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Stelzner S, Lange UG, Rabe SM, Niebisch S, Mehdorn M. [Evidence for the extent and oncological benefits of lymphadenectomy in colon and rectal cancer : A narrative review based on meta-analyses]. CHIRURGIE (HEIDELBERG, GERMANY) 2025; 96:293-305. [PMID: 39792247 DOI: 10.1007/s00104-024-02212-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/25/2024] [Indexed: 01/12/2025]
Abstract
BACKGROUND Lymphadenectomy for rectal cancer is clearly defined by total mesorectal excision (TME). The analogous surgical strategy for the colon, the complete mesocolic excision (CME), follows the same principles of dissection in embryologically predefined planes. METHOD This narrative review initially identified key issues related to lymphadenectomy of rectal and colon cancer. The subsequent search was based on PubMed and focused on meta-analyses. The endpoints for rectal cancer were the benefit of high tie versus low tie and the indications for lateral pelvic lymphadenectomy. For colon cancer the evidence for CME, for the longitudinal extent of resection, for the dissection of infrapyloric and gastroepiploic lymph nodes, for the number of lymph nodes and for the sentinel lymph node technique were used as endpoints. RESULTS An oncological benefit of the high tie cannot be derived from the current data. Lateral pelvic lymphadenectomy should only be selectively performed after chemoradiotherapy (CRT) in cases of remaining lymph nodes with suspected metastases. In most studies CME proved to be oncologically superior, especially in stage III. The longitudinal extent of resection should be at least 10 cm in both directions if the principles of CME are observed. Infrapyloric and gastroepiploic lymph node involvement is to be expected in 0.7-22% of cases, depending on patient selection, which justifies dissection, particularly in carcinomas of both flexure and the transverse colon. The minimum number of lymph nodes to be removed cannot be clearly derived from the available studies. Precisely performed CME and an optimal pathological work-up are important. The sentinel lymph node technique cannot currently be used as a criterion for limiting the extent of resection. CONCLUSION Both TME and CME are reliable standards for the lymphadenectomy in colorectal carcinomas. A lymphadenectomy that goes beyond this is reserved for selected cases and is partly the subject of currently ongoing studies.
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Affiliation(s)
- Sigmar Stelzner
- Klinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstraße 20, 04103, Leipzig, Deutschland.
| | - Undine Gabriele Lange
- Klinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - Sebastian Murad Rabe
- Klinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - Stefan Niebisch
- Klinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - Matthias Mehdorn
- Klinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
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He L, Xiao J, Zheng P, Zhong L, Peng Q. Lymph node regression grading of locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. World J Gastrointest Oncol 2022; 14:1429-1445. [PMID: 36160739 PMCID: PMC9412927 DOI: 10.4251/wjgo.v14.i8.1429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/30/2022] [Accepted: 07/06/2022] [Indexed: 02/05/2023] Open
Abstract
Neoadjuvant chemoradiotherapy (nCRT) and total rectal mesenteric excision are the main standards of treatment for locally advanced rectal cancer (LARC). Lymph node regression grade (LRG) is an indicator of prognosis and response to preoperative nCRT based on postsurgical metastatic lymph node pathology. Common histopathological findings in metastatic lymph nodes after nCRT include necrosis, hemorrhage, nodular fibrosis, foamy histiocytes, cystic cell reactions, areas of hyalinosis, residual cancer cells, and pools of mucin. A number of LRG systems designed to classify the amount of lymph node regression after nCRT is mainly concerned with the relationship between residual cancer cells and regressive fibrosis and with estimating the number of lymph nodes existing with residual cancer cells. LRG offers significant prognostic information, and in most cases, LRG after nCRT correlates with patient outcomes. In this review, we describe the systematic classification of LRG after nCRT, patient prognosis, the correlation with tumor regression grade, and the typical histopathological findings of lymph nodes. This work may serve as a reference to help predict the clinical complete response and determine lymph node regression in patients based on preservation strategies, allowing for the formulation of more accurate treatment strategies for LARC patients, which has important clinical significance and scientific value.
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Affiliation(s)
- Lei He
- School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, Sichuan Province, China
| | - Juan Xiao
- School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, Sichuan Province, China
| | - Ping Zheng
- Department of Pathology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, Sichuan Province, China
| | - Lei Zhong
- Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu 610072, Sichuan Province, China
| | - Qian Peng
- Radiation Therapy Center, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, Sichuan Province, China
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Lei P, Ruan Y, Liu J, Zhang Q, Tang X, Wu J. Prognostic Impact of the Number of Examined Lymph Nodes in Stage II Colorectal Adenocarcinoma: A Retrospective Study. Gastroenterol Res Pract 2020; 2020:8065972. [PMID: 32676106 PMCID: PMC7333032 DOI: 10.1155/2020/8065972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Evaluation of lymph node status is critical in colorectal carcinoma (CRC) treatment. However, as patients with node involvement may be incorrectly classified into earlier stages if the examined lymph node (ELN) number is too small and escape adjuvant therapy, especially for stage II CRC. The aims of this study were to assess the impact of the ELN on the survival of patients with stage II colorectal cancer and to determine the optimal number. METHODS Data from the US Surveillance, Epidemiology, and End Results (SEER) database on stage II resected CRC (1988-2013) were extracted for mathematical modeling as ELN was available since 1988. Relationship between ELN count and stage migration and disease-specific survival was analyzed by using multivariable models. The series of the mean positive LNs, odds ratios (ORs), and hazard ratios (HRs) were fitted with a LOWESS (Locally Weighted Scatterplot Smoothing) smoother, and the structural break points were determined by the Chow test. An independent cohort of cases from 2014 was retrieved for validation in 5-year disease-specific survival (DSS). RESULTS An increased ELN count was associated with a higher possibility of metastasis LN detection (OR 1.010, CI 1.009-1.011, p < 0.001) and better DSS in LN negative patients (OR 0.976, CI 0.975-0.977, p < 0.001). The cut-off point analysis showed a threshold ELN count of 21 nodes (HR 0.692, CI 0.667-0.719, p < 0.001) and was validated with significantly better DSS in the SEER 2009 cohort CRC (OR 0.657, CI 0.522-0.827, p < 0.001). The cut-off value of the ELN count in site-specific surgeries was analyzed as 20 nodes in the right hemicolectomy (HR 0.674, CI 0.638-0.713, p < 0.001), 19 nodes in left hemicolectomy (HR 0.691, CI 0.639-0.749, p < 0.001), and 20 nodes in rectal resection patients (HR 0.671, CI 0.604-0.746, p < 0.001), respectively. CONCLUSIONS A higher number of ELNs are associated with more-accurate node staging and better prognosis in stage II CRCs. We recommend that at least 21 lymph nodes be examined for accurate diagnosis of stage II colorectal cancer.
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Affiliation(s)
- Purun Lei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Ruan
- Department of Thyroid and Breast Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianpei Liu
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qixian Zhang
- Medical Record Management Section, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao Tang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Juekun Wu
- Department of Thyroid and Breast Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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The re-evaluation of optimal lymph node yield in stage II right-sided colon cancer: is a minimum of 12 lymph nodes adequate? Int J Colorectal Dis 2020; 35:623-631. [PMID: 31996986 DOI: 10.1007/s00384-019-03483-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Adequate lymphadenectomy is critical for accurate nodal staging and planning adjuvant therapy in colon cancer. However, the optimal lymph node (LN) yield for stage II right-sided colon cancer (RSCC) is still unclear. This population-based study aimed to determine the optimal LN yield associated with survival and LN positivity in patients with stage II RSCC. METHODS All patients with stage II-III RSCC were identified from the Surveillance, Epidemiology, and End Results database over a 10-year interval (2006-2015). The optimal threshold for LN yield was explored using an outcome-oriented approach based on survival and LN positivity. RESULTS The median number of LNs examined for all 17,385 patients with stage II RSCC was 17 (IQR 12-23). Nineteen LNs were determined as the optimal cut-off point to maximize survival benefit from lymphadenectomy. Increased LN yield was associated with a gradual increase in the risk of node positivity, with no change after 19 nodes. Compared with patients with 19 or more LNs examined, the group with fewer LNs had a significantly poor cancer-specific survival (< 12 nodes: hazard ratio (HR) 2.26, P < 0.001; 12-18 nodes: HR 1.58, P < 0.001) and overall survival (< 12 nodes: HR 1.80, P < 0.001; 12-18 nodes: HR 1.31, P < 0.001). Similar survival results were found in the validation cohort. Patients with older age, small tumor size, and appendix and transverse colon cancer were more likely to receive inadequate LN harvest. CONCLUSION A minimum of 19 LNs is needed to be examined for optimal survival and adequate node staging in lymph node-negative RSCC.
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5
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Son SM, Woo CG, Lee OJ, Lee SJ, Lee TG, Lee HC. Factors affecting retrieval of 12 or more lymph nodes in pT1 colorectal cancers. J Int Med Res 2019; 47:4827-4840. [PMID: 31495249 PMCID: PMC6833376 DOI: 10.1177/0300060519862055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective The aim of this study was to identify clinicopathological factors that affect the number of lymph nodes (LNs) (12 or more) retrieved from patients with colorectal cancer (CRC), particularly those with pathologic T1 (pT1) disease. Methods From 429 CRC patients, 75 pT1 cancers were identified and digitally scanned. Binary logistic regression analysis was performed to identify the clinicopathological factors affecting the number of LNs retrieved from all 429 patients and from the subset of patients with pT1 CRC. Results For the 429 patients, the mean number of harvested LNs per specimen was 20 (median, 19). The number of retrieved LNs was independently associated with maximum tumor diameter > 2.3 cm and right-sided tumor location. The mean number of LNs retrieved from the 75 patients with pT1 CRC was 14 (median, 15); retrieval of 12 or more LNs from this group was independently associated with maximum tumor diameter > 14.1 mm. Conclusion The number of LNs retrieved from patients with CRC was associated with maximum tumor diameter and right-sided tumor location. For patients with pT1 CRC, maximum tumor diameter was independently associated with the harvesting of 12 or more LNs.
