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Dodington DW, Guidolin K, Quereshy F, Chetty R, Serra S, Nowak KM. Are deeper sections and immunohistochemistry useful in detecting micrometastases and isolated tumour cells in colorectal cancer? Pathology 2025:S0031-3025(25)00131-X. [PMID: 40318958 DOI: 10.1016/j.pathol.2025.01.011] [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: 08/23/2024] [Revised: 01/06/2025] [Accepted: 01/28/2025] [Indexed: 05/07/2025]
Abstract
Identification of lymph node metastases is critical for staging of colorectal cancer. Lymph node metastases are classified based on size as macrometastases, micrometastases, or isolated tumour cells (ITCs). Micrometastases are associated with worse prognosis; however, optimal detection methods have yet to be established. The first objective was to determine if deeper levels and immunohistochemistry would detect micrometastases in patients with metastatic disease but negative lymph nodes. Five patients with pT3N0 colorectal adenocarcinoma who developed metastatic disease were identified. Three deeper haematoxylin and eosin (H&E) levels followed by pan-cytokeratin immunohistochemistry was performed on all lymph nodes. No micrometastases were detected; however, ITCs were seen by immunohistochemistry in three of five patients. Driven by these findings, the second objective was to determine if a single level stained for pan-cytokeratin would identify ITCs and if their presence was associated with an increased risk of disease recurrence. A cohort of eight patients with stage IIA (pT3N0M0) colorectal adenocarcinoma who developed distant metastasis was matched to eight control patients who remained disease-free over a 5-year period, and a single pan-cytokeratin stain was performed on all lymph nodes. ITCs were identified in six of eight patients that developed metastasis and in five of eight control patients (odds ratio=1.80; 95% confidence interval=0.21-15.41). In conclusion, three deeper levels and immunohistochemistry did not increase the yield of micrometastases in pT3N0 colorectal adenocarcinoma. While ITCs were readily identified by immunohistochemistry, their presence was not a significant predictor of distant recurrence. These findings do not support the routine use of deeper levels and immunohistochemistry for lymph node staging.
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Affiliation(s)
- David W Dodington
- Laboratory Medicine Program, University Health Network, Toronto, ON, Canada; Department of Laboratory Medicine & Pathobiology, University of Toronto, ON, Canada.
| | - Keegan Guidolin
- Department of Surgery, University of Toronto, ON, Canada; Institute of Biomedical Engineering, University of Toronto, ON, Canada
| | - Fayez Quereshy
- Department of Surgery, University of Toronto, ON, Canada; Department of Surgery, University Health Network, Toronto, ON Canada
| | | | - Stefano Serra
- Laboratory Medicine Program, University Health Network, Toronto, ON, Canada; Department of Laboratory Medicine & Pathobiology, University of Toronto, ON, Canada
| | - Klaudia M Nowak
- Laboratory Medicine Program, University Health Network, Toronto, ON, Canada; Department of Laboratory Medicine & Pathobiology, University of Toronto, ON, Canada
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Lee SH, Pankaj A, Neyaz A, Ono Y, Rickelt S, Ferrone C, Ting D, Patil DT, Yilmaz O, Berger D, Deshpande V, Yılmaz O. Immune microenvironment and lymph node yield in colorectal cancer. Br J Cancer 2023; 129:917-924. [PMID: 37507544 PMCID: PMC10491581 DOI: 10.1038/s41416-023-02372-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/05/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Lymph node (LN) harvesting is associated with outcomes in colonic cancer. We sought to interrogate whether a distinctive immune milieu of the primary tumour is associated with LN yield. METHODS A total of 926 treatment-naive patients with colorectal adenocarcinoma with more than 12 LNs (LN-high) were compared with patients with 12 or fewer LNs (LN-low). We performed immunohistochemistry and quantification on tissue microarrays for HLA class I/II proteins, beta-2-microglobulin (B2MG), CD8, CD163, LAG3, PD-L1, FoxP3, and BRAF V600E. RESULTS The LN-high group was comprised of younger patients, longer resections, larger tumours, right-sided location, and tumours with deficient mismatch repair (dMMR). The tumour microenvironment showed higher CD8+ cells infiltration and B2MG expression on tumour cells in the LN-high group compared to the LN-low group. The estimated mean disease-specific survival was higher in the LN-high group than LN-low group. On multivariate analysis for prognosis, LN yield, CD8+ cells, extramural venous invasion, perineural invasion, and AJCC stage were independent prognostic factors. CONCLUSION Our findings corroborate that higher LN yield is associated with a survival benefit. LN yield is associated with an immune high microenvironment, suggesting that tumour immune milieu influences the LN yield.
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Affiliation(s)
- Soo Hyun Lee
- Department of Pathology, Boston Medical Center, Boston, MA, USA
| | - Amaya Pankaj
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Azfar Neyaz
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Yuho Ono
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Steffen Rickelt
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Cristina Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David Ting
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Deepa T Patil
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Omer Yilmaz
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David Berger
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Vikram Deshpande
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Osman Yılmaz
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Sarkar S, Deodhar KK, Budukh A, Bal MM, Ramadwar M. Assessing the histopathology reports of colorectal carcinoma surgery: An audit of three years with emphasis on lymph node yield. Indian J Cancer 2022; 59:532-539. [PMID: 34380840 DOI: 10.4103/ijc.ijc_1059_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background A comprehensive histopathology report of colorectal carcinoma surgery is important in cancer staging and planning adjuvant treatment. Our aim was to review histopathology reports of operated specimens of colorectal carcinoma in our institution between 2013 and 2015 to assess different histological parameters, including lymph node yield, and to evaluate compliance to minimum data sets. Methods After approval by the institutional review board (IRB), we analyzed 1230 histopathology reports of colorectal carcinoma between 2013 and 2015. Various gross and microscopic findings (along with age, sex) were noted, for example, specimen type, tumor site, resection margins including circumferential resection margin (CRM), lymphovascular invasion, perineural invasion, pTNM stage, lymph node yield, etc. Results Out of 1230 patients, 826 (67.15%) were men and 404 (32.85%) were women. The overall mean age was 52 (range: 18 - 90) years. There were 787 surgeries for rectal cancers. All reports commented on the type of specimen, tumor size (mean = 4.38 cm), proximal, and distal margins. Lymphovascular invasion (LVI) and the pT stage were mentioned in 98.06% and 99.84%, respectively. The overall mean lymph node yield was 18.38 (median = 15, range = 0-130 lymph nodes). A statistically significant difference in lymph node yield was detected between rectal and colonic cancer patients (14.79 and 27.26); post neoadjuvant therapy (NACT) cases, and NACT naive cases (13.51 and 25.11); and high tumor stage and low tumor stage disease (20.60 and 15.22). Not commenting on extramural vascular emboli, tumor budding, and CRM in non-rectal cancer cases were the lacunae. Conclusion Our compliance with minimal data sets is satisfactory. The overall mean lymph node yield was 18.38 (median = 15). Extramural vascular emboli, tumor budding need to be captured.
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Affiliation(s)
- Sourav Sarkar
- Ex Senior Registrar, Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Kedar K Deodhar
- Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Atul Budukh
- Centre for Cancer Epidemiology, Advanced Centre for treatment and Research in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Munita M Bal
- Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Mukta Ramadwar
- Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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Palmeri M, Peri A, Pucci V, Furbetta N, Gallo V, Di Franco G, Pagani A, Dauccia C, Farè C, Gianardi D, Guadagni S, Bianchini M, Comandatore A, Masi G, Cremolini C, Borelli B, Pollina LE, Di Candio G, Pietrabissa A, Morelli L. Pattern of recurrence and survival after D2 right colectomy for cancer: is there place for a routine more extended lymphadenectomy? Updates Surg 2022; 74:1327-1335. [PMID: 35778547 PMCID: PMC9338120 DOI: 10.1007/s13304-022-01317-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/14/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Conventional Right Colectomy with D2 lymphadenectomy (RC-D2) currently represent the most common surgical treatment of right-sided colon cancer (RCC). However, whether it should be still considered a standard of care, or replaced by a routine more extended D3 lymphadenectomy remains unclear. In the present study, we aim to critically review the patterns of relapse and the survival outcomes obtained from our 11-year experience of RC-D2. METHODS Clinical data of 489 patients who underwent RC-D2 for RCC at two centres, from January 2009 to January 2020, were retrospectively reviewed. Patients with synchronous distant metastases and/or widespread nodal involvement at diagnosis were excluded. Post-operative clinical-pathological characteristics and survival outcomes were evaluated including the pattern of disease relapse. RESULTS We enrolled a total of 400 patients with information follow-up. Postoperative morbidity was 14%. The median follow-up was 62 months. Cancer recurrence was observed in 55 patients (13.8%). Among them, 40 patients (72.7%) developed systemic metastases, and lymph-node involvement was found in 7 cases (12.8%). None developed isolated central lymph-node metastasis (CLM), in the D3 site. The estimated 3- and 5-year relapse-free survival were 86.1% and 84.4%, respectively. The estimated 3- and 5-year cancer-specific OS were 94.5% and 92.2%, respectively. CONCLUSIONS The absence of isolated CLM, as well as the cancer-specific OS reported in our series, support the routine use of RC-D2 for RCC. However, D3 lymphadenectomy may be recommended in selected patients, such as those with pre-operatively known CLM, or with lymph-node metastases close to the origin of the ileocolic vessels.
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Affiliation(s)
- Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy, Via Paradisa 2, 56125, Pisa, Italy
| | - Andrea Peri
- Department of General Surgery, University of Pavia, 27100, Pavia, Italy
| | - Valentina Pucci
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy, Via Paradisa 2, 56125, Pisa, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy, Via Paradisa 2, 56125, Pisa, Italy
| | - Virginia Gallo
- Department of General Surgery, University of Pavia, 27100, Pavia, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy, Via Paradisa 2, 56125, Pisa, Italy
| | - Anna Pagani
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Chiara Dauccia
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Camilla Farè
- Department of General Surgery, University of Pavia, 27100, Pavia, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy, Via Paradisa 2, 56125, Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy, Via Paradisa 2, 56125, Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy, Via Paradisa 2, 56125, Pisa, Italy
| | - Annalisa Comandatore
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy, Via Paradisa 2, 56125, Pisa, Italy
| | - Gianluca Masi
- Oncology Unit, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, 56124, Pisa, Italy
| | - Chiara Cremolini
- Oncology Unit, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, 56124, Pisa, Italy
| | - Beatrice Borelli
- Oncology Unit, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, 56124, Pisa, Italy
| | | | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy, Via Paradisa 2, 56125, Pisa, Italy
| | | | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy, Via Paradisa 2, 56125, Pisa, Italy.
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, 56124, Pisa, Italy.
