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de'Angelis N, Schena CA, Azzolina D, Carra MC, Khan J, Gronnier C, Gaujoux S, Bianchi PP, Spinelli A, Rouanet P, Martínez-Pérez A, Pessaux P. Histopathological outcomes of transanal, robotic, open, and laparoscopic surgery for rectal cancer resection. A Bayesian network meta-analysis of randomized controlled trials. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2025; 51:109481. [PMID: 39581810 DOI: 10.1016/j.ejso.2024.109481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Revised: 11/04/2024] [Accepted: 11/16/2024] [Indexed: 11/26/2024]
Abstract
BACKGROUND While total mesorectal excision is the gold standard for rectal cancer, the optimal surgical approach to achieve adequate oncological outcomes remains controversial. This network meta-analysis aims to compare the histopathological outcomes of robotic (R-RR), transanal (Ta-RR), laparoscopic (L-RR), and open (O-RR) resections for rectal cancer. MATERIALS AND METHODS MEDLINE, Embase, and the Cochrane Library were screened from inception to June 2024. Of the 4186 articles screened, 27 RCTs were selected. Pairwise comparisons and Bayesian network meta-analyses applying random effects models were performed. RESULTS The 27 RCTs included a total of 8696 patients. Bayesian pairwise meta-analysis revealed significantly lower odds of non-complete mesorectal excision with Ta-RR (Odds Ratio, OR, 0.60; 95%CI, 0.33, 0.92; P = .02; I2:11.7 %) and R-RR (OR, 0.68; 95%CI, 0.46, 0.94; P = .02; I2:41.7 %) compared with laparoscopy. Moreover, lower odds of positive CRMs were observed in the Ta-RR group than in the L-RR group (OR, 0.36; 95%CI, 0.13, 0.91; P = .02; I2:43.9 %). The R-RR was associated with more lymph nodes harvested compared with L-RR (Mean Difference, MD, 1.24; 95%CI, 0.10, 2.52; P = .03; I2:77.3 %). Conversely, Ta-RR was associated with a significantly lower number of lymph nodes harvested compared with all other approaches. SUCRA plots revealed that Ta-RR had the highest probability of being the best approach to achieve a complete mesorectal excision and negative CRM, followed by R-RR, which ranked the best in lymph nodes retrieved. CONCLUSION When comparing the effectiveness of the available surgical approaches for rectal cancer resection, Ta-RR and R-RR are associated with better histopathological outcomes than L-RR.
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Affiliation(s)
- Nicola de'Angelis
- Unit of Robotic and Minimally Invasive Digestive Surgery, Department of Surgery, Ferrara University Hospital Arcispedale Sant'Anna, via Aldo Moro 8, 44124, Ferrara, Cona), Italy; Department of Translational Medicine and LTTA Centre, University of Ferrara, 44121, Ferrara, Italy.
| | - Carlo Alberto Schena
- Unit of Robotic and Minimally Invasive Digestive Surgery, Department of Surgery, Ferrara University Hospital Arcispedale Sant'Anna, via Aldo Moro 8, 44124, Ferrara, Cona), Italy.
| | - Danila Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara, Italy.
| | - Maria Clotilde Carra
- Department of Translational Medicine and LTTA Centre, University of Ferrara, 44121, Ferrara, Italy; Université Paris Cité, INSERM-Sorbonne Paris Cité Epidemiology and Statistics Research Centre, Paris, France.
| | - Jim Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, University of Portsmouth, Portsmouth, United Kingdom.
| | - Caroline Gronnier
- Eso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Pessac, France.
| | - Sébastien Gaujoux
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France.
| | - Paolo Pietro Bianchi
- Department of Surgery, Asst Santi Paolo e Carlo, Dipartimento di Scienze della Salute, University of Milan, Milan, Italy.
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Philippe Rouanet
- Department of Surgery, Institut Régional du Cancer de Montpellier, Montpellier, France.
| | - Aleix Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain; Biosanitary Research Institute, Valencian International University (VIU), Valencia, Spain.
| | - Patrick Pessaux
- Visceral and Digestive Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France.
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Men V, Bahl P, Jin JZ, Singh PP, Hill AG. Lymph Node Yield and Long-Term Mortality Risk in Patients with Colon Cancer: A 20-Year Follow-Up National Study. Ann Surg Oncol 2024:10.1245/s10434-024-16428-w. [PMID: 39496903 DOI: 10.1245/s10434-024-16428-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Accepted: 10/12/2024] [Indexed: 11/06/2024]
Abstract
BACKGROUND Lymph node status is a well-established prognostic factor for colon cancer, but the optimal number of nodes for accurate staging remains unclear. This study explored the relationship between lymph node yield (LNY) and 5-year mortality rates in colon cancer patients in New Zealand. METHODS Data from the New Zealand Cancer Registry were retrospectively analyzed for patients with TNM stage I, II, and III colon cancer between August 2003 and December 2021, with follow-up until January 2024. The primary outcome was the 5-year all-cause mortality rate, with LNY, age, sex, ethnicity, tumor site, district health board (DHB), and the number of positive nodes as covariates. Statistical analyses included univariate analysis, Cox regression modeling, and chi-squared tests. RESULTS LNY was a significant predictor of 5-year mortality risk (hazard ratio 0.985, p < 0.0001), adjusted for age, sex, ethnicity, tumor site, and DHB. The strongest association between LNY and mortality rate was observed at 12 nodes. Further increases in LNY beyond 22 nodes did not lead to statistically significant differences in mortality rates. Lymph node ratio (LNR) was strongly associated with survival in stage III colon cancer, independent of LNY and the number of positive nodes. CONCLUSIONS Higher LNY is significantly associated with reduced 5-year mortality rates in stage I-III colon cancer up to the 22-node mark. The strong correlation between LNR and mortality highlights its potential value for improving treatment planning in future clinical practice.
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Affiliation(s)
- Velia Men
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
| | - Praharsh Bahl
- South Auckland Clinical Campus, The University of Auckland, Auckland, New Zealand
| | - James Z Jin
- South Auckland Clinical Campus, The University of Auckland, Auckland, New Zealand
| | - Primal Parry Singh
- South Auckland Clinical Campus, The University of Auckland, Auckland, New Zealand
| | - Andrew G Hill
- South Auckland Clinical Campus, The University of Auckland, Auckland, New Zealand
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Naidu K, Chapuis PH, Chan C, Rickard MJFX, West NP, Jayne DG, Ng KS. Tissue morphometric measurements do not predict survival following colorectal cancer surgery. World J Surg Oncol 2024; 22:216. [PMID: 39174976 PMCID: PMC11340191 DOI: 10.1186/s12957-024-03496-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Accepted: 08/10/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Ex vivo tissue morphometric (TM) measurements have been proposed as a quality marker for colorectal cancer (CRC) surgery. However, their survival associations require clarification. This study aimed to evaluate the feasibility of capturing TM measurements based on ex vivo fresh specimen images and explore the association between these TM measurements and survival outcomes. METHODS A prospective cohort study at Concord Hospital, Sydney was conducted with Stage I to III CRC patients (2009-2019) who underwent an anterior resection (AR) or right hemicolectomy (RH). Using high-resolution digital photographs of fresh CRC specimens, ex vivo tissue morphometric (TM) measurements-resected mesentery area (TM A), distances from high vascular tie to tumour (TM B) and bowel wall (TM C), and bowel length (TM D)-were recorded using Image J. Overall survival (OS) and disease-free survival (DFS) estimates and their associations to clinicopathological variables were investigated with Kaplan-Meier and Cox regression analyses. Linear regression models tested association between TM measurements and lymph node (LN) yield. RESULTS Of the 1,425 patients who underwent CRC surgery, TM measurements were performed on 312 patients, with an average age of 69.4 years (SD 12.3), of whom 52.9% were male. The majority had an AR (57.8%). Among AR patients, a 5-year OS rate of 77.4% and a DFS rate of 70.1% were observed, with TM measurements bearing no relationship to survival outcomes. Similarly, RH patients exhibited a 5-year OS rate of 67.2% and a DFS rate of 63.1%, with TM measurements again showing no association with survival. Only TM D (P = 0.02) measurements were associated with the number of LNs examined. CONCLUSION This study successfully demonstrates the feasibility of measuring TM measurements on photographs of ex vivo fresh specimens following CRC surgery. The lack of association with survival outcomes questions the utility of TM measurements as a quality metric of CRC surgery.
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Affiliation(s)
- Krishanth Naidu
- Colorectal Surgery Unit, Concord Hospital, Concord, NSW, 2139, Australia
- Concord Institute of Academic Surgery, Concord Hospital, Building 20, Level 1, Hospital Road, Concord, NSW, 2139, Australia
- Concord Clinical School, Clinical Sciences Building, University of Sydney, Concord Hospital, Concord, NSW, 2139, Australia
| | - Pierre H Chapuis
- Colorectal Surgery Unit, Concord Hospital, Concord, NSW, 2139, Australia
- Concord Institute of Academic Surgery, Concord Hospital, Building 20, Level 1, Hospital Road, Concord, NSW, 2139, Australia
- Concord Clinical School, Clinical Sciences Building, University of Sydney, Concord Hospital, Concord, NSW, 2139, Australia
| | - Charles Chan
- Concord Clinical School, Clinical Sciences Building, University of Sydney, Concord Hospital, Concord, NSW, 2139, Australia
- Department of Anatomical Pathology, Concord Hospital, Concord, NSW, 2139, Australia
| | - Matthew J F X Rickard
- Colorectal Surgery Unit, Concord Hospital, Concord, NSW, 2139, Australia
- Concord Institute of Academic Surgery, Concord Hospital, Building 20, Level 1, Hospital Road, Concord, NSW, 2139, Australia
- Concord Clinical School, Clinical Sciences Building, University of Sydney, Concord Hospital, Concord, NSW, 2139, Australia
| | - Nicholas P West
- Pathology and Data Analytics, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - David G Jayne
- John Goligher Colorectal Unit, St. James's University Hospital, Leeds, UK
- Academic Surgery, Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Kheng-Seong Ng
- Colorectal Surgery Unit, Concord Hospital, Concord, NSW, 2139, Australia.
- Concord Institute of Academic Surgery, Concord Hospital, Building 20, Level 1, Hospital Road, Concord, NSW, 2139, Australia.
- Concord Clinical School, Clinical Sciences Building, University of Sydney, Concord Hospital, Concord, NSW, 2139, Australia.
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Nahas CSR, Nahas SC, Marques CFS, Ribeiro Junior U, Bustamante-Lopez L, Cotti GC, Imperiale AR, Pinto RA, Cecconello I. Prognostic factors for local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. Clinics (Sao Paulo) 2024; 79:100464. [PMID: 39126876 PMCID: PMC11369368 DOI: 10.1016/j.clinsp.2024.100464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/13/2024] [Accepted: 07/14/2024] [Indexed: 08/12/2024] Open
Abstract
Prognostic factors for local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. BACKGROUND The standard curative treatment for locally advanced rectal cancer of the middle and lower thirds is long-course chemoradiotherapy followed by total mesorectal excision. PURPOSE To evaluate the prognostic factors associated with local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. METHODS Retrospective study including patients with rectal cancer T3-4N0M0 or T (any)N + M0 located within 10 cm from the anal border, or patients with T2N0M0 located within 5 cm, treated by long course chemoradiotherapy followed by total mesorectal excision with curative intent. Clinical, demographic, radiologic, surgical, and anatomopathological data were collected. Local recurrence was estimated using the Kaplan-Meier function, and risk was estimated according to each characteristic using univariate and multivariate analyses. RESULTS 270 patients were included, 57.8% male and mean age 61.7 (30‒88) years. At initial staging, 6.7% of patients were stage I, 21.5% stage II, and 71.8% stage III. Open surgery was performed in 65.2%, with sphincter preservation in 78.1%. Mortality within 30 postoperative days was 0.7%. After 49.4 (0.5‒86.1) months of median follow-up, overall and local recurrences were 26.3% and 5.9%. On multivariate analyses, local recurrence was associated with involvement of the mesorectal fascia on restaging MRI (HR = 9.11, p = 0.001) and with pathologic involvement of radial surgical margin (HR = 8.19, p < 0.001). CONCLUSION Local recurrence of rectal cancer treated with long-course chemoradiation and total mesorectal excision is low and is associated with pathologic involvement of the radial surgical margin and can be predicted on restaging MRI.
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Wang Y, Wang X, Chen J, Huang S, Huang Y. Comparative analysis of preoperative chemoradiotherapy and upfront surgery in the treatment of upper-half rectal cancer: oncological benefits, surgical outcomes, and cost implications. Updates Surg 2024; 76:949-962. [PMID: 38240957 DOI: 10.1007/s13304-023-01744-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 12/24/2023] [Indexed: 05/28/2024]
Abstract
The value of neoadjuvant chemoradiotherapy (CRT) is not absolutely clear for upper-half (> 7-15 cm) rectal cancer. This study aimed to compare the efficacy and safety of radical surgery with preoperative CRT vs. upfront surgery (US) in Chinese patients with stage II and III upper-half rectal cancer. A total of 809 patients with locally advanced upper-half rectal cancer between 2017 and 2021 were enrolled retrospectively (280 treated with CRT and 529 treated with US). Through 1:1 propensity score matching, the CRT (172 patients) and US (172 patients) groups were compared for short-term postoperative results and long-term oncological and functional outcomes. In the entire cohort, patients in the CRT group had a younger age, lower distance from the anal verge (DAV), and higher rates of cT4 stage, cN2 stage, mrCRM positivity, EMVI positivity, CEA elevation, and CA-199 elevation than those in the US group. The 5-year disease-free survival (DFS) was lower in the CRT group than in the US group (76% vs. 84%, p = 0.022), while the 5-year overall survival (OS) was comparable between the two groups (85% and 88%, p = 0.084). The distant metastasis rate was higher in the CRT group than in the US group (12.5% vs. 7.8%, p = 0.028), though the local recurrence rate was similar between the two groups (1.1% and 1.3%, p = 1.000). After performing PSM, the 5-year OS (86% vs. 88% p = 0.312), the 5-year DFS (79% vs. 80%, p = 0.435), the local recurrence rate (1.2% vs. 1.7%, p = 1.000), and the distant metastasis rate (11.0% vs. 9.3%, p = 0.593) were comparable between the two groups. Notable pathological downstaging was observed in the CRT group, with a pathological complete response (PCR) rate of 14.5%. In addition, patients in the CRT group had a lower proportion of pT3 (61.6% vs. 77.9%, p < 0.001), pN + (pN1, 15.1% vs. 30.2%, pN2, 9.3% vs. 20.3%, p < 0.001), stage III (24.4% vs. 50.6%, p < 0.001), perineural invasion (19.8% vs. 32.0%, p = 0.014), and lymphovascular invasion (9.3% vs. 25.6%, p < 0.001) than those in the US group. Postoperative complications and long-term functional results were similar, yet there was a trend toward a higher conversion to laparotomy rate (5 (2.9%) vs. 0 (0.0%), p = 0.061) and higher rates of robotic surgery (11.6% vs. 4.7%, p < 0.001), open surgery (7.0% vs. 0.6%, p < 0.001), diverting stoma (47.1% vs. 25.6%, p < 0.001), and surgery costs (1473.6 ± 106.5 vs. 1140.3 ± 54.3$, p = 0.006) in the CRT group. In addition, EMVI (OR = 2.516, p = 0.001) was the only independent risk factor associated with poor response to CRT, and in subgroup analysis of EMVI + , CRT group patients presented a lower 5-year DFS (72.9% vs. 80.5%, p = 0.025) compared to US group patients. CRT prior to surgery has no additional oncological benefits over US in the treatment of upper-half rectal cancer. In contrast, CRT is associated with increased rates of conversion to laparotomy, stoma creation and higher surgery costs. Surgeons tend to favor robotic surgery in the treatment of complex cases such as radiated upper-half rectal cancers. Notably, EMVI + patients with upper-half rectal cancer should be encouraged to undergo upfront surgery, as preoperative CRT may not provide benefits and may lead to delayed treatment effects.
