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Donnelly C, Or M, Toh J, Thevaraja M, Janssen A, Shaw T, Pathma-Nathan N, Harnett P, Chiew KL, Vinod S, Sundaresan P. Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators. Asia Pac J Clin Oncol 2024; 20:259-274. [PMID: 36726222 DOI: 10.1111/ajco.13917] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/19/2022] [Accepted: 12/26/2022] [Indexed: 02/03/2023]
Abstract
AIM To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs). METHODS The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance. RESULTS A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level. CONCLUSION This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.
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Affiliation(s)
- Candice Donnelly
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Michelle Or
- Radiation Oncology Network, Western Sydney Local Health District, Westmead, Australia
| | - James Toh
- Department of Surgery, Westmead Hospital, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
| | | | - Anna Janssen
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | | | - Paul Harnett
- Westmead Clinical School, University of Sydney, Sydney, Australia
- Crown Princess Mary Cancer Centre, Western Sydney Local Health District, Westmead, Australia
| | - Kim-Lin Chiew
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, Australia
- South Western Clinical School, University of New South Wales, Randwick, Australia
- Princess Alexandra Hospital, Division of Cancer Services, Brisbane, Australia
| | - Shalini Vinod
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, Australia
- South Western Clinical School, University of New South Wales, Randwick, Australia
| | - Puma Sundaresan
- Radiation Oncology Network, Western Sydney Local Health District, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
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Wehrle CJ, Woo K, Chang J, Gamaleldin M, DeHaan R, Dahdaleh F, Felder S, Rosen DR, Champagne B, Steele SR, Naffouje SA. Impact of neoadjuvant therapy on nodal harvest in clinical stage III rectal cancer: Establishing optimum cut-offs by disease response. J Surg Oncol 2024; 129:945-952. [PMID: 38221655 DOI: 10.1002/jso.27586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION A minimum lymph node harvest (LNH) of 12 is the current standard for appropriate nodal staging in resectable rectal cancer. However, the rise of neoadjuvant chemoradiation (NCRT) and total neoadjuvant therapy (TNT) has been associated with decreasing number of LNH. We hypothesize that as tumor response to neoadjuvant therapy increases, the optimum for LNH to achieve appropriate nodal staging should decrease. METHODS Patients with clinical stage III rectal adenocarcinoma who underwent NCRT/TNT followed by resection were identified from the National Cancer Database. A JoinPoint regression analysis was used to determine the LNH for each tumor regression grade (TRG) category beyond which the rate of positive nodes does not significantly change. RESULTS Thirteen thousand four hundred and twenty-six patients met inclusion criteria. Of these, 2406 (17.9%) achieved TRG 0 or ypT0 and 8210 (61.2%) achieved ypN0. Collectively, 2043 patients (15.2%) were reported to have a pathologic complete response (ypT0 ypN0). Positive pathologic nodes were found in 15%, 23%, 31%, 54%, and 53% as ypT stage increased from ypT0 to ypT4, respectively. Similarly, ypN+ rates were 15%, 36%, 41%, and 55% in TRG 0-3. No JoinPoint was identified for TRG 0, whereas inflection points were found at 6-10 nodes for TRG1 (p = 0.002) and TRG 2 (p = 0.016), and at 11-15 nodes for TRG 3. CONCLUSION The benchmark of retrieving 12 nodes in resectable stage III rectal cancer is not consistently achieved after NCRT/TNT. We demonstrate that the LNH requirement to establish accurate pathologic nodal staging can vary depending on the tumor response to neoadjuvant therapies.
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Affiliation(s)
- Chase J Wehrle
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Kimberly Woo
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Jenny Chang
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Maysoon Gamaleldin
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Reece DeHaan
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Elmhurst, Illinois, USA
| | - Seth Felder
- Moffitt Cancer Center, GI Oncology Program, Tampa, Florida, USA
| | - David R Rosen
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Bradley Champagne
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Scott R Steele
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Samer A Naffouje
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
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Srivastava S, Kak I, Major P, Bonert M. What is your count? An observational study of lymph node counting in 2,028 colorectal cancer resections. PLoS One 2024; 19:e0295209. [PMID: 38329946 PMCID: PMC10852306 DOI: 10.1371/journal.pone.0295209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/15/2023] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Lymph node status and lymph node count (LNC) are predictors of colorectal cancer outcome. Under-sampling of lymph nodes may lead to clinically relevant stage migration. METHODS Colorectal cancer (CRC) cases with a synoptic report, accessioned 2012-2020 at a regional laboratory, were extracted and retrospectively studied. LNC, positive lymph node count (PLNC), tumour deposits present (TDpos), and 'y' (staging) prefix (YS) were retrieved and tabulated by pathologist using custom software. Statistical analyses were done with R. DATA AND RESULTS The cohort had 2,543 CRC resections. Seventeen pathologists interpreted >50 cases (range: 56-356) each and collectively saw 2,074. After cases with unavailable data were purged, 2,028 cases remained with 43,996 lymph nodes, of which 2,637/43,996 were positive. 368 cases had a 'y' prefix, and 379 had TDpos. The 17 pathologists' median LNC/case was 19.0 (range: 14.0-24.0), and the mean PLNC per case was 1.4 (range: 1.0-2.0). Kruskal-Wallis rank sum tests showed there were differences in LNC (p<0.001) among pathologists; however, PLNC did not show this association (p = 0.2917). T-tests showed that mean LNC (p<0.001) and PLNC (p<0.035) differed between YS. 138 of 2,028 cases had less than the 12 LNC target. Logistic regression revealed a strong association between meeting the LNC target and pathologist (p<0.001) but TDpos was non-predictive (p = 0.4736). CONCLUSIONS Positive lymph node call rate has a good consistency in the laboratory; however, lymph node count varies significantly between pathologists. Standardized counting criteria are needed to improve uniformity and could be aided by synoptic reporting data.