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Affiliation(s)
- Seung-Myoung Son
- Department of Pathology, Chungbuk National University Hospital, Cheongju, Republic of Korea.,Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Chang Gok Woo
- Department of Pathology, Chungbuk National University Hospital, Cheongju, Republic of Korea.,Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Ok-Jun Lee
- Department of Pathology, Chungbuk National University Hospital, Cheongju, Republic of Korea.,Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Sang-Jeon Lee
- Department of Surgery, Chungbuk National University Hospital, Cheongju, Republic of Korea.,Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Taek-Gu Lee
- Department of Surgery, Chungbuk National University Hospital, Cheongju, Republic of Korea.,Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Ho-Chang Lee
- Department of Pathology, Chungbuk National University Hospital, Cheongju, Republic of Korea.,Chungbuk National University College of Medicine, Cheongju, Republic of Korea
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6
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Gumus M, Yumuk PF, Atalay G, Aliustaoglu M, Macunluoglu B, Dane F, Caglar H, Sengoz M, Turhal S. What is the Optimal Number of Lymph Nodes to be Dissected in Colorectal Cancer Surgery? TUMORI JOURNAL 2019; 91:168-72. [PMID: 15948546 DOI: 10.1177/030089160509100212] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Regional lymph node (LN) involvement in colorectal cancer (CRC) identifies the stage and the subset of patients who would benefit from adjuvant chemotherapy. We performed a retrospective analysis to determine if the number of recovered LNs was associated with long-term outcome in patients operated on for stage II and III CRC. Patients and methods Hospital records of 179 patients with CRC followed in our unit from 1997 to April 2003 were reviewed. Results On average 11.68 ± 7.3 LNs were sampled per surgical specimen. Sampling of at least nine LNs appeared to be the minimum number required for accurately predicting LN involvement ( P = 0.002). Three-year rates of disease-free survival (DFS), local recurrence-free survival (LRFS) and overall survival (OS) were lower in patients with fewer than nine LNs sampled ( P = 0.032, P = 0.006 and P = 0.04, respectively). However, this had no impact on the three-year distant metastasis-free survival rate (DMFS) ( P = 0.472). In stage II disease, patients with nine or more LNs dissected had significantly higher three year DFS and LRFS rates than the subgroup with fewer than nine LNs dissected ( P = 0.024 and P = 0.015, respectively), but this did not have any effect on DMFS or OS ( P = 0.406 and P = 0.353, respectively). Conclusion Current protocols provide adjuvant treatment in stage III patients; the problem is to correctly determine stage by recovering as many LNs as possible.
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Affiliation(s)
- Mahmut Gumus
- Oncology Division, Department of Internal Medicine, Marmara University Hospital, Istanbul, Turkey.
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Huang Y, Lin Y, Li J, Zhang X, Tang L, Zhuang Q, Lin F, Lin X, Wu J. Role of postoperative radiotherapy in pT3N0 rectal cancer: A risk-stratification system based on population analyses. Cancer Med 2019; 8:1024-1033. [PMID: 30714683 PMCID: PMC6434337 DOI: 10.1002/cam4.1991] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 12/24/2022] Open
Abstract
The impact of adjuvant radiotherapy in pT3N0 rectal cancer is controversial. We aimed to determine the risk factors for cancer-specific survival (CSS) among these patients and to develop a risk-stratification system to identify which of these patients would benefit from adjuvant radiotherapy. In this review of the Surveillance, Epidemiology, and End Results database (2010-2014), we analyzed the data of pT3N0 rectal cancer patients who had not undergone neoadjuvant radiotherapy. Prognostic factors were identified using the Cox proportional hazards model, and risk scores were derived according to the β regression coefficient. A total of 1021 patients were identified from the database search. The overall 5-year CSS was 86.31%. Multivariate analysis showed that age (P < 0.001), tumor differentiation (P = 0.044), number of nodes resected (P = 0.032), marital status (P = 0.005), and radiotherapy (P = 0.006) were independent prognostic factors for CSS. A risk-stratification system composed of age, tumor differentiation, and number of nodes resected was generated. Low-risk patients had better CSS than high-risk patients (92.13% vs 72.55%, P < 0.001). The addition of radiotherapy to surgery doubled the CSS among the high-risk patients (42.06% vs 91.26%, P = 0.001) but produced no survival benefit among the low-risk patients (93.36% vs 96.38%, P = 0.182). Our risk-stratification model based on age, tumor differentiation, and number of nodes resected predicted the outcomes of pT3N0 rectal cancer patients. This model could help identify patients who may benefit from adjuvant radiotherapy.
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Affiliation(s)
- Yun‐xia Huang
- Department of Radiation OncologyFujian Medical University Cancer HospitalFujian Cancer HospitalFuzhouChina
| | - Yan‐zong Lin
- Department of Gastrointestinal Surgical OncologyFujian Medical University Cancer HospitalFujian Cancer HospitalFuzhouChina
| | - Jin‐luan Li
- Department of Radiation OncologyFujian Medical University Cancer HospitalFujian Cancer HospitalFuzhouChina
| | - Xue‐qing Zhang
- Department of Radiation OncologyFujian Medical University Cancer HospitalFujian Cancer HospitalFuzhouChina
| | - Li‐rui Tang
- Department of Radiation OncologyFujian Medical University Cancer HospitalFujian Cancer HospitalFuzhouChina
| | - Qing‐yang Zhuang
- Department of Radiation OncologyFujian Medical University Cancer HospitalFujian Cancer HospitalFuzhouChina
| | - Fei‐fei Lin
- Department of Radiation OncologyFujian Medical University Cancer HospitalFujian Cancer HospitalFuzhouChina
| | - Xi‐jin Lin
- Department of Radiation OncologyFujian Medical University Cancer HospitalFujian Cancer HospitalFuzhouChina
| | - Jun‐xin Wu
- Department of Radiation OncologyFujian Medical University Cancer HospitalFujian Cancer HospitalFuzhouChina
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Dawson H, Kirsch R, Messenger D, Driman D. A Review of Current Challenges in Colorectal Cancer Reporting. Arch Pathol Lab Med 2019; 143:869-882. [DOI: 10.5858/arpa.2017-0475-ra] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Pathologic assessment of colorectal cancer resection specimens plays an important role in postsurgical management and prognostication in patients with colorectal cancer. Challenges exist in the evaluation and reporting of these specimens, either because of difficulties in applying existing guidelines or related to newer concepts.
Objective.—
To address challenging areas in colorectal cancer pathology and to provide an overview of the literature, current guidelines, and expert recommendations for the handling of colorectal cancer resection specimens in everyday practice.
Data Sources.—
PubMed (US National Library of Medicine, Bethesda, Maryland) literature review; reporting protocols of the College of American Pathologists, the Royal College of Pathologists of the United Kingdom, and the Japanese Society for Cancer of the Colon and Rectum; and classification manuals of the American Joint Committee on Cancer and the Union for International Cancer Control.
Conclusions.—
This review has addressed issues and challenges affecting quality of colorectal cancer pathology reporting. High-quality pathology reporting is essential for prognostication and management of patients with colorectal cancer.
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Affiliation(s)
- Heather Dawson
- From the Institute of Pathology, University of Bern, Bern, Switzerland (Dr Dawson); Pathology and Laboratory Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada (Drs Dawson and Kirsch); the Department of Colorectal Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom (Dr Messenger); and Pathology and Laboratory Medicine, Western Univer
| | - Richard Kirsch
- From the Institute of Pathology, University of Bern, Bern, Switzerland (Dr Dawson); Pathology and Laboratory Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada (Drs Dawson and Kirsch); the Department of Colorectal Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom (Dr Messenger); and Pathology and Laboratory Medicine, Western Univer
| | - David Messenger
- From the Institute of Pathology, University of Bern, Bern, Switzerland (Dr Dawson); Pathology and Laboratory Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada (Drs Dawson and Kirsch); the Department of Colorectal Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom (Dr Messenger); and Pathology and Laboratory Medicine, Western Univer
| | - David Driman
- From the Institute of Pathology, University of Bern, Bern, Switzerland (Dr Dawson); Pathology and Laboratory Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada (Drs Dawson and Kirsch); the Department of Colorectal Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom (Dr Messenger); and Pathology and Laboratory Medicine, Western Univer
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Fortea-Sanchis C, Martínez-Ramos D, Escrig-Sos J. CUSUM charts in the quality control of colon cancer lymph node analysis: a population-registry study. World J Surg Oncol 2018; 16:230. [PMID: 30501634 PMCID: PMC6267835 DOI: 10.1186/s12957-018-1533-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 11/21/2018] [Indexed: 01/23/2023] Open
Abstract
Background The most important determinant of survival in patients with colon cancer is the presence or absence of regional lymph node metastases. This factor is consistently associated with long-term and disease-specific survival. Cumulative summation of differences (CUSUM) charts can help to discriminate abnormalities that cannot be explained by the general variability of a process. We used CUSUM charts to analyse the quality of nodal analysis in colon cancer and to use a population-registry cancer database to estimate the optimal number of lymph nodes for adequate prognostic analysis. Methods This was a multicentre population-registry cancer study from January 2004 to December 2007. We used these data to produce the different CUSUM curves, focusing on the main variables. To calculate survival, we used the Kaplan–Meier method. Results In this study, we examined 548 patients. The CUSUM curves were calculated for overall mortality, specific mortality, and recurrence according to (1) the number of lymph nodes analysed and affected and (2) compared the ratio of the number of lymph nodes affected to the number analysed. Finally, the lymph node ratio was compared to the overall survival CUSUM curve. Discussion This CUSUM control chart analysis reinforces the unquestionable importance of analysing at least 12 lymph nodes in patients with colon cancer in order to accurately estimate their prognosis. However, our findings indicate that the analysis of at least 20 lymph nodes is a more appropriate cutoff point for accomplishing the demanding objective of diagnosing a high-quality prognosis in colon cancer patients.