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Affiliation(s)
- Yangyang Wang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, Fujian, 350001, People's Republic of China
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, People's Republic of China
| | - Xiaojie Wang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, Fujian, 350001, People's Republic of China
| | - Jinhua Chen
- Follow-Up Center, Union Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Shenghui Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, Fujian, 350001, People's Republic of China
| | - Ying Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, Fujian, 350001, People's Republic of China.
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Pinto JV, Pedrosa S, Vales F, Rodrigues Pereira P, Silveira H, Moura CP. Nodal Yield in Level II-IV Neck Dissections in Head and Neck Squamous Cell Carcinoma. Cureus 2024; 16:e63310. [PMID: 39070387 PMCID: PMC11283326 DOI: 10.7759/cureus.63310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2024] [Indexed: 07/30/2024] Open
Abstract
OBJECTIVES The main objective of this study is to analyze factors associated with nodal yield in level II-IV selective neck dissections (NDs) and the secondary objective is to assess its impact on overall and disease-free survival. METHODS Observational retrospective study including adult patients submitted to level II-IV ND from January 2015 to December 2021 in the otorhinolaryngology department of a tertiary hospital center. RESULTS A total of 44 patients and 78 level II-IV NDs (34 bilateral and 10 unilateral) were included. The median age at diagnosis was 60 (22-74) years, and 93.2% of the patients were male. A lower nodal yield was significantly associated with previous radiotherapy (p = 0.042) and extranodal invasion (p < 0.001) and was non-significantly associated with older age (p = 0.065). Furthermore, on a Cox analysis adjusted to the cN status and age, the nodal yield was not associated with five-year disease-free survival (HR = 0.986; 95% CI = 0.922-1.054; p = 0.681) nor with five-year overall survival (HR = 1.006; 95% CI = 0.925-1.095; p = 0.888). CONCLUSION A reduced nodal yield in level II-IV NDs was significantly associated with previous radiotherapy and extranodal extension and non-significantly associated with age. There was no association between the nodal yield and five-year overall survival or disease-free survival.
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Affiliation(s)
- João V Pinto
- Otorhinolaryngology Department, Unidade Local de Saúde de São João, Porto, PRT
- Otorhinolaryngology Department, Faculdade de Medicina da Universidade do Porto, Porto, PRT
- Research, Centro de Investigação em Tecnologias e Serviços de Saúde (CINTESIS), Porto, PRT
| | - Sofia Pedrosa
- Pathology and Laboratory Medicine Department, Unidade Local de Saúde de São João, Porto, PRT
| | - Fernando Vales
- Otorhinolaryngology Department, Unidade Local de Saúde de São João, Porto, PRT
- Otorhinolaryngology Department, Faculdade de Medicina da Universidade do Porto, Porto, PRT
| | - Pedro Rodrigues Pereira
- Pathology and Laboratory Medicine Department, Unidade Local de Saúde de São João, Porto, PRT
| | - Helena Silveira
- Otolarhinoryngology Department, Unidade Local de Saúde de São João, Porto, PRT
| | - Carla P Moura
- Otorhinolaryngology Department, Unidade Local de Saúde de São João, Porto, PRT
- Genetics Department, Porto Medical School, University of Porto, Porto, PRT
- Research, i3S - Instituto de Investigação e Inovação em Saúde, Porto, PRT
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Wehrle CJ, Woo K, Chang J, Gamaleldin M, DeHaan R, Dahdaleh F, Felder S, Rosen DR, Champagne B, Steele SR, Naffouje SA. Impact of neoadjuvant therapy on nodal harvest in clinical stage III rectal cancer: Establishing optimum cut-offs by disease response. J Surg Oncol 2024; 129:945-952. [PMID: 38221655 DOI: 10.1002/jso.27586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION A minimum lymph node harvest (LNH) of 12 is the current standard for appropriate nodal staging in resectable rectal cancer. However, the rise of neoadjuvant chemoradiation (NCRT) and total neoadjuvant therapy (TNT) has been associated with decreasing number of LNH. We hypothesize that as tumor response to neoadjuvant therapy increases, the optimum for LNH to achieve appropriate nodal staging should decrease. METHODS Patients with clinical stage III rectal adenocarcinoma who underwent NCRT/TNT followed by resection were identified from the National Cancer Database. A JoinPoint regression analysis was used to determine the LNH for each tumor regression grade (TRG) category beyond which the rate of positive nodes does not significantly change. RESULTS Thirteen thousand four hundred and twenty-six patients met inclusion criteria. Of these, 2406 (17.9%) achieved TRG 0 or ypT0 and 8210 (61.2%) achieved ypN0. Collectively, 2043 patients (15.2%) were reported to have a pathologic complete response (ypT0 ypN0). Positive pathologic nodes were found in 15%, 23%, 31%, 54%, and 53% as ypT stage increased from ypT0 to ypT4, respectively. Similarly, ypN+ rates were 15%, 36%, 41%, and 55% in TRG 0-3. No JoinPoint was identified for TRG 0, whereas inflection points were found at 6-10 nodes for TRG1 (p = 0.002) and TRG 2 (p = 0.016), and at 11-15 nodes for TRG 3. CONCLUSION The benchmark of retrieving 12 nodes in resectable stage III rectal cancer is not consistently achieved after NCRT/TNT. We demonstrate that the LNH requirement to establish accurate pathologic nodal staging can vary depending on the tumor response to neoadjuvant therapies.
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Affiliation(s)
- Chase J Wehrle
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Kimberly Woo
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Jenny Chang
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Maysoon Gamaleldin
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Reece DeHaan
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Elmhurst, Illinois, USA
| | - Seth Felder
- Moffitt Cancer Center, GI Oncology Program, Tampa, Florida, USA
| | - David R Rosen
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Bradley Champagne
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Scott R Steele
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Samer A Naffouje
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
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Zannier F, Angerilli V, Spolverato G, Brignola S, Sandonà D, Balistreri M, Sabbadin M, Lonardi S, Bergamo F, Mescoli C, Scarpa M, Bao QR, Dei Tos AP, Pucciarelli S, Urso ELD, Fassan M. Impact of DNA mismatch repair proteins deficiency on number and ratio of lymph nodal metastases in colorectal adenocarcinoma. Pathol Res Pract 2023; 243:154366. [PMID: 36774759 DOI: 10.1016/j.prp.2023.154366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/03/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Approximately 15 % of colorectal adenocarcinomas (CRCs) are characterized by an altered expression of DNA mismatch repair (MMR) proteins (i.e. MMR deficiency [MMRd]). Lymph node ratio (LNR) represents one of the most important prognostic markers in non-advanced CRCs. No significant data are available regarding LNR distribution depending on MMR status. PURPOSE OF THE STUDY The aim of the present work was to compare pathological and clinical characteristics of MMRd tumors versus MMR proficient (MMRp) cases. Particular attention was paid to how these molecular sub-groups relate to the LNR. MATERIALS AND METHODS A mono-Institutional series of 1037 consecutive surgically treated stage I-IV CRCs were retrospectively selected and data were obtained from pathological reports. Cases were characterized for MMR/MSI status by means of immunohistochemistry or for microsatellite instability (MSI) analysis. RESULTS MMRd/MSI tumors (n = 194; 18.7 %) showed significant differences in comparison to MMRp lesions for sex (female prevalence 50.5 % vs 40.7 %; p = 0.013), age (74.2 vs 69.2; p < 0.001), location (right side; p < 0.001), diameter (larger than MMRp; p < 0.001), growth pattern (expansive pattern of growth; p < 0.001), peri- (p = 0.0002) and intra-neoplastic (p = 0.0018) inflammatory infiltrate, presence of perineural invasion (p < 0.001), stage (lower stage at presentation; p < 0.001), grade (higher prevalence of high-grade tumors; p < 0.001), and LNR (lower; p < 0.001). CONCLUSIONS MMRd/MSI tumors are a distinct molecular CRC subtype characterized by a significantly lower LNR in comparison to MMRp lesions. These data further support the prognostic impact of MMRd/MSI status in early-stage CRCs.
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Affiliation(s)
| | | | - Gaya Spolverato
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Stefano Brignola
- Department of Pathology, Azienda ULSS 2 Marca Trevigiana, Treviso, Italy
| | - Daniele Sandonà
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | | | - Marianna Sabbadin
- Department of Oncology, Veneto Institute of Oncology, IOV-IRCCS, Padua, Italy
| | - Sara Lonardi
- Department of Oncology, Veneto Institute of Oncology, IOV-IRCCS, Padua, Italy
| | - Francesca Bergamo
- Department of Oncology, Veneto Institute of Oncology, IOV-IRCCS, Padua, Italy
| | - Claudia Mescoli
- Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Marco Scarpa
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Quoc Riccardo Bao
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | | | - Salvatore Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Emanuele L D Urso
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Matteo Fassan
- Department of Medicine (DIMED), University of Padua, Padua, Italy; Veneto Institute of Oncology, IOV-IRCCS, Padua, Italy.
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Xiao J, Shen Y, Yang X, Wei M, Meng W, Wang Z. Methylene blue can increase the number of lymph nodes harvested in colorectal cancer: a meta-analysis. Int J Colorectal Dis 2023; 38:50. [PMID: 36807534 DOI: 10.1007/s00384-023-04312-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2023] [Indexed: 02/23/2023]
Abstract
AIM The lymph node (LN) status plays an important role in colorectal cancer (CRC), which depends on adequate LN harvest. In some studies, methylene blue has been used to increase the number of LNs harvested in vitro. The purpose was to evaluate the effect of methylene blue staining on LN harvest during radical resection of CRC. METHODS The Cochrane Library, MEDLINE, Embase, PubMed, and Web of Science were searched from the dates of inception until 15 October 2022. Studies were included if they were randomized controlled trials or nonrandomized controlled trials for radical resection of rectal cancer according to the principle of total mesorectal excision that compared the use of methylene blue with blank control in LN harvest. The primary outcomes were the number of LNs harvested and the incidence of fewer than 12 LNs harvested. RESULT Of 328 articles found, a meta-analysis was conducted of 15 studies (2 randomized controlled trials and 13 non-randomized controlled trials) composed of 3104 patients. Meta-analysis showed that methylene blue could not only significantly increase the number of LNs harvested in CRC specimens (stained group 28.23 vs unstained group 16.15; weighted mean difference 12.08; 95% CI, 8.03-16.12; p < 0.001; I2 = 95%), but also reduce the incidence of fewer than 12 LNs harvested (methylene blue-stained group 7.91% vs unstained group 30.90%; OR 0.12; 95% CI, 0.05-0.26; p < 0.001; I2 = 78%). CONCLUSION Methylene blue can increase the number of LNs harvested in CRC, reduce the incidence of fewer than 12 LNs harvested, and ensure the accuracy of LN staging.
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Affiliation(s)
- Jianlin Xiao
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Shen
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xuyang Yang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Mingtian Wei
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wenjian Meng
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ziqiang Wang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
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10
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An International Multicenter Prospective Study Evaluating the Long-term Oncological Impact of Adjuvant Chemotherapy in ypN+ Rectal Cancer. Ann Surg 2023; 277:299-304. [PMID: 36305301 DOI: 10.1097/sla.0000000000005742] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the oncological benefit of adjuvant chemotherapy (AC) in node positive (ypN+) rectal cancer after neoadjuvant chemoradiotherapy and radical surgery. BACKGROUND The evidence for AC after total mesorectal excision for locally advanced rectal cancer is conflicting and the net survival benefit is debated. METHODS An international multicenter comparative cohort study was performed comparing oncological outcomes in tertiary rectal cancer centers from the Netherlands and France. Patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy followed by total mesorectal excision surgery and with positive lymph nodes on histologic examination (ypN+) were included for analysis. Kaplan-Meier curves were generated to compare disease-free (DFS) and overall survival in AC and non-AC groups. RESULTS Of 1265 patients screened, a total of 239 rectal cancer patients with ypN+ disease were included. Demographic and clinical characteristics were similar in both groups. Higher systemic recurrence rates were observed in the non-AC group compared with those who received AC [32.0% (n=40) vs 17.5% (n=11), respectively, P =0.034]. DFS at 1 and 5 years postoperatively were significantly better in the AC group (92% vs 80% at 1 year; 72% vs 51% at 5 years, P =0.024), whereas no difference in overall survival was observed. CONCLUSIONS In this multicenter comparative cohort study, we identified an oncological benefit of AC in both systemic recurrence and DFS in ypN+ rectal cancer patients. From this data, systemic chemotherapy continues to confer oncological benefit in locally advanced ypN+ rectal cancer.
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11
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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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12
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Ronellenfitsch U, Mathis N, Friedrichs J, Kleeff J. Lymph Node Yield in Gastrointestinal Cancer Surgery With or Without Prior Neoadjuvant Therapy: Protocol for a Systematic Review and Meta-analysis. JMIR Res Protoc 2022; 11:e35243. [PMID: 35482374 PMCID: PMC9100374 DOI: 10.2196/35243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/31/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Lymph node yield is the number of lymph nodes retrieved during oncological resection and histopathologically identified in the resection specimen. It is an important surrogate parameter for assessing the oncological radicality of the resection of gastrointestinal carcinomas, as well as a prognostic factor in these diseases. It remains unclear if and to what extent neoadjuvant chemotherapy, radiotherapy, or chemoradiotherapy, which have become established treatments for carcinoma of the esophagus, stomach, and rectum and are increasingly used in pancreatic carcinoma, affect the lymph node yield. OBJECTIVE This systematic review with meta-analysis is conducted with the aim of summarizing the available evidence regarding the lymph node yield, an oncological surrogate marker, in patients with gastrointestinal carcinomas undergoing surgery after neoadjuvant therapy compared to those undergoing surgery without neoadjuvant therapy. METHODS Randomized and nonrandomized studies comparing oncological resection of esophageal, stomach, pancreatic, and rectal carcinoma with and without prior neoadjuvant therapy are eligible for inclusion regardless of study design. Publications will be identified with a defined search strategy in 2 electronic databases: PubMed and Cochrane Library. The primary endpoint of the analysis is the number of lymph nodes identified in the resected specimen. Secondary endpoints include the number of harvested metastatic lymph nodes, operation time, postoperative complications, pathological TNM staging, and overall and recurrence-free survival time. Using suitable statistical methods, the endpoints between patients with and without neoadjuvant therapy, as well as in defined subgroups (neoadjuvant chemotherapy, radiotherapy, or chemoradiotherapy; and patients with esophageal, gastric, pancreatic, or rectal cancer), will be compared. RESULTS The literature search and data collection started in October 2021. Results are expected to be published in mid-2022. CONCLUSIONS This meta-analysis will provide the most up-to-date and complete summary of the evidence on an association between neoadjuvant therapy and lymph node yield in gastrointestinal cancer surgery. The underlying hypothesis is that neoadjuvant therapy decreases the number and size of lymph nodes through lymphocyte depletion and radiation-induced fibrosis, thus leading to a lower possible lymph node yield. The findings of the meta-analysis will show if this hypothesis is supported by evidence. TRIAL REGISTRATION PROSPERO CRD218459; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021218459. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/35243.