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Affiliation(s)
- Shivali Srivastava
- Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Ipshita Kak
- Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Pierre Major
- Medical Oncology, McMaster University, Hamilton, ON, Canada
| | - Michael Bonert
- Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Emile SH, Horesh N, Garoufalia Z, Gefen R, Zhou P, Wexner SD. Predictors and survival outcomes of having less than 12 harvested lymph nodes in proctectomy for rectal cancer. Int J Colorectal Dis 2023; 38:225. [PMID: 37688758 DOI: 10.1007/s00384-023-04518-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Current recommendations suggest that a minimum of 12 lymph nodes (LNs) should be harvested during curative rectal cancer resection. We aimed to assess predictors and survival outcomes of harvesting < 12 lymph nodes in rectal cancer surgery. METHODS A retrospective case-control analysis of factors associated with harvesting < 12 LNs in rectal cancer surgery was conducted. Data were derived from the National Cancer Database 2010-2019. Univariate and multivariate binary logistic regression analyses were performed to determine predictors of harvesting < 12 LNs. Association between harvesting < 12 LNs and 5-year overall survival (OS) was assessed using Cox regression and Kaplan Meier statistics. RESULTS 67,529 patients (60.8% male; mean age: 61.2 ± 12.5 years) were included. Median number of harvested LNs was 15 (IQR: 11-20); 27.1% of patients had < 12 harvested LNs. Independent predictors of harvesting < 12 LNs were older age (OR: 1.016;p < 0.001), neoadjuvant systemic treatment (OR: 1.522;p < 0.001), neoadjuvant radiation treatment (OR: 1.367;p < 0.001), longer duration of radiation therapy (OR: 1.003;p < 0.001) and abdominoperineal resection (OR: 1.071;p = 0.017). Higher clinical TNM stage and tumor grade, pull-through coloanal anastomosis, and minimally invasive surgery were independently associated with ≥ 12 harvested LNs. < 12 harvested LNs was independently associated with lower 5-year OS (HR: 1.24;p < 0.001) and shorter mean OS (96.7 vs 102.8 months;p < 0.001) than ≥ 12 harvested LNs. CONCLUSIONS Older age, open resection, and neoadjuvant therapy were independent predictors of < 12 harvested LNs. Conversely, higher clinical TNM stage and tumor grade, coloanal anastomosis, and minimally invasive surgery were predictive of ≥ 12 harvested LNs. < 12 LNs harvested was associated with lower OS.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of Surgery and Transplantation, Sheba Medical Center, Ramat Gan, Tel Aviv University, Tel Aviv, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peige Zhou
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Use of a national registry to define a composite quality metric for rectal cancer. Am J Surg 2023; 225:514-518. [PMID: 36517277 DOI: 10.1016/j.amjsurg.2022.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/23/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Quality assessment in oncologic surgery has traditionally involved reporting discrete metrics that may be difficult for patients and referring providers to interpret. We define a composite quality metric (CQM) for resection in rectal cancer. METHODS We queried the National Cancer Database to identify patients undergoing low anterior resection for clinical stage II-III rectal adenocarcinoma between 2010 and 2017. CQM was defined as appropriate neoadjuvant therapy, margin-negative resection, appropriate lymph node assessment, postoperative length of stay (LOS) < 75th percentile, and no 30-day readmission or mortality. RESULTS 19,721 patients met inclusion criteria; 8,083 (41%) had a CQM. The most common reasons for failure to achieve CQM: inadequate node assessment (27%), prolonged LOS (26%). On Cox modeling, CQM (aHR 0.70, 95% CI [0.66, 0.75]) was associated with improved overall survival. CONCLUSION CQM is independently associated with improved survival in rectal cancer and may be an effective measure of quality.
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Yang H, Xing J, Zhang C, Yao Z, Wu X, Jiang B, Cui M, Su X. Lymph node yield less than 12 is not a poor predictor of survival in locally advanced rectal cancer after laparoscopic TME following neoadjuvant chemoradiotherapy. Front Oncol 2022; 12:1080475. [PMID: 36568169 PMCID: PMC9773987 DOI: 10.3389/fonc.2022.1080475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Purpose Previous studies have confirmed that neoadjuvant chemoradiotherapy (nCRT) may reduce the number of lymph nodes retrieved in rectal cancer. However, it is still controversial whether it is necessary to harvest at least 12 lymph nodes for locally advanced rectal cancer (LARC) patients who underwent nCRT regardless of open or laparoscopic surgery. This study was designed to evaluate the relationship between lymph node yield (LNY) and survival in LARC patients who underwent laparoscopic TME following nCRT. Methods Patients with LARC who underwent nCRT followed by laparoscopic TME were retrospectively analyzed. The relationship between LNY and survival of patients was evaluated, and the related factors affecting LNY were explored. To further eliminate the influence of imbalance of clinicopathological features on prognosis between groups, propensity score matching was conducted. Results A total of 257 consecutive patients were included in our study. The median number of LNY was 10 (7 to 13) in the total cohort. There were 98 (38.1%) patients with 12 or more lymph nodes harvested (LNY ≥12 group), and 159 (61.9%) patients with fewer than 12 lymph nodes retrieved (LNY <12 group). There was nearly no significant difference between the two groups in clinicopathologic characteristics and surgical outcomes except that the age of LNY <12 group was older (P<0.001), and LNY <12 group tended to have more TRG 0 cases (P<0.060). However, after matching, when 87 pairs of patients obtained, the clinicopathological features were almost balanced between the two groups. After a median follow-up of 65 (54 to 75) months, the 5-year OS was 83.9% for the LNY ≥12 group and 83.6% for the LNY <12 group (P=0.893), the 5-year DFS was 78.8% and 73.4%, respectively (P=0.621). Multivariate analysis showed that only patient age, TRG score and ypN stage were independent factors affecting the number of LNY (all P<0.05). However, no association was found between LNY and laparoscopic surgery-related factors. Conclusions For LARC patients who underwent nCRT followed by laparoscopic TME, the number of LNY less than 12 has not been proved to be an adverse predictor for long-term survival. There was no correlation between LNY and laparoscopic surgery-related factors.