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Khan S, Haider G, Abid Z, Bukhari N, Khan SZ, Abid M. Adequacy of Surgical Pathology Reports of Colorectal Carcinoma and Its Significance. Cureus 2021; 13:e16965. [PMID: 34540379 PMCID: PMC8423118 DOI: 10.7759/cureus.16965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Colorectal cancer is the fifth most common cancer in the world. For loco-regionally confined disease surgery is the definitive treatment. An adequate surgical pathology report is mandatory for the selection of adjuvant therapy. The objective of this study is to analyze whether adequate information is provided or not in the surgical pathology reports of colorectal carcinoma as according to College of American Pathologists (CAP) guidelines. Method This is a cross-sectional study carried out in the Department of Clinical Oncology, Jinnah Postgraduate Medical Center (JPMC) Karachi, tertiary care hospital in Pakistan. The duration of the study was from February 2020 to January 2021. A total of 153 surgical pathology reports issued by 11 different hospital-based laboratories after definitive surgery was assessed to look at its concordance rate with the checklist adapted from the CAP guidelines. Results Out of 153 surgical pathology reports, clinical information was provided in 72.5% of reports. Details of tumor extension were present in 88.2%, tumor margin in 75%, surgical procedure in 79%, and tumor deposits in 39.2% of reports. Macroscopic details including tumor perforation and evaluation of mesorectum were documented in 51.6% and 53.5% of the reports respectively. Details regarding perineural invasion along with lymphovascular invasion were present in 81.6% and 93% of the reports, respectively. The treatment effect was documented in only 25% of reports and regional lymph node status has been described in 85% of reports. Parameters described in all surgical pathology reports were: tumor site, tumor type, histologic type, and histologic grade. The pathological stage of the disease was documented in 91.5% of the reports. Conclusion This study concluded that surgical pathology reports of the majority of pathology laboratories were not fully adhered to the checklist provided by the CAP guidelines. This will affect post-operative management along with the prediction of disease prognosis.
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Affiliation(s)
- Salahuddin Khan
- Medical Oncology, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Ghulam Haider
- Medical Oncology, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Zain Abid
- Medical Oncology, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Neelma Bukhari
- Medical Oncology, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Shah Zeb Khan
- Clinical Oncology, Bannu Institute of Nuclear Medicine Oncology and Radiotherapy, Bannu, PAK
| | - Masooma Abid
- Medicine, Jinnah Medical and Dental College, Karachi, PAK
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Tran C, Howlett C, Driman DK. Evaluating the impact of lymph node resampling on colorectal cancer nodal stage. Histopathology 2020; 77:974-983. [PMID: 32654207 DOI: 10.1111/his.14209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/09/2020] [Indexed: 12/20/2022]
Abstract
AIMS Nodal staging in colorectal cancer (CRC) informs prognosis and guides adjuvant treatment decisions. A standard minimum of 12 lymph nodes is widely used, with additional sampling being performed as required. However, there are few data on how lymph node resampling in this context has an impact on nodal stage. The aims of this study were to evaluate the effectiveness of resampling in detecting metastases and tumour deposits, and the impact on stage. METHODS AND RESULTS A retrospective cohort analysis was performed on CRC resections that underwent resampling because of an initial yield of <12 lymph nodes, from 2008 to 2018. Data relating to patient demographics, specimen, malignancy and prosection were collected. Slides were reviewed to quantify nodal metastases and tumour deposits before and after resampling. Among ≥pN1 cases, logistic regression analysis was performed to evaluate factors that predicted the finding of additional metastases and tumour deposits. The cohort comprised 395 cases: resampling identified nodal metastases and/or tumour deposits in 30 (7.6%) cases; nodal upstaging occurred in 20 (5.1%) cases; and eight (2.0%) cases changed from pN0 to ≥pN1. No factors predicted resampling of positive lymph nodes or tumour deposits, and pN upstaging occurred across a variety of cases. A subgroup analysis was performed to assess the impact of resampling on high-risk features in stage II cases (n = 117). There were 33 (8.5%) patients who no longer had any high-risk features after resampling. CONCLUSIONS Lymph node resampling has an impact on nodal staging and possible treatment decisions in a considerable proportion of patients, and is recommended in all cases with <12 lymph nodes.
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Affiliation(s)
- Christopher Tran
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Christopher Howlett
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - David K Driman
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Trepanier M, Erkan A, Kouyoumdjian A, Nassif G, Albert M, Monson J, Lee L. Examining the relationship between lymph node harvest and survival in patients undergoing colectomy for colon adenocarcinoma. Surgery 2019; 166:639-647. [PMID: 31399220 DOI: 10.1016/j.surg.2019.03.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/12/2019] [Accepted: 03/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current standards for lymph node harvest in colorectal cancer surgery may be inadequate. Higher lymph node yield may improve survival, but the number of lymph nodes needed to optimize survival is unknown. The objective of this study was to examine the relationship between lymph node yield and overall survival in patients undergoing colectomy for nonmetastatic colon adenocarcinoma. METHODS The 2010 to 2014 National Cancer Database was queried for patients undergoing colectomy for nonmetastatic colon adenocarcinoma. Adjusted restricted cubic splines were used to model the nonlinear relationship between lymph node harvest and overall survival. Cox proportional hazard determined independent predictors of overall survival. RESULTS A total of 261,423 patients were included. Restricted cubic splines demonstrated that the adjusted improvements in overall survival stabilized after 24 nodes. Patients were divided into: <12, 12 to 23, and ≥24 nodes. On survival analysis, patients with ≥24 nodes had better survival across all N stages compared to other groups (P < .001). Lymph node harvest ≥24 nodes was independently associated with improved overall survival compared to 12 to 23 nodes (hazard ratio 0.82; 95% confidence interval, 0.80-0.85). CONCLUSION Lymph node harvest ≥24 nodes is associated with improved survival in colorectal cancer patients. These data may provide indirect evidence for a more extensive lymphadenectomy for colon cancer.
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Affiliation(s)
- Maude Trepanier
- Surgical Health Outcomes Consortium, Center for Colon and Rectal Surgery, AdventHealth Orlando, Orlando, FL; Department of Surgery, McGill University Health Centre, Montreal, QC
| | - Arman Erkan
- Surgical Health Outcomes Consortium, Center for Colon and Rectal Surgery, AdventHealth Orlando, Orlando, FL
| | - Araz Kouyoumdjian
- Department of Surgery, McGill University Health Centre, Montreal, QC
| | - George Nassif
- Surgical Health Outcomes Consortium, Center for Colon and Rectal Surgery, AdventHealth Orlando, Orlando, FL
| | - Matthew Albert
- Surgical Health Outcomes Consortium, Center for Colon and Rectal Surgery, AdventHealth Orlando, Orlando, FL
| | - John Monson
- Surgical Health Outcomes Consortium, Center for Colon and Rectal Surgery, AdventHealth Orlando, Orlando, FL
| | - Lawrence Lee
- Surgical Health Outcomes Consortium, Center for Colon and Rectal Surgery, AdventHealth Orlando, Orlando, FL; Department of Surgery, McGill University Health Centre, Montreal, QC.
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Gumus M, Yumuk PF, Atalay G, Aliustaoglu M, Macunluoglu B, Dane F, Caglar H, Sengoz M, Turhal S. What is the Optimal Number of Lymph Nodes to be Dissected in Colorectal Cancer Surgery? TUMORI JOURNAL 2019; 91:168-72. [PMID: 15948546 DOI: 10.1177/030089160509100212] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Regional lymph node (LN) involvement in colorectal cancer (CRC) identifies the stage and the subset of patients who would benefit from adjuvant chemotherapy. We performed a retrospective analysis to determine if the number of recovered LNs was associated with long-term outcome in patients operated on for stage II and III CRC. Patients and methods Hospital records of 179 patients with CRC followed in our unit from 1997 to April 2003 were reviewed. Results On average 11.68 ± 7.3 LNs were sampled per surgical specimen. Sampling of at least nine LNs appeared to be the minimum number required for accurately predicting LN involvement ( P = 0.002). Three-year rates of disease-free survival (DFS), local recurrence-free survival (LRFS) and overall survival (OS) were lower in patients with fewer than nine LNs sampled ( P = 0.032, P = 0.006 and P = 0.04, respectively). However, this had no impact on the three-year distant metastasis-free survival rate (DMFS) ( P = 0.472). In stage II disease, patients with nine or more LNs dissected had significantly higher three year DFS and LRFS rates than the subgroup with fewer than nine LNs dissected ( P = 0.024 and P = 0.015, respectively), but this did not have any effect on DMFS or OS ( P = 0.406 and P = 0.353, respectively). Conclusion Current protocols provide adjuvant treatment in stage III patients; the problem is to correctly determine stage by recovering as many LNs as possible.
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Affiliation(s)
- Mahmut Gumus
- Oncology Division, Department of Internal Medicine, Marmara University Hospital, Istanbul, Turkey.
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Tsai HL, Chen YT, Yeh YS, Huang CW, Ma CJ, Wang JY. Apical Lymph Nodes in the Distant Metastases and Prognosis of Patients with Stage III Colorectal Cancer with Adequate Lymph Node Retrieval Following FOLFOX Adjuvant Chemotherapy. Pathol Oncol Res 2019; 25:905-913. [PMID: 29299827 DOI: 10.1007/s12253-017-0381-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/21/2017] [Indexed: 01/10/2023]
Abstract
The aim of the study was to assess apical lymph nodes (APNs) for predicting distant metastases in patients with stage III colorectal cancer (CRC) curatively treated with FOLFOX adjuvant chemotherapy and adequate lymph node retrieval. We investigated the correlation between APN metastasis and clinical outcomes. This retrospective study examined 97 patients. All patients were followed until death, loss to follow-up, or May 2017. Clinicopathological variables, including the APN status, were assessed. Multivariate logistic regression model was used to identify the independent risk factors for APN and distant metastases, and Cox proportional regression model was used to evaluate the association between APN metastasis and oncologic outcomes. Multivariate analyses revealed the N2 stage as an independent predictor of APN metastasis [P = 0.036; odds ratio (OR): 3.016; 95% confidence interval (CI): 1.076-8.499], while APN metastasis was an independent risk factor for distant metastases (P < 0.001; OR: 13.876; 95% CI: 3.815-50.475). Furthermore, APN metastasis was an independent risk factor for poorer disease-free survival (DFS) and overall survival (OS) (P < 0.001 and P = 0.005, respectively). The liver (31.6%) was the most common site of distant metastases in patients with APN metastases. APN metastasis is an important prognostic factor for node-positive CRC; it enhanced the distant metastases in patients with stage III CRC curatively treated with adequate lymph node retrieval following FOLFOX adjuvant chemotherapy. Therefore, for patients with stage III CRC involving APN metastasis, prospectively randomized trials are mandatory to investigate different therapeutic strategies in addition to conventional FOLFOX adjuvant chemotherapy.
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Affiliation(s)
- Hsiang-Lin Tsai
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung, 807, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ting Chen
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Pathology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yung-Sung Yeh
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung, 807, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung, 807, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Jen Ma
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung, 807, Taiwan
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung, 807, Taiwan.