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Affiliation(s)
- Ulrich Ronellenfitsch
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Nika Mathis
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Juliane Friedrichs
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Jörg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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13
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Lin Z, Li X, Song J, Zheng R, Chen C, Li A, Xu B. The Effect of Lymph Node Harvest on Prognosis in Locally Advanced Middle-Low Rectal Cancer After Neoadjuvant Chemoradiotherapy. Front Oncol 2022; 12:816485. [PMID: 35242710 PMCID: PMC8886163 DOI: 10.3389/fonc.2022.816485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/24/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the relationship between lymph node harvest and the prognosis in locally advanced rectal cancer (LARC) patients after neoadjuvant chemoradiotherapy (nCRT). METHODS Patients who were diagnosed with clinical LARC and treated with nCRT and radical surgery between June 2008 and July 2017 were included in this study. The relationship between lymph node retrieval and prognosis was analyzed. Other lymph node-related indicators were explored. RESULTS A total of 837 patients with a median follow-up of 61 (7-139) months were included in the study. The five-year DFS and OS rates of all patients were 74.9% and 82.3%, respectively. Multivariate survival analysis suggested that dissection of ≥ 12 lymph nodes did not improve OS or DFS. 7 was selected as the best cutoff value for the total number of lymph nodes retrieved by Cox multivariate analysis (χ2 = 10.072, HR: 0.503, P=0.002). Dissection of ≥ 5 positive lymph nodes (PLNs) was an independent prognostic factor for poorer DFS (HR: 2.104, P=0.004) and OS (HR: 3.471, p<0.001). A positive lymph node ratio (LNR) of more than 0.29 was also an independent prognostic factor for poorer DFS (HR: 1.951, P=0.002) and OS (HR: 2.434, p<0.001). CONCLUSION The recommends that at least 7 harvested lymph nodes may be more appropriate for LARC patients with nCRT. PLN and LNR may be prognostic factors for LARC patients with ypN+ after nCRT.
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Affiliation(s)
- Zhuangbin Lin
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,The Graduate School, Fujian Medical University, Fuzhou, China.,Department of Radiation Oncology, Fujian Branch of Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, Fuzhou, China.,Department of Radiation Oncology, Fujian Children's Hospital, Fuzhou, China
| | - Xiaobo Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China
| | - Jianyuan Song
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China
| | - Rong Zheng
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Cheng Chen
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China
| | - Anchuan Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Benhua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, China
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14
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Otmani IE, Effared B, Agy FE, Abkari ME, Mazaz K, Benjelloun EB, Ousadden A, Benbrahim Z, Bouhafa T, Chbani L. Lymph Nodes With Germinal Centers Are Not Associated With Tumor Response After Neoadjuvant Treatment in Locally Advanced Rectal Cancer. CLINICAL PATHOLOGY 2022; 15:2632010X221132974. [PMCID: PMC9629553 DOI: 10.1177/2632010x221132974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022]
Abstract
In patients with locally advanced rectal cancer, neoadjuvant radiotherapy or chemoradiotherapy followed by total mesorectal excision as a standard of care. We aimed to explore the number, size, germinal centers, extracapsular invasion of lymph nodes (LN), and their impact on overall survival and disease free survival. Furthermore we also investigated the characteristics of lymph nodes in patients who received neoadjuvant therapy and those who underwent surgery between 2011 and 2018. The count and measurement of lymph nodes was assessed by careful visual inspection and manual palpation. The predictive cut-off value of the lymph node ratio (LNR) was determined based on the receiver operating characteristic (ROC), method and the survival outcomes based on Kaplan-Meier curves. We found that the size and the number of lymph nodes decreased significantly after neoadjuvant treatment. The mean LN for patients who received neoadjuvant therapy was 12.68 ± 6.69 and for patients who did not receive neoadjuvant therapy was 16.29 ± 5.61 ( P = .012). The average size for patients who received neoadjuvant therapy followed by surgery was 3.30 ± 1.10 versus 4.22 ± 1.18 mm for control group (surgery only) ( P < .001), an LNR of 0.13 (sensitivity: 86%, specificity: 47%, AUC: 60%, 95% CI, 0.41%-0.76%) predicted recurrence and metastasis. Presence of lymph nodes with germinal centers was significantly associated with absence of vascular invasion, nodal tumor deposits, distant metastasis, and lower age group (<50 years). However there was no association seen between overall survival and relapse free, total number of lymph nodes enlarged and extracapsular invasion in positive nodes. Finally there is no association between lymph nodes with germinal centers and tumor response after neoadjuvant treatment in locally advanced rectal cancer.
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Affiliation(s)
- Ihsane El Otmani
- Laboratory of Biomedical and Translational Research, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
- Laboratory of Health Sciences and Technologies, Higher Institute of Health Sciences, Hassan First University of Settat, Settat, Morocco
| | - Boubacar Effared
- Laboratory of Anatomic Pathology and Molecular Pathology, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Fatima El Agy
- Laboratory of Biomedical and Translational Research, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
- Laboratory of Anatomic Pathology and Molecular Pathology, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Mohammed El Abkari
- Department of Gastroenterology, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Khalid Mazaz
- Department of General surgery, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - El Bachir Benjelloun
- Department of General surgery, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Abdelmalek Ousadden
- Department of General surgery, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Zineb Benbrahim
- Department of Medical Oncology, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Touria Bouhafa
- Department of Radiotherapy, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Laila Chbani
- Laboratory of Biomedical and Translational Research, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
- Laboratory of Anatomic Pathology and Molecular Pathology, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
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15
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Wu Q, Zhang Z, Chen Y, Chang J, Jiang Y, Zhu D, Wei Y. Impact of Inadequate Number of Lymph Nodes Examined on Survival in Stage II Colon Cancer. Front Oncol 2021; 11:736678. [PMID: 34616683 PMCID: PMC8489731 DOI: 10.3389/fonc.2021.736678] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/27/2021] [Indexed: 12/09/2022] Open
Abstract
Background Inadequate number of lymph nodes examined was not uncommon. We aimed to assess the clinical role of inadequate number of lymph nodes examined in stage II colon cancer. Methods The cancer data used in our study were obtained from the SEER (Surveillance, Epidemiology and End Results) program. Using the chi-square test, all the variables obtained in our study were compared based on whether patients had enough (≥12) lymph nodes examined. Kaplan–Meier analysis was used for overall survival (OS) analysis, and log-rank test was applied to compare different N stages with the total number of lymph nodes examined. Multivariate analysis was carried out by creating a Cox proportional hazard model to assess the prognostic roles of different variables. Results In total, 80,296 stage II/III colon cancer patients were recruited for our study. N0 stage with <8 lymph nodes examined would present with a worse prognosis compared to N1 stage (5-year OS rates, 51.6% vs. 57.1%, p < 0.001). Multivariate analyses indicated that OS of N0 stage with <8 lymph nodes examined was similar to that of N1 stage after adjusting for other recognized prognostic factors [hazard ratios (HRs) = 1.051, 95% confidence intervals (CIs) = 1.014–1.090, p = 0.018]. Conclusions N0 stage with less than eight lymph nodes examined in stage II colon cancer presented with no better OS compared to that of N1 stage. Stage II colon cancer with less than eight lymph nodes examined needed to be given greater emphasis in clinical practice.
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Affiliation(s)
- Qi Wu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiyuan Zhang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yijiao Chen
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiang Chang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yudong Jiang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dexiang Zhu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ye Wei
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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16
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Qiu L, Hu J, Weng Z, Liu S, Jiang G, Cai X. A prospective study of dual-energy computed tomography for differentiating metastatic and non-metastatic lymph nodes of colorectal cancer. Quant Imaging Med Surg 2021; 11:3448-3459. [PMID: 34341722 DOI: 10.21037/qims-20-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 04/28/2021] [Indexed: 11/06/2022]
Abstract
Background Colorectal cancer (CRC) is the third most common malignancy worldwide, and lymph node metastasis is considered to be a risk factor for local recurrence and a poor prognosis in colorectal cancer. However, there remains a lack of reliable and non-invasive biomarkers to identify the lymph node status of CRC patients preoperatively. The purpose of this study was to explore the ability of dual-energy computed tomography (DECT) to differentiate metastatic from non-metastatic lymph nodes in colorectal cancer. Methods Seventy-one patients with primary colorectal cancer underwent contrast-enhanced dual-energy computed tomography imaging preoperatively. The colorectal specimen was scanned postoperatively, and lymph nodes were matched to the pathology report. The following dual-energy computed tomography quantitative parameters were analyzed: dual-energy curve slope value (λHU), standardized iodine concentration (n△HU), iodine water ratio (nIWR), electron density value (nρeff), and effective atom-number (nZ), based on metastatic and non-metastatic lymph node differentiation. Also, sensitivity and specificity analyses were performed using receiver operating characteristic curves. Results In all patients, one hundred and fifty lymph nodes, including 66 non-metastatic and 84 metastatic lymph nodes, were matched using the radiological-pathological correlation. Metastatic nodes had significantly greater λHU, n△HU, and nIWR values than non-metastatic nodes in both the arterial and venous phases (P<0.01). The area under curve (AUC), sensitivity, and specificity were 0.80, 80%, and 66% for λHU; 0.86, 70%, and 95% for n△HU; and 0.88, 71%, and 95% for nIWR in the arterial phase. There was no significant difference in electron density and effective Z values between metastatic and non-metastatic lymph nodes. Conclusions DECT quantitative parameters may help differentiate between metastatic and normal lymph nodes in patients with CRC.
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Affiliation(s)
- Lin Qiu
- Medical Imaging Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Junjiao Hu
- Medical Imaging Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zeping Weng
- Pathology Department, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Sirun Liu
- Medical Imaging Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Guangyu Jiang
- Pathology Department, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiangran Cai
- Medical Imaging Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
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17
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Jonnada PK, Karunakaran M, Rao D. Outcomes of level of ligation of inferior mesenteric artery in colorectal cancer: a systematic review and meta-analysis. Future Oncol 2021; 17:3645-3661. [PMID: 34259582 DOI: 10.2217/fon-2021-0149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The level of ligation of the inferior mesenteric artery (IMA) is a critical factor that can influence outcomes. The aim of this meta-analysis was to compare outcomes following high or low ligation of IMA. A systematic search was performed for relevant articles published between 2000 and 2020. Meta-analysis was performed using fixed-effects or random-effects models; 31 studies were included. Results show significantly lower rates of anastomotic leak, postoperative morbidity and urinary dysfunction with low ligation compared with high ligation. Though recurrence rates were similar, 5-year overall survival was longer in the low ligation group. Low ligation of IMA decreases anastomotic leak rates and overall morbidity. Addition of IMA nodal clearance to low ligation appears to improve overall survival in colorectal cancer.
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Affiliation(s)
| | | | - Dayakar Rao
- Yashoda Cancer Institute, Hyderabad, Telangana, 500036, India
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18
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Zuhdy M, Metwally IH, Eldamshety O, Roshdy S. Operative Feasibility and Short-Term Oncologic Outcome of Rigid Versus Flexible Platforms in Transanal Total Mesorectal Excision. Indian J Surg Oncol 2021; 12:222-228. [PMID: 33814857 DOI: 10.1007/s13193-021-01282-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 01/27/2021] [Indexed: 10/22/2022] Open
Abstract
Several transanal platforms were used to perform transanal total mesorectal excision (TaTME). They can be classified into rigid reusable platforms or flexible single-use platforms. The choice of transanal platform usually depends on the availability and the surgeon's discretion. To the best of our knowledge, this is the first study to compare the operative and oncologic outcome of flexible and rigid platforms during TaTME. This is a retrospective cohort study in which rectal cancer patients operated by TaTME in two tertiary centers from June 2013 to April 2019 were included. They were classified into two groups according to the platform used either the rigid platform group (n = 17) or the flexible platform (n = 14). Operative feasibility and short-term oncologic data were analyzed and reported. A total number of 31 patients were divided into either the rigid platform group (n = 17) versus the flexible platform one (n = 14). Shorter operating time, less blood loss, better TME specimens, and lymph node yield were reported in the flexible platform group. Flexible platforms were associated with better operative outcomes. Although there were no differences in circumferential and distal margins between the two groups, better TME specimens' quality and lymph node yield were reported in the flexible platform group. Future prospective trials are encouraged to provide better evidence.
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Affiliation(s)
- Mohammad Zuhdy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt.,Department of Gastrointestinal Surgery, IRCCS San Raffaele, University Vita e Salute, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina, 60 20132 Milan, Italy
| | - Islam H Metwally
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt
| | - Osama Eldamshety
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt
| | - Sameh Roshdy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt
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19
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Tan L, Liu ZL, Ma Z, He Z, Tang LH, Liu YL, Xiao JW. Prognostic impact of at least 12 lymph nodes after neoadjuvant therapy in rectal cancer: A meta-analysis. World J Gastrointest Oncol 2020; 12:1443-1455. [PMID: 33362914 PMCID: PMC7739152 DOI: 10.4251/wjgo.v12.i12.1443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/28/2020] [Accepted: 10/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The number of dissected lymph nodes (LNs) in rectal cancer after neoadjuvant therapy has a controversial effect on the prognosis.
AIM To investigate the prognostic impact of the number of LN dissected in rectal cancer patients after neoadjuvant therapy.
METHODS We performed a systematic review and searched PubMed, Embase (Ovid), MEDLINE (Ovid), Web of Science, and Cochrane Library from January 1, 2000 until January 1, 2020. Two reviewers examined all the publications independently and extracted the relevant data. Articles were eligible for inclusion if they compared the number of LNs in rectal cancer specimens resected after neoadjuvant treatment (LNs ≥ 12 vs LNs < 12). The primary endpoints were the overall survival (OS) and disease-free survival (DFS).
