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Mroczkowski P, Kim S, Otto R, Lippert H, Zajdel R, Zajdel K, Merecz-Sadowska A. Prognostic Value of Metastatic Lymph Node Ratio and Identification of Factors Influencing the Lymph Node Yield in Patients Undergoing Curative Colon Cancer Resection. Cancers (Basel) 2024; 16:218. [PMID: 38201643 PMCID: PMC10778473 DOI: 10.3390/cancers16010218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/10/2023] [Accepted: 12/31/2023] [Indexed: 01/12/2024] Open
Abstract
Due to the impact of nodal metastasis on colon cancer prognosis, adequate regional lymph node resection and accurate pathological evaluation are required. The ratio of metastatic to examined nodes may bring an additional prognostic value to the actual staging system. This study analyzes the identification of factors influencing a high lymph node yield and its impact on survival. The lymph node ratio was determined in patients with fewer than 12 or at least 12 evaluated nodes. The study included patients after radical colon cancer resection in UICC stages II and III. For the lymph node ratio (LNR) analysis, node-positive patients were divided into four categories: i.e., LNR 1 (<0.05), LNR 2 (≥0.05; <0.2), LNR 3 (≥0.2; <0.4), and LNR 4 (≥0.4), and classified into two groups: i.e., those with <12 and ≥12 evaluated nodes. The study was conducted on 7012 patients who met the set criteria and were included in the data analysis. The mean number of examined lymph nodes was 22.08 (SD 10.64, median 20). Among the study subjects, 94.5% had 12 or more nodes evaluated. These patients were more likely to be younger, women, with a lower ASA classification, pT3 and pN2 categories. Also, they had no risk factors and frequently had a right-sided tumor. In the multivariate analysis, a younger age, ASA classification of II and III, high pT and pN categories, absence of risk factors, and right-sided location remained independent predictors for a lymph node yield ≥12. The univariate survival analysis of the entire cohort demonstrated a better five-year overall survival (OS) in patients with at least 12 lymph nodes examined (68% vs. 63%, p = 0.027). The LNR groups showed a significant association with OS, reaching from 75.5% for LNR 1 to 33.1% for LNR 4 (p < 0.001) in the ≥12 cohort, and from 74.8% for LNR2 to 49.3% for LNR4 (p = 0.007) in the <12 cohort. This influence remained significant and independent in multivariate analyses. The hazard ratios ranged from 1.016 to 2.698 for patients with less than 12 nodes, and from 1.248 to 3.615 for those with at least 12 nodes. The LNR allowed for a more precise estimation of the OS compared with the pN classification system. The metastatic lymph node ratio is an independent predictor for survival and should be included in current staging and therapeutic decision-making processes.
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Affiliation(s)
- Paweł Mroczkowski
- Department for General and Colorectal Surgery, Medical University of Lodz, Pl. Hallera 1, 90-647 Lodz, Poland;
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, 39120 Magdeburg, Germany; (S.K.); (R.O.); (H.L.)
- Department for Surgery, University Hospital Knappschaftskrankenhaus, Ruhr-University, In der Schornau 23-25, 44892 Bochum, Germany
| | - Samuel Kim
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, 39120 Magdeburg, Germany; (S.K.); (R.O.); (H.L.)
- Sanitätsversorgungszentrum Torgelow, Bundeswehr Neumühler Str. 10b, 17358 Torgelow, Germany
| | - Ronny Otto
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, 39120 Magdeburg, Germany; (S.K.); (R.O.); (H.L.)
| | - Hans Lippert
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, 39120 Magdeburg, Germany; (S.K.); (R.O.); (H.L.)
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Leipziger Str. 44, 39120 Magdeburg, Germany
| | - Radosław Zajdel
- Department of Economic and Medical Informatics, University of Lodz, 90-214 Lodz, Poland;
- Department of Medical Informatics and Statistics, Medical University of Lodz, 90-645 Lodz, Poland;
| | - Karolina Zajdel
- Department of Medical Informatics and Statistics, Medical University of Lodz, 90-645 Lodz, Poland;
| | - Anna Merecz-Sadowska
- Department of Economic and Medical Informatics, University of Lodz, 90-214 Lodz, Poland;
- Department of Allergology and Respiratory Rehabilitation, Medical University of Lodz, 90-725 Lodz, Poland
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Hacım NA, Akbaş A, Ulgen Y, Aktokmakyan TV, Meric S, Tokocin M, Karabay O, Altinel Y. Influence of colonic mesenteric area on the number of lymph node retrieval for colon cancer: a prospective cohort study. Ann Coloproctol 2023; 39:77-84. [PMID: 34525506 PMCID: PMC10009066 DOI: 10.3393/ac.2021.00444.0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The minimum harvested 12 lymph nodes (LNs) is regarded as the limit for accurate staging of nodal status in colorectal cancer patients. Besides the association of the lengths of resected intestinal segments and vascular pedicles, the mesocolic mesenteric area's impact on LN count has not been studied. We aimed to evaluate the associations between metric variables, including the mesocolic mesentery area on the nodal harvest. METHODS All consecutive patients who underwent elective colectomy with a curative intention for colon adenocarcinoma were prospectively included. The metric variables included the lengths of resected intestinal segments, vascular pedicle, and colonic mesenteric area. The variables influencing the LN count and the correlation between the total LN count and the specimens' relevant metric measurements were analyzed. RESULTS There were 46 patients with a median age of 64 years. The median count for total LNs was 22, and the LN positivity was 59.2%. There was an inadequate LN yield (<12) in 3 patients (6.1%). No significant associations were found between the adequacy of nodal harvest and the demographic, clinical, and tumoral features (P>0.05). There were significant positive correlations between total LN number and length of vascular pedicle and mesenteric area (r=0.576, P<0.001 and r=0.566, P<0.001). CONCLUSION The length of the vascular pedicle and mesenteric area were significantly correlated with total LN counts. Although there was no significant impact on the length of resected segments, the colonic mesenteric area can be used alone as a measure for the assessment of the nodal yield in colon cancer.