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Yang H, Chen L, Wu X, Zhang C, Yao Z, Xing J, Cui M, Jiang B, Su X. Patterns and predictors of recurrence after laparoscopic resection of rectal cancer. Front Oncol 2022; 12:1034838. [DOI: 10.3389/fonc.2022.1034838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/13/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeThis study was designed to evaluate the patterns and predictors of recurrence in patients who underwent laparoscopic resection of rectal cancer.MethodsPatients with rectal cancer receiving laparoscopic resection between April 2009 and March 2016 were retrospectively analyzed. The association of recurrence with clinicopathological characteristics was evaluated using multivariate analyses.ResultsA total of 405 consecutive patients were included in our study. Within a median follow-up time of 62 months, 77 patients (19.0%) experienced disease recurrence: 10 (2.5%) had locoregional recurrence (LR), 61 (15.1%) had distant metastasis (DM), and 6 (1.5%) developed LR and DM synchronously. The lung was the most common site of metastasis. Multivariate analyses indicated that involved circumferential resection margin (CRM) was the only independent predictor for LR (OR=13.708, 95% CI 3.478-54.026, P<0.001), whereas elevated baseline level of CA19-9 (OR=3.299, 95% CI 1.461-7.449, P=0.032), advanced pN stage (OR=2.292, 95% CI 1.177-4.462, P=0.015) and harvested lymph nodes less than 12 (OR=2.418, 95% CI 1.245-4.695, P=0.009) were independently associated with DM. Patients receiving salvage surgery showed superior 3-year survival compared with palliative treatment after relapse (90.9% vs. 20.5%; P=0.017). The estimated 5-year DFS and CSS for the entire cohort was 80.2% and 83.1%, respectively.ConclusionsDM was more common than LR after laparoscopic resection of rectal cancer, and there were several clinicopathological factors related to LR and DM. Involved CRM and suboptimal lymph node yield were adverse surgery-related factors of tumor recurrence, which should be paid more attention to during the operation.
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Suszták N, Besznyák I, Almási K, Bursics A, Kelemen D, Borowski DW, Bánky B. Improved Accuracy of Lymph Node Staging and Long-Term Survival Benefit in Colorectal Cancer With Ex Vivo Arterial Methylene Blue Infiltration. Pathol Oncol Res 2022; 28:1610742. [PMID: 36330051 PMCID: PMC9624224 DOI: 10.3389/pore.2022.1610742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022]
Abstract
Introduction:Ex vivo methylene blue (MB) injection into the main supplying arteries of the colorectal specimen after surgical removal is an uncomplicated technique to support lymph node harvest during pathological evaluation. The primary aim of this randomized, interventional, bicentric trial was to evaluate the impact of MB injection on lymph node yield, with secondary aims assessing the accuracy of lymph node staging and the effect on 5-year overall survival for patients undergoing resection of colorectal cancer. Methods: In the study period between December 2013 and August 2015, 200 colorectal resections were performed at two independent onco-surgery centers of Hungary. Following surgical resection, each specimen was randomly assigned either to the control (standard pathological work-up) or to the MB staining group before formaldehyde fixation. Patient-level surgical and clinical data were retrieved from routinely collected clinical datasets. Survival status data were obtained from the National Health Insurance Fund of Hungary. Results: A total of 162 specimens, 82 in the control and 80 in the MB groups, were included for analysis. Baseline characteristics were equally distributed among study groups, except for specimen length. Both the median of total number of lymph nodes retrieved (control 11 ± 8 [0–33] nodes vs. MB 14 ± 6 [0–42] nodes; p < 0.01), and the ratio of cases with at least 12 removed lymph nodes (36/82, 43.9% vs. 53/80, 66.3%; p < 0.01) were higher in the MB group. The rate of accurate lymph node staging was non-significantly improved. As for rectal cancer, nodal staging accuracy (16/31, 51.6% vs. 23/30, 76.7%; p = 0.04) and the proportion with minimum 12 lymph node retrieval (7/31, 22.6%, vs. 18/30, 60%; p < 0.01) was improved by MB injection. In Mantel–Cox regression, a statistically significant survival benefit with methylene blue injection at 5 years post-surgery was proven (51.2% vs. 68.8%; p = 0.04). Conclusion: In our experience, postoperative ex vivo arterial methylene blue injection appears to be an uncomplicated technique, improving lymph node yield and decreasing the chance of insufficient nodal staging. The technique might also associate with a 5-year overall survival benefit.
