooled it.
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Who cites it
12 citing papers in PubMed, 2 syntheses or guidelines pooled it, 17 citations in OpenAlex.
- A scoping review of TSR analysis in colorectal cancer: implications for automated solutions.Oncology reviews · 2025Pooled it
- Impact of Tumor-Stroma Ratio on the Prognosis of Colorectal Cancer: A Systematic Review.Frontiers in oncology · 2021Pooled it
- Automating tumor-stroma ratio quantification in colon cancer patients from the UNITED study.ESMO open · 2026Article
- The tumour-stroma ratio as predictive aid towards a biopsy-based treatment strategy in rectal carcinoma.Histopathology · 2025Article
- Tumour-stroma ratio (TSR) in breast cancer: comparison of scoring core biopsies versus resection specimens.Virchows Archiv : an international journal of pathology · 2024Article
- The Glasgow Microenvironment Score: an exemplar of contemporary biomarker evolution in colorectal cancer.The journal of pathology. Clinical research · 2024Review
- Results from the UNITED study: a multicenter study validating the prognostic effect of the tumor-stroma ratio in colon cancer.ESMO open · 2024Article
- Development of Tier 2 LC-MRM-MS protein quantification methods for liquid biopsies.Journal of mass spectrometry and advances in the clinical lab · 2023Article
- A high tumour-stroma ratio (TSR) in colon tumours and its metastatic lymph nodes predicts poor cancer-free survival and chemo resistance.Clinical & translational oncology : official publication of the Federation of Spanish Oncology Societies and of the National Cancer Institute of Mexico · 2022Article
- Standardization of the tumor-stroma ratio scoring method for breast cancer research.Breast cancer research and treatment · 2022Review
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Authors and funding
8 authors at 4 institutions in 2 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundThe amount of stroma in the primary tumor is an important prognostic parameter. The tumor-stroma ratio (TSR) was previously validated by international research groups as a robust parameter with good interobserver agreement.
objectiveThe Uniform Noting for International Application of the Tumor-Stroma Ratio as an Easy Diagnostic Tool (UNITED) study was developed to bring the TSR to clinical implementation. As part of the study, an e-Learning module was constructed to confirm the reproducibility of scoring the TSR after proper instruction.
methodsThe e-Learning module consists of an autoinstruction for TSR determination (instruction video or written protocol) and three sets of 40 cases (training, test, and repetition sets). Scoring the TSR is performed on hematoxylin and eosin-stained sections and takes only 1-2 minutes. Cases are considered stroma-low if the amount of stroma is ≤50%, whereas a stroma-high case is defined as >50% stroma. Inter- and intraobserver agreements were determined based on the Cohen κ score after each set to evaluate the reproducibility.
resultsPathologists and pathology residents (N=63) with special interest in colorectal cancer participated in the e-Learning. Forty-nine participants started the e-Learning and 31 (63%) finished the whole cycle (3 sets). A significant improvement was observed from the training set to the test set; the median κ score improved from 0.72 to 0.77 (P=.002).
conclusionse-Learning is an effective method to instruct pathologists and pathology residents for scoring the TSR. The reliability of scoring improved from the training to the test set and did not fall back with the repetition set, confirming the reproducibility of the TSR scoring method.
trial registrationThe Netherlands Trial Registry NTR7270; https://www.trialregister.nl/trial/7072. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/13464.
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