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Affiliation(s)
- Nadir Adnan Hacım
- Department of General Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Akbaş
- Department of General Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Yigit Ulgen
- Department of Pathology, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | | | - Serhat Meric
- Department of General Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Merve Tokocin
- Department of General Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Onder Karabay
- Department of Surgery, Yedikule Surp Pırgiç Armenian Hospital, Istanbul, Turkey
| | - Yuksel Altinel
- Department of General Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey
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Sarkar S, Deodhar KK, Budukh A, Bal MM, Ramadwar M. Assessing the histopathology reports of colorectal carcinoma surgery: An audit of three years with emphasis on lymph node yield. Indian J Cancer 2022; 59:532-539. [PMID: 34380840 DOI: 10.4103/ijc.ijc_1059_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background A comprehensive histopathology report of colorectal carcinoma surgery is important in cancer staging and planning adjuvant treatment. Our aim was to review histopathology reports of operated specimens of colorectal carcinoma in our institution between 2013 and 2015 to assess different histological parameters, including lymph node yield, and to evaluate compliance to minimum data sets. Methods After approval by the institutional review board (IRB), we analyzed 1230 histopathology reports of colorectal carcinoma between 2013 and 2015. Various gross and microscopic findings (along with age, sex) were noted, for example, specimen type, tumor site, resection margins including circumferential resection margin (CRM), lymphovascular invasion, perineural invasion, pTNM stage, lymph node yield, etc. Results Out of 1230 patients, 826 (67.15%) were men and 404 (32.85%) were women. The overall mean age was 52 (range: 18 - 90) years. There were 787 surgeries for rectal cancers. All reports commented on the type of specimen, tumor size (mean = 4.38 cm), proximal, and distal margins. Lymphovascular invasion (LVI) and the pT stage were mentioned in 98.06% and 99.84%, respectively. The overall mean lymph node yield was 18.38 (median = 15, range = 0-130 lymph nodes). A statistically significant difference in lymph node yield was detected between rectal and colonic cancer patients (14.79 and 27.26); post neoadjuvant therapy (NACT) cases, and NACT naive cases (13.51 and 25.11); and high tumor stage and low tumor stage disease (20.60 and 15.22). Not commenting on extramural vascular emboli, tumor budding, and CRM in non-rectal cancer cases were the lacunae. Conclusion Our compliance with minimal data sets is satisfactory. The overall mean lymph node yield was 18.38 (median = 15). Extramural vascular emboli, tumor budding need to be captured.
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Affiliation(s)
- Sourav Sarkar
- Ex Senior Registrar, Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Kedar K Deodhar
- Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Atul Budukh
- Centre for Cancer Epidemiology, Advanced Centre for treatment and Research in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Munita M Bal
- Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Mukta Ramadwar
- Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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Yang CC, Tian YF, Liu WS, Chou CL, Cheng LC, Chu SS, Lee CC. The association between the composite quality measure "textbook outcome" and long term survival in operated colon cancer. Medicine (Baltimore) 2020; 99:e22447. [PMID: 33019430 PMCID: PMC7535643 DOI: 10.1097/md.0000000000022447] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to investigate the relationship between textbook outcome and survival in patients with surgically treated colon cancer. A total of 804 surgical cases were enrolled between June 1, 2010 and December 31, 2014. Textbook outcome was defined as patients who had colon cancer surgery and met the six healthcare parameters of surgery within 6 weeks, radical resection, lymph node (LN) yield ≥12, no ostomy, no adverse outcome and colonoscopy before/after surgery within 6 months. The effect of textbook outcome on 5-year disease-specific survival (DSS) was calculated using the Kaplan-Meier method. A Cox regression model was used to find significant independent variables and stratified analysis used to determine whether text-book outcome had a survival benefit. A textbook outcome was achieved in 59.5% of patients undergoing colon cancer surgery. Important obstacles to achieving textbook outcome were no stomy, no adverse outcome and LN yield ≥12. Patients with text-book outcome had statistically significant better 5-year DSS compared to those with-out (80.1% vs. 58.3%). Multivariate analyses indicated that colon cancer patients with textbook outcome had better 5-year DSS after adjusting for various confounders ([aHR], 0.44; 95% CI, 0.34-0.57). Thus, besides being an index of short-term quality of care, textbook outcomes could be used as a prognosticator of long-term outcomes, such as 5-year survival rates.