RESULTS Nine articles were included in the meta-analyses. Statistical analysis revealed a statistically significant difference in OS [hazard ratio (HR) = 0.76, 95% confidence interval (CI): 0.66-0.88, I2 = 12.2%, P = 0.336], DFS (HR = 0.76, 95%CI: 0.63-0.92, I2 = 68.4%, P = 0.013), and distant recurrence (DR) (HR = 0.63, 95%CI: 0.48-0.93, I2 = 30.5%, P = 0.237) between the LNs ≥ 12 and LNs < 12 groups, but local recurrence (HR = 0.67, 95%CI: 0.38-1.16, I2 = 0%, P = 0.348) showed no statistical difference. Moreover, subgroup analysis of LN negative patients revealed a statistically significant difference in DFS (HR = 0.67, 95%CI: 0.52-0.88, I2 = 0%, P = 0.565) between the LNs ≥ 12 and LNs < 12 groups.
CONCLUSION Although neoadjuvant therapy reduces LN production in rectal cancer, our data indicate that dissecting at least 12 LNs after neoadjuvant therapy may improve the patients’ OS, DFS, and DR.
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Affiliation(s)
- Ling Tan
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Zi-Lin Liu
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Zhou Ma
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Zhou He
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Lin-Han Tang
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Yi-Lei Liu
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
| | - Jiang-Wei Xiao
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu 610500, Sichuan Province, China
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20
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Xi K, Yu H, Xi K. A retrospective study on the impact of the number of resected lymph nodes on the survival outcome of stage IV rectal cancer patients after preoperative therapy. J Gastrointest Oncol 2020; 11:870-879. [PMID: 33209483 DOI: 10.21037/jgo-20-175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background There is no consensus on the optimal number of examined LNs for stage IV rectal cancer patients after preoperative therapy. We aimed to explore the impact of the number of resected lymph nodes (LNs) on the survival outcomes of stage IV rectal cancer patients after preoperative therapy. Methods Clinicopathologic data of 556 patients diagnosed with stage IV rectal cancer between 1st January, 2010 and 31st December, 2015 from the Surveillance, Epidemiology, and End Results (SEER) database after preoperative therapy were reviewed. The patients were further divided into two groups: the ≥15 resected LNs group and <15 resected LNs group based on the X-tile software analysis results of the number of resected LNs. Results Both univariate and multivariate regression analyses revealed that the number of resected LNs and N status were significantly positively correlated with the survival outcome of the patients. Patients in the ≥15 resected LNs group had a significant better cancer-specific survival (CSS) (P=0.003) than those in the <15 resected LNs group. The 3-year CSS rate was 63.2% for patients with ≥15 resected LNs compared with 55.7% for those with <15 resected LNs. The 5-year CSS rate was 50.2% and 30.5% for patients in the ≥15 resected LNs group and those in the <15 resected LNs group, respectively. Conclusions The number of resected LNs is an important independent prognostic factor that influences the survival outcome of stage IV rectal cancer patients after receiving preoperative therapy.
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Affiliation(s)
- Kexiang Xi
- Department of Obstetrics, Jieyang People's Hospital, Jieyang, China
| | - Hui Yu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Kexing Xi
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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21
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Schlick CJR, Khorfan R, Odell DD, Merkow RP, Bentrem DJ. Adequate Lymphadenectomy as a Quality Measure in Esophageal Cancer: Is there an Association with Treatment Approach? Ann Surg Oncol 2020; 27:4443-4456. [PMID: 32519142 PMCID: PMC7282211 DOI: 10.1245/s10434-020-08578-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The national comprehensive cancer network defines adequate lymphadenectomy as evaluation of ≥ 15 lymph nodes in esophageal cancer. However, varying thresholds have been suggested following neoadjuvant therapy. OBJECTIVES Our objectives were to (1) explore trends in adequate lymphadenectomy rates over time; (2) evaluate unadjusted lymphadenectomy yield by treatment characteristics; and (3) identify independent factors associated with adequate lymphadenectomy. METHODS The National Cancer Data Base was used to identify patients who underwent esophagectomy for cancer from 2004 to 2015. Adequate lymphadenectomy trends over time were evaluated using the Cochrane-Armitage test, and lymph node yield by treatment approach was compared using the Mann-Whitney U and Kruskal-Wallis tests. Associations with treatment factors were assessed by multivariable logistic regression. RESULTS Among 24,413 patients, 9919 (40.6%) had adequate lymphadenectomy. Meeting the nodal threshold increased over time (52.6% in 2015 vs. 26.0% in 2004; p < 0.01). Lymph node yield did not differ based on neoadjuvant therapy (median 12 [interquartile range 7-19] with and without neoadjuvant therapy; p = 0.44). Adequate lymphadenectomy was not associated with neoadjuvant therapy (40.5% vs. 40.8%, odds ratio [OR] 0.94, 95% confidence interval [CI] 0.82-1.07), but was associated with surgical approach (52.7% of laparoscopic cases, OR 1.28, 95% CI 1.06-1.56; 61.2% of robotic cases, OR 1.71, 95% CI 1.34-2.19, vs. 43.5% of open cases), and increasing annual esophagectomy volume (55.6% in the fourth quartile vs. 32.6% in the first quartile; OR 3.57, 95% CI 2.35-5.43). CONCLUSIONS Despite increases over time, only 50% of patients undergo adequate lymphadenectomy during esophageal cancer resection. Adequate lymphadenectomy was not associated with neoadjuvant therapy. Focusing on surgical approach and esophagectomy volume may further improve adequate lymphadenectomy rates.
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Affiliation(s)
- Cary Jo R Schlick
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St. Clair St, Chicago, IL, 60611, USA
| | - Rhami Khorfan
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St. Clair St, Chicago, IL, 60611, USA
| | - David D Odell
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St. Clair St, Chicago, IL, 60611, USA
| | - Ryan P Merkow
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St. Clair St, Chicago, IL, 60611, USA
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - David J Bentrem
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St. Clair St, Chicago, IL, 60611, USA.
- Surgical Service, Jesse Brown VA Medical Center, Chicago, IL, USA.
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22
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Song J, Chen Z, Huang D, Wu Y, Lin Z, Chi P, Xu B. Nomogram Predicting Overall Survival of Resected Locally Advanced Rectal Cancer Patients with Neoadjuvant Chemoradiotherapy. Cancer Manag Res 2020; 12:7375-7382. [PMID: 32884350 PMCID: PMC7443447 DOI: 10.2147/cmar.s255981] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/10/2020] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The overall survival (OS) of resected locally advanced rectal cancer patients who underwent neoadjuvant chemoradiotherapy (nCRT) was significantly different, even among patients with the same tumor stage. The nomogram was designed to predict OS of rectal cancer with nCRT and divide the patients into different risk groups. MATERIALS AND METHODS Based on materials from 911 rectal cancer patients with nCRT, the multivariable Cox regression model was carried out to select the significant prognostic factors for overall survival. And then, the nomogram was formulated using these independent prognostic factors. The discrimination of the nomogram was assessed by concordance index (C-index), calibration curves and time-dependent area under curve (AUC). The patients respective risk scores were calculated through the nomogram. The best cut-off risk score was calculated to stratify the patients. The survival curves of the two different risk cohorts were performed, which assessed the predictive ability of the nomogram. RESULTS Age, cT stage, pretreatment CEA, pretreatment CA19-9, surgery, posttreatment CEA, posttreatment CA19-9, pT stage, pN stage and adjuvant chemotherapy were selected for the construction of the nomogram. And then the nomogram was constructed with independent prognostic factors. The C-index of the nomogram was 0.724, which showed the nomogram provided good discernment. The acceptable agreement between the predictions of nomogram and actual observations was illustrated by calibration plots for 3-, 5- and 10-year OS in the cohort. Time-dependent AUC with 6-fold cross-validation also showed consistent results of the nomogram. Risk group stratification confirmed that the nomogram had great capacity for distinguishing the prognosis. CONCLUSION The nomogram was developed and validated to predict overall survival of resected locally advanced rectal cancer patients with nCRT. The proposed nomogram might help clinicians to develop individualized treatment strategies. However, further studies are warranted to optimize the nomogram by finding out other unknown prognostic factors, and more external validation is still required.
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Affiliation(s)
- Jianyuan Song
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
- Department of Oncology, Fujian Medical University Union Clinical Medicine College, Fuzhou, Fujian Province, People's Republic of China
- Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Zhuhong Chen
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
| | - Daxin Huang
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
| | - Yimin Wu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
| | - Zhuangbin Lin
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
- Department of Oncology, Fujian Medical University Union Clinical Medicine College, Fuzhou, Fujian Province, People's Republic of China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
| | - Benhua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
- Department of Oncology, Fujian Medical University Union Clinical Medicine College, Fuzhou, Fujian Province, People's Republic of China
- Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
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23
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Kılıç D, Sert F, Görken İB, Arıcan Alıcıkuş Z, Aktürk N, Kaytan Sağlam E, Kizir A, Özkök S, Yılmaz HT, Göçen F, Yalman D. Prognostic significance of early complete response in patients with locally advanced rectal cancer undergoing preoperative chemoradiotherapy: Multicentric study of Turkish Society for Radiation Oncology Group (TROD). TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:368-377. [PMID: 32519956 DOI: 10.5152/tjg.2020.19225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS To assess the effect of various parameters on the oncologic outcomes, including the time interval between therapy and surgery (S) in locally advanced rectal cancer (LARC) patients receiving preoperative chemoradiotherapy (CRT). MATERIALS AND METHODS The data of 914 LARC patients who received preoperative CRT between 1994 and 2015 were collected retrospectively. Patients received 45-50.4 Gy RT with 5FU based chemotherapy (CT). They all underwent radical resection followed by maintenance CT. Clinical and pathologic variables were compared between the pCR and no-pCR groups. Survival was estimated by the Kaplan-Meier method and Cox proportional hazard model was used in multivariate analysis. RESULTS After median follow-up of 60.5 (range=12-297.6) months, median overall survival (OS) was 58.75 months and disease-free survival (DFS) 53.32 months. pCR was observed in 18.9% of all cases. pCR, lymphovascular invasion and metastatic lymph node ratio (mLNR) were significantly associated with OS and DFS on multivariate analysis. The 5-year OS and DFS rates were better in pCR group (95.3% vs 80.7% for OS, p<0.0001 and 87.4% vs 71% for DFS, p<0.0001). pCR patients with 4-8 weeks interval had lower rates of distant metastasis (9% vs 20%, p=0.01) and any recurrences (13.6% vs 29.6%, p=0.001) than the remaining. Both OS and DFS were better in favor of pCR achieved at 4-8 week interval time (p<0.0001 for each). CONCLUSION pCR after preoperative CRT in LARC correlated with better oncologic outcome. The best OS and DFS durations were achieved in patients who experienced pCR after 4-8-weeks interval before surgery.
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Affiliation(s)
- Diclehan Kılıç
- Department of Radiation Oncology, Gazi University School of Medicine, Ankara, Turkey
| | - Fatma Sert
- Department of Radiation Oncology, Ege University Institute of Oncology, İzmir, Turkey
| | - İlknur Bilkay Görken
- Department of Radiation Oncology, Dokuz Eylul University School of Medicine, İzmir, Turkey
| | - Zümre Arıcan Alıcıkuş
- Department of Radiation Oncology, Dokuz Eylul University School of Medicine, İzmir, Turkey
| | - Nesrin Aktürk
- Department of Radiation Oncology, Dokuz Eylul University School of Medicine, İzmir, Turkey
| | - Esra Kaytan Sağlam
- Department of Radiation Oncology, İstanbul University Institute of Oncology, İstanbul, Turkey
| | - Ahmet Kizir
- Department of Radiation Oncology, İstanbul University Institute of Oncology, İstanbul, Turkey
| | - Serdar Özkök
- Department of Radiation Oncology, Ege University Institute of Oncology, İzmir, Turkey
| | | | - Füsun Göçen
- Department of Radiation Oncology, Onkomer Oncology Center, İzmir, Turkey
| | - Deniz Yalman
- Department of Radiation Oncology, Ege University Institute of Oncology, İzmir, Turkey
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24
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Yu Y, Sultana R, Rangabashyam MS, Mohan N, Hwang JSG, Soong YL, Tan NC, Iyer GN, Tan HK. Impact of Radiotherapy on Neck Dissection Nodal Count in Patients With Head and Neck Cancer. Laryngoscope 2020; 130:1947-1953. [PMID: 32401396 DOI: 10.1002/lary.28620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 02/05/2020] [Accepted: 02/25/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES/HYPOTHESIS Our study aimed to review the impact of preoperative radiotherapy (RT) and other factors on the lymph node count of neck dissection (ND) specimens from patients with head and neck cancer (HNC). A retrospective study was conducted on all patients with head and neck cancers who had undergone NDs in Singapore General Hospital between 1992 and 2013. STUDY DESIGN Retrospective study. METHODS Patients were categorized into two groups: patients treated with RT with or without chemotherapy before ND and patients who had undergone ND surgery without previous history of RT. The primary endpoint for this study would be the lymph node count from ND. RESULTS The study cohort consists of 1,024 NDs on 829 patients. There were 597 (58.3%) radical/modified radical NDs involving levels I-V. Within this group, 75 (12.6%) NDs had preoperative RT. Preoperative RT and age were found to significantly reduce nodal yield in both univariate and multivariate analysis in the radical/modified radical ND subgroup. In our multivariate analysis, preoperative RT was shown to decrease the nodal yield by 7.464 (P = .0002, 95% confidence interval [CI]: -11.35 to -3.58). Advanced age independently decreases nodal yield, even after accounting for the effect of RT (P = .0002, 95% CI: -0.27 to -0.08). In addition, preoperative RT has a more pronounced effect in reducing lymph node count in the older age group. CONCLUSIONS Preoperative RT and advanced age are independent and synergistic factors that reduce nodal count from NDs in patients with head and neck cancers. LEVEL OF EVIDENCE 4 Laryngoscope, 130: 1947-1953, 2020.