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Affiliation(s)
- Nóra Suszták
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Department of Surgery, St. Imre University Teaching Hospital, Budapest, Hungary
- *Correspondence: Nóra Suszták,
| | - István Besznyák
- Department of Surgery, Uzsoki Street Hospital, Budapest, Hungary
| | - Kálmán Almási
- Department of Pathology, Aladar Petz County Teaching Hospital, Győr, Hungary
| | - Attila Bursics
- Department of Surgery, Uzsoki Street Hospital, Budapest, Hungary
| | - Dóra Kelemen
- Department of Pathology, Uzsoki Street Hospital, Budapest, Hungary
| | | | - Balázs Bánky
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
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Bliggenstorfer JT, Ginesi M, Steinhagen E, Stein SL. Lymph node yield after rectal resection is a predictor of survival among patients with node-negative rectal adenocarcinoma. Surgery 2022; 172:1292-1299. [DOI: 10.1016/j.surg.2022.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 01/06/2022] [Accepted: 01/28/2022] [Indexed: 10/31/2022]
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Prognostic Implications of Nodal Yield in Rectal Cancer After Neoadjuvant Therapy: Is Nodal Yield Still Relevant Post Neoadjuvant Therapy? Indian J Surg 2021. [DOI: 10.1007/s12262-021-03154-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Lin YM, Chou CL, Kuo YH, Wu HC, Tsai CJ, Ho CH, Chen YC, Yang CC, Lin CW. Optimal Lymph Node Yield for Survival Prediction in Rectal Cancer Patients After Neoadjuvant Therapy. Cancer Manag Res 2021; 13:8037-8047. [PMID: 34729022 PMCID: PMC8554321 DOI: 10.2147/cmar.s328666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/12/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose A lymph node (LN) yield ≥12 is required to for accurate determination of nodal status for colorectal cancer but cannot always be achieved after neoadjuvant therapy. This study aims to determine the difference in LN yield from rectal cancer patients treated with and without neoadjuvant therapy and the effects of specific LN yields on survival. Patients and Methods The study cohort included a total of 4344 rectal cancer patients treated between January 2007 and December 2015, 2260 (52.03%) of whom received neoadjuvant therapy. Data were retrieved from the Taiwan nationwide cancer registry database. The minimum acceptable LN yield below 12 was investigated using the maximum area under the ROC curve. Results The median LN yield was 12 (8-17) for patients who received neoadjuvant therapy and 17 (13-24) for those who did not. The recommended LN yield ≥12 was achieved in 82.73% of patients without and 57.96% of those with neoadjuvant therapy (p < 0.0001). Patients with LN yield ≥12 had a higher OS probability than did those with LN <12 (OR, 1.33; 95% CI, 1.06-1.66; p = 0.0124). However, the predictive accuracy for survival was greater for LN yield ≥10 (AUC, 0.7767) than cut-offs of 12, 8, or 6, especially in patients with pathologically-negative nodes (AUC, 0.7660). Conclusion Neoadjuvant therapy significantly reduces the LN yield in subsequent surgery. A lower yield (LN ≥ 10) may be adequate for nodal evaluation in rectal cancer patients after neoadjuvant therapy.
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Affiliation(s)
- Yu-Min Lin
- Division of Hepatogastroenterology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chia-Lin Chou
- Division of Colorectal Surgery, Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan.,Department of Medical Laboratory Science and Biotechnology, Chung Hwa University of Medical Technology, Tainan, Taiwan
| | - Yu-Hsuan Kuo
- Division of Hematology and Oncology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Cosmetic Science, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Hung-Chang Wu
- Division of Hematology and Oncology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Pharmacy, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Chia-Jen Tsai
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.,Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Yi-Chen Chen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Chieh Yang
- Department of Pharmacy, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan.,Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Cheng-Wei Lin
- Department of Biochemistry and Molecular Cell Biology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Cell Physiology and Molecular Image Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Lau LW, Kethman WC, Bingmer KE, Ofshteyn A, Steinhagen E, Charles R, Dietz D, Stein SL. Evaluating disparities in delivery of neoadjuvant guideline-based chemoradiation for rectal cancer: A multicenter, propensity score-weighted cohort study. J Surg Oncol 2021; 124:810-817. [PMID: 34159619 DOI: 10.1002/jso.26572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite guideline recommendations, some patients still receive care inappropriate for their clinical stage of disease. Identification of factors that contribute to variation in guideline base care may help eradicate disparities in the treatment of early and locally advanced rectal cancer. METHODS The American College of Surgeons National Cancer Database from 2010 to 2015 was analyzed with propensity score weighting to identify factors associated with delivery and omission of neoadjuvant guideline-based chemoradiation (GBC) for those with early and locally advanced rectal cancer. RESULTS Only 74% of patients with rectal cancer received stage-appropriate neoadjuvant chemoradiation; 4544 (88%) of those with early stage disease and 8675 (68%) in locally advanced disease. Chemotherapy and radiotherapy were not planned in 27% and 34% respectively, of those who did not receive GBC. Factors associated with receipt of non-guideline-based neoadjuvant chemoradiation were age >65 years, Medicare insurance, treatment at a community facility, West-South-Central geography, having locally advanced disease, and Charlson-Deyo score >3. Receipt of ideal guideline-based neoadjuvant chemoradiation conferred a survival benefit at 5 years. CONCLUSION Patient and non-patient factors contribute to disparities in guideline-based delivery of neoadjuvant chemoradiation in the treatment of rectal cancer. Identification of these risk factors are important to help standardize care and improve survival outcomes.