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Affiliation(s)
| | - Yu-Feng Tian
- Division of Colorectal Surgery, Department of Surgery, Chi-Mei Medical Center
- Department of Health and Nutrition, Chia-Nan University of Pharmacy and Science, Tainan
| | - Wen-Shan Liu
- Department of Radiation Oncology
- School of Medicine, National Defense Medical Center
| | - Chia-Lin Chou
- Division of Colorectal Surgery, Department of Surgery, Chi-Mei Medical Center
| | - Li-Chin Cheng
- Division of Colorectal Surgery, Department of Surgery, Chi-Mei Medical Center
| | | | - Ching-Chih Lee
- School of Medicine, National Defense Medical Center
- Department of Otolaryngology, Head and Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung
- Institute of Hospital and Health Care Administration, National Yang-Ming University
- Department of Otolaryngology, Head and Neck Surgery, Tri-Service General Hospital, Taipei, Taiwan (R.O.C.)
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Yasaitis L, Bekelman JE, Polsky D. Relation Between Narrow Networks and Providers of Cancer Care. J Clin Oncol 2017; 35:3131-3135. [PMID: 28678667 DOI: 10.1200/jco.2017.73.2040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose Health insurers offer plans covering a narrow subset of providers in an attempt to lower premiums and compete for consumers. However, narrow networks may limit access to high-quality providers, particularly those caring for patients with cancer. Methods We examined provider networks offered on the 2014 individual health insurance exchanges, assessing oncologist supply and network participation in areas that do and do not contain one of 69 National Cancer Institute (NCI)-Designated Cancer Centers. We characterized a network's inclusion of oncologists affiliated with NCI-Designated Cancer Centers relative to oncologists excluded from the network within the same region and assessed the relationship between this relative inclusion and each network's breadth. We repeated these analyses among networks offered in the same regions as the subset of 27 NCI-Designated Cancer Centers identified as National Comprehensive Cancer Network (NCCN) Cancer Centers. Results In regions containing NCI-Designated Cancer Centers, there were 13.7 oncologists per 100,000 residents and 4.9 (standard deviation [SD], 2.8) networks covering a mean of 39.4% (SD, 26.2%) of those oncologists, compared with 8.8 oncologists per 100,000 residents and 3.2 (SD, 2.1) networks covering on average 49.9% (SD, 26.8%) of the area's oncologists ( P < .001 for all comparisons). There was a strongly significant correlation ( r = 0.4; P < .001) between a network's breadth and its relative inclusion of oncologists associated with NCI-Designated Cancer Centers; this relationship held when considering only affiliation with NCCN Cancer Centers. Conclusion Narrower provider networks are more likely to exclude oncologists affiliated with NCI-Designated or NCCN Cancer Centers. Health insurers, state regulators, and federal lawmakers should offer ways for consumers to learn whether providers of cancer care with particular affiliations are in or out of narrow provider networks.
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Affiliation(s)
- Laura Yasaitis
- All authors: University of Pennsylvania, Philadelphia, PA
| | | | - Daniel Polsky
- All authors: University of Pennsylvania, Philadelphia, PA
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Lisovsky M, Schutz SN, Drage MG, Liu X, Suriawinata AA, Srivastava A. Number of Lymph Nodes in Primary Nodal Basin and a “Second Look” Protocol as Quality Indicators for Optimal Nodal Staging of Colon Cancer. Arch Pathol Lab Med 2016; 141:125-130. [DOI: 10.5858/arpa.2015-0401-oa] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Evaluation of 12 or more lymph nodes (LNs) is currently used as a quality indicator for adequacy of pathologic examination of colon cancer resections.
Objective.—To evaluate the utility of a focused LN search in the immediate vicinity of the tumor and a “second look” protocol in improving LN staging in colon cancer.
Design.—Lymph nodes were submitted separately from the primary nodal basin (PNB) and secondary nodal basin (SNB) defined as an area less than 5 cm away and an area greater than 5 cm away from the tumor edge, respectively, in 201 consecutive resections (2010–2013). One hundred sixty-eight consecutive tumors (2006–2009) were used as a control group. A second search was performed in all cases that were N0 after the first search.
Results.—In cases that were N0 after the first search, 20.9 ± 10.8 LNs were collected from the PNB, compared to 8.5 ± 9.1 from the SNB. Positive LNs were found in N+ tumors in the PNB in all cases but in only 9% (4 of 46) of SNBs (P < .001). A second search increased node count by an average of 10 additional LNs. In 5 of 114 cases (4.4%), N0 after the first search converted to N+ after a second search that yielded 1 to 4 positive LNs, all of which were in the PNB.
Conclusions.—Emphasis on the number of LNs examined from the PNB and a “second look” protocol improve nodal staging.