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Affiliation(s)
- Carlos Fortea-Sanchis
- Department of Surgery, Division of Colorectal Surgery, Consorcio Hospitalario Provincial de Castellón, Av. Doctor Clara, 19, 12002, Castellón, Spain.
| | - David Martínez-Ramos
- Department of Surgery, Hospital General de Castellón, Av. Benicassim s/n, 12004, Castellón, Spain
| | - Javier Escrig-Sos
- Department of Surgery, Hospital General de Castellón, Av. Benicassim s/n, 12004, Castellón, Spain
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10
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Del Paggio JC, Peng Y, Wei X, Nanji S, MacDonald PH, Krishnan Nair C, Booth CM. Population-based study to re-evaluate optimal lymph node yield in colonic cancer. Br J Surg 2017; 104:1087-1096. [PMID: 28542954 DOI: 10.1002/bjs.10540] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 12/16/2016] [Accepted: 02/14/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND It is well established that lymph node (LN) yield in colonic cancer resection has prognostic significance, although optimal numbers are not clear. Here, LN thresholds associated with both LN positivity and survival were evaluated in a single population-based data set. METHODS Treatment records were linked to the Ontario Cancer Registry to identify a 25 per cent random sample of all patients with stage II/III colonic cancer between 2002 and 2008. Multivariable regression and Cox models evaluated factors associated with LN positivity and cancer-specific survival (CSS) respectively. Optimal thresholds were obtained using sequential regression analysis. RESULTS On adjusted analysis of 5508 eligible patients, younger age (P < 0·001), left-sided tumours (P = 0·003), higher T category (P < 0·001) and greater LN yield (relative risk 0·89, 95 per cent c.i. 0·81 to 0·97; P = 0·007) were associated with a greater likelihood of LN positivity. Regression analyses with multiple thresholds suggested no substantial increase in LN positivity beyond 12-14 LNs. Cox analysis of stage II disease showed that lower LN yield was associated with a significant increase in the risk of death from cancer (CSS hazard ratio range 1·55-1·74; P < 0·001) compared with a greater LN yield, with no significant survival benefit beyond a yield of 20 LNs. Similarly, for stage III disease, a lower LN yield was associated with an increase in the risk of death from cancer (CSS hazard ratio range 1·49-2·20; P < 0·001) versus a large LN yield. In stage III disease, there was no observed LN threshold for survival benefit in the data set. CONCLUSION There is incongruity in the optimal LN evaluation for colonic cancer. Although the historically stated threshold of 12 LNs may ensure accurate staging in colonic cancer, thresholds for optimal survival are associated with far greater yields.
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Affiliation(s)
- J C Del Paggio
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Y Peng
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - X Wei
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - S Nanji
- Departments of Oncology, Queen's University, Kingston, Ontario, Canada.,Departments of Surgery, Queen's University, Kingston, Ontario, Canada
| | - P H MacDonald
- Departments of Surgery, Queen's University, Kingston, Ontario, Canada
| | - C Krishnan Nair
- Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, India
| | - C M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Departments of Oncology, Queen's University, Kingston, Ontario, Canada.,Departments of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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11
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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] [Received: 02/01/2016] [Revised: 06/08/2016] [Accepted: 06/13/2016] [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
| | - 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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Impact of age on the prognostic value of number of lymph nodes retrieved in patients with stage II colorectal cancer. Int J Colorectal Dis 2016; 31:1307-13. [PMID: 27234041 DOI: 10.1007/s00384-016-2602-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE A small number of lymph nodes retrieved (NLNR) is a known risk factor in stage II colorectal cancer. NLNR is influenced by age, but little is known about whether the impact of small NLNR on survival differs with age. This retrospective study sought to determine such impact in elderly patients with stage II colorectal cancer. METHODS We reviewed data for 2100 patients with stage II colorectal cancer who underwent surgery without adjuvant chemotherapy between January 1997 and December 2003. The optimal cutoff value of NLNR for survival was determined, and the impact of small NLNR on survival was analyzed. The association between age and NLNR was evaluated. The relation between age and risk of small NLNR with respect to survival was then assessed to determine the impact of small NLNR on elderly patients' survival. RESULTS The optimal cutoff value of NLNR was determined as 6. The small NLNR group (SNG) showed significantly worse prognosis than the large NLNR group (LNG) (p < 0.001). Age, surgical method, and scope of lymph node dissection were significantly associated with NLNR. A potential interaction was noted between age and risk of small NLNR in relation to relapse-free survival (RFS). Five-year RFS was significantly worse in SNG than in LNG for elderly patients (41.7 and 76.4 %, respectively; p < 0.001) but not for non-elderly patients (75.9 and 84.6 %, respectively; p = 0.083). CONCLUSIONS NLNR <6 was identified to be an important prognostic factor for elderly patients with stage II colorectal cancer.
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Yegen G, Keskin M, Büyük M, Kunduz E, Balık E, Sağlam EK, Kapran Y, Asoğlu O, Güllüoğlu M. The effect of neoadjuvant therapy on the size, number, and distribution of mesorectal lymph nodes. Ann Diagn Pathol 2015; 20:29-35. [PMID: 26706785 DOI: 10.1016/j.anndiagpath.2015.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 10/12/2015] [Indexed: 12/14/2022]
Abstract
The current therapeutic approach to patients with locally advanced rectal cancer is neoadjuvant radiotherapy or chemoradiotherapy followed by total mesorectal excision. We aimed to investigate the number, size, and distribution of metastatic and nonmetastatic lymph nodes within the mesorectum; whether neoadjuvant therapy has any impact on the number and size of the lymph nodes; and the impact of metastatic lymph node localization on overall and disease-free survival. Specimens from 50 consecutive patients with stage II/III rectal cancer receiving either neoadjuvant radiotherapy or chemoradiotherapy were investigated. Lymph node dissection was carried out by careful visual inspection and palpation. The localization of the each lymph node within the mesorectum and the relation with the tumor site were noted. The size and the number of lymph nodes retrieved decreased significantly with neoadjuvant therapy. Majority of the metastatic and nonmetastatic lymph nodes were located at or proximally to the tumor level and posterior side of the mesorectum. No relation was observed between the overall and disease-free survival, and the localization of the metastatic lymph nodes. Presence of lymph node metastases proximal to the tumor level has no impact on survival compared with the presence of lymph node metastasis only in the peritumoral region of the mesorectum. Although neoadjuvant therapy decreases the size and the number of lymph nodes, reaching an ideal number of lymph nodes for accurate staging is still possible with careful naked eye examination and dissection of perirectal fat. As the majority of metastatic and nonmetastatic lymph nodes are located in peritumoral and proximal compartment, and posterior side of the mesorectum, these regions should be the major interest of dissection.
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Affiliation(s)
- Gülçin Yegen
- Istanbul University Istanbul Faculty of Medicine, Department of Pathology, Istanbul, Turkey
| | - Metin Keskin
- Istanbul University Istanbul Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Melek Büyük
- Istanbul University Istanbul Faculty of Medicine, Department of Pathology, Istanbul, Turkey
| | - Enver Kunduz
- Istanbul University Istanbul Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Emre Balık
- Koç University, Faculty of Medicine, Department of General Surgery and Istanbul University Istanbul Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Esra Kaytan Sağlam
- Istanbul University, Institute of Oncology, Department of Radiation Oncology, Istanbul, Turkey
| | - Yersu Kapran
- Istanbul University Istanbul Faculty of Medicine, Department of Pathology, Istanbul, Turkey
| | - Oktar Asoğlu
- Liv Hospital, Department of General Surgery and Istanbul University Istanbul Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Mine Güllüoğlu
- Istanbul University Istanbul Faculty of Medicine, Department of Pathology, Istanbul, Turkey.
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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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Increased number of metastatic lymph nodes in adenocarcinoma of the ampulla of Vater as a prognostic factor: A proposal of new nodal classification. Surgery 2014; 155:74-84. [DOI: 10.1016/j.surg.2013.08.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 08/12/2013] [Indexed: 12/15/2022]
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The effect of preoperative chemoradiotherapy on lymph nodes harvested in TME for rectal cancer. World J Surg Oncol 2013; 11:292. [PMID: 24246069 PMCID: PMC3879099 DOI: 10.1186/1477-7819-11-292] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 06/27/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adequate lymph nodes resection in rectal cancer is important for staging and local control. This retrospective analysis single center study evaluated the effect of neoadjuvant chemoradiation on the number of lymph nodes in rectal carcinoma, considering some clinicopathological parameters. METHODS A total of 111 patients undergone total mesorectal excision for rectal adenocarcinoma from July 2005 to May 2012 in our center were included. No patient underwent any prior pelvic surgery or radiotherapy. Chemoradiotherapy was indicated in patients with rectal cancer stage II or III before chemoradiation. RESULTS One-hundred and eleven patients were considered. The mean age was 67.6 yrs (range 36 - 84, SD 10.8). Fifty (45.0%) received neoadjuvant therapy before resection. The mean number of removed lymph nodes was 13.6 (range 0-39, SD 7.3). In the patients who received neoadjuvant therapy the number of nodes detected was lower (11.5, SD 6.5 vs. 15.3, SD 7.5, p = 0.006). 37.4% of patients with preoperative chemoradiotherapy had 12 or more lymph nodes in the specimen compared to the 63.6% of those who had surgery at the first step (p: 0.006).Other factors associated in univariate analysis with lower lymph nodes yield included stage (p 0.005) and grade (p 0.0003) of the tumour. Age, sex, tumor site, type of operation, surgeons and pathologists did not weight upon the number of the removed lymph nodes. CONCLUSION In TME surgery for rectal cancer, preoperative CRT results into a reduction of lymph nodes yield in univariate analisys and linear regression.