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Affiliation(s)
- Yue Yu
- Division of Surgery and Surgical Oncology, Singapore General Hospital and National Cancer Centre, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Mahalakshmi S Rangabashyam
- Division of Surgery and Surgical Oncology, Singapore General Hospital and National Cancer Centre, Singapore.,SingHealth Duke-NUS Head and Neck Centre, Singapore
| | - Niraj Mohan
- Division of Surgery and Surgical Oncology, Singapore General Hospital and National Cancer Centre, Singapore
| | | | - Yoke-Lim Soong
- SingHealth Duke-NUS Head and Neck Centre, Singapore.,Division of Radiation Oncology, National Cancer Centre, Singapore
| | - Ngian-Chye Tan
- Division of Surgery and Surgical Oncology, Singapore General Hospital and National Cancer Centre, Singapore.,SingHealth Duke-NUS Head and Neck Centre, Singapore.,Duke-NUS Medical School, Singapore
| | - Gopalakrishna N Iyer
- Division of Surgery and Surgical Oncology, Singapore General Hospital and National Cancer Centre, Singapore.,SingHealth Duke-NUS Head and Neck Centre, Singapore.,Duke-NUS Medical School, Singapore
| | - Hiang-Khoon Tan
- Division of Surgery and Surgical Oncology, Singapore General Hospital and National Cancer Centre, Singapore.,SingHealth Duke-NUS Head and Neck Centre, Singapore.,Duke-NUS Medical School, Singapore
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25
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Yeo CS, Syn N, Liu H, Fong SS. A lower cut-off for lymph node harvest predicts for poorer overall survival after rectal surgery post neoadjuvant chemoradiotherapy. World J Surg Oncol 2020; 18:58. [PMID: 32197615 PMCID: PMC7085151 DOI: 10.1186/s12957-020-01833-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/09/2020] [Indexed: 01/02/2023] Open
Abstract
Background A lymph node harvest (LNH) of < 12 is a predictor for poor prognosis in rectal cancer patients. However, neoadjuvant chemoradiotherapy (NACRT) is known to decrease LNH; hence, a cut-off of 12 is inappropriate in such patients. This paper aims to establish a LNH cut-off predictive for disease-free and overall survival in NACRT patients. Methods A retrospective review of patients who underwent elective surgery for rectal cancer from 2006 to 2013 was performed. All patients with R1/2 resections and presence of metastases and those operated on for recurrence were excluded. Patient demographics, clinical features, operative details, LNH, 30-day mortality and disease-free and overall survival were recorded. P values of < 0.05 were considered significant. Results A total of 257 patients were studied, with 174 (68%) males and a median age of 66 years. Ninety-four (37%) patients received long-course NACRT, and 122 (48%) patients were stage 2 and below. Median LNH was 17, which was reduced in the NACRT group (14 versus 23, P < 0.01). Average length of stay was 9 ± 8 days, with a major post-operative complication rate of 4%. Using hazard ratio plots for the NACRT subgroup, LNH cut-offs of 16.5 and 8.5 were obtained for disease-free survival (DFS) and overall survival (OS) respectively. Survival analysis showed that a LNH cut-off of 8.5 was a significant predictor of OS (P < 0.001). Conclusion LNH is reduced in patients receiving NACRT before rectal cancer surgery. A LNH of 9 and above is associated with improved overall survival. We propose that this can be used as a tool for prognosis.
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Affiliation(s)
- Charleen Shanwen Yeo
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Huimin Liu
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Sau Shung Fong
- Raffles Surgery Centre, Raffles Hospital, Singapore, Singapore
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26
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Lee JM, Yang SY, Han YD, Cho MS, Hur H, Min BS, Lee KY, Kim NK. Can better surgical outcomes be obtained in the learning process of robotic rectal cancer surgery? A propensity score-matched comparison between learning phases. Surg Endosc 2020; 35:770-778. [PMID: 32055993 DOI: 10.1007/s00464-020-07445-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/10/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although studies of robotic rectal cancer surgery have demonstrated the effects of learning on operation time, comparisons have failed to demonstrate differences in clinicopathological outcomes between unadjusted learning phases. This study aimed to investigate the learning curve of robotic rectal cancer surgery for clinicopathological outcomes and compare surgical outcomes between adjusted learning phases. Study design We enrolled 506 consecutive patients with rectal adenocarcinoma who underwent robotic resection by a single surgeon between 2007 and 2018. Risk-adjusted cumulative sum (RA-CUSUM) for surgical failure was used to analyze the learning curve. Surgical failure was defined as the occurrence of any of the following: conversion to open surgery, severe complications (Clavien-Dindo grade ≥ 3a), insufficient number of harvested lymph nodes (LNs), or R1 resection. Comparisons between learning phases analyzed by RA-CUSUM were performed before and after propensity score matching. RESULTS In RA-CUSUM analysis, the learning curve was divided into two learning phases: phase 1 (1st-177th cases, n = 177) and phase 2 (178th-506th cases, n = 329). Before matching, patients in phase 2 had deeper tumor invasion and higher rates of positive LNs on pretreatment images and preoperative chemoradiotherapy. After matching, phase 1 (n = 150) and phase 2 (n = 150) patients exhibited similar clinical characteristics. Phase 2 patients had lower rates of surgical failure overall and these components: conversion to open surgery, severe complications, and insufficient harvested LNs. CONCLUSIONS For robotic rectal cancer surgery, surgical outcomes improved after the 177th case. Further studies by other robotic surgeons are required to validate our results.
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Affiliation(s)
- Jong Min Lee
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Seung Yoon Yang
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Yoon Dae Han
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Min Soo Cho
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Hyuk Hur
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Byung Soh Min
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Kang Young Lee
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Nam Kyu Kim
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea.
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27
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Choi JH, Kim JH, Lee DH, Byun S, Jung K, Kim SE, Moon W, Park MI, Park SJ. The clinical significance of simple endoscopic scoring of patients with rectal cancer after concurrent chemoradiotherapy. J Gastrointest Oncol 2019; 10:1073-1079. [PMID: 31949924 PMCID: PMC6955009 DOI: 10.21037/jgo.2019.08.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/08/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Neoadjuvant concurrent chemoradiotherapy (CCRT) is an effective treatment option for patients with rectal cancer. In this study, we investigated the clinical efficacy of simple endoscopic scoring of patients with rectal cancer after CCRT. METHODS Between July 2008 and October 2015, medical records including endoscopic imaging from 41 patients with rectal cancer who received CCRT were retrospectively reviewed. Two expert gastroenterologists reviewed the endoscopic images and assigned scores from 0-3 according to post-CCRT findings. The scoring criteria were as follows: 0= scar without marginal elevation; 1= clean-based ulcer without marginal elevation; 2= clean-based ulcer with marginal elevation; 3= non-clean-based ulcer. We evaluated image scores to predict long-term outcomes using Kaplan-Meier curves and Cox regression models. RESULTS The median follow-up duration was 55 months (interquartile range: 35-76 months). Patients with a low score (≤2) had a 17.2% recurrence rate, whereas patients with a high score [3] had a 50.0% recurrence rate. Patients with a low score had longer disease-free survival (DFS) than those with a high score in log-rank test (P=0.026). In multivariate Cox regression analysis, a high score was a significant predictor of poor DFS in patients with rectal cancer after CCRT treatment (hazard ratio =4.89, 95% confidence interval: 1.11-21.50, P=0.036). CONCLUSIONS This simple endoscopic scoring approach is helpful for predicting prognosis of patients with rectal cancer after treatment with CCRT.
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Affiliation(s)
- Ji Hun Choi
- Department of Gastroenterology, Kosin University College of Medicine, Busan, Korea
| | - Jae Hyun Kim
- Department of Gastroenterology, Kosin University College of Medicine, Busan, Korea
| | - Do Hyeong Lee
- Department of Gastroenterology, Kosin University College of Medicine, Busan, Korea
| | - Sanghwan Byun
- Department of Gastroenterology, Kosin University College of Medicine, Busan, Korea
| | - Kyoungwon Jung
- Department of Gastroenterology, Kosin University College of Medicine, Busan, Korea
| | - Sung Eun Kim
- Department of Gastroenterology, Kosin University College of Medicine, Busan, Korea
| | - Won Moon
- Department of Gastroenterology, Kosin University College of Medicine, Busan, Korea
| | - Moo In Park
- Department of Gastroenterology, Kosin University College of Medicine, Busan, Korea
| | - Seun Ja Park
- Department of Gastroenterology, Kosin University College of Medicine, Busan, Korea
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28
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Prognostic Implication of Metastatic Lymph Node Ratio in Colorectal Cancers: Comparison Depending on Tumor Location. J Clin Med 2019; 8:jcm8111812. [PMID: 31683773 PMCID: PMC6912301 DOI: 10.3390/jcm8111812] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/13/2019] [Accepted: 10/26/2019] [Indexed: 12/11/2022] Open
Abstract
Background: The proportion of the number of involved lymph nodes (LNs) to the number of examined LNs—defined as metastatic LN ratio (mLNR)—has been considered as a prognostic parameter. This study aims to elucidate the prognostic implication of the mLNR in colorectal cancer (CRC) according to the tumor location. Methods: We evaluated the correlation between prognoses and the involved and examined LNs as well as mLNR according to the tumor location in 266 surgically resected human CRCs. Besides, to evaluate the optimal cutoff for high and low mLNRs, we investigated the correlation between mLNR and survival according to the various cutoffs. Results: LN metastasis was found in 146 cases (54.9%), and colon and rectal cancers were found in 116 (79.5%) and 30 (20.5%) of the cases, respectively. The mean mLNRs were significantly higher in rectal cancer than in colon cancer (0.38 ± 0.28 vs. 0.21 ± 0.24, P = 0.003). Besides this, the number of involved LNs in rectal cancer was significantly high compared to colon cancer (11.83 ± 10.92 vs. 6.37 ± 7.78, P = 0.014). However, there was no significant difference in the examined LNs between the rectal and colon cancers (31.90 ± 12.28 vs. 36.60 ± 18.11, P = 0.181). In colon cancer, a high mLNR was significantly correlated with worse survival for all cutoffs (0.1, 0.2, 0.3, and 0.4). However, rectal cancer only showed a significant correlation between high mLNR and worse survival in the subgroup with a cutoff of 0.2. Conclusions: Our results showed that high mLNR was significantly correlated with worse survival. The number of involved LNs and mLNRs were significantly higher in rectal cancer than in colon cancer. The cutoff of 0.2 can be useful for the differentiation of prognostic groups, regardless of tumor location.
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Hill SS, Chung SK, Meyer DC, Crawford AS, Sturrock PR, Harnsberger CR, Davids JS, Maykel JA, Alavi K. Impact of Preoperative Care for Rectal Adenocarcinoma on Pathologic Specimen Quality and Postoperative Morbidity: A NSQIP Analysis. J Am Coll Surg 2019; 230:17-25. [PMID: 31672638 DOI: 10.1016/j.jamcollsurg.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/18/2019] [Accepted: 09/16/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Comprehensive and multidisciplinary care are critical in rectal cancer treatment. We sought to determine if completeness of preoperative care was associated with pathologic specimen quality and postoperative morbidity. STUDY DESIGN Clinical stage I-III rectal adenocarcinoma patients who underwent elective low anterior resection or abdominoperineal resection were identified from the 2016-2017 American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database. The 3 preoperative NSQIP variables (colonoscopy, stoma marking, and neoadjuvant chemoradiation) were used to divide patients into 2 cohorts: complete vs incomplete preoperative care. The primary outcome was a composite higher pathologic specimen quality score (>12 lymph nodes, negative circumferential, and negative distal margins). The secondary outcome was 30-day morbidity. Preoperative characteristics were compared with ANOVAs and chi-square tests. Outcomes measures were evaluated with logistic regression. RESULTS We identified 1,125 patients: 591 (52.5%) complete and 534 (47.5%) incomplete. The complete group was younger, had more women, lower-third rectal tumors, clinical stage III disease, and neoadjuvant treatment. The complete group had higher odds of better pathologic specimen quality after adjusting for age, sex, tumor location, stage, and neoadjuvant therapy (adjusted odds ratio [aOR] 1.75, p = 0.001). The complete group had decreased rates of transfusions (odds ratio [OR] 0.47, p < 0.001), postoperative ileus (OR 0.67, p = 0.01), sepsis (OR 0.32, p = 0.01), and readmissions (OR 0.60, p = 0.003). Other complications did not statistically differ between groups. CONCLUSIONS Complete preoperative care in rectal adenocarcinoma is associated with higher pathologic specimen quality and reduced postoperative morbidity. This highlights the importance of adherence to guideline-directed care.
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Affiliation(s)
- Susanna S Hill
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Sebastian K Chung
- Division of General Surgery, University of Massachusetts Medical School, Worcester, MA
| | - David C Meyer
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Allison S Crawford
- Division of General Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Paul R Sturrock
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Cristina R Harnsberger
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Jennifer S Davids
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Justin A Maykel
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA.
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Chen N, Sun TT, Li ZW, Yao YF, Wang L, Wu AW. Fat clearance and conventional fixation identified ypN0 rectal cancers following intermediate neoadjuvant radiotherapy have similar long-term outcomes. World J Gastrointest Oncol 2019; 11:877-886. [PMID: 31662826 PMCID: PMC6815923 DOI: 10.4251/wjgo.v11.i10.877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 07/23/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND As a prognostic factor for colorectal cancer, lymph node (LN) status, particularly the number of LN harvested, has been demonstrated to be essential in the evaluation of quality control in terms of surgical specimen. Neoadjuvant chemoradiation, however, decreases the LN harvest. Therefore, certain approaches (such as fat clearance or methylene blue) has drawn significant attention in order to raise LN yield. AIM To compare the long-term oncologic outcome of ypN0 rectal cancer identified using fat clearance (FC) or conventional fixation (CF) following 30 Gy in 10 fractions (30 Gy/10f) of neoadjuvant radiotherapy (nRT). METHODS Three hundred and eighty-two patients with resectable and locally advanced rectal cancer were treated by 30 Gy/10f intermediate nRT (biologically equivalent dose of 36 Gy) plus total mesorectal excision. Two specimen fixation methods (FC or CF) were non-randomly used. The ypN0 status was identified in 124 and 101 patients in the FL and CF groups, respectively. Primary endpoints were local recurrence-free survival (LRFS) and cancer-specific survival (CSS). RESULTS The median follow-up of patients was 5.1 years. The median numbers of retrieved LNs in the FC and CF groups were 19.5 (range, 4-47) and 12 (range, 0-44), respectively, with a significant difference (P = 0.000). The percentages of patients with 12 or more retrieved nodes were 82.3% and 50.5% (101/159) in the FC and CF groups, respectively, with a significant difference (P = 0.000). The LRFS at 5 years were 95.7% and 94.6% in the FC and CF groups, respectively, without statistical difference (P = 0.819). The CSS at 5 years were 92.0% and 87.2% in the FC and CF groups, respectively, without statistical difference (P = 0.482). CONCLUSION For patients with ypN0 rectal cancer who underwent 30 Gy/10f preoperative radiotherapy, the increased retrieval of LNs using fat clearance is not associated with survival benefit. This time-consuming fixation method has a low efficacy as a routine practice.