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Affiliation(s)
| | | | | | | | | | - Amitabh Srivastava
- From the Department of Pathology (Drs Lisovsky, Liu, and Suriawinata and Ms Schutz), Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and the Department of Pathology (Drs Drage and Srivastava), Brigham & Women's Hospital, Boston, Massachusetts
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Choi JP, Park IJ, Lee BC, Hong SM, Lee JL, Yoon YS, Kim CW, Lim SB, Lee JB, Yu CS, Kim JC. Variability in the lymph node retrieval after resection of colon cancer: Influence of operative period and process. Medicine (Baltimore) 2016; 95:e4199. [PMID: 27495024 PMCID: PMC4979778 DOI: 10.1097/md.0000000000004199] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The purpose of this study was to evaluate variations in the number of retrieved lymph nodes (LNs) over time and to determine the factors that influence the retrieval of <12 LNs during colon cancer resection.Patients with colon cancer who were surgically treated between 1997 and 2013 were identified from our institutional tumor registry. Patient, tumor, and pathologic variables were evaluated. Factors that influenced the retrieval of <12 LNs were evaluated using multivariate logistic regression modeling, including time effects.In total, 6967 patients were identified. The median patient age was 61 years (interquartile range [IQR] = 45-79 years) and 58.4% of these patients were male. The median number of LNs retrieved was 21 (IQR = 14-29), which increased from 14 (IQR = 11-27) in 1997 to 26 (IQR = 19-34) in 2013. The proportion of patients with ≥12 retrieved LNs increased from 72% in 1997 to 98.8% in 2013 (P < 0.00001). This corresponded to the more recent emphasis on a multidisciplinary approach to adequate LN evaluation. The number of retrieved LNs was also found to be associated with age, sex, tumor location, T stage, and operative year. Tumor location and T stage influenced the number of retrieved LNs, irrespective of the operative year (P < 0.05). Factors including a tumor location in the sigmoid/left colon, old age, open resection, earlier operative year, and early T stage were more likely to be associated with <12 recovered LNs (P < 0.5; chi-squared test) (P < 0.001).The total number of retrieved LNs may be influenced by tumor location and T stage of a colon cancer, irrespective of the year of surgery. LN retrieval after colon cancer resection has increased in recent years due to a better awareness of its importance and the use of multidisciplinary approaches.
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Affiliation(s)
- Jung Pil Choi
- Department of Surgery, Dong Kang Medical Center, Ulsan
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center
- Correspondence: In Ja Park, Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea (e-mail: )
| | - Byung Cheol Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center
| | - Seung Mo Hong
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center
| | - Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center
| | - Jung Bok Lee
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center
| | - Jin Cheon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center
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Wood P, Peirce C, Mulsow J. Non-surgical factors influencing lymph node yield in colon cancer. World J Gastrointest Oncol 2016; 8:466-473. [PMID: 27190586 PMCID: PMC4865714 DOI: 10.4251/wjgo.v8.i5.466] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/15/2015] [Accepted: 03/09/2016] [Indexed: 02/05/2023] Open
Abstract
There are numerous factors which can affect the lymph node (LN) yield in colon cancer specimens. The aim of this paper was to identify both modifiable and non-modifiable factors that have been demonstrated to affect colonic resection specimen LN yield and to summarise the pertinent literature on these topics. A literature review of PubMed was performed to identify the potential factors which may influence the LN yield in colon cancer resection specimens. The terms used for the search were: LN, lymphadenectomy, LN yield, LN harvest, LN number, colon cancer and colorectal cancer. Both non-modifiable and modifiable factors were identified. The review identified fifteen non-surgical factors: (13 non-modifiable, 2 modifiable) which may influence LN yield. LN yield is frequently reduced in older, obese patients and those with male sex and increased in patients with right sided, large, and poorly differentiated tumours. Patient ethnicity and lower socioeconomic class may negatively influence LN yield. Pre-operative tumour tattooing appears to increase LN yield. There are many factors that potentially influence the LN yield, although the strength of the association between the two varies greatly. Perfecting oncological resection and pathological analysis remain the cornerstones to achieving good quality and quantity LN yields in patients with colon cancer.
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Märkl B. Stage migration vs immunology: The lymph node count story in colon cancer. World J Gastroenterol 2015; 21:12218-12233. [PMID: 26604632 PMCID: PMC4649108 DOI: 10.3748/wjg.v21.i43.12218] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/26/2015] [Indexed: 02/06/2023] Open
Abstract
Lymph node staging is of crucial importance for the therapy stratification and prognosis estimation in colon cancer. Beside the detection of metastases, the number of harvested lymph nodes itself has prognostic relevance in stage II/III cancers. A stage migration effect caused by missed lymph node metastases has been postulated as most likely explanation for that. In order to avoid false negative node staging reporting of at least 12 lymph nodes is recommended. However, this threshold is met only in a minority of cases in daily practice. Due to quality initiatives the situation has improved in the past. This, however, had no influence on staging in several studies. While the numbers of evaluated lymph nodes increased continuously during the last decades the rate of node positive cases remained relatively constant. This fact together with other indications raised doubts that understaging is indeed the correct explanation for the prognostic impact of lymph node harvest. Several authors assume that immune response could play a major role in this context influencing both the lymph node detectability and the tumor’s behavior. Further studies addressing this issue are need. Based on the findings the recommendations concerning minimal lymph node numbers and adjuvant chemotherapy should be reconsidered.