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Allaix ME, Arezzo A, Cassoni P, Mistrangelo M, Giraudo G, Morino M. Metastatic lymph node ratio as a prognostic factor after laparoscopic total mesorectal excision for extraperitoneal rectal cancer. Surg Endosc 2012; 27:1957-67. [DOI: 10.1007/s00464-012-2694-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 10/23/2012] [Indexed: 12/11/2022]
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Kuijpers CCHJ, van Slooten HJ, Schreurs WH, Moormann GRHM, Abtahi MA, Slappendel A, Cliteur V, van Diest PJ, Jiwa NM. Better retrieval of lymph nodes in colorectal resection specimens by pathologists' assistants. J Clin Pathol 2012; 66:18-23. [PMID: 23087331 DOI: 10.1136/jclinpath-2012-201089] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Errors in surgical pathology are partly due to the increasing workload of pathologists. To reduce this workload, 'pathologists' assistants' (PAs) have been trained to take over some of the pathologists' recurrent tasks. One of these tasks is the precise examination of ≥10 lymph nodes (LNs), which is of paramount importance to reduce the risk of understaging of colorectal cancer patients. AIMS To evaluate the role of PAs in harvesting LNs in colorectal resection specimens and, by doing so, in improving patient safety. METHODS LN harvest was retrospectively reviewed in 557 pathology reports on colorectal resection specimens collected in two Dutch hospitals from 2008 until 2011. RESULTS PAs sampled ≥10 LNs in significantly more cases than pathologists did (83.2% vs 60.9% in hospital A and 79.2% vs 67.6% in hospital B) and recovered on average significantly more LNs than pathologists did (18.5 vs 12.2 in hospital A and 16.6 vs 13.2 in hospital B). PAs harvested a significantly higher percentage of LNs <5 mm than pathologists did (64.2% vs 53.7%). The percentages of colon cancer patients eligible for adjuvant chemotherapy due to inadequate LN sampling alone were significantly higher for cases dissected by pathologists than for those dissected by PAs (17.3% vs 1.1% in hospital A and 13.1% vs 3.4% in hospital B) CONCLUSIONS: PAs contribute to patient safety since they recover more and, in particular, smaller LNs from colorectal resection specimens than pathologists do. Moreover, they help to reduce costs and morbidity by reducing the number of patients eligible for adjuvant chemotherapy due to inadequate LN sampling alone.
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Tasi CK, Chen CY, Liu CY, Wu YY. Reliability and Effectiveness of GEWF Solution in the Identification of Lymph Nodes in Specimens of Colorectal Carcinoma. Int J Surg Pathol 2012; 20:589-95. [DOI: 10.1177/1066896912457204] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Lymph node status is pivotal in the staging process of cancer. With regards to colorectal cancer, lymph node retrieval is always laborious. Sometimes, it is also a challenge to recover a minimum of 12 lymph nodes from the pericolorectal tissue. Among many proposed adjunctive solutions, GEWF solution (glacial acetic acid, ethanol, distilled water, and formaldehyde) has been introduced recently and suggested to be superior. To further evaluate its efficiency, the pericolorectal tissue, which has been reexamined extensively in the conventional condition, was refixed into GEWF solution in this study. More lymph nodes were found in 75% (n = 6) of the 8 experimental cases, and 50% (n = 4) of them had 12 or more yielded lymph nodes eventually. In addition, no adverse influences on the expressions of immunohistochemical and special stains were seen. These data support the reliability and effectiveness of GEWF solution in improvement of lymph node yield.
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Affiliation(s)
- Chin-Kuan Tasi
- Department of Pathology, Sijhih Cathay General Hospital, New Taipei City, Taiwan
| | - Ching-Yuan Chen
- Department of Pathology, Sijhih Cathay General Hospital, New Taipei City, Taiwan
| | - Chih-Yi Liu
- Department of Pathology, Sijhih Cathay General Hospital, New Taipei City, Taiwan
| | - Yih-Yiing Wu
- Department of Pathology, Sijhih Cathay General Hospital, New Taipei City, Taiwan
- Department of Pathology, Taipei City Hospital, Renai Branch, Taipei, Taiwan
- College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
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Oyasiji T, Baldwin K, Katz SC, Espat NJ, Somasundar P. Feasibility of purely laparoscopic resection of locally advanced rectal cancer in obese patients. World J Surg Oncol 2012; 10:147. [PMID: 22799628 PMCID: PMC3411465 DOI: 10.1186/1477-7819-10-147] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 07/16/2012] [Indexed: 02/04/2023] Open
Abstract
Background Totally laparoscopic (without hand-assist) resection for rectal cancer continues to evolve, and both obesity and locally advanced disease are perceived to add to the complexity of these procedures. There is a paucity of data on the impact of obesity on perioperative and oncologic outcomes for totally-laparoscopic rectal cancer resection (TLRR) for locally advanced disease. Methods In order to identify potential limitations of TLRR, a single-institution database was queried and identified 26 patients that underwent TLRR for locally advanced rectal cancers (T3/T4) over a three-year period. Patients were classified as normal-weight (NW, body mass index (BMI)=18.5 to 24.9kg/m2), overweight (OW, BMI=25 to 29.9kg/m2) and obese (OB, BMI >/= 30kg/m2). Perioperative outcomes, lymph node harvest and margin status were assessed. Results Seven patients were classified as NW (26.9%), 12 as OW (46.2%) and 7 as OB (26.9%). Age, tumor stage, gender and American Society of Anesthesiologists (ASA) scores were similar. OB had more co-morbidities (median 3.0, range 0.0 to 5.0 vs. 2.0, range 0.0 to 3.0 for NW and 1.0, range 0.0 to 3.0 for OW). Five patients had tumors <5cm from anal verge (NW=2; OW=1; OB=2). A median of 19.0, range 9.0 to 32.0; 20.0, range 9.0 to 46.0 and 19.0, range 15.0 to 31.0 lymph nodes were retrieved in the NW, OW and OB, respectively (Not Significant (NS)). Median node ratios for NW, OW and OB were 0.32, 0.13 and 0.00, respectively. All groups had negative proximal and distal margins. Radial margins were negative for 100% of NW, 83.3% of OW and 85.7% of OB (NS). Conversion rates were 14.3% for NW, 16.7% for OW & 0% for OB (NS). NW, OW and OB had complication rates of 28.3%, 33.3% and 14.3%, respectively. Median operative time, median estimated blood loss and median length of hospital stay were similar for all groups. Conclusion The perceived limitation that obesity would have on TLRR was not demonstrated by the analyzed data. Although our findings are limited by the modest sized cohort, the results suggest that it is reasonable to offer TLRR to obese patients with rectal cancer.
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Affiliation(s)
- Tolutope Oyasiji
- Division of Surgical Oncology, Department of Surgery, Roger Williams Medical Center, Boston University, Prior 4, 825 Chalkstone Avenue, Providence, RI 02908, USA
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Belt EJT, te Velde EA, Krijgsman O, Brosens RPM, Tijssen M, van Essen HF, Stockmann HBAC, Bril H, Carvalho B, Ylstra B, Bonjer HJ, Meijer GA. High lymph node yield is related to microsatellite instability in colon cancer. Ann Surg Oncol 2012; 19:1222-30. [PMID: 21989661 PMCID: PMC3309135 DOI: 10.1245/s10434-011-2091-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lymph node (LN) yield in colon cancer resection specimens is an important indicator of treatment quality and has especially in early-stage patients therapeutic implications. However, underlying disease mechanisms, such as microsatellite instability (MSI), may also influence LN yield, as MSI tumors are known to exhibit more prominent lymphocytic antitumor reactions. The aim of the present study was to investigate the association of LN yield, MSI status, and recurrence rate in colon cancer. METHODS Clinicopathological data and tumor samples were collected from 332 stage II and III colon cancer patients. DNA was isolated and PCR-based MSI analysis performed. LN yield was defined as "high" when 10 or more LNs were retrieved and "low" in case of fewer than 10 LNs. RESULTS Tumors with high LN yield were significantly associated with the MSI phenotype (high LN yield: 26.3% MSI tumors vs low LN yield: 15.1% MSI tumors; P=.01), mainly in stage III disease. Stage II patients with high LN yield had a lower recurrence rate compared with those with low LN yield. Patients with MSI tumors tended to develop fewer recurrences compared with those with MSS tumors, mainly in stage II disease. CONCLUSIONS In the present study, high LN yield was associated with MSI tumors, mainly in stage III patients. Besides adequate surgery and pathology, high LN yield is possibly a feature caused by biologic behavior of MSI tumors.
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Affiliation(s)
- E. J. Th. Belt
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Surgery, Kennemer Gasthuis, Haarlem, The Netherlands
| | - E. A. te Velde
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - O. Krijgsman
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - R. P. M. Brosens
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Surgery, Zaans Medical Centre, Zaandam, The Netherlands
| | - M. Tijssen
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - H. F. van Essen
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | | | - H. Bril
- Department of Pathology, Kennemer Gasthuis, Haarlem, The Netherlands
| | - B. Carvalho
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - B. Ylstra
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - H. J. Bonjer
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - G. A. Meijer
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
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Porter GA, Urquhart R, Bu J, Johnson P, Rayson D, Grunfeld E. Improving nodal harvest in colorectal cancer: so what? Ann Surg Oncol 2011; 19:1066-73. [PMID: 21969083 DOI: 10.1245/s10434-011-2073-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adequate nodal harvest (≥12 lymph nodes) in colorectal cancer has been shown to optimize staging and has been proposed as a quality indicator of colorectal cancer care. We previously demonstrated a population-based improvement in adequate nodal harvest over time, particularly with the use of an audit and feedback strategy. The goal of this current study is to evaluate the impact of improved adequate nodal harvest on 3 relevant clinical outcomes: node positivity rate, use of adjuvant chemotherapy, and survival. METHODS This current population-based study included all patients undergoing resection for primary stage I-III colorectal cancer in Nova Scotia, Canada, from January 1, 2001 to December 31, 2005. Linkage of the provincial cancer registry with other administrative databases (hospital discharge data, physician claims data, and national census data) provided clinical, demographic, diagnostic, treatment event, and survival data. The association between increase in adequate node harvest and relevant clinical outcomes was examined for all patients and in a subgroup analysis of patients who received care in a health district that used audit and feedback to improve nodal harvest. RESULTS Among the 2,250 patients, the median nodal harvest was 8, and the overall node positive rate was 35.9%. Despite significant improvement in the proportion of patients undergoing adequate nodal harvest over time (P<.0001), no significant change was observed in the node positivity rate (P=.51), proportion of patients undergoing adjuvant chemotherapy (P=.83), or survival (P=.25). In the subgroup analysis confined to patients where audit and feedback was used to improve nodal harvest rates, clinical outcomes were not improved. CONCLUSIONS Although improvements in the rate of adequate nodal harvest did occur over time, no corresponding meaningful improvement in clinical outcomes was noted. Given the need that quality indicators not only be associated with outcome, but also that outcome improves as such indicators are optimized, this study questions the inclusion of a nodal harvest≥12 lymph nodes as a quality indicator of colorectal cancer care.
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Affiliation(s)
- Geoffrey A Porter
- Department of Surgery, QEII Health Sciences Centre, Dalhousie University, Halifax, NS, Canada.