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
- Center for Biomarkers and Biotech Drugs, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
- Research Center for Environmental Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Okada K, Sadahiro S, Chan LF, Ogimi T, Miyakita H, Saito G, Tanaka A, Suzuki T. The Number of Natural Killer Cells in the Largest Diameter Lymph Nodes Is Associated with the Number of Retrieved Lymph Nodes and Lymph Node Size, and Is an Independent Prognostic Factor in Patients with Stage II Colon Cancer. Oncology 2018; 95:288-296. [PMID: 30138925 DOI: 10.1159/000491019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 06/18/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We previously reported that the largest diameter of retrieved lymph nodes (LNs) correlates with the number of LNs and is a prognostic factor in stage II colon cancer. We examine whether T, B, and natural killer (NK) cells in LNs are related to the number of LNs and survival. METHODS The subjects comprised 320 patients with stage II colon cancer. An LN with the largest diameter was selected in each patient. The positive area ratios of cells that stained for CD3 and CD20, and the numbers of CD56-positive cells were measured. RESULTS The CD3-positive area ratio was 0.39 ± 0.08 and CD20-positive area ratio was 0.42 ± 0.10. The mean number of CD56-positive cells was 19.3 ± 22.7. The area ratios of B cells and T cells and the number of NK cells were significantly related to the sizes of the largest diameter LNs. The number of NK cells significantly correlated with the number of LNs and was an independent prognostic factor. On multivariate analysis, pathological T stage (T4 or T3; HR 4.71; p < 0.001) and the number of CD56-positive cells (high or low; HR 0.22; p < 0.001) were found to be independent prognostic factors. CONCLUSIONS The number of NK cells in the largest diameter LNs can most likely be used as a predictor of recurrence.
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12
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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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13
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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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14
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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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15
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Widmar M, Keskin M, Strombom P, Beltran P, Chow OS, Smith JJ, Nash GM, Shia J, Russell D, Garcia-Aguilar J. Lymph node yield in right colectomy for cancer: a comparison of open, laparoscopic and robotic approaches. Colorectal Dis 2017; 19. [PMID: 28649796 PMCID: PMC5642033 DOI: 10.1111/codi.13786] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM Studies have demonstrated a relationship between lymph node (LN) yield and survival after colectomy for cancer. The impact of surgical technique on LN yield has not been well explored. METHOD This is a retrospective study of right colectomy (RC) for cancer at a single institution from 2012 to 2014. Exclusion criteria were previous colectomy and emergent and palliative operations. All data were collected by chart review. Primary outcomes were LN yield and the LN to length of surgical specimen (LN-LSS) ratio. Multivariable mixed models were created with surgeon and pathologist as random effects. Sensitivity analyses were performed to exclude Stage IV cancers and to analyse groups on an 'as-treated' basis. RESULTS We identified 181 open (O-RC), 163 laparoscopic (L-RC) and 119 robotic (R-RC) right colectomies. O-RC was more commonly performed in women with metastatic disease. The mean LN yield was 28, 29 and 34 in O-RC, L-RC and R-RC, respectively; the respective mean LN-LSS ratios were 0.83, 0.91 and 1.0. The R-RC approach produced a higher LN yield than the other approaches (P < 0.01), and a higher LN-LSS ratio than O-RC (P < 0.01). These findings were unchanged in sensitivity analyses. CONCLUSION Robotic right colectomy improves LN yield and the LN-LSS ratio, which may reflect better mesocolic excision. The effect of these findings on survival requires further investigation.
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Affiliation(s)
- Maria Widmar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center,Department of Surgery, Icahn School of Medicine at Mount Sinai
| | - Metin Keskin
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center
| | - Paul Strombom
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center
| | - Pedro Beltran
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center
| | - Oliver S Chow
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center
| | - J. Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center
| | - Garrett M Nash
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center
| | | | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center
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16
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Del Paggio JC, Peng Y, Wei X, Nanji S, MacDonald PH, Krishnan Nair C, Booth CM. Population-based study to re-evaluate optimal lymph node yield in colonic cancer. Br J Surg 2017; 104:1087-1096. [PMID: 28542954 DOI: 10.1002/bjs.10540] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 12/16/2016] [Accepted: 02/14/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND It is well established that lymph node (LN) yield in colonic cancer resection has prognostic significance, although optimal numbers are not clear. Here, LN thresholds associated with both LN positivity and survival were evaluated in a single population-based data set. METHODS Treatment records were linked to the Ontario Cancer Registry to identify a 25 per cent random sample of all patients with stage II/III colonic cancer between 2002 and 2008. Multivariable regression and Cox models evaluated factors associated with LN positivity and cancer-specific survival (CSS) respectively. Optimal thresholds were obtained using sequential regression analysis. RESULTS On adjusted analysis of 5508 eligible patients, younger age (P < 0·001), left-sided tumours (P = 0·003), higher T category (P < 0·001) and greater LN yield (relative risk 0·89, 95 per cent c.i. 0·81 to 0·97; P = 0·007) were associated with a greater likelihood of LN positivity. Regression analyses with multiple thresholds suggested no substantial increase in LN positivity beyond 12-14 LNs. Cox analysis of stage II disease showed that lower LN yield was associated with a significant increase in the risk of death from cancer (CSS hazard ratio range 1·55-1·74; P < 0·001) compared with a greater LN yield, with no significant survival benefit beyond a yield of 20 LNs. Similarly, for stage III disease, a lower LN yield was associated with an increase in the risk of death from cancer (CSS hazard ratio range 1·49-2·20; P < 0·001) versus a large LN yield. In stage III disease, there was no observed LN threshold for survival benefit in the data set. CONCLUSION There is incongruity in the optimal LN evaluation for colonic cancer. Although the historically stated threshold of 12 LNs may ensure accurate staging in colonic cancer, thresholds for optimal survival are associated with far greater yields.
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Affiliation(s)
- J C Del Paggio
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Y Peng
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - X Wei
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - S Nanji
- Departments of Oncology, Queen's University, Kingston, Ontario, Canada.,Departments of Surgery, Queen's University, Kingston, Ontario, Canada
| | - P H MacDonald
- Departments of Surgery, Queen's University, Kingston, Ontario, Canada
| | - C Krishnan Nair
- Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, India
| | - C M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Departments of Oncology, Queen's University, Kingston, Ontario, Canada.,Departments of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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17
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Lisovsky M, Schutz SN, Drage MG, Liu X, Suriawinata AA, Srivastava A. Number of Lymph Nodes in Primary Nodal Basin and a “Second Look” Protocol as Quality Indicators for Optimal Nodal Staging of Colon Cancer. Arch Pathol Lab Med 2016; 141:125-130. [DOI: 10.5858/arpa.2015-0401-oa] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Evaluation of 12 or more lymph nodes (LNs) is currently used as a quality indicator for adequacy of pathologic examination of colon cancer resections.
Objective.—To evaluate the utility of a focused LN search in the immediate vicinity of the tumor and a “second look” protocol in improving LN staging in colon cancer.
Design.—Lymph nodes were submitted separately from the primary nodal basin (PNB) and secondary nodal basin (SNB) defined as an area less than 5 cm away and an area greater than 5 cm away from the tumor edge, respectively, in 201 consecutive resections (2010–2013). One hundred sixty-eight consecutive tumors (2006–2009) were used as a control group. A second search was performed in all cases that were N0 after the first search.
Results.—In cases that were N0 after the first search, 20.9 ± 10.8 LNs were collected from the PNB, compared to 8.5 ± 9.1 from the SNB. Positive LNs were found in N+ tumors in the PNB in all cases but in only 9% (4 of 46) of SNBs (P < .001). A second search increased node count by an average of 10 additional LNs. In 5 of 114 cases (4.4%), N0 after the first search converted to N+ after a second search that yielded 1 to 4 positive LNs, all of which were in the PNB.
Conclusions.—Emphasis on the number of LNs examined from the PNB and a “second look” protocol improve nodal staging.
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Affiliation(s)
| | | | | | | | | | - Amitabh Srivastava
- From the Department of Pathology (Drs Lisovsky, Liu, and Suriawinata and Ms Schutz), Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and the Department of Pathology (Drs Drage and Srivastava), Brigham & Women's Hospital, Boston, Massachusetts
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18
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Farshidfar F, Weljie AM, Kopciuk KA, Hilsden R, McGregor SE, Buie WD, MacLean A, Vogel HJ, Bathe OF. A validated metabolomic signature for colorectal cancer: exploration of the clinical value of metabolomics. Br J Cancer 2016; 115:848-57. [PMID: 27560555 PMCID: PMC5046202 DOI: 10.1038/bjc.2016.243] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/15/2016] [Accepted: 07/15/2016] [Indexed: 12/24/2022] Open
Abstract
Background: Timely diagnosis and classification of colorectal cancer (CRC) are hindered by unsatisfactory clinical assays. Our aim was to construct a blood-based biomarker series using a single assay, suitable for CRC detection, prognostication and staging. Methods: Serum metabolomic profiles of adenoma (N=31), various stages of CRC (N=320) and healthy matched controls (N=254) were analysed by gas chromatography-mass spectrometry (GC-MS). A diagnostic model for CRC was derived by orthogonal partial least squares-discriminant analysis (OPLS-DA) on a training set, and then validated on an independent data set. Metabolomic models suitable for identifying adenoma, poor prognosis stage II CRC and discriminating various stages were generated. Results: A diagnostic signature for CRC with remarkable multivariate performance (R2Y=0.46, Q2Y=0.39) was constructed, and then validated (sensitivity 85% specificity 86%). Area under the receiver-operating characteristic curve was 0.91 (95% CI, 0.87–0.96). Adenomas were also detectable (R2Y=0.35, Q2Y=0.26, internal AUROC=0.81, 95% CI, 0.70–0.92). Also of particular interest, we identified models that stratified stage II by prognosis, and classified cases by stage. Conclusions: Using a single assay system, a suite of CRC biomarkers based on circulating metabolites enables early detection, prognostication and preliminary staging information. External population-based studies are required to evaluate the repeatability of our findings and to assess the clinical benefits of these biomarkers.
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Affiliation(s)
- Farshad Farshidfar
- Department of Surgery, University of Calgary, Calgary, AB, Canada.,Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Aalim M Weljie
- Department of Biological Sciences, University of Calgary, Calgary, AB, Canada.,Institute for Translational Medicine and Therapeutics, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen A Kopciuk
- Department of Mathematics and Statistics, University of Calgary, Calgary, AB, Canada.,Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada
| | - Robert Hilsden
- Department of Medicine, University of Calgary, Calgary, AB, Canada.,Forzani and MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, AB, Canada
| | - S Elizabeth McGregor
- Department of Oncology, University of Calgary, Calgary, AB, Canada.,Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada
| | - W Donald Buie
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Anthony MacLean
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Hans J Vogel
- Department of Biological Sciences, University of Calgary, Calgary, AB, Canada
| | - Oliver F Bathe
- Department of Surgery, University of Calgary, Calgary, AB, Canada.,Department of Oncology, University of Calgary, Calgary, AB, Canada
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19
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Kennelly RP, Murphy B, Larkin JO, Mehigan BJ, McCormick PH. Activated systemic inflammatory response at diagnosis reduces lymph node count in colonic carcinoma. World J Gastrointest Oncol 2016; 8:623-628. [PMID: 27574555 PMCID: PMC4980653 DOI: 10.4251/wjgo.v8.i8.623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 04/06/2016] [Accepted: 05/27/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate a link between lymph node yield and systemic inflammatory response in colon cancer.