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Kent I, Rudnicki Y, Abu-Ghanem Y, White I, Spitz B, Avital S. Mesenteric root dissection with individualized ileo-colic vessel ligation versus mesenteric pedicle stapling. Surg Endosc 2015; 30:3021-5. [PMID: 26487235 DOI: 10.1007/s00464-015-4593-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 09/21/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Numerous factors have been associated with the number of lymph nodes retrieved during laparoscopic colectomy. This study compared the impact of vascular pedicle ligation method on the number of retrieved lymph nodes in patients undergoing laparoscopic right hemicolectomy for cancer. Mesenteric root dissection with individualized vessel ligation was compared to en bloc vascular root stapling. METHODS Data were retrospectively collected from a database of patients' charts including operative and pathological reports. All patients that underwent laparoscopic colectomy in a single department were identified. Patients that underwent elective laparoscopic right hemicolectomy for cancer were further evaluated. The impact of the method used for ileo-colic vascular transection, age, gender, nodes status, T stage, BMI and the operating surgeon on the number of retrieved lymph nodes was studied. RESULTS Among 239 laparoscopic colectomies, 75 patients underwent elective laparoscopic right colectomy for cancer. Ileo-colic vascular transection was routinely performed at the level of the inferior border of the pancreas. In total, 34 patients underwent ileo-colic vascular root dissection with individualized vessel ligation and 41 underwent vascular root stapling. No difference was found in the mean number of retrieved lymph nodes between pedicle dissection and vascular root stapling (18.7 ± 5.9 vs. 19.6 ± 7.9, P = 0.396), and in the rate of patients who had 12 nodes or more (97.1 vs. 92.7 %, P = 0.401). BMI above 30 was associated with decreased number of retrieved nodes (P = 0.001). CONCLUSIONS No difference was found in the number of retrieved lymph nodes between ileo-colic vascular root dissection with individual vessel ligation and vascular root stapling in patients undergoing laparoscopic right hemicolectomy for cancer. High BMI was associated with decreased number of retrieved nodes in both groups. A standard approach regarding the level of mesenteric root transection, regardless of the ligation approach, leads to adequate lymph node harvesting by different surgeons.
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Affiliation(s)
- Ilan Kent
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.
| | - Yaron Rudnicki
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | | | - Ian White
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | - Baruch Spitz
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | - Shmuel Avital
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
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Park Y, Yong YG, Yun SH, Jung KU, Huh JW, Cho YB, Kim HC, Lee WY, Chun HK. Learning curves for single incision and conventional laparoscopic right hemicolectomy: a multidimensional analysis. Ann Surg Treat Res 2015; 88:269-75. [PMID: 25960990 PMCID: PMC4422880 DOI: 10.4174/astr.2015.88.5.269] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 09/29/2014] [Accepted: 10/28/2014] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study aimed to compare the learning curves and early postoperative outcomes for conventional laparoscopic (CL) and single incision laparoscopic (SIL) right hemicolectomy (RHC). METHODS This retrospective study included the initial 35 cases in each group. Learning curves were evaluated by the moving average of operative time, mean operative time of every five consecutive cases, and cumulative sum (CUSUM) analysis. The learning phase was considered overcome when the moving average of operative times reached a plateau, and when the mean operative time of every five consecutive cases reached a low point and subsequently did not vary by more than 30 minutes. RESULTS Six patients with missing data in the CL RHC group were excluded from the analyses. According to the mean operative time of every five consecutive cases, learning phase of SIL and CL RHC was completed between 26 and 30 cases, and 16 and 20 cases, respectively. Moving average analysis revealed that approximately 31 (SIL) and 25 (CL) cases were needed to complete the learning phase, respectively. CUSUM analysis demonstrated that 10 (SIL) and two (CL) cases were required to reach a steady state of complication-free performance, respectively. Postoperative complications rate was higher in SIL than in CL group, but the difference was not statistically significant (17.1% vs. 3.4%). CONCLUSION The learning phase of SIL RHC is longer than that of CL RHC. Early oncological outcomes of both techniques were comparable. However, SIL RHC had a statistically insignificant higher complication rate than CL RHC during the learning phase.
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Affiliation(s)
- Yoonah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yuen Geng Yong
- Department of Surgery, Columbia Hospital, Kuala Lumpur, Malaysia, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Uk Jung
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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12
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Abstract
BACKGROUND Nodal staging is crucial in determining the use of adjuvant chemotherapy for colon cancer. The number of metastatic lymph nodes has been positively correlated with the number of lymph nodes examined. Current guidelines recommend that at minimum 12 to 14 lymph nodes be assessed. In some studies, mismatch repair deficiency has been associated with lymph node yield. OBJECTIVE The purpose of this work was to determine whether mismatch repair-deficient colorectal tumors are associated with increased lymph node yield. DESIGN We queried an institutional database to analyze colectomy specimens with immunohistochemistry for mismatch repair genes in patients treated for colorectal cancer between 1999 and 2012. Before 2006, immunohistochemistry was performed at the request of an oncologist or surgeon. After 2006, it was routinely performed for patients <50 years of age. We measured the association of clinical and pathologic features with lymph node quantity. Fourteen predictors and confounders were jointly analyzed in a multivariable linear regression model. SETTINGS The study was conducted at a single tertiary care institution. PATIENTS Tissue specimens from 256 patients were reviewed. MAIN OUTCOME MEASURES The correlation of tumor, patient, and operative variables to the yield of mesenteric lymph nodes was measured. RESULTS Of 256 colectomy specimens reviewed, 94 had mismatch repair deficiency. On univariate analysis, mismatch repair deficiency was associated with lower lymph node yield, older patient age, right-sided tumors, and poor differentiation. The linear regression model identified 5 variables with independent relationships to lymph node yield, including patient age, specimen length, lymph node ratio, perineural invasion, and tumor size. A positive correlation was observed with tumor size, specimen length, and perineural invasion. Tumor location had a more complex, nonlinear, quadratic relationship with lymph node yield; proximal tumors were associated with a higher yield than more distal lesions. Mismatch repair deficiency was not independently associated with lymph node yield. LIMITATIONS Mismatch repair immunohistochemistry based on patient age, family history, and pathologic features may reduce the generalizability of these results. Our sample size was too small to identify variables with small measures of effect. The retrospective nature of the study did not permit a true assessment of the extent of mesenteric resection. CONCLUSIONS Patient age, length of bowel resected, lymph node ratio, perineural invasion, tumor size, and tumor location were significant predictors of lymph node yield. However, when controlling for surgical and pathologic factors, mismatch repair protein expression did not predict lymph node yield.