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Affiliation(s)
- Lung W Lau
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - William C Kethman
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katherine E Bingmer
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Asya Ofshteyn
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Emily Steinhagen
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ronald Charles
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - David Dietz
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sharon L Stein
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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13
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Effects of neoadjuvant chemotherapy plus chemoradiotherapy on lymph nodes in rectal adenocarcinoma. Virchows Arch 2021; 479:657-666. [PMID: 33983519 DOI: 10.1007/s00428-021-03108-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/13/2021] [Accepted: 04/21/2021] [Indexed: 11/11/2022]
Abstract
The pathological nodal stage, determination of which requires examination of ≥ 12 lymph nodes, is one of the main prognostic factors in rectal cancer. Neoadjuvant chemoradiotherapy (CRT) may reduce the number of both lymph nodes retrieved and positive lymph nodes. Induction chemotherapy before CRT aimed at reducing the rate of distant metastases. However, the impact of this new treatment on number of lymph nodes retrieved and positive lymph nodes is unknown. This study was performed to evaluate the effects of neoadjuvant chemotherapy on lymph nodes in locally advanced rectal cancer treated by CRT. We retrospectively included patients with T2 - 4 Nx M0 rectal cancer and compared those receiving neoadjuvant chemotherapy plus CRT with those receiving CRT alone. From 2012 to 2019, 85 patients were treated with neoadjuvant chemotherapy + CRT and 189 with CRT alone. The number of lymph nodes retrieved (19 vs. 17, respectively, P = 0.434), the rate of specimens with ≥ 12 lymph nodes (92% vs. 88%, respectively, P = 0.397), and the median number of positive lymph nodes (1 vs. 2, respectively, P = 0.878) were similar between the two groups. However, the rate of pN0 was higher after neoadjuvant chemotherapy + CRT compared to CRT (75% vs. 62%, respectively, P = 0.030). Neoadjuvant chemotherapy before CRT for locally advanced rectal cancer did not modify the number of lymph nodes retrieved or the number of positive lymph nodes compared to CRT alone. However, it significantly increased the rate of tumors without any positive lymph nodes (ypN0).
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14
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Zhang H, Sun G, Zheng K, Lou Z, Gao XH, Meng RG, Furnée EJB, Zhang W. Prognostic factors in patients with complete response of the tumour (ypT0) after neoadjuvant chemoradiotherapy and radical resection of rectal cancer. ANZ J Surg 2021; 91:E190-E195. [PMID: 33559307 DOI: 10.1111/ans.16544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 11/13/2020] [Accepted: 12/06/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are only a few studies on the prognosis of patients with complete response of the tumour (ypT0) after neoadjuvant chemoradiotherapy (NCRT) and radical resection of rectal cancer. The aim of the study was to identify prognostic factors with regard to oncological outcome in ypT0 patients after NCRT and radical resection. METHODS All ypT0 patients with rectal cancer after NCRT and radical resection between January 2010 and June 2019 were included. Cox univariate and multivariate regression analyses were used to determine the prognostic factors of these patients. RESULTS Seventy-six patients with ypT0 rectal cancer were included. In nine patients (11.8%), lymph node metastasis was identified. Age, gender, elevated carcinoembryonic antigen (CEA) and ypN+ were risk factors associated with a worse 5-year disease-free survival (DFS) rate in univariate analysis (P = 0.08, 0.14, 0.007 and 0.003, respectively). In multivariate analysis, ypN+ and elevated CEA before NCRT were independent risk factors for worse 5-year DFS (P = 0.005 and 0.021, respectively). Elevated CEA before NCRT, post-operative chemotherapy and ypN+ were risk factors associated with worse overall survival in univariate analysis (P = 0.14, 0.002 and 0.17, respectively). However, in multivariate analysis, none of these three factors were independent risk factors for worse overall survival (P = 0.20, 0.34 and 0.06, respectively). CONCLUSION ypN+ and elevated CEA before NCRT were found to be independent risk factors for an unfavourable DFS in ypT0 patients with complete response of the tumour after neoadjuvant chemoradiotherapy for rectal cancer.