METHODS: A prospectively maintained database was interrogated. All patients undergoing curative colonic resection were included. Neutrophil lymphocyte ratio (NLR) and albumin were used as markers of SIR. In keeping with previously studies, NLR ≥ 4, albumin < 35 was used as cut off points for SIR. Statistical analysis was performed using 2 sample t-test and χ2 tests where appropriate.
RESULTS: Three hundred and two patients were included for analysis. One hundred and ninety-five patients had NLR < 4 and 107 had NLR ≥ 4. There was no difference in age or sex between groups. Patients with NLR of ≥ 4 had lower mean lymph node yields than patients with NLR < 4 [17.6 ± 7.1 vs 19.2 ± 7.9 (P = 0.036)]. More patients with an elevated NLR had node positive disease and an increased lymph node ratio (≥ 0.25, P = 0.044).
CONCLUSION: Prognosis in colon cancer is intimately linked to the patient’s immune response. Assuming standardised surgical technique and sub specialty pathology, lymph node count is reduced when systemic inflammatory response is activated.
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20
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Kazakydasan S, Rahman ZAA, Ismail SM, Abraham MT, Kallarakkal TG. Prognostic significance of VEGF-C in predicting micrometastasis and isolated tumour cells in N0 oral squamous cell carcinoma. J Oral Pathol Med 2016; 46:194-200. [PMID: 27417330 DOI: 10.1111/jop.12476] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lymph node metastasis in oral squamous cell carcinoma (OSCC) is a well-known independent prognostic factor. However, the identification of occult tumour cells within the lymph nodes has remained a challenge for the pathologist as well as the clinician. OBJECTIVE The aim of this study was to determine the prevalence of micrometastasis and isolated tumour cells (ITCs) in pathologically staged N0 OSCC of the tongue and buccal mucosa and to assess its correlation with vascular endothelial growth factor C, (VEGF-C) expression in the primary tumour. METHODS Thirty-four cases of N0 OSCC comprising of 17 cases each from the tongue and buccal mucosa were evaluated by immunohistochemistry for VEGF-C expression. The corresponding lymph nodes from levels I and II were pathologically examined and cross-detected for micrometastasis and ITCs with desmoglein 3 (DSG3). RESULTS The prevalence of micrometastasis and ITCs in OSCC of the tongue and buccal mucosa was 23.5% and 17.6%, respectively. A total of 12 out of 151 lymph nodes contained micrometastatic tumour foci and ITCs. A higher expression of VEGF-C in the primary tumour was associated with a greater probability for the occurrence of micrometastasis and ITCs in the lymph nodes. CONCLUSION High expression of VEGF-C in the primary tumour may be a good determinant for detection of occult tumour cells in the lymph nodes of OSCC cases.
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Affiliation(s)
- Sarvambika Kazakydasan
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
| | - Zainal Ariff Abdul Rahman
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.,Oral Cancer Research and Coordinating Centre, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
| | - Siti Mazlipah Ismail
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.,Oral Cancer Research and Coordinating Centre, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
| | - Mannil Thomas Abraham
- Department of Oral and Maxillofacial Surgery, Hospital Tengku Ampuan Rahimah, Ministry of Health, Klang, Selangor, Malaysia
| | - Thomas George Kallarakkal
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.,Oral Cancer Research and Coordinating Centre, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
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Impact of age on the prognostic value of number of lymph nodes retrieved in patients with stage II colorectal cancer. Int J Colorectal Dis 2016; 31:1307-13. [PMID: 27234041 DOI: 10.1007/s00384-016-2602-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE A small number of lymph nodes retrieved (NLNR) is a known risk factor in stage II colorectal cancer. NLNR is influenced by age, but little is known about whether the impact of small NLNR on survival differs with age. This retrospective study sought to determine such impact in elderly patients with stage II colorectal cancer. METHODS We reviewed data for 2100 patients with stage II colorectal cancer who underwent surgery without adjuvant chemotherapy between January 1997 and December 2003. The optimal cutoff value of NLNR for survival was determined, and the impact of small NLNR on survival was analyzed. The association between age and NLNR was evaluated. The relation between age and risk of small NLNR with respect to survival was then assessed to determine the impact of small NLNR on elderly patients' survival. RESULTS The optimal cutoff value of NLNR was determined as 6. The small NLNR group (SNG) showed significantly worse prognosis than the large NLNR group (LNG) (p < 0.001). Age, surgical method, and scope of lymph node dissection were significantly associated with NLNR. A potential interaction was noted between age and risk of small NLNR in relation to relapse-free survival (RFS). Five-year RFS was significantly worse in SNG than in LNG for elderly patients (41.7 and 76.4 %, respectively; p < 0.001) but not for non-elderly patients (75.9 and 84.6 %, respectively; p = 0.083). CONCLUSIONS NLNR <6 was identified to be an important prognostic factor for elderly patients with stage II colorectal cancer.
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Wood P, Peirce C, Mulsow J. Non-surgical factors influencing lymph node yield in colon cancer. World J Gastrointest Oncol 2016; 8:466-473. [PMID: 27190586 PMCID: PMC4865714 DOI: 10.4251/wjgo.v8.i5.466] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/15/2015] [Accepted: 03/09/2016] [Indexed: 02/05/2023] Open
Abstract
There are numerous factors which can affect the lymph node (LN) yield in colon cancer specimens. The aim of this paper was to identify both modifiable and non-modifiable factors that have been demonstrated to affect colonic resection specimen LN yield and to summarise the pertinent literature on these topics. A literature review of PubMed was performed to identify the potential factors which may influence the LN yield in colon cancer resection specimens. The terms used for the search were: LN, lymphadenectomy, LN yield, LN harvest, LN number, colon cancer and colorectal cancer. Both non-modifiable and modifiable factors were identified. The review identified fifteen non-surgical factors: (13 non-modifiable, 2 modifiable) which may influence LN yield. LN yield is frequently reduced in older, obese patients and those with male sex and increased in patients with right sided, large, and poorly differentiated tumours. Patient ethnicity and lower socioeconomic class may negatively influence LN yield. Pre-operative tumour tattooing appears to increase LN yield. There are many factors that potentially influence the LN yield, although the strength of the association between the two varies greatly. Perfecting oncological resection and pathological analysis remain the cornerstones to achieving good quality and quantity LN yields in patients with colon cancer.
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Ashktorab H, Ogundipe T, Brim H, Shahnazi A, Laiyemo AO, Lee E, Shokrani B, Nouraie M. Lymph nodes' evaluation in relation to colorectal cancer staging among African Americans. BMC Cancer 2015; 15:976. [PMID: 26673446 PMCID: PMC4682272 DOI: 10.1186/s12885-015-1946-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 11/20/2015] [Indexed: 01/28/2023] Open
Abstract
Background Lymph nodes’ examination in colorectal cancer (CRC) resection specimens is an important determinant that aids in the accuracy of CRC staging and treatment outcomes. Current guidelines call for the examination of at least 12 lymph nodes (LN) in resected specimens in order to establish accurate staging. Aim To investigate lymph nodes’ examination protocol as it relates to accurate CRC staging. Methods We reviewed 216 African American CRC patients from 1996–2013 who underwent CRC resection and met inclusion criteria for this study. The number of retrieved LNs, length of resected specimens, tumor grade, stage, location, size and histology were examined. Results The cohort study was made of 49 % males, median age was 63 years and 45 % of patients were at stage III and IV. The median (IQR) number of examined LNs was 15 (10–22) and the rate of patients with more than 12 examined LNs was 64 %. There was a gradual increase in the percentage of patients with adequate number (>12) of examined LNs during the study period (from 60 % in 1996–2000 to 84 % in 2010–2013 period, P = 0.014). Adequate LNs resection was neither associated with shift of stage from II to III (P = 0.3) nor with the changes from stage IIIa to IIIc (P = 0.9). Metastatic LNs were observed in 8 % of samples with LNs (>12) vs. 13 % of samples with <12 examined LNs (P = 0.1). Patients that had pre-surgical treatment (chemotherapy and radiotherapy) before surgery had <12 LNs examined. There was also a trend of having more examined lymph nodes in large tumors. Conclusions Our study shows that there has been an increase in the number of lymph nodes examined in CRC resections since the advent of the current quality initiative. However this increase does not seem to affect the stage or percentage of metastatic lymph nodes’ detection in CRC patients.
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Affiliation(s)
- Hassan Ashktorab
- Department of Medicine and Cancer Center, Howard University College of Medicine, 2041 Georgia Avenue, Washington, DC, 20060, USA.
| | - Temitayo Ogundipe
- Department of Medicine and Cancer Center, Howard University College of Medicine, 2041 Georgia Avenue, Washington, DC, 20060, USA.
| | - Hassan Brim
- Department of Pathology, Howard University College of Medicine, Washington, DC, USA.
| | - Anahita Shahnazi
- Department of Medicine and Cancer Center, Howard University College of Medicine, 2041 Georgia Avenue, Washington, DC, 20060, USA.
| | - Adeyinka O Laiyemo
- Department of Medicine and Cancer Center, Howard University College of Medicine, 2041 Georgia Avenue, Washington, DC, 20060, USA.
| | - Edward Lee
- Department of Pathology, Howard University College of Medicine, Washington, DC, USA.
| | - Babak Shokrani
- Department of Pathology, Howard University College of Medicine, Washington, DC, USA.
| | - Mehdi Nouraie
- Department of Medicine and Cancer Center, Howard University College of Medicine, 2041 Georgia Avenue, Washington, DC, 20060, USA.
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Märkl B. Stage migration vs immunology: The lymph node count story in colon cancer. World J Gastroenterol 2015; 21:12218-12233. [PMID: 26604632 PMCID: PMC4649108 DOI: 10.3748/wjg.v21.i43.12218] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/26/2015] [Indexed: 02/06/2023] Open
Abstract
Lymph node staging is of crucial importance for the therapy stratification and prognosis estimation in colon cancer. Beside the detection of metastases, the number of harvested lymph nodes itself has prognostic relevance in stage II/III cancers. A stage migration effect caused by missed lymph node metastases has been postulated as most likely explanation for that. In order to avoid false negative node staging reporting of at least 12 lymph nodes is recommended. However, this threshold is met only in a minority of cases in daily practice. Due to quality initiatives the situation has improved in the past. This, however, had no influence on staging in several studies. While the numbers of evaluated lymph nodes increased continuously during the last decades the rate of node positive cases remained relatively constant. This fact together with other indications raised doubts that understaging is indeed the correct explanation for the prognostic impact of lymph node harvest. Several authors assume that immune response could play a major role in this context influencing both the lymph node detectability and the tumor’s behavior. Further studies addressing this issue are need. Based on the findings the recommendations concerning minimal lymph node numbers and adjuvant chemotherapy should be reconsidered.