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13
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Lymphatic spread, nodal count and the extent of lymphadenectomy in cancer of the colon. Cancer Treat Rev 2014; 40:405-13. [DOI: 10.1016/j.ctrv.2013.09.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 09/13/2013] [Accepted: 09/16/2013] [Indexed: 02/08/2023]
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14
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Destri GL, Carlo ID, Scilletta R, Scilletta B, Puleo S. Colorectal cancer and lymph nodes: The obsession with the number 12. World J Gastroenterol 2014; 20:1951-1960. [PMID: 24587671 PMCID: PMC3934465 DOI: 10.3748/wjg.v20.i8.1951] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 01/06/2014] [Indexed: 02/06/2023] Open
Abstract
Lymphadenectomy of colorectal cancer is a decisive factor for the prognostic and therapeutic staging of the patient. For over 15 years, we have asked ourselves if the minimum number of 12 examined lymph nodes (LNs) was sufficient for the prevention of understaging. The debate is certainly still open if we consider that a limit of 12 LNs is still not the gold standard mainly because the research methodology of the first studies has been criticized. Moreover many authors report that to date both in the United States and Europe the number “12” target is uncommon, not adequate, or accessible only in highly specialised centres. It should however be noted that both the pressing nature of the debate and the dissemination of guidelines have been responsible for a trend that has allowed for a general increase in the number of LNs examined. There are different variables that can affect the retrieval of LNs. Some, like the surgeon, the surgery, and the pathology exam, are without question modifiable; however, other both patient and disease-related variables are non-modifiable and pose the question of whether the minimum number of examined LNs must be individually assigned. The lymph nodal ratio, the sentinel LNs and the study of the biological aspects of the tumor could find valid application in this field in the near future.
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15
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Impact of Schwartz enhanced visualization solution on staging colorectal cancer and clinicopathological features associated with lymph node count. Dis Colon Rectum 2013; 56:1028-35. [PMID: 23929011 DOI: 10.1097/dcr.0b013e31829c41ba] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Stage-specific survival for colon cancer improves when more lymph nodes are reported in the surgical specimen. This has led to a minimum standard of identifying 12 lymph nodes as a quality indicator. OBJECTIVE The aim of this study was to determine whether the addition of Schwartz solution increases node yield and impacts pathologic staging. DESIGN This is a prospective cohort study. SETTING The study was conducted in an academic medical center. PATIENTS Included were 104 consecutive patients with colorectal cancer. MAIN OUTCOME MEASURES Lymph node counts before and after specimen treatment with Schwartz solution and incidence of upstaging were measured. RESULTS An additional 20 minutes (interquartile range, 15-40 minutes) was spent searching for lymph nodes, increasing the median number of nodes from 22.5 to 29.0 nodes. However, only 1 patient was upstaged. Schwartz solution decreased the number of specimens with less than 12 lymph nodes from 15 to 6. The following factors were associated with Schwartz solution leading to the detection of additional nodes: number of nodes detected initially with formalin only (p < 0.000), mesenteric fat volume (p < 0.000), mesenteric fat weight (p < 0.000), length of specimen (p < 0.016), tumor greatest dimension (p < 0.016), patient body surface area (p < 0.034), and patient age (p < 0.003). LIMITATIONS Clinical data for this study were obtained retrospectively and were not available for all of the patients. CONCLUSIONS Although Schwartz solution increased the number of nodes detected in 95% of patients and improved compliance with the 12-node standard for colon resection, there was minimal impact on cancer staging. Upstaging is unlikely to explain the increase in overall survival in patients with higher lymph node counts, casting doubt on the validity of this process measure as a meaningful quality indicator. Rather, the lymph node count may be a reflection of inherent tumor biology or host-related factors.
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16
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Merkow RP, Bentrem DJ. Importance of and adherence to lymph node staging standards in gastrointestinal cancer. Surg Oncol Clin N Am 2012; 21:407-16, viii. [PMID: 22583990 DOI: 10.1016/j.soc.2012.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In gastrointestinal oncology, one of the most important factors influencing cancer-specific survival is the presence of positive lymph nodes. Although it remains controversial, adequate lymph node examination is required for accurate staging such that patients can receive appropriate adjuvant treatments and for stratification in clinical trials. Nevertheless, wide variation exists in the quality of lymph node examination in the United States, and many centers are not meeting guideline treatment recommendations.