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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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Lindboe CF. Lymph node harvest in colorectal adenocarcinoma specimens: the impact of improved fixation and examination procedures. APMIS 2011; 119:347-55. [PMID: 21569092 DOI: 10.1111/j.1600-0463.2011.02748.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A review of 1050 pathology reports from colorectal adenocarcinoma specimens examined at the Department of Pathology, Sørlandet sykehus HF, Kristiansand, Norway during the period 1995-2006 revealed a poor performance of most doctors concerning lymph node harvest. A mean of 8.1 nodes per specimen (range 12.3-2.1) and a mean proportion of 22.3% of specimens with ≥12 lymph nodes (range 47.1-0%) were found. A small pilot study was undertaken in 2007 to evaluate the effect of prolonged formalin fixation and the use of a special lymph node fixative [glacial acetic acid, ethanol, water and formaldehyde (GEWF) solution] with regard to the number of retrieved nodes. This showed that one extra day formalin fixation and the use of GEWF solution considerably enhanced the detection of lymph nodes, particularly those of smaller size. Based on these findings, our routines concerning handling of colorectal cancer specimens were changed during 2007. After this time all specimens have been fixed in a mixture of GEWF solution and formalin for at least 48 h and the doctors have been encouraged to find as many lymph nodes as possible. In cases revealing <12 nodes after microscopical examination, the specimens have been re-examined and searched for additional nodes. A review of lymph node retrieval in 423 cases of colorectal cancer during the period 2008-2010 showed that the mean number of nodes per specimen had increased to 16.8 (range 29.0-13.3) and the proportion of specimens with ≥12 nodes to 78.0% (range 96.8-63.6%). Thus, these changes of routines which were easy to implement without significant extra costs have considerably improved lymph node harvest at our department. The use of a special lymph node fixative (e.g. GEWF solution) is highly recommended not only for detection of nodes in colorectal specimens, but also for retrieval of lymph nodes embedded in fat tissue generally.
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Stocchi L, Fazio VW, Lavery I, Hammel J. Individual Surgeon, Pathologist, and Other Factors Affecting Lymph Node Harvest in Stage II Colon Carcinoma. Is a Minimum of 12 Examined Lymph Nodes Sufficient? Ann Surg Oncol 2011; 18:405-412. [DOI: 10.1245/s10434-010-1308-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Porter GA, Urquhart R, Bu J, Johnson P, Grunfeld E. The impact of audit and feedback on nodal harvest in colorectal cancer. BMC Cancer 2011; 11:2. [PMID: 21199578 PMCID: PMC3024990 DOI: 10.1186/1471-2407-11-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 01/03/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adequate nodal harvest (≥ 12 lymph nodes) in colorectal cancer has been shown to optimize staging and proposed as a quality indicator of colorectal cancer care. An audit within a single health district in Nova Scotia, Canada presented and published in 2002, revealed that adequate nodal harvest occurred in only 22% of patients. The goal of this current study was to identify factors associated with adequate nodal harvest, and specifically to examine the impact of the audit and feedback strategy on nodal harvest. METHODS This population-based study included all patients undergoing resection for primary colorectal cancer in Nova Scotia, Canada, from 01 January 2001 to 31 December 2005. Linkage of the provincial cancer registry with other databases (hospital discharge, physician claims data, and national census data) provided clinicodemographic, diagnostic, and treatment-event data. Factors associated with adequate nodal harvest were examined using multivariate logistic regression. The specific interaction between year and health district was examined to identify any potential effect of dissemination of the previously-performed audit. RESULTS Among the 2,322 patients, the median nodal harvest was 8; overall, 719 (31%) had an adequate nodal harvest. On multivariate analysis, audited health district (p < 0.0001), year (p < 0.0001), younger age (p < 0.0001), non-emergent surgery (p < 0.0001), more advanced stage (p = 0.008), and previous cancer history (p = 0.03) were associated with an increased likelihood of an adequate nodal harvest. Interaction between year and audited health district was identified (p = 0.006) such that the increase in adequate nodal harvest over time was significantly greater in the audited health district. CONCLUSIONS Improvements in colorectal cancer nodal harvest did occur over time. A published audit demonstrating suboptimal nodal harvest appeared to be an effective knowledge translation tool, though more so for the audited health district, suggesting a potentially beneficial effect of audit and feedback strategies.
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Affiliation(s)
- Geoffrey A Porter
- Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
- Cancer Outcomes Research Program, Cancer Care Nova Scotia, Halifax, Nova Scotia, Canada
| | - Robin Urquhart
- Cancer Outcomes Research Program, Cancer Care Nova Scotia, Halifax, Nova Scotia, Canada
| | - Jingyu Bu
- Cancer Outcomes Research Program, Cancer Care Nova Scotia, Halifax, Nova Scotia, Canada
- Surveillance and Epidemiology Unit, Cancer Care Nova Scotia, Halifax, Nova Scotia, Canada
| | - Paul Johnson
- Department of Surgery, Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Eva Grunfeld
- Ontario Institute for Cancer Research and Cancer Care Ontario, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Vather R, Sammour T, Kahokehr A, Connolly A, Hill A. Quantitative lymph node evaluation as an independent marker of long-term prognosis in stage III rectal cancer. ANZ J Surg 2010; 81:883-8. [PMID: 22507414 DOI: 10.1111/j.1445-2197.2010.05595.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prognostic significance of lymph node evaluation is not well described for rectal cancer due to a lack of reproducibility in nodal counts and variable use of adjuvant and neoadjuvant therapy. The aim of this study was to examine the role of quantitative lymph node evaluation as an independent marker of prognosis in stage III rectal cancer. METHODS New Zealand Cancer Registry data were retrieved for consecutive patients with rectal cancer from January 1995 to July 2003. Cases with node-negative tumours, distant metastases, death within 30 days of surgery and incomplete data fields were excluded. Three nodal stratification systems were investigated - Total Number of Nodes examined (TNN), Absolute number of Positive Nodes (APN) and Lymph Node Ratio (LNR). Univariate and Cox regression analyses were performed with 5-year all-cause mortality as the primary end point. RESULTS The study identified 895 stage III rectal cancer cases. The mean APN and LNR were significantly higher in patients who died within 5 years. An increasing APN or LNR was associated with a significant increase in 5-year mortality. The APN and LNR were also powerful predictors of 5-year mortality after correcting for other factors using Cox regression. The TNN was of no prognostic significance. CONCLUSIONS Both the APN and LNR are highly effective at independently predicting and stratifying 5-year mortality in stage III rectal cancer. The significant predictive value of the LNR is likely to be a reflection of the APN rather than one functioning in autonomy, given that the TNN was of no prognostic significance.
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Affiliation(s)
- Ryash Vather
- Department of Surgery, South Auckland Clinical School, Middlemore Hospital, Otahuhu, Auckland, New Zealand
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Martínez-Ramos D, Escrig-Sos J, Hoashi JS, Rivadulla-Serrano I, Salvador-Sanchís JL, Ruiz Del Castillo J. [A method for individualising the risk of a negative lymph node classification error in cancer of the colon]. Cir Esp 2010; 88:383-9. [PMID: 21040908 DOI: 10.1016/j.ciresp.2010.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 09/06/2010] [Accepted: 09/15/2010] [Indexed: 12/27/2022]
Abstract
INTRODUCTION In cancer of the colon, the number of lymph nodes that should be analysed before a patient is classified as free of lymph node involvement has been widely discussed. A mathematical model is proposed which is based on the Bayes Theorem for calculating the probability of error (PE) similar to that normally used to evaluate a diagnostic test, but adapted to a quantitative variable, the lymph node count. METHODS The clinical histories of 480 patients routinely operated on in attempt to cure cancer of the colon were reviewed. Cases with any kind of metastasis were excluded. The proposed formula based on the Bayes Theorem was applied with the aim of calculating the PEs for the complete series and for different patient sub-groups (T2, T3, and T4 tumours). RESULTS For the probabilities of error of classifying a patient as N negative, which varied between 5% and 1% (near or practically 0), the minimum number of negative lymph nodes required for analysis fluctuated between 7 and 17, respectively, for the complete series. This minimum figure was also variable for the different sub-groups (T2, T3, and T4 tumours) studied. These numbers mainly depended on the case characteristics of a specific study group as regards the prevalence of the N+ cases that they dealt with, and of its historically demonstrated ability to collect and identify positive lymph nodes in those patients that had them. CONCLUSION From a mathematical point of view, the minimum number of lymph nodes that have to be analysed in cancer of the colon in order to classify a patient as N negative is not a constant. This depends on the error that is prepared to be assumed for that diagnosis, possibly depending on certain tumour traits, and also may be adapted to the cases of each study group.
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Fang QX, Lü LZ, Yang B, Zhao ZS, Wu Y, Zheng XC. L1, β-catenin, and E-cadherin expression in patients with colorectal cancer: correlation with clinicopathologic features and its prognostic significance. J Surg Oncol 2010; 102:433-42. [PMID: 20672319 DOI: 10.1002/jso.21537] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Currently, there are no clinically used/routine biomarkers that accurately predict whether colorectal cancer (CRC) patients will or will not respond to adjuvant chemotherapy. The aim of this study was to investigate L1, β-catenin, and E-cadherin expression in patients with CRC and their relationship to tumor progression, and to identify patients who will respond to chemotherapy. METHODS A total of 142 patients who underwent surgical treatment for CRC were chosen retrospectively. The samples from these patients were analyzed by immunohistochemistry. SPSS-14 program package was used for statistical calculation. RESULTS Expression of L1, β-catenin, and E-cadherin were found to be strongly associated with invasion and metastasis of CRC. Cox multivariate analysis results indicated that L1 expression and stage of Dukes could be considered as the independent prognostic factors for survival. Furthermore, our study found that the 5-year survival rate was the significantly associated with the expression of L1, β-catenin (normal and ectopic expression), and E-cadherin for Dukes' stage B (P < 0.01) patients. However, no such result was found for Dukes' stage A (P > 0.05) and C (P > 0.05) patients. CONCLUSION Our study provided reference for identifying patients who need adjuvant chemotherapy. L1, β-catenin, and E-cadherin could be considered as biomarkers to predict whether CRC patients will or will not respond to adjuvant chemotherapy.