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25
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Yegen G, Keskin M, Büyük M, Kunduz E, Balık E, Sağlam EK, Kapran Y, Asoğlu O, Güllüoğlu M. The effect of neoadjuvant therapy on the size, number, and distribution of mesorectal lymph nodes. Ann Diagn Pathol 2015; 20:29-35. [PMID: 26706785 DOI: 10.1016/j.anndiagpath.2015.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 10/12/2015] [Indexed: 12/14/2022]
Abstract
The current therapeutic approach to patients with locally advanced rectal cancer is neoadjuvant radiotherapy or chemoradiotherapy followed by total mesorectal excision. We aimed to investigate the number, size, and distribution of metastatic and nonmetastatic lymph nodes within the mesorectum; whether neoadjuvant therapy has any impact on the number and size of the lymph nodes; and the impact of metastatic lymph node localization on overall and disease-free survival. Specimens from 50 consecutive patients with stage II/III rectal cancer receiving either neoadjuvant radiotherapy or chemoradiotherapy were investigated. Lymph node dissection was carried out by careful visual inspection and palpation. The localization of the each lymph node within the mesorectum and the relation with the tumor site were noted. The size and the number of lymph nodes retrieved decreased significantly with neoadjuvant therapy. Majority of the metastatic and nonmetastatic lymph nodes were located at or proximally to the tumor level and posterior side of the mesorectum. No relation was observed between the overall and disease-free survival, and the localization of the metastatic lymph nodes. Presence of lymph node metastases proximal to the tumor level has no impact on survival compared with the presence of lymph node metastasis only in the peritumoral region of the mesorectum. Although neoadjuvant therapy decreases the size and the number of lymph nodes, reaching an ideal number of lymph nodes for accurate staging is still possible with careful naked eye examination and dissection of perirectal fat. As the majority of metastatic and nonmetastatic lymph nodes are located in peritumoral and proximal compartment, and posterior side of the mesorectum, these regions should be the major interest of dissection.
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Affiliation(s)
- Gülçin Yegen
- Istanbul University Istanbul Faculty of Medicine, Department of Pathology, Istanbul, Turkey
| | - Metin Keskin
- Istanbul University Istanbul Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Melek Büyük
- Istanbul University Istanbul Faculty of Medicine, Department of Pathology, Istanbul, Turkey
| | - Enver Kunduz
- Istanbul University Istanbul Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Emre Balık
- Koç University, Faculty of Medicine, Department of General Surgery and Istanbul University Istanbul Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Esra Kaytan Sağlam
- Istanbul University, Institute of Oncology, Department of Radiation Oncology, Istanbul, Turkey
| | - Yersu Kapran
- Istanbul University Istanbul Faculty of Medicine, Department of Pathology, Istanbul, Turkey
| | - Oktar Asoğlu
- Liv Hospital, Department of General Surgery and Istanbul University Istanbul Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Mine Güllüoğlu
- Istanbul University Istanbul Faculty of Medicine, Department of Pathology, Istanbul, Turkey.
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26
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da Costa DW, Vrouenraets BC, Witte BI, van Dekken H. Which Lymph Nodes Contain Metastases in Colon Cancer Patients? A Retrospective Histopathological Evaluation of 156 Patients. Int J Surg Pathol 2015. [DOI: 10.1177/1066896915597751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background. We hypothesized that a reliable N0 status can be established by sampling and evaluating the largest lymph nodes in the resected large-bowel specimen of patients with colon cancer. Patients and methods. This was a retrospective analysis of all surgical colon cancer patients treated between 2008 and 2010, excluding those who had received neoadjuvant treatment. We analyzed the relationship between lymph node size and the presence of metastasis. Furthermore, we examined other prognostic factors for a histopathological N+ status. Results. Our patient group consisted of 156 patients with a median age of 73 years (range = 29-91 years). A total of 2044 lymph nodes (a median of 12 per patient, range = 2-47 nodes) were harvested, 1803 (88.2%) without and 241 (11.8%) with tumor spread. Using a unique ranking model, we found that in 58 out of the 59 N+ patients (98.3%, 95% confidence interval = 90.9% to 99.9%), the largest tumor-positive node was among the 5 largest lymph nodes in the specimen. The examination of ≥10 lymph nodes had no effect on the chance of finding a positive lymph node compared with examination of <10 nodes ( P = .46). Conclusion. In our study, the N-stage was determined by the 5 largest nodes in almost all specimens. The chance of finding a small tumor-positive node when the larger ones were clean was very small.
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27
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Chen SC, Shyr YM, Chou SC, Wang SE. The role of lymph nodes in predicting the prognosis of ampullary carcinoma after curative resection. World J Surg Oncol 2015. [PMID: 26205252 PMCID: PMC4513626 DOI: 10.1186/s12957-015-0643-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Lymph node involvement is one of the well-demonstrated prognostic factors in ampullary carcinoma. The aim of this study is to clarify the role of lymph nodes in predicting the survival outcome of ampullary carcinoma. METHODS A cohort of consecutive curative pancreaticoduodenectomies for ampullary carcinoma from 1999 to 2014 was retrospectively analyzed. The effect of node-associated variables, including lymph node status, positive lymph node number, total harvested lymph node (THLN) number, and lymph node ratio (LNR) was examined using univariate and multivariate analyses for survival outcome prediction. RESULTS In 194 evaluable patients, univariate analysis demonstrated that stage, cell differentiation, perineural invasion, and nodal status were significant conventional prognostic factors. Concerning the node-associated variables, positive nodal status, positive lymph node number≥2, THLN number<14, and LNR≥0.15 were significantly associated with poorer survival outcomes, with a 5-year survival rate of 20.3, 38.9, 25.4, and 18%, respectively. By multivariate analysis, nodal status and THLN number were two independent predictors of survival. The most favorable 5-year survival rate was 84.4% in patients with negative nodal involvement and THLN number≥14, compared with the poorest 5-year survival rate of 16.1% in those with positive nodal status and THLN number<14. CONCLUSIONS Tumor biology reflected by lymph node status is the most important independent prognostic factor; nevertheless, surgical radicality based on THLN number also plays a significant role in the survival outcome for patients with ampullary carcinoma after curative pancreaticoduodenectomy.
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Affiliation(s)
- Shih-Chin Chen
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, 10 F 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, 10 F 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
| | - Shu-Cheng Chou
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, 10 F 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, 10 F 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
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da Costa DW, van Dekken H, Witte BI, van Wagensveld BA, van Tets WF, Vrouenraets BC. Lymph Node Yield in Colon Cancer: Individuals Can Make the Difference. Dig Surg 2015; 32:269-74. [PMID: 26113047 DOI: 10.1159/000381863] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 03/24/2015] [Indexed: 01/18/2023]
Abstract
AIM To investigate the influence of individual surgeons and pathologists on examining an adequate (i.e. ≥10) number of lymph nodes in colon cancer resection specimens. PATIENTS AND METHODS The number of lymph nodes was evaluated in surgically treated patients for colon cancer at our hospital from 2008 through 2010, excluding patients who had received neo-adjuvant treatment. The patient group consisted of 156 patients with a median age of 73 (interquartile range (IQR) 63-82 years) and a median of 12 lymph nodes per patient (IQR 8-15). In 106 patients (67.9%), 10 or more nodes were histopathologically examined. RESULTS At univariate analysis, the examination of ≥10 nodes was influenced by tumour size (p = 0.05), tumour location (p = 0.015), type of resection (p = 0.034), individual surgeon (p = 0.023), and pathologist (p = 0.005). Neither individual surgeons nor pathologists did statistically and significantly influence the chance of finding an N+ status. Age (p = 0.044), type of resection (p = 0.007), individual surgeon (p = 0.012) and pathologist (p = 0.004) were independent prognostic factors in a multivariate model for finding ≥10 nodes. CONCLUSION Though cancer staging was not affected in this study, individual efforts by surgeons and pathologists play a critical role in achieving optimal lymph node yield through conventional methods.
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Affiliation(s)
- David W da Costa
- Department of Surgery, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands
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Frankel WL, Jin M. Serosal surfaces, mucin pools, and deposits, oh my: challenges in staging colorectal carcinoma. Mod Pathol 2015; 28 Suppl 1:S95-108. [PMID: 25560604 DOI: 10.1038/modpathol.2014.128] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 07/11/2014] [Accepted: 07/12/2014] [Indexed: 02/06/2023]
Abstract
Colorectal carcinoma is the third most common cancer in the United States. Proper and standardized pathologic staging is vital for prognostic assessment and impacts therapeutic decisions. The Tumor Node Metastasis (TNM) staging system was developed by the American Joint Committee on Cancer (AJCC) to be a data-driven, evidence-based staging system providing an accurate prediction of outcome. The AJCC 7th edition (2010) included several changes clarifying some issues and leading to new controversies. We aim to address selected challenging issues in tumor T staging, neoadjuvant treatment effects in rectal cancer, and definition of lymph node vs tumor deposit. Serosal involvement in colorectal cancer is staged as T4, which is associated with decreased survival and may impact additional therapy decisions. Although careful sampling and sectioning are helpful, challenges remain in interpretation of tumor within 1 mm of serosal surface with a reaction. Elastic stain as a surrogate marker for serosal invasion has been studied, but its usefulness remains unclear. Some unique issues in rectal cancer include the presence of serosa in proximal but not in distal tumors and post-neoadjuvant effects. Tumor should be staged based on tumor cells rather than acellular mucin pools. Additionally, tumor response should be graded only in primary tumor but not in lymph nodes or metastatic sites. The distinction between tumor deposits and lymph nodes has been modified in AJCC TNM from using size in the 5th edition, to the round contour in the 6th edition, to only features of residual lymph node architecture in the 7th edition. Interobserver variability remains but tumor deposits should be documented when present. The number of deposits should not be added to the total number of positive lymph nodes, and the N1c designation should only be used in cases without any positive lymph nodes. Future clarification will likely evolve as more data become available.