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Affiliation(s)
- Ryan P Merkow
- Department of Surgery and Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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17
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Shia J, Wang H, Nash GM, Klimstra DS. Lymph node staging in colorectal cancer: revisiting the benchmark of at least 12 lymph nodes in R0 resection. J Am Coll Surg 2012; 214:348-55. [PMID: 22225644 DOI: 10.1016/j.jamcollsurg.2011.11.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/16/2011] [Accepted: 11/23/2011] [Indexed: 12/18/2022]
Affiliation(s)
- Jinru Shia
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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18
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Barbas AS, Turley RS, Mantyh CR, Migaly J. Effect of surgeon specialization on long-term survival following colon cancer resection at an NCI-designated cancer center. J Surg Oncol 2011; 106:219-23. [DOI: 10.1002/jso.22154] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 10/31/2011] [Indexed: 11/07/2022]
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19
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Hohenberger P, Du W, Post S. Extended resections for colorectal cancer - indications for supraradical lymphadenectomy. Colorectal Dis 2011; 13 Suppl 7:74-7. [PMID: 22098525 DOI: 10.1111/j.1463-1318.2011.02783.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The laparoscopic approach to standard resections in colorectal cancer has proven that it may provide equal rates of R0 resections and adequate retrieval of lymph nodes as open procedures if performed by experienced hands. There might be difficulties in more advanced tumors or those with lymphatic spread beyond typical drainage areas and more extensive operations might be required. An atypical pattern of lymphatic spread often is associated with other adverse factors such as multifocality of primary cancers and adverse tumorbiological factors such as grade. Such patient subgroups may be defined beforehand and include particularly patients with underlying ulcerative colitis. Repetitively, extended lymph node dissection approaches have been advocated, however neither in randomised trails nor in meta-analysis has a more favourable outcome of patients undergoing such extended lymphatic dissections been demonstrated. Sticking to the rules of classical dissection of lymphatic drainage basins with removal of adequate lymph node numbers is one corner stone for successful treatment of colorectal cancer. The other one refers to a detailed description of the procedure performed in order to make the surgical procedure trackable.
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Affiliation(s)
- P Hohenberger
- Division of Surgical Oncology and Thoracic Surgery, Mannheim University Medical Center, University of Heidelberg, Heidelberg, Germany.
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20
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Abstract
Approximately one third of patients diagnosed with early-stage colon cancer will present with lymph node involvement (stage III) and about one quarter with transmural bowel wall invasion but negative lymph nodes (stage II). Adjuvant chemotherapy targets micrometastatic disease to improve disease-free (DFS) and overall survival (OS). While beneficial for stage III patients, the role of adjuvant chemotherapy is unestablished in stage II disease. This likely relates to the improved outcome of these patients, and the difficulties in developing studies with sufficient power to document benefit in this patient population. However, recent investigation also suggests that molecular differences may exist between stage II and III cancers and within stage II patients. Validated pathologic prognostic markers are useful at identifying stage II patients at high risk for recurrence for whom the benefit from adjuvant chemotherapy may be greater. Such high-risk features include higher T stage (T4 v T3), suboptimal lymph node retrieval, presence of lymphovascular invasion, bowel obstruction, or bowel perforation, and poorly differentiated histology. However, for the majority of patients who do not carry any of these adverse features and are classified as "average-risk" stage II patients, the benefit of adjuvant chemotherapy remains unproven. Emerging understanding of the underlying biology of stage II colon cancer has identified molecular markers that may change this paradigm and improve our risk assessment and treatment choices for stage II disease. Assessment of microsatellite stability (MSI), which serves as a marker for DNA mismatch repair (MMR) system function, has emerged as a useful tool for risk stratification of patients with stage II colon cancer. Patients with high frequency of MSI have been shown to have increased OS and limited benefit from 5-fluorouracil (5-FU)-based chemotherapy. Additional research is necessary to clearly define the most appropriate way to use this marker and others in routine clinical practice.
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Affiliation(s)
- Efrat Dotan
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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21
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Shanmugam C, Hines RB, Jhala NC, Katkoori VR, Zhang B, Posey JA, Bumpers HL, Grizzle WE, Eltoum IE, Siegal GP, Manne U. Evaluation of lymph node numbers for adequate staging of Stage II and III colon cancer. J Hematol Oncol 2011; 4:25. [PMID: 21619690 PMCID: PMC3124418 DOI: 10.1186/1756-8722-4-25] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 05/28/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although evaluation of at least 12 lymph nodes (LNs) is recommended as the minimum number of nodes required for accurate staging of colon cancer patients, there is disagreement on what constitutes an adequate identification of such LNs. METHODS To evaluate the minimum number of LNs for adequate staging of Stage II and III colon cancer, 490 patients were categorized into groups based on 1-6, 7-11, 12-19, and ≥ 20 LNs collected. RESULTS For patients with Stage II or III disease, examination of 12 LNs was not significantly associated with recurrence or mortality. For Stage II (HR = 0.33; 95% CI, 0.12-0.91), but not for Stage III patients (HR = 1.59; 95% CI, 0.54-4.64), examination of ≥20 LNs was associated with a reduced risk of recurrence within 2 years. However, examination of ≥20 LNs had a 55% (Stage II, HR = 0.45; 95% CI, 0.23-0.87) and a 31% (Stage III, HR = 0.69; 95% CI, 0.38-1.26) decreased risk of mortality, respectively. For each six additional LNs examined from Stage III patients, there was a 19% increased probability of finding a positive LN (parameter estimate = 0.18510, p < 0.0001). For Stage II and III colon cancers, there was improved survival and a decreased risk of recurrence with an increased number of LNs examined, regardless of the cutoff-points. Examination of ≥7 or ≥12 LNs had similar outcomes, but there were significant outcome benefits at the ≥20 cutoff-point only for Stage II patients. For Stage III patients, examination of 6 additional LNs detected one additional positive LN. CONCLUSIONS Thus, the 12 LN cut-off point cannot be supported as requisite in determining adequate staging of colon cancer based on current data. However, a minimum of 6 LNs should be examined for adequate staging of Stage II and III colon cancer patients.