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Affiliation(s)
- Nan Chen
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing 100142, China
| | - Ting-Ting Sun
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing 100142, China
| | - Zhong-Wu Li
- Department of Pathology, Peking University Cancer Hospital, Beijing 100142, China
| | - Yun-Feng Yao
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing 100142, China
| | - Lin Wang
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing 100142, China
| | - Ai-Wen Wu
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing 100142, China
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Wang Y, Zhou M, Yang J, Sun X, Zou W, Zhang Z, Zhang J, Shen L, Yang L, Zhang Z. Increased lymph node yield indicates improved survival in locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. Cancer Med 2019; 8:4615-4625. [PMID: 31250569 PMCID: PMC6712464 DOI: 10.1002/cam4.2372] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/22/2019] [Accepted: 06/12/2019] [Indexed: 12/17/2022] Open
Abstract
PURPOSE It is recommended for colorectal cancer to harvest at least 12 lymph nodes (LNs) during surgery to avoid understaging of the disease. However, it is still controversial whether it is necessary to harvest from locally advanced rectal cancer (LARC) patients who underwent neoadjuvant chemoradiotherapy (neo-CRT). The impact of lymph node yield (LNY) on prognosis in LARC patients was analyzed. MATERIALS/METHODS In total, 495 LARC patients who underwent neo-CRT in 2006-2015 were analyzed. After examining clinicopathological distribution differences between the LNY subgroups (with the threshold of 12), univariate and multivariate Cox survival analyses were performed. Survival plots were obtained from Kaplan-Meier analyses. Similar subgroup analyses were performed according to the tumor regression grade (TRG) and metastatic status of post-operational LNs. RESULTS Of the 495 patients, 287 (57.98%) had an LNY of less than 12. Nearly no significant clinicopathological difference was found between the LNY subgroups, including the TRG scores. Multivariate survival analysis demonstrated that at least 12 LNs examined was an independent prognostic feature of good overall survival (OS), disease-free survival (DFS), and distant metastasis free survival (DMFS), but not local recurrence free survival (LRFS). However, in the subgroup analyses, no association was found between LNY and prognosis in patients with good TRG scores (0-1) or negative LNs. CONCLUSIONS For LARC patients treated with neo-CRT, an LNY of at least 12 indicated an improved survival. Decreased LNY was not related to better tumor regression. It suggests that a sufficiently high LNY is still required, especially in those with a potentially poor tumor response.
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Affiliation(s)
- Yaqi Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Menglong Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Jianing Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Xiaoyang Sun
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Wei Zou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Zhiyuan Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Jing Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Lijun Shen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Lifeng Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
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Tiselius C, Kindler C, Rosenblad A, Smedh K. Localization of mesenteric lymph node metastases in relation to the level of arterial ligation in rectal cancer surgery. Eur J Surg Oncol 2019; 45:989-994. [DOI: 10.1016/j.ejso.2019.01.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/25/2019] [Indexed: 01/13/2023] Open
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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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Lee CHA, Wilkins S, Oliva K, Staples MP, McMurrick PJ. Role of lymph node yield and lymph node ratio in predicting outcomes in non-metastatic colorectal cancer. BJS Open 2018; 3:95-105. [PMID: 30734020 PMCID: PMC6354193 DOI: 10.1002/bjs5.96] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/02/2018] [Indexed: 02/06/2023] Open
Abstract
Background Lymph node yield (LNY) of 12 or more in resection of colorectal cancer is recommended in current international guidelines. Although a low LNY (less than 12) is associated with poorer outcome in some studies, its prognostic value is unclear in patients with early‐stage colorectal or rectal cancer with a complete pathological response following neoadjuvant therapy. Lymph node ratio (LNR), which reflects the proportion of positive to total nodes obtained, may be more accurate in predicting outcome in stage III colorectal cancer. This study aimed to identify factors correlating with LNY and evaluate the prognostic role of LNY and LNR in colorectal cancer. Methods An observational study was performed on patients with colorectal cancer treated at three hospitals in Melbourne, Australia, from January 2010 to March 2016. Association of LNY and LNR with clinical variables was analysed using linear regression. Disease‐free (DFS) and overall (OS) survival were investigated with Cox regression and Kaplan–Meier survival analyses. Results Some 1585 resections were analysed. Median follow‐up was 27·1 (range 0·1–71) months. Median LNY was 16 (range 0–86), and was lower for rectal cancers, decreased with increasing age, and increased with increasing stage. High LNY (12 or more) was associated with better DFS in colorectal cancer. Subgroup analysis indicated that low LNY was associated with poorer DFS and OS in stage III colonic cancer, but had no effect on DFS and OS in rectal cancer (stages I–III). Higher LNR was predictive of poorer DFS and OS. Conclusion Low LNY (less than 12) was predictive of poor DFS in stage III colonic cancer, but was not a factor for stage I or II colonic disease or any rectal cancer. LNR was a predictive factor in DFS and OS in stage III colonic cancer, but influenced DFS only in rectal cancer.
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Affiliation(s)
- C H A Lee
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia
| | - S Wilkins
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
| | - K Oliva
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia
| | - M P Staples
- Cabrini Institute Cabrini Hospital Malvern Victoria Australia
| | - P J McMurrick
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia
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Abstract
Tumor stage, as determined by the Tumor, Node, Metastasis (TNM) staging system, is the single most influential factor determining treatment decisions and outcome among patients with colorectal cancer. Several stage-related elements in pathology reports consistently pose diagnostic challenges: recognition of serosal penetration by tumor (ie, pT3 vs pT4a), evaluation of regional lymph nodes, distinction between tumor deposits and effaced lymph nodes, and assessment of tumor stage in the neoadjuvant setting. This article discusses each of these issues in detail and provides practical tips regarding colorectal cancer staging.
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Affiliation(s)
- Rhonda K Yantiss
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA.
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Okuyama T, Sameshima S, Takeshita E, Yoshioka R, Yamagata Y, Ono Y, Tagaya N, Noie T, Oya M. Therapeutic effects of oxaliplatin-based neoadjuvant chemotherapy and chemoradiotherapy in patients with locally advanced rectal cancer: a single-center, retrospective cohort study. World J Surg Oncol 2018; 16:105. [PMID: 29871650 PMCID: PMC5989356 DOI: 10.1186/s12957-018-1403-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 05/22/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (NACRT) has now become the standard treatment for locally advanced rectal cancer (LARC). NACRT has decreased local relapse (LR) rate in patients with LARC; however, distant relapse has recently attracted much attention. This study aimed to assess the feasibility and efficiency of neoadjuvant chemotherapy (NAC) for LARC. METHODS Data on patients with cT3/4 and N+ rectal cancer who were treated in our institution from April 2010 to February 2016 were reviewed retrospectively. Twenty-seven patients who received 2-9 cycles of oxaliplatin-based NAC and 28 patients who received NACRT (45 Gy delivered in 25 fractions and 5-fluorouracil-based oral chemotherapy) were analyzed. The primary and secondary endpoints of the present study were the 3-year relapse-free survival (RFS) and the local and distant relapse rates, respectively. RESULTS Regardless of the kind of neoadjuvant therapy, no patient experienced any grade 3-4 therapy-related adverse events. The frequent toxic events were grade 1 diarrhea in patients with NACRT and neutropenia in patients with NAC. A significantly higher proportion of patients with NAC underwent laparoscopic surgery and anterior resection (p = 0.037 and p = 0.003, respectively). The percentages of patients with lymph node yield less than 12 in the NAC group, and those in the NACRT group were 26 and 68%, respectively (p = 0.002). Comparing the NAC with the NACRT groups, the local relapse and distant relapse rates were 7.4 and 7.1% and 7.4 and 18%, respectively. There were no significant differences in 3-year RFS and 4-year overall survival (OS) between NAC and NACRT (3-year RFS 85.2 vs. 70.4%, p = 0.279; 4-year OS 96.3 vs. 89.1%, p = 0.145, respectively). With an analysis excluding patients who received postoperative adjuvant chemotherapy, no patients who received NAC had a distant relapse, and there was a significant difference in 3-year RFS compared with the NACRT groups (94.4 vs. 63.2%, p = 0.043). CONCLUSION These outcomes suggest that the therapeutic effect of oxaliplatin-based NAC is at least equal to that of NACRT and that NAC is a feasible and promising option for LARC.
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Affiliation(s)
- Takashi Okuyama
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Shinichi Sameshima
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Emiko Takeshita
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Ryuji Yoshioka
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Yukinori Yamagata
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Yuko Ono
- Department of Pathology, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Nobumi Tagaya
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Tamaki Noie
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Masatoshi Oya
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
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Ng SK, Lu CT, Pakneshan S, Leung M, Siu S, Lam AKY. Harvest of lymph nodes in colorectal cancer depends on demographic and clinical characteristics of the patients. Int J Colorectal Dis 2018; 33:19-22. [PMID: 29134274 DOI: 10.1007/s00384-017-2927-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to study the impact of clinical factors on the lymph node sampling in a large cohort of patients with colorectal cancer. METHODS A colorectal cancer database of 2298 patients in Queensland, Australia, was established. Zero-inflated regression method was used to model positive lymph node counts given the number of lymph nodes examined, with patient's demographic and clinical factors as covariates in the model. Sensitivity and survival analyses were performed to illustrate the applicability of the recommendation of the minimum number of lymph nodes need to be pathologically examined. RESULTS Younger patients with a larger sized tumour located at the left colon or rectum require fewer lymph nodes to be pathologically examined. Overall, 45.9% of the patients require eight or nine lymph nodes and 31.5% needs ten or 11 lymph nodes to be harvested for pathological examination. A simple formula could be used to obtain the minimum number of lymph node sampling required in patients with colorectal cancer based on patients' age as well as site and dimension of the cancer. CONCLUSIONS The findings provide practical information about that the minimum number of lymph nodes that could be harvested at the time of collection of lymph nodes for pathological examination for patients with colorectal cancer. The minimum number of lymph nodes harvested depends on demographic (age) and clinical (location and dimension of cancer) characteristics of the patients with colorectal cancer.
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Affiliation(s)
- Shu-Kay Ng
- School of Medicine, Griffith Medical School, Griffith University, Gold Coast, QLD, 4222, Australia
| | - Cu-Tai Lu
- Department of Surgery, Gold Coast Hospital, Gold Coast, QLD, Australia
| | - Sahar Pakneshan
- School of Medicine, Griffith Medical School, Griffith University, Gold Coast, QLD, 4222, Australia
| | - Melissa Leung
- School of Medicine, Griffith Medical School, Griffith University, Gold Coast, QLD, 4222, Australia
| | - Simon Siu
- School of Medicine, Griffith Medical School, Griffith University, Gold Coast, QLD, 4222, Australia
| | - Alfred King-Yin Lam
- School of Medicine, Griffith Medical School, Griffith University, Gold Coast, QLD, 4222, Australia.
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Abdel-Misih SRZ, Wei L, Benson AB, Cohen S, Lai L, Skibber J, Wilkinson N, Weiser M, Schrag D, Bekaii-Saab T. Neoadjuvant Therapy for Rectal Cancer Affects Lymph Node Yield and Status Without Clear Implications on Outcome: The Case for Eliminating a Metric and Using Preoperative Staging to Guide Therapy. J Natl Compr Canc Netw 2017; 14:1528-1534. [PMID: 27956537 DOI: 10.6004/jnccn.2016.0164] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 08/17/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nodal status has long been considered pivotal to oncologic care, staging, and management. This has resulted in the establishment of rudimentary metrics regarding adequate lymph node yield in colon and rectal cancers for accurate cancer staging. In the era of neoadjuvant treatment, the implications of lymph node yield and status on patient outcomes remains unclear. PATIENT AND METHODS This study included 1,680 patients with locally advanced rectal cancer from the NCCN prospective oncology database stratified into 3 groups based on preoperative therapy received: no neoadjuvant therapy, neoadjuvant chemoradiation, and neoadjuvant chemotherapy. Clinicopathologic characteristics and survival were compared between the groups, with univariate and multivariate analyses undertaken. RESULTS The clinicopathologic characteristics demonstrated statistically significant differences and heterogeneity among the 3 groups. The neoadjuvant chemoradiation group demonstrated the statistically lowest median lymph node yield (n=15) compared with 17 and 18 for no-neoadjuvant and neoadjuvant chemotherapy, respectively (P<.0001). Neoadjuvant treatment did impact survival, with chemoradiation demonstrating increased median overall survival of 42.7 compared with 37.3 and 26.6 months for neoadjuvant chemotherapy and no-neoadjuvant therapy, respectively (P<.0001). Patients with a yield of fewer than 12 lymph nodes had improved median overall survival of 43.3 months compared with 36.6 months in patients with 12 or more lymph nodes (P=.009). Multivariate analysis demonstrated that neither node yield nor status were predictors for overall survival. DISCUSSION This analysis reiterates that nodal yield in rectal cancer is multifactorial, with neoadjuvant therapy being a significant factor. Node yield and status were not significant predictors of overall survival. A nodal metric may not be clinically relevant in the era of neoadjuvant therapy, and guidelines for perioperative therapy may need reconsideration.