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Affiliation(s)
- Hang Zhang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China.,Department of Hepatobiliary Surgery, Hospital of the PLA Navy, Qingdao, China
| | - Ge Sun
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China.,Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Kuo Zheng
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Zheng Lou
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Xian H Gao
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Rong G Meng
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Edgar J B Furnée
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
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15
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Mei SW, Liu Z, Wang Z, Pei W, Wei FZ, Chen JN, Wang ZJ, Shen HY, Li J, Zhao FQ, Wang XS, Liu Q. Impact factors of lymph node retrieval on survival in locally advanced rectal cancer with neoadjuvant therapy. World J Clin Cases 2020; 8:6229-6242. [PMID: 33392304 PMCID: PMC7760431 DOI: 10.12998/wjcc.v8.i24.6229] [Citation(s) in RCA: 3] [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: 08/23/2020] [Revised: 10/20/2020] [Accepted: 11/04/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Conventional clinical guidelines recommend that at least 12 lymph nodes should be removed during radical rectal cancer surgery to achieve accurate staging. The current application of neoadjuvant therapy has changed the number of lymph node dissection. AIM To investigate factors affecting the number of lymph nodes dissected after neoadjuvant chemoradiotherapy in locally advanced rectal cancer and to evaluate the relationship of the total number of retrieved lymph nodes (TLN) with disease-free survival (DFS) and overall survival (OS). METHODS A total of 231 patients with locally advanced rectal cancer from 2015 to 2017 were included in this study. According to the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) tumor-node-metastasis (TNM) classification system and the NCCN guidelines for rectal cancer, the patients were divided into two groups: group A (TLN ≥ 12, n = 177) and group B (TLN < 12, n = 54). Factors influencing lymph node retrieval were analyzed by univariate and binary logistic regression analysis. DFS and OS were evaluated by Kaplan-Meier curves and Cox regression models. RESULTS The median number of lymph nodes dissected was 18 (range, 12-45) in group A and 8 (range, 2-11) in group B. The lymph node ratio (number of positive lymph nodes/total number of lymph nodes) (P = 0.039) and the interval between neoadjuvant therapy and radical surgery (P = 0.002) were independent factors of the TLN. However,TLN was not associated with sex, age, ASA score, clinical T or N stage, pathological T stage, tumor response grade (Dworak), downstaging, pathological complete response, radiotherapy dose, preoperative concurrent chemotherapy regimen, tumor distance from anal verge, multivisceral resection, preoperative carcinoembryonic antigen level, perineural invasion, intravascular tumor embolus or degree of differentiation. The pathological T stage (P < 0.001) and TLN (P < 0.001) were independent factors of DFS, and pathological T stage (P = 0.011) and perineural invasion (P = 0.002) were independent factors of OS. In addition, the risk of distant recurrence was greater for TLN < 12 (P = 0.009). CONCLUSION A shorter interval to surgery after neoadjuvant chemoradiotherapy for rectal cancer under indications may cause increased number of lymph nodes harvested. Tumor shrinkage and more extensive lymph node retrieval may lead to a more favorable prognosis.
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Affiliation(s)
- Shi-Wen Mei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zheng Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Wei Pei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Fang-Ze Wei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jia-Nan Chen
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zhi-Jie Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hai-Yu Shen
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Juan Li
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Fu-Qiang Zhao
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xi-Shan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Qian Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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16
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Yang H, Yao Z, Cui M, Xing J, Zhang C, Zhang N, Liu M, Xu K, Tan F, Su X. Influence of tumor location on short- and long-term outcomes after laparoscopic surgery for rectal cancer: a propensity score matched cohort study. BMC Cancer 2020; 20:761. [PMID: 32795280 PMCID: PMC7427716 DOI: 10.1186/s12885-020-07255-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the short- and long-term outcomes after laparoscopic resection for low rectal cancer (LRC) compared with mid/high rectal cancer (M/HRC). METHODS Patients with rectal cancer undergoing laparoscopic resection with curative intent were retrospectively reviewed between 2009 and 2015. After matched 1:1 by using propensity score analysis, perioperative and oncological outcomes were compared between LRC and M/HRC groups. Multivariate analysis was performed to identify independent factors of overall survival (OS) and disease-free survival (DFS). RESULTS Of 373 patients who met the criteria for inclusion, 198 patients were matched for the analysis. Laparoscopic surgery for LRC required longer operative time (P<0.001) and more blood loss volume (P = 0.015) compared with M/HRC, and the LRC group tended to have a higher incidence of postoperative complications (16.2% vs. 8.1%, P = 0.082). There was no significant difference in local recurrence between the two groups (9.1% vs. 4.0%, P = 0.251), whereas distant metastasis was inclined to be more frequent in LRC patients compared with M/HRC (21.2% vs. 12.1%, P = 0.086). The LRC group showed significantly inferior 5-year OS (77.0% vs. 86.4%, P = 0.033) and DFS (71.2% vs. 86.2%, P = 0.017) compared with the M/HRC group. Multivariate analysis indicated that tumor location was an independent predictor of DFS (HR = 2.305, 95% CI 1.203-4.417, P = 0.012). CONCLUSION Tumor location of the rectal cancer significantly affected the clinical and oncological outcomes after laparoscopic surgery, and it was an independent predictor of DFS.
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Affiliation(s)
- Hong Yang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Zhendan Yao
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Ming Cui
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Jiadi Xing
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Chenghai Zhang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Nan Zhang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Maoxing Liu
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Kai Xu
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Fei Tan
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Xiangqian Su
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China.
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Lymph Node Harvest After Neoadjuvant Treatment for Rectal Cancer and Its Impact on Oncological Outcomes. Indian J Surg Oncol 2020; 11:692-698. [PMID: 33281409 DOI: 10.1007/s13193-020-01162-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/07/2020] [Indexed: 12/24/2022] Open
Abstract
The aim of this study was to analyze the influence of neoadjuvant treatment on nodal harvest after rectal cancer surgery and its impact on long-term oncological outcomes. A retrospective analysis of patients with rectal cancer who received curative intent treatment from 2002 to 2012 in our institution was performed. Data on various clinic-pathological and treatment details were recovered from the records. The number of nodes harvested after surgery was analyzed. The influence of number of nodes harvested on overall survival and disease free survival was analyzed. Among the 459 patients included in this study, 326 underwent surgery after neoadjuvant treatment (NAT). The mean number of nodes harvested was significantly lower in patients who received NAT compared with those who did not (8.9 ± 5.77 vs 14 ± 9.84, p < 0.001). However, the mean number of pathologically positive nodes was not significantly different. A minimum of 12 nodes were harvested in only 27.9% of patients who received NAT. No lymph nodes were identified in the specimen in 15 patients (4.6%) who underwent surgery after NAT. The only independent factors influencing harvest of a minimum of 12 nodes were patient age and NAT. The 5-year overall survival was not significantly different in patients in whom < 12 or ≥ 12 nodes were harvested (64% vs 69% respectively, p = 0.5). Neoadjuvant chemoradiation significantly reduces nodal harvest in patients undergoing treatment for rectal cancer. However, this reduced nodal harvest did not adversely impact survival in patients. However, every effort must be made by the surgeon and the pathologist to maximize the nodal harvest.