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Affiliation(s)
- Qing-Xia Fang
- Department of Pharmacy, Zhejiang Provincial People's Hospital, Hangzhou, China
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Elferink MAG, Siesling S, Lemmens VEPP, Visser O, Rutten HJ, van Krieken JHJM, Tollenaar RAEM, Langendijk JA. Variation in Lymph Node Evaluation in Rectal Cancer: A Dutch Nationwide Population-Based Study. Ann Surg Oncol 2010; 18:386-95. [DOI: 10.1245/s10434-010-1269-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Indexed: 11/18/2022]
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Basten O, Bandorski D, Bismarck C, Neumann K, Fisseler-Eckhoff A. [Acetone compression. A fast, standardized method to investigate gastrointestinal lymph nodes]. DER PATHOLOGE 2010; 31:218-24. [PMID: 20012620 DOI: 10.1007/s00292-009-1256-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Lymph node staging is the most important prognostic parameter in malignant gastrointestinal tumors. Manual dissection of adipose tissue is time-consuming and also depends on the experience of the individual examiner. By combining elution with acetone and mechanical compression using simple equipment it was possible to completely embed adipose tissue from 404 surgical specimens (colon 348, stomach 28, greater omentum 14, other location 14) without manual dissection. As a result of the procedure, the weight of the adipose tissue could be reduced by 90%-95%, making full histological examination possible. The colon specimens included an average of 43.8 lymph nodes (14-109) in 14 embedding cassettes (1-38) with a native fat weight of 234.7 g (42.8-820 g). The quality of histological staining, including immunohistochemical and molecular investigations, is of comparable quality to routine work-up. Elution with acetone enables the prompt, standardized and full histological work-up of adipose tissue without manual dissection. Moreover, additional costs are low. The number of lymph nodes required by medical associations was attained in all cases and often exceeded. This method was successfully used in other organs (greater omentum, breast).
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Affiliation(s)
- O Basten
- Institut für Pathologie und Zytologie, Neue Kasseler Str. 23a, 35039 Marburg.
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Sara S, Poncet G, Voirin D, Laverriere MH, Anglade D, Faucheron JL. Can adequate lymphadenectomy be obtained by laparoscopic resection in rectal cancer? Results of a case-control study in 200 patients. J Gastrointest Surg 2010; 14:1244-7. [PMID: 20502976 DOI: 10.1007/s11605-010-1228-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 05/11/2010] [Indexed: 01/31/2023]
Abstract
AIM The aim of this study is to compare pathological findings in rectal cancer specimens obtained by laparoscopy or laparotomy. MATERIALS AND METHODS Bowel length, distal and circumferential margins, and number of total and positive nodes harvested were prospectively recorded in specimens obtained from 100 consecutive patients who had a laparoscopic total mesorectal excision for cancer. These data were compared with those extracted from a well-matched group of 100 patients who had an open procedure. RESULTS The mean length of the specimens was 31.04 cm in the case group and 29.45 cm in the control group (not significant (NS)). All distal margins in both groups were negative. The circumferential margin was positive in four cases in the case group and nine cases in the control group (NS). The mean number of lymph nodes harvested was 13.76 nodes/patient in the case group and 12.74 nodes/patient in the control group (NS). The mean number of involved lymph nodes was 1.18 node/case in the case group and 1.96 node/case in group 2 (NS). CONCLUSION There is no difference between laparoscopic or open approaches concerning specimen's length, distal margin, circumferential margin, and total and positive lymph nodes. Laparoscopic rectal resection is not only technically feasible but it seems also oncologically safe.
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Affiliation(s)
- Samer Sara
- Department of Colorectal Surgery, University Hospital, Grenoble cedex, France
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Fewer than 12 lymph nodes can be expected in a surgical specimen after high-dose chemoradiation therapy for rectal cancer. Dis Colon Rectum 2010; 53:1023-9. [PMID: 20551754 DOI: 10.1007/dcr.0b013e3181dadeb4] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Lymph node harvest of >or=12 has been adopted as a marker for adequacy of resection for colorectal cancer. We have noted a paucity of lymph nodes in rectal cancer specimens after neoadjuvant therapy, positing that the number of lymph nodes depends on the response to radiation and may not be an appropriate benchmark. Our purpose was to determine whether the number of lymph nodes harvested after neoadjuvant therapy is a useful quality indicator. METHODS A database of rectal cancer patients was queried to identify patients undergoing total mesorectal excision after neoadjuvant chemoradiation between January 1997 and August 2007. We compared patients with <12 lymph nodes to those with >or=12 lymph nodes relative to multiple patient and treatment factors. RESULTS One hundred seventy-six patients were identified (119 men; mean age, 60.4 y (range, 22-87)). Mean lymph node harvest was 10.1 (range, 1-38). Only 28% had >or=12 lymph nodes and 32% had <6 lymph nodes. There was no statistically significant difference in lymph node harvest relative to radiation dosage, age, tumor response, or type of surgery. There was no correlation between the number of lymph nodes harvested and the number of nodes positive for cancer. CONCLUSIONS With a standardized surgical technique and pathologic evaluation, the number of lymph nodes present after neoadjuvant chemoradiation and total mesorectal excision for rectal cancer varies greatly.
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Elferink MAG, Siesling S, Visser O, Rutten HJ, van Krieken JHJM, Tollenaar RAEM, Lemmens VEPP. Large variation between hospitals and pathology laboratories in lymph node evaluation in colon cancer and its impact on survival, a nationwide population-based study in the Netherlands. Ann Oncol 2010; 22:110-117. [PMID: 20595447 DOI: 10.1093/annonc/mdq312] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND adequate lymph node (LN) evaluation is important for planning treatment in patients with colon cancer. Aims of this study were to identify factors associated with adequate nodal examination and to determine its relationship with stage distribution and survival. PATIENTS AND METHODS data from patients with colon carcinoma stages I-III who underwent surgical treatment and diagnosed in the period 2000-2006 were retrieved from the Netherlands Cancer Registry. Multilevel logistic analysis was carried out to examine the influence of relevant factors on the number of evaluated LNs. The relationship with survival was analysed using Cox regression analysis. RESULTS the number of examined LN was determined for 30 682 of 33 206 tumours. Median number of evaluated LN was 8, ranging from 4 to 15 between pathology laboratories. Females, younger patients, right-sided pN+ tumours with higher pT stage and patients diagnosed in an academic centre were less likely to have nine or less LN evaluated. Unexplained variation between hospitals and pathology laboratories remained, leading to differences in stage distribution. With increasing number of evaluated LN, the risk of death decreased. CONCLUSION there was large diversity in nodal examination among patients with colon cancer, leading to differences in stage distribution and being associated with survival.
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Affiliation(s)
- M A G Elferink
- Department of Research, Comprehensive Cancer Centre North East, Enschede/Groningen.
| | - S Siesling
- Department of Research, Comprehensive Cancer Centre North East, Enschede/Groningen; Department of Health Technology and Services Research, University of Twente, Enschede
| | - O Visser
- Comprehensive Cancer Centre Amsterdam, Amsterdam
| | - H J Rutten
- Department of Surgery, Catharina Hospital, Eindhoven
| | - J H J M van Krieken
- Department of Pathology, Radboud University Nijmegen Medical Centre, Nijmegen
| | | | - V E P P Lemmens
- Department of Research, Comprehensive Cancer Centre South, Eindhoven; Department of Public Health, Erasmus MC University, Rotterdam, The Netherlands
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Abstract
Since Cuthbert Dukes fundamental work linking cancer stage to prognosis, the pathologist has had an ever-expanding role in the multidisciplinary management of rectal cancer. Gross dissection techniques and histologic evaluation are reviewed. The evolving tumor size, node status, metastasis classification (TNM) staging system is outlined. The pathologist's critical role in correctly assessing circumferential margins and establishing resection adequacy and staging accuracy via lymph node assessment is emphasized.
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Affiliation(s)
- Joseph E Willis
- Department of Pathology, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH 44106, USA.
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Choi HK, Law WL, Poon JTC. The optimal number of lymph nodes examined in stage II colorectal cancer and its impact of on outcomes. BMC Cancer 2010; 10:267. [PMID: 20529352 PMCID: PMC2895612 DOI: 10.1186/1471-2407-10-267] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2009] [Accepted: 06/08/2010] [Indexed: 12/12/2022] Open
Abstract
Background Lymph node status is the most important prognostic factor for colorectal cancer. The number of lymph nodes that should be histologically examined has been controversial. The aims of this study were to assess the impact of the number of lymph nodes examined on survival of patients with stage II colorectal cancer and to determine the optimal number of lymph nodes that should be examined. Methods The study included 664 patients who underwent resection for stage II colorectal cancer. The clinical and histopathologic data of the patients were prospectively collected and analyzed. Results The median number of lymph nodes examined was 12 (range: 1 to 58). The 5-year disease free survival rate was significantly higher for patients with 12 or more lymph nodes examined compared to those with less than 12 lymph nodes examined. The significant difference in 5-year disease free survival persisted if the dividing number increased progressively from 12 to 23. However, the difference in survival was most significant (lowest p value and highest hazard ratio) for the number 21. The 5-year disease free survival of patients with 21 or more lymph nodes examined was 80% whereas that of patients with less than 21 lymph nodes examined was 60% (p = 0.001, hazard ratio 2.08). Multivariate analysis showed that 21 or more lymph nodes examined was a factor that independently influenced survival. The 5-year disease free survival also increased progressively with the number of lymph node examined up to the number 21. After the number 21, the survival rate did not increase further. It was likely that 21 was the optimal number, at and above which the chance of lymph node metastasis was minimal. Conclusions The number of lymph nodes examined in colorectal cancer specimen significantly influences survival. It is recommended that at least 21 lymph nodes should be examined for accurate diagnosis of stage II colorectal cancer.