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Affiliation(s)
- Wendy L Frankel
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ming Jin
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Okada K, Sadahiro S, Suzuki T, Tanaka A, Saito G, Masuda S, Haruki Y. The size of retrieved lymph nodes correlates with the number of retrieved lymph nodes and is an independent prognostic factor in patients with stage II colon cancer. Int J Colorectal Dis 2015; 30:1685-93. [PMID: 26260481 PMCID: PMC4675793 DOI: 10.1007/s00384-015-2357-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE In stage II colon cancer, patients with many retrieved lymph nodes (LNs) have been reported to have better oncological outcomes. We tested the hypothesis that the greater number of retrieved LNs is related to a larger LN size. METHODS The subjects comprised 320 patients with stage II colon cancer who underwent curative resection. All operations were elective and were performed by the same surgeons. The maximum long axis and short axis diameters of LNs were measured on hematoxylin-eosin-stained specimens. RESULTS A total of 4,744 LNs were evaluated. The number of retrieved LNs was 14.8 ± 10.1 (mean ± SD). The long axis diameter was 4.8 ± 2.6 mm, with a median value of 4.3 mm, a maximum value of 20.4 mm, and a minimum value of 0.6 mm. The corresponding short axis diameters were 3.4 ± 1.7, 3.0, 15.1, and 0.5 mm, respectively. The highest correlation coefficient for the association with the number of LNs was obtained for the maximum value of the long axis diameter (0.59). Multivariate analysis revealed that age, tumor location, pathological T stage, and the maximum long axis diameter were independent prognostic factors. The number of LNs was not a significant factor. Patients with less than 12 LNs and a maximum long axis diameter of less than 10 mm had significantly poorer outcomes (p < 0.001). CONCLUSION In patients with stage II colon cancer, the maximum long axis diameter of LNs correlated with the number of LNs and was an independent prognostic factor.
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Affiliation(s)
- Kazutake Okada
- />Department of Surgery, Tokai University, 143 Shimokasuya Isehara, Kanagawa, 259-1193 Japan
| | - Sotaro Sadahiro
- />Department of Surgery, Tokai University, 143 Shimokasuya Isehara, Kanagawa, 259-1193 Japan
| | - Toshiyuki Suzuki
- />Department of Surgery, Tokai University, 143 Shimokasuya Isehara, Kanagawa, 259-1193 Japan
| | - Akira Tanaka
- />Department of Surgery, Tokai University, 143 Shimokasuya Isehara, Kanagawa, 259-1193 Japan
| | - Gota Saito
- />Department of Surgery, Tokai University, 143 Shimokasuya Isehara, Kanagawa, 259-1193 Japan
| | - Shinobu Masuda
- />Department of Pathology, Nihon University, Tokyo, Japan
| | - Yasuo Haruki
- />Department of Basic Medical Science, Tokai University, Isehara, Japan
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Issaka A, Ermerak NO, Bilgi Z, Kara VH, Celikel CA, Batirel HF. Preoperative Chemoradiation Therapy Decreases the Number of Lymph Nodes Resected During Esophagectomy. World J Surg 2014; 39:721-6. [DOI: 10.1007/s00268-014-2847-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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32
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Park IJ, Yu CS, Lim SB, Yoon YS, Kim CW, Kim TW, Kim JH, Kim JC. Prognostic implications of the number of retrieved lymph nodes of patients with rectal cancer treated with preoperative chemoradiotherapy. J Gastrointest Surg 2014; 18:1845-1851. [PMID: 25091834 DOI: 10.1007/s11605-014-2509-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 03/16/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of the number of retrieved lymph nodes (LNs) on oncological outcomes in patients with rectal cancer remains unclear. This study was designed to evaluate the prognostic implications of the number of retrieved LNs in patients with rectal cancer receiving preoperative chemoradiotherapy (CRT). METHODS The study cohort consisted of 859 patients with locally advanced (cT3-4 or cN+) mid to low rectal cancer that had been treated with preoperative CRT and radical resection between 2000 and 2009. Multivariate analysis and the Kaplan-Meier method were used to evaluate the influence of the number of retrieved LNs on disease-free survival (DFS). RESULTS The median number of LNs retrieved from included patients was 13 (interquartile range [IQR] 9-17). Multivariate analysis confirmed the independent prognostic importance of the number of retrieved LNs on DFS (hazard ratio = 0.97, 95% confidence interval = 0.95-0.99, p = 0.029). The 3-year DFS rate in patients with yp stage II rectal cancer was associated with the total number of retrieved LNs. CONCLUSIONS DFS was associated with the number of LNs retrieved from patients with rectal cancer who received preoperative CRT, especially among patients with ypT3-4 N0 stage tumors. The oncological importance of the number of retrieved LNs should be considered when treating these patients.
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Affiliation(s)
- In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, South Korea,
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Bläker H, Hildebrandt B, Riess H, von Winterfeld M, Ingold-Heppner B, Roth W, Kloor M, Schirmacher P, Dietel M, Tao S, Jansen L, Chang-Claude J, Ulrich A, Brenner H, Hoffmeister M. Lymph node count and prognosis in colorectal cancer: the influence of examination quality. Int J Cancer 2014; 136:1957-66. [PMID: 25231924 DOI: 10.1002/ijc.29221] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 08/27/2014] [Accepted: 09/03/2014] [Indexed: 12/21/2022]
Abstract
Colorectal cancer guidelines recommend adjuvant chemotherapy in stage II disease when less than 12 lymph nodes are assessed. The recommendation bases on previous studies showing an association of a low lymph node count and adverse outcome. Compared to current standards, however, the quality of lymph node examination in the studies was low. We, therefore, investigated the prognostic role of <12 lymph nodes in cancers diagnosed adherent to current quality measures. Stage I-IV colorectal cancers from 1,899 patients enrolled into a population-based cohort study were investigated for the prognostic impact of a lymph node count <12. The stage specific share of patients diagnosed with ≥12 nodes (stage I-IV: 62, 85, 85, 78%, respectively) was used to compare lymph node examination quality to other studies. We found no impact of a lymph node count <12 on overall, cancer-specific or recurrence-free survival for any tumour stage. Compared to studies reporting an adverse prognostic impact of a low lymph node count in stages II and III the stage-specific shares of patients with ≥12 nodes were markedly higher in this study (85% vs. 24-58% in previous analyses) and this correlated with increased rates of stage III compared to stage II cancers. In conclusion our data indicate, that the previously reported effect of a low lymph node count on the patients' outcomes is eliminated by improved lymph node examination quality and thus question the general applicability of a 12 lymph node cut off for adjuvant chemotherapy decision making in stage II disease.
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Affiliation(s)
- Hendrik Bläker
- Department of General Pathology, Institute of Pathology, Charite University Medicine Hospital, Charitéplatz 1, Berlin, Germany
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Kır G, Alimoglu O, Sarbay BC, Bas G. Ex vivo intra-arterial methylene blue injection in the operation theater may improve the detection of lymph node metastases in colorectal cancer. Pathol Res Pract 2014; 210:818-21. [PMID: 25282546 DOI: 10.1016/j.prp.2014.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 08/04/2014] [Accepted: 09/10/2014] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Lymph node (LN) assessment after colorectal cancer resection is fundamentally important for therapeutic and prognostic reasons. LN positivity is an indication for adjuvant treatment. This study aimed to investigate whether immediate postoperative intra-arterial methylene blue (MB) injection (MBI) into colorectal cancer specimens by a surgeon in the operating room could improve the rate of total LN and metastatic LN recovery for pathological examination. MATERIALS AND METHODS Seventy-three consecutive patients prospectively enrolled between January 2011 and December 2013 were assigned to the methylene blue (MB)-stained group and compared with 107 controls in the unstained group. RESULTS The median number and range values of metastatic LNs, the number of LNs <0.5 cm, the total number of LNs harvested, and the number of cases with LN metastasis were significantly different between the MB-stained and MB-unstained groups (p = 0.016, p = 0.010, p = 0.025, and p = 0.006 respectively). CONCLUSIONS Immediate MBI (fresh, unfixed samples) by a surgeon in the operating room may result in a significant increase in the number of metastatic LNs diagnosed and the number of cases with positive LNs. Shifting of the injection from the pathology laboratory to the operation theater would be a good alternative whenever the operation theater is not the area located as the pathology department.
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Affiliation(s)
- G Kır
- Pathology Department, Umraniye Education and Research Hospital, Istanbul, Turkey.
| | - O Alimoglu
- General Surgery Department, Medeniyet University, Istanbul, Turkey
| | - B C Sarbay
- Pathology Department, Umraniye Education and Research Hospital, Istanbul, Turkey
| | - G Bas
- General Surgery Department, Umraniye Education and Research Hospital, Istanbul, Turkey
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Budde CN, Tsikitis VL, Deveney KE, Diggs BS, Lu KC, Herzig DO. Increasing the number of lymph nodes examined after colectomy does not improve colon cancer staging. J Am Coll Surg 2014; 218:1004-11. [PMID: 24661856 DOI: 10.1016/j.jamcollsurg.2014.01.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 12/31/2013] [Accepted: 01/22/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current quality initiatives call for examination of at least 12 lymph nodes in curative colon cancer resections. The aim of this study was to determine if the number of nodes harvested has increased, and if the increased number nodes correlates with improved staging or overall survival. STUDY DESIGN A review of the Surveillance, Epidemiology, and End Results program database from 2004-2010 was performed. All patients who underwent colon cancer resection during this date range were analyzed. Number of nodes retrieved, patient stage, overall survival, and overall survival by stage were examined. Multivariable analysis controlled for stage, cancer site, age, year of diagnosis, and number of nodes retrieved. Improved staging was defined as increased detection of stage III patients. RESULTS A total of 147,076 patients met inclusion criteria. Median number of nodes analyzed increased sequentially with each year examined, from 12 in 2004 to 17 in 2010. Despite greater number of total nodes obtained and analyzed, there was no increase in the percentage of patients with positive nodes (stage III disease). On multivariable analysis, after controlling for stage, site of disease, age, and year of diagnosis, there was a slight overall survival benefit with increasing nodal retrieval (hazard ratio = 0.987 for each additional node removed; 95% CI, 0.986-0.988; p < 0.001). CONCLUSIONS Since quality initiatives have been put in place, there has been an increase in the number of nodes examined in colon cancer resections, but no improvement in staging. The improved survival seen with higher node counts was independent of stage, site of disease, patient age, and year of diagnosis.
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Affiliation(s)
- Cristina N Budde
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR.
| | - Vassiliki L Tsikitis
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Karen E Deveney
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Brian S Diggs
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Kim C Lu
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Daniel O Herzig
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
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Adequacy of lymph node retrieval for ampullary cancer and its association with improved staging and survival. World J Surg 2014; 37:1397-404. [PMID: 23546531 DOI: 10.1007/s00268-013-1995-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of the present study was to determine the optimal number of lymph nodes (LN) examined to stage pN0 tumors after surgery for ampulla of Vater carcinoma (AVC). METHODS We reviewed retrospectively 127 patients with AVC who underwent pancreaticoduodenectomy (1990-2008). Univariate and multivariate analysis was performed. RESULTS Fifty-nine patients (46.5 %) were pN0, whereas 68 patients (53.5 %) were pN1. The 5-year disease-specific survival (DSS) was worse for pN1 patients than for pN0 patients (46 vs. 77 %; P < 0.0001). In the pN0 cohort, the optimal cut-off number of LN analyzed was found to be 12. The 5-year DSS for patients with ≤ 12 LN was 50 %, compared with 89 % in those with >12 LN (P = 0.001). By multivariate analysis, a LN count >12 was the only independent predictor associated with improved survival (HR 0.16, P = 0.003) among pN0 patients. Among pN1 patients, a LN count >12 was associated with a significantly better 5-year DSS (59 vs. 22 %; P = 0.027). Patients with a lymph node ratio (LNR) >0.20 had a 5-year DSS of 24 %, compared with 58 % in those with 0 < LNR ≤ 0.20 (P = 0.038). CONCLUSIONS Removal of more than 12 LN for examination is associated with improved survival rate after surgery for AVC in both pN0 and pN1 patients.