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18
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Chetty R, McCarthy AJ. Neoadjuvant chemoradiation and rectal cancer. J Clin Pathol 2018; 72:97-101. [PMID: 30593459 DOI: 10.1136/jclinpath-2018-205592] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/23/2018] [Indexed: 01/13/2023]
Abstract
Neoadjuvant chemoradiation (NACR) is now standard of care in stage II and III rectal cancer. The advent of this modality of treatment has impacted on the way the pathological evaluation of resection specimens that have been subjected to preoperative chemoradiation is conducted. The gross description, sectioning and microscopic examination have had to be adapted to accommodate the changes induced by NACR. Attempts at introducing a uniform approach to the gross triaging and reporting of these specimens have been met with muted response. There still exists much variation in approach. The purpose of this overview is to highlight some of the newer developments and issues around NACR-treated rectal cancers from a pathological point of view. The NACR-treated resection specimens should be handled in a consistent manner, at least within individual institutions, if not universally. There should be generous sampling with multiple sections taken as tumour is often sequestered deep in the bowel wall. Microscopic examination should be extra vigilant as residual cancer can be present as single cells or small clusters, often deep in the muscularis propria or serosa. Acellular pools of mucin or non-viable tumour cells in mucin within the bowel wall or lymph nodes are not regarded as positive and do not upstage the tumour. The issue of grading of regression has been the subject of much debate, and several approaches have been published. It is recommended that a system that has clinical meaning and use to oncologists be used. Lymph node counts will be reduced after NACR, but reasonable attempts to accrue 12 nodes should be made.
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Affiliation(s)
- Runjan Chetty
- Laboratory Medicine Program, Department of Anatomical Pathology, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Aoife J McCarthy
- Laboratory Medicine Program, Department of Anatomical Pathology, University Health Network and University of Toronto, Toronto, Ontario, Canada
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19
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Bustamante-Lopez LA, Nahas CSR, Nahas SC, Marques CFS, Pinto RA, Cotti GC, Imperiale AR, de Mello ES, Ribeiro U, Cecconello I. Pathologic complete response implies a fewer number of lymph nodes in specimen of rectal cancer patients treated by neoadjuvant therapy and total mesorectal excision. Int J Surg 2018; 56:283-287. [PMID: 29981939 DOI: 10.1016/j.ijsu.2018.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/30/2018] [Accepted: 07/02/2018] [Indexed: 12/26/2022]
Abstract
Studies have suggested that the use of neoadjuvant chemoradiation results in a lower lymph nodes yield in rectal cancer patients. OBJECTIVE To evaluate factors associated with less than 12 lymph nodes harvested on patients with rectal cancer treated with preoperative chemoradiotherapy followed by total mesorectal excision. PATIENTS This was a cohort/retrospective single cancer center study. Low and mid locally advanced rectal cancer or T2N0 under risk of sphincter resection underwent chemoradiotherapy followed by total mesorectal excision with curative intent. Chemotherapy consisted of 5-FU and leucovorin IV. Total dose of pelvic radiation was 5040 Gys. All patients were staged and restaged by digital rectal examination, proctoscopy, colonoscopy, CT of abdomen and chest, and MRI of the pelvis. Patients were stratified in two groups: ≥12 and < 12 L N retrieved. The possible factors affecting number of LN were analyzed. RESULTS 95 patients met the inclusion criteria. Mean LN harvest was 23.2 (3-67). 81 patients (85%) had ≥12 L N. Gender, age, tumor size, tumor stage, tumor location, length of specimen, presence of LN involvement, type of surgery, and surgical access showed no association with number of LN retrieved. Only pathological complete response showed a statistically significant association with <12 L N on univariate (p = 0.004) and multivariate analyses (p = 0.002). LIMITATIONS Data were collected retrospectively. The number of patients disparity between the two groups. CONCLUSIONS Complete pathologic response is associated with <12 L N harvested. Thus, the number of lymph nodes should not be used as a surrogate for oncologic adequacy of resection in patients with pathologic complete response.