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Affiliation(s)
- Hok Kwok Choi
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong
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Quality Control in Colorectal Cancer Care: How Many Lymph Nodes Should Be Harvested? Reply to Letter. World J Surg 2010. [DOI: 10.1007/s00268-010-0421-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lymph node retrieval in rectal cancer is dependent on many factors--the role of the tumor, the patient, the surgeon, the radiotherapist, and the pathologist. Am J Surg Pathol 2010; 33:1547-53. [PMID: 19661781 DOI: 10.1097/pas.0b013e3181b2e01f] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Lymph node status is the strongest prognostic factor for survival in colorectal cancer. There are several guidelines concerning the minimum numbers of lymph nodes that need to be examined to make reliable staging possible, but there is no consensus in the available literature. In this study, we determine in patients with rectal cancer factors that relate to the number of lymph nodes found and the presence of lymph node metastasis. In addition, the number of examined lymph nodes was correlated with prognosis. A total of 1227 patients were selected from a multicenter prospective randomized trial investigating the value of neoadjuvant radiotherapy. The median number of examined lymph nodes in all patients was 7.0. The number of retrieved lymph nodes in patients with node metastasis was significantly higher than in node negative patients. After neoadjuvant radiotherapy fewer lymph nodes were retrieved (6.9 vs. 8.5; P<0.0001). Variations in lymph node yield between pathology laboratories and individual pathologists were striking. The following patient and tumor characteristics are associated with a significant lower lymph node retrieval: age over 60 years, overweight, small size, and low invasion depth of the tumor, poor differentiation grade, and absence of a lymphoid reaction. Node negative patients in whom seven or less lymph nodes were examined had a lower recurrence free interval than patients in whom at least 8 lymph nodes were examined (17.0% vs. 10.7%, P=0.016). We conclude that in pathology laboratories a median of at least 8 lymph nodes need to be examined in rectal cancer specimens, but that higher numbers are desirable and achievable in most cases, even after preoperative radiotherapy.
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Morcos B, Baker B, Al Masri M, Haddad H, Hashem S. Lymph node yield in rectal cancer surgery: effect of preoperative chemoradiotherapy. Eur J Surg Oncol 2010; 36:345-9. [PMID: 20071133 DOI: 10.1016/j.ejso.2009.12.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 12/14/2009] [Accepted: 12/22/2009] [Indexed: 02/06/2023] Open
Abstract
AIM Adequate lymph node resection in rectal cancer is important for staging and local control. This study aims to verify the effect of neoadjuvant chemoradiation, as well as some clinicopathological features, on the yield of lymph nodes in rectal carcinoma. METHODS Data on consecutive patients who had total mesorectal excision for rectal adenocarcinoma at a single cancer center between January 2003 and July 2008 were reviewed. No patient had any prior pelvic surgery or radiotherapy. Patients had neoadjuvant chemoradiotherapy if they were stage II or III. RESULTS A total of 116 patients were included. The mean age was 53 years (range 29-83). Fifty-nine patients (51%) received neoadjuvant therapy before resection. The mean number of lymph nodes removed was 18 (range 4-67) per specimen. There was less lymph node yield in patients who received neoadjuvant therapy (16 vs. 19, p = 0.008). Only 64% of patients who had preoperative therapy had 12 lymph nodes or more in the specimen as opposed to 88% of those who had surgery upfront (p = 0.003). Other factors associated with lower lymph node yield included: female sex (p = 0.03) and tumour location in the lower rectum (p = 0.002). Age, tumour stage and grade, type of operation and surgical delay did not affect the number of lymph nodes removed. CONCLUSION Preoperative chemoradiotherapy for rectal cancer results in reduction in lymph node yield. Female sex and lower rectal tumours are also associated with retrieval of fewer lymph nodes.
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Affiliation(s)
- B Morcos
- Department of Surgery and Surgical Oncology, King Hussein Cancer Center, Amman, Jordan.
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Baxter NN, Ricciardi R, Simunovic M, Urbach DR, Virnig BA. An evaluation of the relationship between lymph node number and staging in pT3 colon cancer using population-based data. Dis Colon Rectum 2010; 53:65-70. [PMID: 20010353 DOI: 10.1007/dcr.0b013e3181c70425] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The number of lymph nodes examined has been proposed as a quality benchmark for colon cancer surgery, although it is unknown whether this strategy reduces understaging. METHODS We identified 11,044 patients who underwent surgery for colon cancer with pT3 wall penetration between 1988 and 2003 from the Surveillance, Epidemiology and End Results cancer registry. We determined the proportion of patients who were node positive for each node count. We used logistic regression to predict the odds of being node positive by node count after adjusting for confounders. We used joinpoint analysis to determine whether there was a consistent relationship between node count and the odds of being node positive. RESULTS The proportion of patients found to be node positive increased with node count at low counts (<or=5-6 nodes), but patients with 7 nodes identified were as likely to be node positive as patients with 30 or more nodes (odds ratio = 0.97; 95% CI = 0.90-1.05). Joinpoint analysis demonstrated a dramatic increase in odds of node positivity with increasing node count to 5 nodes (slope = 0.2; P < .0001). Between 6 and 13 nodes there was a marginal increase in odds of positive nodes (slope = 0.03; P = .006), but when more nodes were evaluated, odds of node positivity actually declined (slope = -0.01; P = .04). CONCLUSIONS Staging of pT3 colon cancer improves with increasing node count, but only when the node count is low (<5-7 nodes). At higher counts, an increased node count has marginal effects on staging.
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Affiliation(s)
- Nancy N Baxter
- Department of Surgery and Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada.
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Araújo SDA, Cabral MMDÁ, Lacerda Filho A, Horta JGÁ, Luz MMPD, Silva RGD. Impacto do uso da solução reveladora de linfonodos no estadiamento do câncer colorretal. ACTA ACUST UNITED AC 2009. [DOI: 10.1590/s0101-98802009000300001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUÇÃO: A avaliação anátomo-patológica do câncer colorretal (CCR) em relação ao acometimento linfonodal é fundamental para o prognóstico da doença e para a indicação de terapias adjuvantes. Tem sido considerado um número mínimo de 12 linfonodos na peça cirúrgica para que se obtenha adequado estadiamento linfonodal, embora se admita que quanto maior o número de linfonodos dissecados, maior é a probabilidade de se encontrar linfonodos metastáticos. OBJETIVOS: avaliar o número de linfonodos obtidos em peças cirúrgicas de CCR antes e após a utilização rotineira de solução reveladora de linfonodos na gordura mesocólica. MATERIAL E MÉTODOS: Foram avaliados 706 laudos anátomo-patológicos de CCR, sendo 582 sem tratamento do espécime cirúrgico com solução reveladora e 124 após uso de solução reveladora. Resultados: Houve predominância do sexo feminino (57,6%) e a média de idade foi de 61,36 anos. A maioria dos tumores localizava-se distalmente à flexura esplênica (60%). A média de linfonodos dissecados após uso da solução reveladora foi igual a 28,97, enquanto que no período anterior ao uso desta solução esta média foi de 16,73 (p < 0,001). A porcentagem de peças com 11 linfonodos dissecados ou menos (pNx) diminuiu significativamente após a utilização da solução reveladora (32,7 para 3,2%, com p < 0,0001). Ao contrário, houve aumento significativo do número de casos estadiados como pN0, pN1, pN2 e pN3 após o uso da solução reveladora. CONCLUSÃO: O uso da solução reveladora de linfonodos causa grande impacto no estudo anátomo-patológico das peças cirúrgicas do CCR, sendo altamente aconselhável sua introdução na rotina dos serviços de patologia cirúrgica.
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El-Gazzaz G, Hull T, Hammel J, Geisler D. Does a laparoscopic approach affect the number of lymph nodes harvested during curative surgery for colorectal cancer? Surg Endosc 2009; 24:113-8. [PMID: 19517186 DOI: 10.1007/s00464-009-0534-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 04/14/2009] [Accepted: 05/01/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND This study aimed to assess the number of lymph nodes (LNs) harvested after laparoscopic and open colorectal cancer resections. METHODS Between 1996 and 2007, 431 colorectal cancer patients underwent laparoscopic resection. During the periods of 1996-1997, 2002-2003, and 2006-2007, 243 patients undergoing laparoscopic colorectal cancer resection were matched 1-2 by age, operation, gender, operation date, body mass index (BMI), and tumor stage (TNM) to 486 patients undergoing open surgery. The numbers of examined and involved LNs were compared according to tumor location and year of surgery. RESULTS Colorectal cancer resections (243 laparoscopic and 486 open procedures) were performed for 729 patients (447 men) with a mean age of 66.2 +/- 12.3 years and a mean BMI of 28.5 +/- 7.3. The mean number of LNs per case was 24.8 +/- 20.6. The number of LNs retrieved did not differ between laparoscopic and open surgery (p = 0.4). A significant difference was observed between the number of involved LNs retrieved laparoscopically (2.2 +/- 3.8) and the number retrieved by open surgery (1.6 +/- 4; p = 0.03). There were significant differences between the numbers of LNs retrieved from the right colon (28.1 +/- 14.6), left colon (24.5 +/- 17.6), and rectum (19.1 +/- 15.1) (p < 0.001). There were significantly fewer examined LNs in laparoscopic than in open cases during 2002 and 2003 (p = 0.003). CONCLUSION Laparoscopic resection of colorectal cancer can achieve lymph node retrieval similar to that achieved by the open approach. In this era of new technology, laparoscopic lymph node harvest is becoming more optimized.
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Affiliation(s)
- Galal El-Gazzaz
- A30 Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Positive lymph node retrieval ratio optimises patient staging in colorectal cancer. Br J Cancer 2009; 100:1530-3. [PMID: 19401684 PMCID: PMC2696755 DOI: 10.1038/sj.bjc.6605049] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Alternative lymph node (LN) parameters have been proposed to improve staging in colorectal cancer. This study compared these alternative parameters with conventional TNM staging in predicting long-term survival in patients undergoing curative resection. A total of 295 consecutive patients (mean age 70 years; range 39–95; s.d. 10.4) underwent resection for colorectal cancer from 2001 to 2004. Age, sex, primary tumour site, TNM stage and chemotherapy/radiotherapy were recorded. Patients with colon and rectal cancers were analysed separately for LN parameters: LN total; adequate LN retrieval (⩾12) and inadequate (<12); total number of negative LN; total number of positive LN and the ratio of positive LN to total LN (pLNR). Univariate and multivariate survival analysis was performed. The median number of LN retrieved was 10 (1–57) with adequate LN retrieval in 147 cases (49.8%). For each T and N stage, inadequate LN retrieval did not adversely affect long-term survival (P>0.05). On multivariate analysis, only pLNR was an independent predictor of overall survival in both colon and rectal cancers (HR 11.65, 95% CI 5.00–27.15, P<0.001 and HR 13.40, 95% CI 3.64–49.10, P<0.001, respectively). Application of pLNR subdivided patients into four prognostic groups. Application of the pLNR improved patient stratification in colorectal cancer and should be considered in future staging systems.