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McFadden C, McKinley B, Greenwell B, Knuckolls K, Culumovic P, Schammel D, Schammel C, Trocha SD. Differential lymph node retrieval in rectal cancer: associated factors and effect on survival. J Gastrointest Oncol 2013; 4:158-63. [PMID: 23730511 DOI: 10.3978/j.issn.2078-6891.2013.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 04/03/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Recent publications have identified positive associations between numbers of lymph nodes pathologically examined and five-year overall survival (5-yr OS) in colon cancer. However, focused examinations of relationships between survival of rectal cancer and lymph node counts are less common. We conducted a single institution, retrospective review of rectal cancer resections to determine whether lymph node counts correlated with 5-yr OS and to explore the relationship between lymph node counts and various clinical and pathologic factors. METHODS A retrospective review of our institutional tumor registry identified 159 patients with AJCC Stage 1, 2, or 3 rectal cancers that underwent surgical resection at our institution over eleven years. Univariate analysis was used to explore the relationship between lymph node counts and age, AJCC Stage, time period of diagnosis, preoperative radiotherapy, and performance of TME. Survival analysis was performed by the Kaplan-Meier method and the Cox proportional hazards model. RESULTS In univariate analysis, there was an association between increased lymph node counts and age <70, higher stage, and diagnosis during the later portion of the study period [all P-values <0.05]. Lymph node counts were not associated with survival in Kaplan-Meier analysis or in multivariate Cox proportional hazards analysis. CONCLUSIONS Increasing lymph node counts improve survival and the accuracy of colorectal cancer staging. The body of literature recommends identical minimum lymph node counts in both colon and rectal cancer. In our study, which exclusively examined rectal cancer, we could not demonstrate that increased lymph node counts were associated with improved survival.
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Bouvier AM, Faivre J. Lymph node evaluation for resected colorectal cancer. COLORECTAL CANCER 2013. [DOI: 10.2217/crc.13.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY The negative impact of regional lymph node metastasis on survival from nonmetastatic colorectal cancers is proportional to the number of nodes harvested. A thorough lymph node examination by the pathologist is essential for accurate staging. Recommendations in the USA and Europe stipulate that a minimum of 12–15 lymph nodes must be examined to accurately predict regional node negativity. The prognostic separation for stage III colorectal cancer obtained by the lymph node ratio is superior to that of the absolute number of positive nodes. The extent of mesenteric resection, pathologic technique, age or tumor location may influence lymph node yield. In the future, biological significance and clinical impact on outcome of very small amounts of tumor in regional nodes could help in staging patients. The current data are considered insufficient to recommend either the routine examination of multiple tissue levels of paraffin blocks or the use of special/ancillary techniques.
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Affiliation(s)
- Anne-Marie Bouvier
- Digestive Cancers Registry of Burgundy, University Hospital Dijon, Inserm U866, University of Burgundy, Dijon, France.
| | - Jean Faivre
- Digestive Cancers Registry of Burgundy, University Hospital Dijon, Inserm U866, University of Burgundy, Dijon, France
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Kuijpers CCHJ, van Slooten HJ, Schreurs WH, Moormann GRHM, Abtahi MA, Slappendel A, Cliteur V, van Diest PJ, Jiwa NM. Better retrieval of lymph nodes in colorectal resection specimens by pathologists' assistants. J Clin Pathol 2012; 66:18-23. [PMID: 23087331 DOI: 10.1136/jclinpath-2012-201089] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Errors in surgical pathology are partly due to the increasing workload of pathologists. To reduce this workload, 'pathologists' assistants' (PAs) have been trained to take over some of the pathologists' recurrent tasks. One of these tasks is the precise examination of ≥10 lymph nodes (LNs), which is of paramount importance to reduce the risk of understaging of colorectal cancer patients. AIMS To evaluate the role of PAs in harvesting LNs in colorectal resection specimens and, by doing so, in improving patient safety. METHODS LN harvest was retrospectively reviewed in 557 pathology reports on colorectal resection specimens collected in two Dutch hospitals from 2008 until 2011. RESULTS PAs sampled ≥10 LNs in significantly more cases than pathologists did (83.2% vs 60.9% in hospital A and 79.2% vs 67.6% in hospital B) and recovered on average significantly more LNs than pathologists did (18.5 vs 12.2 in hospital A and 16.6 vs 13.2 in hospital B). PAs harvested a significantly higher percentage of LNs <5 mm than pathologists did (64.2% vs 53.7%). The percentages of colon cancer patients eligible for adjuvant chemotherapy due to inadequate LN sampling alone were significantly higher for cases dissected by pathologists than for those dissected by PAs (17.3% vs 1.1% in hospital A and 13.1% vs 3.4% in hospital B) CONCLUSIONS: PAs contribute to patient safety since they recover more and, in particular, smaller LNs from colorectal resection specimens than pathologists do. Moreover, they help to reduce costs and morbidity by reducing the number of patients eligible for adjuvant chemotherapy due to inadequate LN sampling alone.
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Jepsen RK, Ingeholm P, Lund EL. Upstaging of early colorectal cancers following improved lymph node yield after methylene blue injection. Histopathology 2012; 61:788-94. [PMID: 22804356 DOI: 10.1111/j.1365-2559.2012.04287.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIMS To evaluate whether the use of intra-arterial methylene blue injection improves lymph node yield, and to determine whether a higher lymph node count results in upstaging in colorectal cancer. METHOD AND RESULTS We performed a retrospective study of colorectal cancer specimens (n = 234) 1 year after implementation of the method. All colorectal cancer specimens from the previous year served as our control group. Data concerning tumour characteristics, lymph node count, number of positive lymph nodes and success of methylene injection had been prospectively collected in accordance with the department's ongoing registration. The method was easy to implement and perform with a high rate of success (86%). The number of identified lymph nodes was highly significantly improved in the study group (P < 0.0001). In resections with pT1/T2 tumours, we demonstrated a significant increase in the number of resection specimens containing positive lymph nodes, with an increase in pN1 resections from 9.4% in the control group to 26.7% in the study group (P = 0.04). CONCLUSIONS THE methylene blue technique significantly improves lymph node identification in colorectal cancer specimens, and the improved lymph node identification leads to upstaging of International Union Against Cancer (UICC) pT1/pT2 cancers.
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Belt EJT, te Velde EA, Krijgsman O, Brosens RPM, Tijssen M, van Essen HF, Stockmann HBAC, Bril H, Carvalho B, Ylstra B, Bonjer HJ, Meijer GA. High lymph node yield is related to microsatellite instability in colon cancer. Ann Surg Oncol 2012; 19:1222-30. [PMID: 21989661 PMCID: PMC3309135 DOI: 10.1245/s10434-011-2091-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lymph node (LN) yield in colon cancer resection specimens is an important indicator of treatment quality and has especially in early-stage patients therapeutic implications. However, underlying disease mechanisms, such as microsatellite instability (MSI), may also influence LN yield, as MSI tumors are known to exhibit more prominent lymphocytic antitumor reactions. The aim of the present study was to investigate the association of LN yield, MSI status, and recurrence rate in colon cancer. METHODS Clinicopathological data and tumor samples were collected from 332 stage II and III colon cancer patients. DNA was isolated and PCR-based MSI analysis performed. LN yield was defined as "high" when 10 or more LNs were retrieved and "low" in case of fewer than 10 LNs. RESULTS Tumors with high LN yield were significantly associated with the MSI phenotype (high LN yield: 26.3% MSI tumors vs low LN yield: 15.1% MSI tumors; P=.01), mainly in stage III disease. Stage II patients with high LN yield had a lower recurrence rate compared with those with low LN yield. Patients with MSI tumors tended to develop fewer recurrences compared with those with MSS tumors, mainly in stage II disease. CONCLUSIONS In the present study, high LN yield was associated with MSI tumors, mainly in stage III patients. Besides adequate surgery and pathology, high LN yield is possibly a feature caused by biologic behavior of MSI tumors.
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Affiliation(s)
- E. J. Th. Belt
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Surgery, Kennemer Gasthuis, Haarlem, The Netherlands
| | - E. A. te Velde
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - O. Krijgsman
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - R. P. M. Brosens
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Surgery, Zaans Medical Centre, Zaandam, The Netherlands
| | - M. Tijssen
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - H. F. van Essen
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | | | - H. Bril
- Department of Pathology, Kennemer Gasthuis, Haarlem, The Netherlands
| | - B. Carvalho
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - B. Ylstra
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - H. J. Bonjer
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - G. A. Meijer
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
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Patent blue staining as a method to improve lymph node detection in rectal cancer following neoadjuvant treatment. Eur J Surg Oncol 2012; 38:252-8. [DOI: 10.1016/j.ejso.2011.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 12/19/2011] [Indexed: 02/07/2023] Open
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MacQuarrie E, Arnason T, Gruchy J, Yan S, Drucker A, Huang WY. Microsatellite instability status does not predict total lymph node or negative lymph node retrieval in stage III colon cancer. Hum Pathol 2012; 43:1258-64. [PMID: 22305240 DOI: 10.1016/j.humpath.2011.10.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 10/01/2011] [Accepted: 10/11/2011] [Indexed: 12/12/2022]
Abstract
The relationship between higher total lymph node resection number in colorectal cancer resection specimens and improved overall survival is well known. Recent studies describe an association between a high rate of microsatellite instability and a high total lymph node count in colorectal cancer. Higher lymph node retrieval may potentially explain the improved survival seen in cancers with microsatellite instability. We investigate whether these associations can be validated in a cohort of American Joint Committee on Cancer stage III colon cancers. Medical records from 200 cases of stage III colon cancer resection specimens were reviewed, and sufficient tissue was available for 168. Expression of DNA mismatch repair proteins was determined by immunohistochemistry, and microsatellite status, by polymerase chain reaction. The mean total lymph node count in cases with microsatellite instability versus microsatellite stable tumors (15.9 versus 16.9; P = .664) and the mean number of negative lymph nodes in each respective category (12.2 versus 13.6; P = .522) were not significantly different. There was no difference between microsatellite stable cases and cases with microsatellite instability when total lymph node counts (P = .953) or negative lymph node counts (P = .381) were analyzed with respect to percentage of cases above and below the medians. This cohort of stage III colon cancers does not support a significant relationship between microsatellite status and a higher retrieval of total or negative lymph nodes. Although microsatellite instability is associated with improved overall survival in our cohort (P = .026), the reason for this does not appear to be related to higher numbers of retrieved lymph nodes.