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22
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Steele SR, Chen SL, Stojadinovic A, Nissan A, Zhu K, Peoples GE, Bilchik A. The impact of age on quality measure adherence in colon cancer. J Am Coll Surg 2011; 213:95-103; discussion 104-5. [PMID: 21601492 DOI: 10.1016/j.jamcollsurg.2011.04.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Revised: 04/13/2011] [Accepted: 04/13/2011] [Indexed: 12/28/2022]
Abstract
BACKGROUND Recently lymph node yield (LNY) has been endorsed as a quality measure of colon cancer resection adequacy. It is unclear whether this measure is relevant to all ages. We hypothesized that total lymph node yield (LNY) is negatively correlated with increasing age and overall survival (OS). STUDY DESIGN The Surveillance, Epidemiology and End Results (SEER) database was queried for all nonmetastatic colon cancer patients diagnosed from 1992 to 2004 (n = 101,767), grouped by age (<40, 41 to 45, 46 to 50, and in 5-year increments until 86+ years). Proportions of patients meeting the 12 LNY minimum criterion were determined in each age group and analyzed with multivariate linear regression adjusting for demographics and American Joint Committee on Cancer (AJCC) 6(th) Edition stage. OS comparisons in each age category were based on the guideline of 12 LNY. RESULTS Mean LNY decreased with increasing age (18.7 vs 11.4 nodes/patient, youngest vs oldest group, p < 0.001). The proportion of patients meeting the 12 LNY criterion also declined with each incremental age group (61.9% vs 35.2% compliance, youngest vs oldest, p < 0.001). Multivariate regression demonstrated a negative effect of each additional year in age and log (LNY) with coefficient of -0.003 (95% CI -0.003 to -0.002). When stratified by age and nodal yield using the 12 LNY criterion, OS was lower for all age groups in stage II colon cancer with less than 12 LNY, and each age group over 60 years with less than 12 LNY for stage III colon cancer (p < 0.05). CONCLUSIONS Every attempt to adhere to proper oncologic principles should be made at the time of colon cancer resection regardless of age. The prognostic significance of the 12 LN minimum criterion should be applied even to elderly colon cancer patients.
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Affiliation(s)
- Scott R Steele
- Department of Surgery, Division of Colorectal Surgery, Madigan Army Medical Center, Tacoma, WA, USA
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23
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Barbas A, Turley R, Mantyh C, Migaly J. Advanced fellowship training is associated with improved lymph node retrieval in colon cancer resections. J Surg Res 2011; 170:e41-6. [PMID: 21612795 DOI: 10.1016/j.jss.2011.03.055] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 03/05/2011] [Accepted: 03/18/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Examination of at least 12 lymph nodes has been established as the standard of care for adequate staging of colon cancer. The purpose of this study was to determine whether surgeon fellowship training, patient body mass index (BMI), and surgical approach (open versus laparoscopic) are important factors associated with lymph node retrieval at an NCI/NCCN-designated center. METHODS We conducted a retrospective review of patients undergoing colectomy for colon cancer from 1994 to 2009. Patients who underwent right, left, and sigmoid colectomy by open or laparoscopic approaches were included. Lymph node retrieval and risk factors for inadequate nodal retrieval (<12 nodes) were analyzed. RESULTS A total of 371 patients were included. Lymph node retrieval was found to be significantly increased when surgeons had fellowship training compared with no advanced training (19.9 ± 10.6 versus 14.8 ± 10.6, P = 0.0007). Lymph node retrieval was found to be significantly decreased in obese patients (BMI ≥ 30) compared with non-obese patients (17.3 ± 10.0 versus 19.9 ± 11.5, P = 0.05). There was no significant difference between open and laparoscopic approaches. On multivariate analysis, lack of fellowship training, surgery performed prior to establishment of NCI guidelines for lymph node retrieval, and small tumor size were independent predictors of inadequate lymph node retrieval. CONCLUSION Advanced fellowship training of surgeons appears to be associated with higher lymph node retrieval and decreased risk of performing inadequate nodal retrieval. Small tumor size and surgery performed prior to establishment of the 12 lymph node benchmark were also associated with inadequate nodal retrieval.
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Affiliation(s)
- Andrew Barbas
- Section of Colon and Rectal Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
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