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Affiliation(s)
- Sherif R Z Abdel-Misih
- From Division of Surgical Oncology, The Ohio State University Wexner Medical Center/Arthur G. James Cancer Hospital, Columbus, Ohio; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois; Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania; City of Hope Comprehensive Cancer Center, Duarte, California; University of Texas MD Anderson Cancer Center, Houston, Texas; Kalispell Regional Healthcare Specialists, Kalispell Regional Healthcare, Kalispell, Montana; Memorial Sloan Kettering Cancer Center, New York, New York; Dana-Farber Cancer Institute, Boston, Massachusetts; and Depaartment of Medicine, Division of Hematology/Oncology, Mayo Clinic Cancer Center, Phoenix, Arizona
| | - Lai Wei
- From Division of Surgical Oncology, The Ohio State University Wexner Medical Center/Arthur G. James Cancer Hospital, Columbus, Ohio; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois; Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania; City of Hope Comprehensive Cancer Center, Duarte, California; University of Texas MD Anderson Cancer Center, Houston, Texas; Kalispell Regional Healthcare Specialists, Kalispell Regional Healthcare, Kalispell, Montana; Memorial Sloan Kettering Cancer Center, New York, New York; Dana-Farber Cancer Institute, Boston, Massachusetts; and Depaartment of Medicine, Division of Hematology/Oncology, Mayo Clinic Cancer Center, Phoenix, Arizona
| | - Al B Benson
- From Division of Surgical Oncology, The Ohio State University Wexner Medical Center/Arthur G. James Cancer Hospital, Columbus, Ohio; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois; Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania; City of Hope Comprehensive Cancer Center, Duarte, California; University of Texas MD Anderson Cancer Center, Houston, Texas; Kalispell Regional Healthcare Specialists, Kalispell Regional Healthcare, Kalispell, Montana; Memorial Sloan Kettering Cancer Center, New York, New York; Dana-Farber Cancer Institute, Boston, Massachusetts; and Depaartment of Medicine, Division of Hematology/Oncology, Mayo Clinic Cancer Center, Phoenix, Arizona
| | - Steven Cohen
- From Division of Surgical Oncology, The Ohio State University Wexner Medical Center/Arthur G. James Cancer Hospital, Columbus, Ohio; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois; Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania; City of Hope Comprehensive Cancer Center, Duarte, California; University of Texas MD Anderson Cancer Center, Houston, Texas; Kalispell Regional Healthcare Specialists, Kalispell Regional Healthcare, Kalispell, Montana; Memorial Sloan Kettering Cancer Center, New York, New York; Dana-Farber Cancer Institute, Boston, Massachusetts; and Depaartment of Medicine, Division of Hematology/Oncology, Mayo Clinic Cancer Center, Phoenix, Arizona
| | - Lily Lai
- From Division of Surgical Oncology, The Ohio State University Wexner Medical Center/Arthur G. James Cancer Hospital, Columbus, Ohio; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois; Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania; City of Hope Comprehensive Cancer Center, Duarte, California; University of Texas MD Anderson Cancer Center, Houston, Texas; Kalispell Regional Healthcare Specialists, Kalispell Regional Healthcare, Kalispell, Montana; Memorial Sloan Kettering Cancer Center, New York, New York; Dana-Farber Cancer Institute, Boston, Massachusetts; and Depaartment of Medicine, Division of Hematology/Oncology, Mayo Clinic Cancer Center, Phoenix, Arizona
| | - John Skibber
- From Division of Surgical Oncology, The Ohio State University Wexner Medical Center/Arthur G. James Cancer Hospital, Columbus, Ohio; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois; Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania; City of Hope Comprehensive Cancer Center, Duarte, California; University of Texas MD Anderson Cancer Center, Houston, Texas; Kalispell Regional Healthcare Specialists, Kalispell Regional Healthcare, Kalispell, Montana; Memorial Sloan Kettering Cancer Center, New York, New York; Dana-Farber Cancer Institute, Boston, Massachusetts; and Depaartment of Medicine, Division of Hematology/Oncology, Mayo Clinic Cancer Center, Phoenix, Arizona
| | - Neal Wilkinson
- From Division of Surgical Oncology, The Ohio State University Wexner Medical Center/Arthur G. James Cancer Hospital, Columbus, Ohio; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois; Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania; City of Hope Comprehensive Cancer Center, Duarte, California; University of Texas MD Anderson Cancer Center, Houston, Texas; Kalispell Regional Healthcare Specialists, Kalispell Regional Healthcare, Kalispell, Montana; Memorial Sloan Kettering Cancer Center, New York, New York; Dana-Farber Cancer Institute, Boston, Massachusetts; and Depaartment of Medicine, Division of Hematology/Oncology, Mayo Clinic Cancer Center, Phoenix, Arizona
| | - Martin Weiser
- From Division of Surgical Oncology, The Ohio State University Wexner Medical Center/Arthur G. James Cancer Hospital, Columbus, Ohio; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois; Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania; City of Hope Comprehensive Cancer Center, Duarte, California; University of Texas MD Anderson Cancer Center, Houston, Texas; Kalispell Regional Healthcare Specialists, Kalispell Regional Healthcare, Kalispell, Montana; Memorial Sloan Kettering Cancer Center, New York, New York; Dana-Farber Cancer Institute, Boston, Massachusetts; and Depaartment of Medicine, Division of Hematology/Oncology, Mayo Clinic Cancer Center, Phoenix, Arizona
| | - Deborah Schrag
- From Division of Surgical Oncology, The Ohio State University Wexner Medical Center/Arthur G. James Cancer Hospital, Columbus, Ohio; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois; Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania; City of Hope Comprehensive Cancer Center, Duarte, California; University of Texas MD Anderson Cancer Center, Houston, Texas; Kalispell Regional Healthcare Specialists, Kalispell Regional Healthcare, Kalispell, Montana; Memorial Sloan Kettering Cancer Center, New York, New York; Dana-Farber Cancer Institute, Boston, Massachusetts; and Depaartment of Medicine, Division of Hematology/Oncology, Mayo Clinic Cancer Center, Phoenix, Arizona
| | - Tanios Bekaii-Saab
- From Division of Surgical Oncology, The Ohio State University Wexner Medical Center/Arthur G. James Cancer Hospital, Columbus, Ohio; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois; Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania; City of Hope Comprehensive Cancer Center, Duarte, California; University of Texas MD Anderson Cancer Center, Houston, Texas; Kalispell Regional Healthcare Specialists, Kalispell Regional Healthcare, Kalispell, Montana; Memorial Sloan Kettering Cancer Center, New York, New York; Dana-Farber Cancer Institute, Boston, Massachusetts; and Depaartment of Medicine, Division of Hematology/Oncology, Mayo Clinic Cancer Center, Phoenix, Arizona
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Cox ML, Adam MA, Shenoi MM, Turner MC, Sun Z, Mantyh CR, Migaly J. Resected irradiated rectal cancers: Are twelve lymph nodes really necessary in the era of neoadjuvant therapy? Am J Surg 2017; 216:444-449. [PMID: 28890055 DOI: 10.1016/j.amjsurg.2017.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 08/10/2017] [Accepted: 08/21/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Our study aims to identify the minimum number of lymph nodes (LN) associated with improved survival in patients who underwent NRT for stage II-III rectal cancer. METHODS Adults with clinical stage II and III rectal adenocarcinoma in the National Cancer Data Base were stratified by NRT. Multivariable Cox regression modeling with restricted cubic splines was used to determine the minimum number of LNs associated with improved survival. RESULTS Of 38,363 patients, 76% received NRT. After adjustment, a LNY≥12 was associated with improved survival among patients receiving NRT (HR 0.79, p < 0.0001) and those without NRT (HR 0.88, p = 0.04). Among patients receiving NRT, factors independently associated with LNY≥12 were younger age, private insurance, low comorbidity score, a recent year of diagnosis, higher T stage and grade, APR resection, and academic institution. CONCLUSIONS A minimum LNY of 12 confers a survival benefit for rectal cancer patients regardless of receiving neoadjuvant radiation therapy.
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Affiliation(s)
- Morgan L Cox
- Department of General Surgery, Duke University Medical Center, Durham, NC, United States.
| | - Mohamed A Adam
- Department of General Surgery, Duke University Medical Center, Durham, NC, United States
| | - Mithun M Shenoi
- Department of General Surgery, Duke University Medical Center, Durham, NC, United States
| | - Megan C Turner
- Department of General Surgery, Duke University Medical Center, Durham, NC, United States
| | - Zhifei Sun
- Department of General Surgery, Duke University Medical Center, Durham, NC, United States
| | - Christopher R Mantyh
- Department of General Surgery, Duke University Medical Center, Durham, NC, United States
| | - John Migaly
- Department of General Surgery, Duke University Medical Center, Durham, NC, United States
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Bustamante-Lopez L, Nahas CS, Nahas SC, Ribeiro U, Marques CF, Cotti G, Rocco A, Cecconello I. Understanding the factors associated with reduction in the number of lymph nodes in rectal cancer patients treated by neoadjuvant treatment. Int J Colorectal Dis 2017; 32:925-927. [PMID: 28035459 DOI: 10.1007/s00384-016-2747-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Rectal cancer patients frequently present with locally advanced disease for which the standard of care includes neoadjuvant chemoradiotherapy followed by total mesorectal excision. Positive lymph nodes are one of the most powerful risk factors for recurrence and survival in colorectal cancer. In the absence of specific rectal guidelines, the literature recommends to the pathologist to optimize the number of rectal lymph nodes (LN) retrieved. We made a literature review in order to identify factors that could potentially affect the number of LN retrieved in specimens of patients with rectal cancer treated by chemoradiotherapy (CRT) followed by total mesorectal excision (TME). RESULTS Age did not have a significant effect on LN yield. The effect of sex on LN number is not consistent in the literature. Most of the papers did not find a relationship between lower LN obtained and gender. Laparoscopy for primary rectal cancer is associated with a greater number of LN as well as short-term benefits. Tumors in the upper rectum are associated with a higher number of LN than those in the mid and lower rectum. The type of surgery had no effect on lymph node yield either. Tumors with complete or almost complete pathologic regression were exactly the ones with lower number of lymph nodes detected. Approximately one-third of patients with neoadjuvant treatment had less than 12 LN yield. CONCLUSION The tumor regression grade is the most important factor for the decrease in the number of lymph nodes.
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Affiliation(s)
- L Bustamante-Lopez
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil.
| | - C S Nahas
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - S C Nahas
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - U Ribeiro
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - C F Marques
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - G Cotti
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - A Rocco
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - I Cecconello
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
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Lymph node yield after rectal resection in patients treated with neoadjuvant radiation for rectal cancer: A systematic review and meta-analysis. Eur J Cancer 2016; 72:84-94. [PMID: 28027520 DOI: 10.1016/j.ejca.2016.10.031] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/05/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The lymph node status represents a major prognostic factor in colorectal cancer. However, it was demonstrated that neoadjuvant chemoradiotherapy (CRT) decreases the numbers of lymph nodes in the specimen. Several studies describe less than 12 lymph nodes in the resected specimen of rectal cancer patients after neoadjuvant radiation. This meta-analysis quantifies the influence of neoadjuvant CRT or radiotherapy (RT) only on the lymph node yield in rectal cancer patients. METHODS We performed a systematic review and searched PubMed, EMBASE and the Cochrane Library without any language restriction from 1st of January 1980 until 31st March 2015. Two reviewers examined all publications independently and extracted the relevant data if the study assessed lymph node counts or positive lymph node yields of patients who received neoadjuvant treatment compared with patients who did not receive neoadjuvant treatment. Meta-analyses were conducted to quantify the mean difference in lymph node yield. RESULTS A total of 34 articles (including 37 datasets) were included in the meta-analyses. Neoadjuvant CRT resulted in a mean reduction of 3.9 lymph nodes (95% confidence interval [CI] 3.7-4.1) and an average reduction in harvested positive lymph nodes of 0.7 (95% CI 0.2-1.2) compared with patients who received no neoadjuvant therapy. Individuals who received neoadjuvant RT had, in average, 2.1 lymph node less (95% CI 1.7-2.5) resected compared with their counterparts who received no neoadjuvant treatment. CONCLUSIONS Neoadjuvant CRT or RT only in rectal cancer patients leads to a decrease in lymph node harvest of approximately four and two lymph nodes, respectively. We therefore stress the importance of intensifying all efforts from involved subspecialities (i.e. surgeons and pathologists) to reach the benchmark harvest of 12 resected lymph nodes according to current guidelines.
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Xu Z, Berho ME, Becerra AZ, Aquina CT, Hensley BJ, Arsalanizadeh R, Noyes K, Monson JRT, Fleming FJ. Lymph node yield is an independent predictor of survival in rectal cancer regardless of receipt of neoadjuvant therapy. J Clin Pathol 2016; 70:584-592. [PMID: 27932667 DOI: 10.1136/jclinpath-2016-203995] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 11/08/2016] [Accepted: 11/13/2016] [Indexed: 01/05/2023]
Abstract
AIMS Lymph node yield (LNY) is used as a marker of adequate oncological resection. The American Joint Committee on Cancer (AJCC) currently recommends that at least 12 nodes are necessary to confirm node-negative disease for rectal cancer. A LNY of 12 is not always achieved, particularly in patients who have undergone neoadjuvant treatment. This study attempts to examine factors associated with LNY and its prognostic impact following neoadjuvant chemoradiation in rectal cancer. METHODS The 2006-2011 National Cancer Data Base was queried for patients with clinical stage I-III rectal cancer who underwent a proctectomy. Suboptimal LNY was defined as <12 lymph nodes examined. A mixed-effects multinomial logistic regression model was used to identify independent factors associated with LNY. Mixed-effects Cox proportional hazards models were used to estimate the adjusted effect of LNY on 5-year overall survival. RESULTS 25 447 patients met inclusion criteria. Overall, 62% of the cohort received neoadjuvant chemoradiation and 32% had suboptimal LNY. The median LNY for patients who received neoadjuvant therapy was 13 (IQR: 9-18) and for patients who did not receive neoadjuvant therapy was 15 (IQR: 12-21). After risk adjustment, there was a 3.5-fold difference in the rate of suboptimal LNY among individual hospitals (27%-95%). Suboptimal LNY was independently associated with an 18% increased hazard of death among patients who did not receive neoadjuvant treatment and a 20% increased hazard of death among those who did receive neoadjuvant treatment when controlled for adjuvant treatment, staging, proximal/distal margins and other patient factors. CONCLUSIONS Suboptimal LNY is independently associated with worse overall survival regardless of neoadjuvant therapy, pathological staging and patient factors in rectal cancer. This finding underlies the importance and challenge of an optimal lymph node evaluation for prognostication, especially for patients receiving neoadjuvant therapy.
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Affiliation(s)
- Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Mariana E Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, Florida, USA
| | - Adan Z Becerra
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Christopher T Aquina
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Bradley J Hensley
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Reza Arsalanizadeh
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Katia Noyes
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida, College of Medicine, Orlando, Florida, USA
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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Ecker BL, Peters MG, McMillan MT, Sinnamon AJ, Zhang PJ, Kelz RR, Roses RE, Drebin JA, Fraker DL, Karakousis GC. Implications of Lymph Node Evaluation in the Management of Resectable Soft Tissue Sarcoma. Ann Surg Oncol 2016; 24:425-433. [DOI: 10.1245/s10434-016-5641-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Indexed: 11/18/2022]
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Kreis ME, Maurer CA, Ruppert R, Ptok H, Strassburg J, Junginger T, Merkel S, Hermanek P. [Lymph node dissection after primary surgery and neoadjuvant radiochemotherapy of rectal cancer. Interim analysis of a multicenter prospective observational study (OCUM)]. Chirurg 2016. [PMID: 26223668 DOI: 10.1007/s00104-015-0062-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The OCUM trial (NCT01325649) aims to clarify whether low rates of local recurrence are also achieved when the indications for neoadjuvant radiochemotherapy are not based on the clinical TNM staging but on preoperative magnetic resonance imaging with measurement of the tumor distance to the circumferential resection margin. In this interim analysis the lymph node status in OCUM patients was investigated as a surrogate parameter for quality of surgery and histopathological work-up. MATERIAL AND METHODS Until now a total of 560 patients have been included in this study. Total mesorectal excision (TME) without pretreatment was undertaken in 338 patients (60.4 %) and neoadjuvant radiochemotherapy was administered in 222 (39.6 %) patients. The histological work-up was performed according to the guidelines of the German Association of Pathologists. Data are given as median values and ranges in brackets. RESULTS The lymph node yield was 24 (7-79) in 338 patients undergoing primary TME surgery without pretreatment, while 20 (3-56) lymph nodes were identified in patients after neoadjuvant radiochemotherapy (p = 0.001). A minimum of 12 lymph nodes were analyzed in 335 out of 338 patients (99.1 %) and in 209 out of 222 patients (94.1 %) following neoadjuvant radiochemotherapy (p = 0.001). Lymph node metastasis was identified (p = 0.362) in 116 out of 338 patients without pretreatment (34.3 %) and in 71 out of 222 patients after neoadjuvant radiochemotherapy (32.0 %). Patient age did not influence the number of identified lymph nodes or rate of lymph node metastasis. CONCLUSION In this trial the number of identified lymph nodes suggests that the quality of surgery and histopathological work-up were adequate compared to the standards defined by national guidelines. Neoadjuvant radiochemotherapy led to a reduced lymph node yield compared to surgery without pretreatment; however, this did not influence the rate of lymph node metastasis.