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Affiliation(s)
- Erin MacQuarrie
- Division of Anatomical Pathology, Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada B3H 1V8
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McDonald JR, Renehan AG, O'Dwyer ST, Haboubi NY. Lymph node harvest in colon and rectal cancer: Current considerations. World J Gastrointest Surg 2012; 4:9-19. [PMID: 22347537 PMCID: PMC3277879 DOI: 10.4240/wjgs.v4.i1.9] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 04/18/2011] [Accepted: 04/25/2011] [Indexed: 02/06/2023] Open
Abstract
The prognostic significance of identifying lymph node (LN) metastases following surgical resection for colon and rectal cancer is well recognized and is reflected in accurate staging of the disease. An established body of evidence exists, demonstrating an association between a higher total LN count and improved survival, particularly for node negative colon cancer. In node positive disease, however, the lymph node ratios may represent a better prognostic indicator, although the impact of this on clinical treatment has yet to be universally established. By extension, strategies to increase surgical node harvest and/or laboratory methods to increase LN yield seem logical and might improve cancer staging. However, debate prevails as to whether or not these extrapolations are clinically relevant, particularly when very high LN counts are sought. Current guidelines recommend a minimum of 12 nodes harvested as the standard of care, yet the evidence for such is questionable as it is unclear whether an increasing the LN count results in improved survival. Findings from modern treatments, including down-staging in rectal cancer using pre-operative chemoradiotherapy, paradoxically suggest that lower LN count, or indeed complete absence of LNs, are associated with improved survival; implying that using a specific number of LNs harvested as a measure of surgical quality is not always appropriate. The pursuit of a sufficient LN harvest represents good clinical practice; however, recent evidence shows that the exhaustive searching for very high LN yields may be unnecessary and has little influence on modern approaches to treatment.
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Affiliation(s)
- James R McDonald
- James R McDonald, Andrew G Renehan, Sarah T O'Dwyer, Department of Surgery, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom
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Rhoads KF, Cullen J, Ngo JV, Wren SM. Racial and ethnic differences in lymph node examination after colon cancer resection do not completely explain disparities in mortality. Cancer 2012; 118:469-77. [PMID: 21751191 DOI: 10.1002/cncr.26316] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 04/01/2011] [Accepted: 05/02/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND In 1999, a multidisciplinary panel of experts in colorectal cancer reviewed the relevant medical literature and issued a consensus recommendation for a 12-lymph node (LN) minimum examination after resection for colon cancer. Some authors have shown racial/ethnic differences in receipt of this evidence-based care. To date, however, none has investigated the correlation between disparities in LN examination and disparities in outcomes after colon cancer treatment. METHODS This retrospective analysis used California Cancer Registry linked to California Office of Statewide Health Planning and Development discharge data (1996-2006). Chi-square analysis, logistic regression, and Cox proportional hazard models predicted disparities in receipt of an adequate examination and the effect of an inadequate exam on mortality and disparities. Patients with stage I and II colon cancers undergoing surgery in California were included; patients with stage III and IV disease were excluded. RESULTS A total of 37,911 records were analyzed. Adequate staging occurred in fewer than half of cases. An inadequate examination (<12 LNs) was associated with higher mortality rates. Hispanics had the lowest odds of receiving an adequate exam; however, blacks, not Hispanics, had the highest risk of mortality compared with whites. This disparity was not completely explained by inadequate LN examination. CONCLUSIONS Inadequate LN exam occurs often and is associated with increased mortality. There are disparities in receipt of the minimum exam, but this only explains a small part of the observed disparity in mortality. Improving the quality of LN examination alone is unlikely to correct colon cancer disparities.
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Affiliation(s)
- Kim F Rhoads
- Section of Colon and Rectal Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680F, Stanford, CA 94305, USA.
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Fan L, Levy M, Aguilar CE, Mertens RB, Dhall D, Frishberg DP, Wang HL. Lymph node retrieval from colorectal resection specimens for adenocarcinoma: is it worth the extra effort to find at least 12 nodes? Colorectal Dis 2011; 13:1377-83. [PMID: 20969717 DOI: 10.1111/j.1463-1318.2010.02472.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIM Retrieval of a minimum of 12 lymph nodes has been recommended for adequately staging a node-negative colorectal cancer (CRC). This study was designed to determine whether the extra effort expended to recover more nodes for histological examination improves the accuracy of staging. METHOD Pathology reports, histology worklists, and haematoxylin and eosin (H&E) slides of 334 CRC resections were reviewed. The total number of nodes and the number of positive nodes harvested from the first and additional searches were recorded for each patient. RESULTS The number of nodes retrieved from the 334 resections at the first search ranged from 0 to 57 (mean: 14.2), with 195 patients (58.4%) having ≥ 12 nodes. Nodal metastasis was found in 122 (33.6%) patients. Additional searches were performed on 115 patients, including 91 with < 12 nodes. The mean number of nodes recovered in these patients increased significantly, from 9.1 to 14.2 (P < 0.0001). Thirty-one additional positive nodes were found in 19 patients following the further searches, and 12 (63.2%) of the 19 patients were upstaged using the American Joint Committee on Cancer (AJCC) 6th edition (2002) staging criteria. The total number of nodes retrieved and the probability of obtaining ≥ 12 nodes correlated negatively with the age of the patient and the rectosigmoid location of the tumours, but positively with the specimen length, the pericolic/perirectal fat width, female gender and tumour size. CONCLUSION Although a number of patient and specimen variables influence the number of lymph nodes retrieved, our observations support the importance of a thorough search for nodes in CRC specimens in order to achieve accurate tumour staging.
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Affiliation(s)
- L Fan
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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Kotake K, Honjo S, Sugihara K, Hashiguchi Y, Kato T, Kodaira S, Muto T, Koyama Y. Number of lymph nodes retrieved is an important determinant of survival of patients with stage II and stage III colorectal cancer. Jpn J Clin Oncol 2011; 42:29-35. [PMID: 22102737 DOI: 10.1093/jjco/hyr164] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The number of lymph nodes retrieved is recognized to be a prognostic factor of Stage II colorectal cancer. However, the prognostic significance of the number of lymph nodes retrieved in Stage III colorectal cancer remains controversial. METHODS The relationship between the number of lymph nodes retrieved and clinical and pathological factors, and significance of the number of lymph nodes retrieved for prognosis of Stage II and III colorectal cancer were investigated. A total of 16 865 patients with T3/T4 colorectal cancer who had R0 resection were analysed. RESULTS The arithmetic mean of the number of lymph nodes retrieved of all cases was 20.0. The number of lymph nodes retrieved were varied according to several clinical and pathological variables with significant difference, and the greater difference was observed in scope of nodal dissection. Survival of Stages II and III was significantly associated with the number of lymph nodes retrieved. Five-year overall survival of the patients with ≤ 9 of the number of lymph nodes retrieved and those with >27 differed by 6.4% for Stage II colon cancer, 8.8% for Stage III colon cancer, 12.5% for Stage II rectal cancer and 10.6% for Stage III rectal cancer. With one increase in the number of lymph nodes retrieved, the mortality risk was decreased by 2.1% for Stage II and by 0.8% for Stage III, respectively. The cut-off point of the number of lymph nodes retrieved was not obtained. CONCLUSIONS The number of lymph nodes retrieved was shown to be an important prognostic variable not only in Stage II but also in Stage III colorectal cancer, and it was most prominently determined by the scope of nodal dissection. A cut-off value for the number of lymph nodes retrieved was not found, and it is necessary to carry out appropriate nodal dissection and examine as many lymph nodes as possible.
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Affiliation(s)
- Kenjiro Kotake
- Department of Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi-ken 320-0834, Japan.
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The number of high-risk factors is related to outcome in stage II colonic cancer patients. Eur J Surg Oncol 2011; 37:964-70. [DOI: 10.1016/j.ejso.2011.08.135] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 08/26/2011] [Accepted: 08/28/2011] [Indexed: 01/21/2023] Open
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Wakeman C, Yu V, Chandra R, Staples M, Wale R, McLean C, Bell S. Lymph node yield following injection of patent blue V dye into colorectal cancer specimens. Colorectal Dis 2011; 13:e266-9. [PMID: 21689343 DOI: 10.1111/j.1463-1318.2011.02673.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The study aimed to assess whether the ex vivo injection of patent blue V dye would increase lymph node yield in operative specimens of colorectal cancer. METHOD A randomized controlled trial was carried out in which patients undergoing resection for colonic cancer were allocated to patent V blue or no patent blue V dye submucosal injection of the operative specimen. The number of lymph nodes found in each group was compared. RESULTS Between 1 January and 31 December 2008, 68 patients were randomized. Thirty-three patients received patent blue V dye and 34 did not. In the former group the median number of blue nodes identified was 11, compared with a median of 9 in the no dye group. After the application of Carnoy's solution lymph node count was 16 in each group. There was no significant difference between all these results. CONCLUSION Ex vivo injection of patent blue V dye submucosally in a peritumour location did not increase the lymph node count or the percentage of specimens having more than 12 lymph nodes identified.
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Affiliation(s)
- C Wakeman
- Christchurch Hospital, Christchurch, New Zealand.
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Lindboe CF. Lymph node harvest in colorectal adenocarcinoma specimens: the impact of improved fixation and examination procedures. APMIS 2011; 119:347-55. [PMID: 21569092 DOI: 10.1111/j.1600-0463.2011.02748.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A review of 1050 pathology reports from colorectal adenocarcinoma specimens examined at the Department of Pathology, Sørlandet sykehus HF, Kristiansand, Norway during the period 1995-2006 revealed a poor performance of most doctors concerning lymph node harvest. A mean of 8.1 nodes per specimen (range 12.3-2.1) and a mean proportion of 22.3% of specimens with ≥12 lymph nodes (range 47.1-0%) were found. A small pilot study was undertaken in 2007 to evaluate the effect of prolonged formalin fixation and the use of a special lymph node fixative [glacial acetic acid, ethanol, water and formaldehyde (GEWF) solution] with regard to the number of retrieved nodes. This showed that one extra day formalin fixation and the use of GEWF solution considerably enhanced the detection of lymph nodes, particularly those of smaller size. Based on these findings, our routines concerning handling of colorectal cancer specimens were changed during 2007. After this time all specimens have been fixed in a mixture of GEWF solution and formalin for at least 48 h and the doctors have been encouraged to find as many lymph nodes as possible. In cases revealing <12 nodes after microscopical examination, the specimens have been re-examined and searched for additional nodes. A review of lymph node retrieval in 423 cases of colorectal cancer during the period 2008-2010 showed that the mean number of nodes per specimen had increased to 16.8 (range 29.0-13.3) and the proportion of specimens with ≥12 nodes to 78.0% (range 96.8-63.6%). Thus, these changes of routines which were easy to implement without significant extra costs have considerably improved lymph node harvest at our department. The use of a special lymph node fixative (e.g. GEWF solution) is highly recommended not only for detection of nodes in colorectal specimens, but also for retrieval of lymph nodes embedded in fat tissue generally.
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