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Hsu CW, Lin CH, Wang JH, Wang HT, Ou WC, King TM. Factors that influence 12 or more harvested lymph nodes in early-stage colorectal cancer. World J Surg 2009; 33:333-9. [PMID: 19082656 DOI: 10.1007/s00268-008-9850-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The number of lymph nodes required for accurate staging is a critical component in early-stage (stage A and B) colorectal cancer (CRC). Current guidelines demand at least 12 lymph nodes to be retrieved. Results of previous studies were contradictory in factors, which influenced the number of harvested lymph nodes. This study was designed to determine the factors that influence the number of harvested lymph nodes (> or =12) in early-stage CRC in a single institution. METHODS Between 2003 and 2007, data on patients who underwent surgery for early-stage CRC were analyzed retrospectively. Data for a total of 470 patients were collected and all the tumor-bearing specimens were fixed with node identification performed. Several possible factors that influence 12 or more harvested lymph nodes were investigated and classified into four aspects: (1) operating surgeon, (2) examining pathologist, (3) patient (age, sex, and body mass index), and (4) disease (maximal length of tumor, length of specimen, tumor localization, tumor cell differentiation, Dukes stage, type of resection, and type of tumor). RESULTS A total of 289 patients (61.5%) with 12 or more harvested lymph nodes and 181 patients (38.5%) with < 12 lymph nodes were analyzed. The results demonstrate that within a single institution the maximal length of tumor, tumor localization, and depth of tumor invasion according to Dukes stage were independent influencing factors of 12 or more harvested lymph nodes. Maximal length of tumor was associated with more harvested lymph nodes (P < 0.001). Neither the operating surgeon nor the examining pathologist had significant influence on the number of harvested lymph nodes. CONCLUSIONS The number of harvested lymph nodes was highly variable in patients who underwent resection of early-stage CRC. Neither the operating surgeon nor the examining pathologist had significant influence on the number of harvested lymph nodes. Therefore, from the viewpoint of the surgeons, disease itself is the most important factor influencing the number of harvested lymph nodes.
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Affiliation(s)
- Chao-Wen Hsu
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Veteran General Hospital, 386 Ta-Chung 1st RD., Kaohsiung, 81346, Taiwan, ROC.
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Vather R, Sammour T, Zargar-Shoshtari K, Metcalf P, Connolly A, Hill A. Lymph node examination as a predictor of long-term outcome in Dukes B colon cancer. Int J Colorectal Dis 2009; 24:283-8. [PMID: 18716784 DOI: 10.1007/s00384-008-0540-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mortality from cancer recurrence in Dukes B patients is approximately 25-30%. Outcome in Dukes B patients improves in direct relation to the number of lymph nodes examined. Examining fewer lymph nodes risks understaging and also such patients are less likely to receive chemotherapy. The aim of this study was to assess the impact of the number of lymph nodes examined on recurrence and mortality in Dukes B colon cancers. MATERIALS AND METHODS A retrospective database was constructed of 328 consecutive patients who underwent resection for Dukes B colorectal cancer between January 1993 and December 2001 at Middlemore Hospital. Patients with incomplete data, previous colorectal cancer, or perioperative deaths were excluded as were cases of rectal cancer. Data for the remaining 216 patients was subjected to multivariate and logistic regression analysis with 'patient death' or 'cancer recurrence' (CRec5) within 5 years as endpoints. A graph was constructed depicting CRec5 as broken down by lymph node strata. Receiver operator characteristic (ROC) curves were constructed for mortality and CRec5. RESULTS The mean number of lymph nodes examined was 16.0 (median 14; range 2-48). The mean number of lymph nodes examined in those who died within 5 years was 12.8 vs. 17.5 in those who remained alive (p = 0.0027). The mean number of lymph nodes examined in those with evidence of recurrence within 5 years was 11.8 vs. 17.1 in those without recurrence (p = 0.0007). Analysis at various lymph node strata showed a sharp and statistically significant drop in the recurrence rate after the 16th node mark. The ROC curve for CRec5 showed that examination of 12 lymph nodes provided maximum sensitivity (0.60) and specificity (0.64). CONCLUSION Examination of more than 16 lymph nodes is associated with a significant reduction in cancer recurrence. This supports the current clinical practice of harvesting and analysing as many nodes as possible during surgical resection and pathological analysis.
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Affiliation(s)
- Ryash Vather
- Department of Surgery, South Auckland Clinical School, University of Auckland, Middlemore Hospital, PO Box 93311, Otahuhu, Auckland, New Zealand
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Kelder W, Inberg B, Schaapveld M, Karrenbeld A, Grond J, Wiggers T, Plukker JT. Impact of the number of histologically examined lymph nodes on prognosis in colon cancer: a population-based study in the Netherlands. Dis Colon Rectum 2009; 52:260-7. [PMID: 19279421 DOI: 10.1007/dcr.0b013e3181979164] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The impact of the reported number of lymph nodes at pathologic examination of colon specimens on survival was studied. METHODS The data of 2,281 patients with localized colon cancer were retrospectively reviewed. The effect of tumor characteristics and surgical and pathologic factors on the number of lymph nodes and examined lymph node numbers on nodal status and survival were analyzed. RESULTS The number of examined nodes increased with T stage, left-sided tumors, and mucinous morphology, but decreased with age. The proportion of node-positive patients increased with a larger number of nodes. A high number of examined nodes and high T stage affected nodal status. The five-year overall survival was 51.3 percent for node-positive patients vs. 68.2 percent for node-negative patients. Node-negative patients had a significantly higher five-year crude and relative survival when more lymph nodes were examined. This was not found for the node-positive group and for all patients combined. CONCLUSIONS T stage, localization, and patient age were predictive for the number of nodes examined. A higher number of examined nodes was associated with an increase in node positivity. The survival benefit can be explained by stage migration. Eventually this may lead to an overall survival benefit, as more patients are classified as node-positive, and therefore will receive adjuvant therapy.
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Affiliation(s)
- Wendy Kelder
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
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Vather R, Sammour T, Kahokehr A, Connolly AB, Hill AG. Lymph Node Evaluation and Long-Term Survival in Stage II and Stage III Colon Cancer: A National Study. Ann Surg Oncol 2008; 16:585-93. [DOI: 10.1245/s10434-008-0265-8] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 11/12/2008] [Accepted: 11/12/2008] [Indexed: 12/12/2022]
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Damadi AA, Julien L, Arrangoiz R, Raiji M, Weise D, Saxe AW. Does Obesity Influence Lymph Node Harvest among Patients Undergoing Colectomy for Colon Cancer? Am Surg 2008. [DOI: 10.1177/000313480807401107] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Adequate lymph node harvest among patients undergoing colectomy for cancer is critical for staging and therapy. Obesity is prevalent in the American population. We investigated whether lymph node harvest was compromised in obese patients undergoing colectomy for cancer. Medical records of patients who had undergone colectomy for colon cancer were reviewed. We correlated the number of lymph nodes with body mass index (BMI) and compared the number of lymph nodes among patients with BMI less than 30 kg/m2 to those with BMI of 30 kg/m2 or greater (“obese”). Among all 191 patients, the correlation coefficient was 0.04 (P > 0.2). The mean number of nodes harvested from 122 nonobese patients was 12.4 ± 6 and that for 69 obese patients 12.8 ± 6 (P > 0.2). Among 130 patients undergoing right colectomy and 35 patients undergoing sigmoid colectomy, the correlation coefficients were 0.02 (P > 0.2) and 0.16 (P > 0.2), respectively. There was not a statistically significant difference in lymph node harvest between obese and nonobese patients (14.1 ± 7 vs 13.8 ± 6, P > 0.2; and 11.8 ± 6 vs 8.6 ± 5, P > 0.2), respectively. Obesity did not compromise the number of lymph nodes harvested from patients undergoing colectomy for colon cancer.
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Affiliation(s)
- Amir A. Damadi
- Department of Surgery, Michigan State University, East Lansing, Michigan; and
| | - Lucas Julien
- Department of Surgery, Michigan State University, East Lansing, Michigan; and
| | - Rodrigo Arrangoiz
- Department of Surgery, Michigan State University, East Lansing, Michigan; and
| | - Manish Raiji
- Department of Surgery, Michigan State University, East Lansing, Michigan; and
| | - David Weise
- Department of Pathology, McLaren Regional Medical Center, Flint, Michigan
| | - Andrew W. Saxe
- Department of Surgery, Michigan State University, East Lansing, Michigan; and
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Kelder W, Inberg B, Plukker JTM, Groen H, Baas PC, Tiebosch ATMG. Effect of modified Davidson's fixative on examined number of lymph nodes and TNM-stage in colon carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2008; 34:525-30. [PMID: 17561364 DOI: 10.1016/j.ejso.2007.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Accepted: 04/21/2007] [Indexed: 10/23/2022]
Abstract
AIMS We evaluated the effect of modified Davidson's fixative (mDF) on the number of lymph nodes examined and staging in patients with colon carcinoma. METHODS The results of two different fixation methods used in the pathological preparation of the resection specimens were analyzed. A traditional formalin preparation with manual dissection of all nodes was performed in 117 colon specimens between January 2003 and July 2004. After July 2004, the resected specimens of 125 patients was fixated in mDF. Differences in the retrieval and number of nodes and size of suspected nodal metastases were measured. All lymph nodes were stained with conventional H&E methods. RESULTS The median number of examined nodes increased from 5 (0-17) to 13 (0-35) nodes after the introduction of mDF (p<0.001). The type of resection and the T-stage influenced the number of retrieved nodes significantly. The percentage of node-positive cases increased from 30% to 41% (p=0.077) with mDF, the median size of the retrieved lymph nodes decreased from 9 mm before to 6 mm after mDF (p<0.001) and more micrometastases were found (6% vs. 16%, p=0.03). CONCLUSIONS With mDF technique more lymph nodes were retrieved in the resected colon specimens. Smaller nodes and more micrometastases were found, leading to more node positive patients.
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Affiliation(s)
- W Kelder
- Department of Surgery, Martini Hospital, PO Box 30033, 9700 RM, Groningen, The Netherlands.
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