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Affiliation(s)
- M E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland.
| | | | - R Ruppert
- Klinikum München Neuperlach, München, Deutschland
| | - H Ptok
- Carl-Thiem-Klinikum, Cottbus, Deutschland
| | - J Strassburg
- Vivantes Klinikum Friedrichshain, Berlin, Deutschland
| | - T Junginger
- Universitätsmedizin Mainz, Mainz, Deutschland
| | - S Merkel
- Chirurgische Klinik, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - P Hermanek
- Chirurgische Klinik, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
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Münster M, Hanisch U, Tuffaha M, Kube R, Ptok H. Ex Vivo Intra-arterial Methylene Blue Injection in Rectal Cancer Specimens Increases the Lymph-Node Harvest, Especially After Preoperative Radiation. World J Surg 2016; 40:463-70. [PMID: 26310202 DOI: 10.1007/s00268-015-3230-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The examination of as large a number of lymph nodes as possible in rectal carcinoma resectates is important for exact staging. However, after neoadjuvant radiochemotherapy (RCT), it can be difficult to obtain a sufficient number of lymph nodes. We therefore investigated whether staining with methylene blue via the inferior mesenteric artery can lead to an increase in the yield of lymph nodes in rectal carcinoma tissue after neoadjuvant RCT. METHODS In a prospective, unicentric study rectal carcinoma resectates from three consecutive groups of patients were examined (Group I, no staining; Group II, staining with methylene blue; Group III, again no staining). The numbers of lymph nodes examined were compared (a) between the groups and (b) between patients who had not, or who had, received neoadjuvant RCT. RESULTS In all, 75 rectal carcinoma preparations were assessed. The yield of lymph nodes investigated before the use of staining (Group I) increased when staining was introduced (Group II), both for the patients without neoadjuvant RCT (20.9 vs. 31.3, p = 0.018) and for those who did receive this (15.0 vs. 35.1; p = 0.003). After withdrawal of the staining procedure (Group III), the lymph-node yield remained high for the patients without neoadjuvant RCT (31.3 vs. 30.4; p = 0.882), but it reverted to a lower value for those who did receive neoadjuvant RCT (35.1 vs. 24.2; p = 0.029). Before the introduction of staining (Group I), significantly fewer lymph nodes were examined for patients who received neoadjuvant RCT (15.0 vs. 20.9; p = 0.039). However, with staining (Group II), no difference was found associated with the use or non-use of neoadjuvant RCT (31.3 vs. 35.1; p = 0.520). CONCLUSION The use of methylene blue staining of rectal carcinoma preparations leads to a significant increase in the number of lymph nodes examined after neoadjuvant RCT. This can be expected to improve the accuracy of lymph-node staging of neoadjuvant-treated rectal carcinoma.
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Affiliation(s)
- Maria Münster
- Department of Surgery, Carl-Thiem-Hospital Cottbus, Thiemstr. 111, 03048, Cottbus, Germany
| | - Uwe Hanisch
- Institute of Pathology, Carl-Thiem-Hospital Cottbus, Thiemstr. 111, 03048, Cottbus, Germany
| | - Muin Tuffaha
- Institute of Pathology, Carl-Thiem-Hospital Cottbus, Thiemstr. 111, 03048, Cottbus, Germany
| | - Rainer Kube
- Department of Surgery, Carl-Thiem-Hospital Cottbus, Thiemstr. 111, 03048, Cottbus, Germany
| | - Henry Ptok
- Department of Surgery, Carl-Thiem-Hospital Cottbus, Thiemstr. 111, 03048, Cottbus, Germany.
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Ceelen W, Willaert W, Varewyck M, Libbrecht S, Goetghebeur E, Pattyn P. Effect of Neoadjuvant Radiation Dose and Schedule on Nodal Count and Its Prognostic Impact in Stage II-III Rectal Cancer. Ann Surg Oncol 2016; 23:3899-3906. [PMID: 27380639 DOI: 10.1245/s10434-016-5363-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND It is unknown how neoadjuvant treatment schedule affects lymph node count (LNC) and lymph node ratio (LNR) and how these correlate with overall survival (OS) in rectal cancer (RC). METHODS Data were used from the Belgian PROCARE rectal cancer registry on RC patients treated with surgery alone, short-term radiotherapy with immediate surgery (SRT), or chemoradiation with deferred surgery (CRT). The effect of neoadjuvant therapy on LNC was examined using Poisson log-linear analysis. The association of LNC and LNR with overall survival (OS) was studied using Cox proportional hazards models. RESULTS Data from 4037 patients were available. Compared with surgery alone, LNC was reduced by 12.3 % after SRT and by 31.3 % after CRT (p < 0.001). In patients with surgery alone, the probability of finding node-positive disease increased with LNC, while after SRT and CRT no increase was noted for more than 12 and 18 examined nodes, respectively. Per node examined, we found a decrease in hazard of death of 2.7 % after surgery alone and 1.5 % after SRT, but no effect after CRT. In stage III patients, the LNR but not (y)pN stage was significantly correlated with OS regardless of neoadjuvant therapy. Specifically, a LNR > 0.4 was associated with a significantly worse outcome. CONCLUSIONS Nodal counts are reduced in a schedule-dependent manner by neoadjuvant treatment in RC. After chemoradiation, the LNC does not confer any prognostic information. A LNR of >0.4 is associated with a significantly worse outcome in stage III disease, regardless of neoadjuvant therapy type.
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Affiliation(s)
- Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium.
| | - Wouter Willaert
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Machteld Varewyck
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - Sasha Libbrecht
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - Els Goetghebeur
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
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Leonard D, Remue C, Abbes Orabi N, van Maanen A, Danse E, Dragean A, Debetancourt D, Humblet Y, Jouret-Mourin A, Maddalena F, Medina Benites A, Scalliet P, Sempoux C, Van den Eynde M, De Schoutheete JC, Kartheuser A. Lymph node ratio and surgical quality are strong prognostic factors of rectal cancer: results from a single referral centre. Colorectal Dis 2016; 18:O175-84. [PMID: 27128602 DOI: 10.1111/codi.13362] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 02/11/2016] [Indexed: 02/08/2023]
Abstract
AIM Nodal stage is a strong prognostic factor of oncological outcome of rectal cancer. To compensate for the variation in total number of harvested nodes, calculation of the lymph node ratio (LNR) has been advocated. The aim of the study was to compare the impact, on the long-term oncological outcome, of the LNR with other predictive factors, including the quality of total mesorectal excision (TME) and the state of the circumferential resection margin. METHOD Consecutive patients having elective surgery for nonmetastatic rectal cancer were extracted from a prospectively maintained database. Retrospective uni- and multivariate analyses were performed based on patient-, surgical- and tumour-related factors. The prognostic value of the LNR on overall survival (OS) and on overall recurrence-free survival (ORFS) was assessed and a cut-off value was determined. RESULTS From 1998 to 2013, out of 456 patients, 357 with nonmetastatic disease were operated on for rectal cancer. Neoadjuvant radiochemotherapy was administered to 66.7% of the patients. The mean number of lymph nodes retrieved was 12.8 ± 8.78 per surgical specimen. A lower lymph node yield was obtained in patients who received neoadjuvant chemoradiotherapy (11.8 vs 14.2; P = 0.014). The 5-year ORFS was 71.8% and the 5-year OS was 80.1%. Multivariate analysis confirmed LNR, the quality of TME and age to be independent prognostic factors of OS. LNR, age and perineural infiltration were independently associated with ORFS. Low- and high-risk patients could be discriminated using an LNR cut-off value of 0.2. CONCLUSION LNR is an independent prognostic factor of OS and ORFS. In line with the principles of optimal surgical management, the quality of TME and lymph node yield are essential technical requirements.
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Affiliation(s)
- D Leonard
- Colorectal Surgery Unit, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - C Remue
- Colorectal Surgery Unit, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - N Abbes Orabi
- Colorectal Surgery Unit, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - A van Maanen
- Statistical Support Unit, Institut Roi Albert II, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - E Danse
- Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium.,Department of Radiology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - A Dragean
- Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium.,Department of Radiology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - D Debetancourt
- Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - Y Humblet
- Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium.,Department of Medical Oncology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - A Jouret-Mourin
- Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium.,Department of Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - F Maddalena
- Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - A Medina Benites
- Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - P Scalliet
- Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium.,Department of Radiation Oncology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - C Sempoux
- Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium.,Department of Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - M Van den Eynde
- Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium.,Department of Medical Oncology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - J C De Schoutheete
- Colorectal Surgery Unit, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - A Kartheuser
- Colorectal Surgery Unit, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium
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Qiu L, Liu XL, Liu SR, Weng ZP, Chen XQ, Feng YZ, Cai XR, Guo CY. Role of quantitative intravoxel incoherent motion parameters in the preoperative diagnosis of nodal metastasis in patients with rectal carcinoma. J Magn Reson Imaging 2016; 44:1031-9. [PMID: 27019309 DOI: 10.1002/jmri.25250] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 03/08/2016] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To evaluate the diagnostic value of intravoxel incoherent motion imaging (IVIM) in differentiating metastatic and nonmetastatic lymph nodes in patients with rectal carcinoma. MATERIALS AND METHODS In all, 68 patients with histologically proven rectal carcinoma underwent an IVIM sequence (b = 0, 25, 50, 75, 100, 150, 200, 400, 600, 800, 1000, 1200, 1500, and 2000 s/mm(2) ) on a 3.0T MRI scanner. The IVIM parameters (D, D*, f, and apparent diffusion coefficient [ADC] values) in metastatic and nonmetastatic lymph nodes were measured and calculated. Receiver-operating characteristic (ROC) analyses were conducted to determine the optimal thresholds, the sensitivities, and specificities for differentiation. RESULTS Mean D, f, and ADC values of metastatic lymph nodes were significantly greater than those of the normal lymph nodes (P < 0.01), whereas the mean D* value of metastatic lymph node was statistically lower (P = 0.03). The AUC, sensitivity, specificity, and the cutoff value, respectively, for differentiating metastatic from nonmetastatic lymph nodes for D, D*, f, and ADC were as follows: D, 0.9460, 89.25%, 91.04%, and 1.14 × 10(-3) mm(2) /s; D*, 0.6930, 64.18%, 82.80%, and 7.02 × 10(-3) mm(2) /s; f, 0.7810, 92.47%, 55.22%, and 0.27%; ADC, 0.8970, 87.10%, 88.06%, and 0.80 × 10(-3) mm(2) /s. The ROC curves demonstrated that the area under the ROC (AUC) of the D, ADC, f, and D* values successively decreased, and D had the highest AUC, with D* values being lowest. CONCLUSION An IVIM sequence may be helpful in diagnosing metastatic lymph nodes of rectal carcinoma. Average D and ADC values are more sensitive than f and D* values in this differentiation. J. MAGN. RESON. IMAGING 2016;44:1031-1039.
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Affiliation(s)
- Lin Qiu
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Xiao-Ling Liu
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Si-Run Liu
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Ze-Ping Weng
- Department of Pathology, First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Xiao-Qiao Chen
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - You-Zhen Feng
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Xiang-Ran Cai
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China.
| | - Chang-Yu Guo
- Serviço de Imagiologia, Centro Hospitalar Conde de São Januário (CHCSJ), Estrada do Visconde de S. Januário, Macau.
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49
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Ong MLH, Schofield JB. Assessment of lymph node involvement in colorectal cancer. World J Gastrointest Surg 2016; 8:179-192. [PMID: 27022445 PMCID: PMC4807319 DOI: 10.4240/wjgs.v8.i3.179] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/24/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Lymph node metastasis informs prognosis and is a key factor in deciding further management, particularly adjuvant chemotherapy. It is core to all contemporary staging systems, including the widely used tumor node metastasis staging system. Patients with node-negative disease have 5-year survival rates of 70%-80%, implying a significant minority of patients with occult lymph node metastases will succumb to disease recurrence. Enhanced staging techniques may help to identify this subset of patients, who might benefit from further treatment. Obtaining adequate numbers of lymph nodes is essential for accurate staging. Lymph node yields are affected by numerous factors, many inherent to the patient and the tumour, but others related to surgical and histopathological practice. Good lymph node recovery relies on close collaboration between surgeon and pathologist. The optimal extent of surgical resection remains a subject of debate. Extended lymphadenectomy, extra-mesenteric lymph node dissection, high arterial ligation and complete mesocolic excision are amongst the surgical techniques with plausible oncological bases, but which are not supported by the highest levels of evidence. With further development and refinement, intra-operative lymphatic mapping and sentinel lymph node biopsy may provide a guide to the optimum extent of lymphadenectomy, but in its present form, it is beset by false negatives, skip lesions and failures to identify a sentinel node. Once resected, histopathological assessment of the surgical specimen can be improved by thorough dissection techniques, step-sectioning of tissue blocks and immunohistochemistry. More recently, molecular methods have been employed. In this review, we consider the numerous factors that affect lymph node yields, including the impact of the surgical and histopathological techniques. Potential future strategies, including the use of evolving technologies, are also discussed.
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50
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Lykke J, Jess P, Roikjaer O. The prognostic value of lymph node ratio in a national cohort of rectal cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:504-12. [PMID: 26856955 DOI: 10.1016/j.ejso.2016.01.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/13/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To analyze the prognostic implications of the lymph node ratio (LNR) in curative resected rectal cancer. SUMMARY BACKGROUND DATA It has been proposed that the LNR has a high prognostic impact in colorectal cancer, but the lymph node ratio has not been evaluated exclusively for rectal cancer in a large national cohort study. METHODS All 6793 patients in Denmark diagnosed with stage I to III adenocarcinoma of the rectum, and so treated in the period from 2003 to 2011, were included in the analysis. The cohort was divided into two groups according to whether or not neo-adjuvant treatment had been given. RESULTS In a multivariate analysis the pN status, ypN status and lymph node yield were found to be independent prognostic factors for overall survival, irrespective of neo-adjuvant therapy. The LNR was also found to be a significant prognostic factor with a Hazard Ratio ranging from 1.154 (95% CI: 0.930-1.432) (LNR: 0.01-0.08) to 2.974 (95% CI: 2.452-3.606) (LNR > 0.5) in the group of patients who had surgery to begin with and from 1.381 (95% CI: 0.891-2.139) (LNR: 0.01-0.08) to 2.915 (95% CI: 2.244-3.787) (LNR > 0.5) in the group of patients who had neo-adjuvant treatment. CONCLUSIONS The LNR reflects the influence on survival from N-status and the lymph node yield and since LNR was shown to be a significant prognostic predictor for overall survival in patients with curatively resected stage III rectal cancer irrespective of neo-adjuvant therapy we recommend that the introduction of LNR should be considered for rectal cancer in a revised TNM classification.
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Affiliation(s)
- J Lykke
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark.
| | - P Jess
- Department of Surgery, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark
| | - O Roikjaer
- Department of Surgery, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark
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