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Affiliation(s)
| | - Caio Sergio Rizkallah Nahas
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Rodrigo Ambar Pinto
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Guilherme Cutait Cotti
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Antonio Rocco Imperiale
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Evandro Sobroza de Mello
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
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20
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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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21
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Bustamante-Lopez L, Nahas CS, Nahas SC, Ribeiro U, Marques CF, Cotti G, Rocco A, Cecconello I. Understanding the factors associated with reduction in the number of lymph nodes in rectal cancer patients treated by neoadjuvant treatment. Int J Colorectal Dis 2017; 32:925-927. [PMID: 28035459 DOI: 10.1007/s00384-016-2747-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Rectal cancer patients frequently present with locally advanced disease for which the standard of care includes neoadjuvant chemoradiotherapy followed by total mesorectal excision. Positive lymph nodes are one of the most powerful risk factors for recurrence and survival in colorectal cancer. In the absence of specific rectal guidelines, the literature recommends to the pathologist to optimize the number of rectal lymph nodes (LN) retrieved. We made a literature review in order to identify factors that could potentially affect the number of LN retrieved in specimens of patients with rectal cancer treated by chemoradiotherapy (CRT) followed by total mesorectal excision (TME). RESULTS Age did not have a significant effect on LN yield. The effect of sex on LN number is not consistent in the literature. Most of the papers did not find a relationship between lower LN obtained and gender. Laparoscopy for primary rectal cancer is associated with a greater number of LN as well as short-term benefits. Tumors in the upper rectum are associated with a higher number of LN than those in the mid and lower rectum. The type of surgery had no effect on lymph node yield either. Tumors with complete or almost complete pathologic regression were exactly the ones with lower number of lymph nodes detected. Approximately one-third of patients with neoadjuvant treatment had less than 12 LN yield. CONCLUSION The tumor regression grade is the most important factor for the decrease in the number of lymph nodes.
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Affiliation(s)
- L Bustamante-Lopez
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil.
| | - C S Nahas
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - S C Nahas
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - U Ribeiro
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - C F Marques
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - G Cotti
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - A Rocco
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - I Cecconello
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
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22
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Fan WH, Xiao J, An X, Jiang W, Li LR, Gao YH, Chen G, Kong LH, Lin JZ, Wang JP, Pan ZZ, Ding PR. Patterns of recurrence in patients achieving pathologic complete response after neoadjuvant chemoradiotherapy for rectal cancer. J Cancer Res Clin Oncol 2017; 143:1461-1467. [PMID: 28386648 PMCID: PMC5504135 DOI: 10.1007/s00432-017-2383-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/21/2017] [Indexed: 12/20/2022]
Abstract
PURPOSE The aim of this study was to characterize the patterns of recurrence in patients achieving pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (CRT) for locally advanced rectal cancer. METHODS Patients with locally advanced rectal cancer treated with neoadjuvant CRT and who achieved pCR from January 2004 to December 2012 were collected. The primary outcome measurement was the patterns of recurrence. RESULTS Among 195 patients who achieved pCR, 18 developed recurrence. Furthermore, local recurrence occurred in 1.5% of patients (3/195), while distant metastases occurred in 7.7% of patients (15/195), which included 7 lung metastases, 1 liver metastasis, and 8 metastases in other locations. CONCLUSIONS Our study indicated that patients achieving pCR following neoadjuvant CRT have a favorable prognosis, with distant metastases predominating in all recurrences. Among patients with distant metastases, non-liver metastases were the predominant pattern.
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Affiliation(s)
- Wen-Hua Fan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jian Xiao
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Xin An
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Wu Jiang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Li-Ren Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Yuan-Hong Gao
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Gong Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Ling-Heng Kong
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jun-Zhong Lin
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jian-Ping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.
| | - Zhi-Zhong Pan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.
| | - Pei-Rong Ding
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.
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23
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Lymphadenectomy in Colorectal Cancer: Therapeutic Role and How Many Nodes Are Needed for Appropriate Staging? CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0349-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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24
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Gurawalia J, Dev K, Nayak SP, Kurpad V, Pandey A. Less than 12 lymph nodes in the surgical specimen after neoadjuvant chemo-radiotherapy: an indicator of tumor regression in locally advanced rectal cancer? J Gastrointest Oncol 2016; 7:946-957. [PMID: 28078118 DOI: 10.21037/jgo.2016.09.03] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The number of lymph node retrieved in the surgical specimen is important for tumor staging and has paramount impact on prognosis in colorectal cancer and imitates the adequacy of lymph node surgical clearance. The paucity of lymph node yields in patients undergoing resection after preoperative chemo radiotherapy (CRT) in rectal cancer has seen. Lower total number of lymph nodes in the total mesoractal excision (TME) specimen after CRT, could a marker of better tumor response. METHODS We retrospectively reviewed the prospectively managed data of patients underwent excision for rectal cancer, who treated by neoadjuvant radiotherapy with or without chemotherapy in locally advanced rectal cancer. From 2010 to 2014, 364 patients underwent rectal cancer surgery, of which ninety-one treated with neoadjuvant treatment. Standard surgical and pathological protocols were followed. Patients were categorized into two groups based on the number of total harvested lymph nodes with group 1, having 12 or more nodes harvested, and group 2 including patients who had <12 lymph nodes harvested. The total number of lymph nodes retrieved from the surgical specimen was correlated with grade of tumor regression with neoadjuvant treatment. RESULTS Out of 91 patients, 38 patients (42%) had less than 12 lymph nodes examined in specimen. The difference in median number of lymph nodes was observed significantly as 9 (range, 2-11) versus 16 (range, 12-32), in group 2 and 1, respectively (P<0.01). Patients with fewer lymph node group were comparable with respect to age, BMI, pre-operative staging, neoadjuvant treatment. Pathological complete response in tumor pCR was seen with significantly higher rate (40% vs. 26%, P<0.05) in group 2. As per Mandard criteria, there was significant difference in tumor regression grade (TRG) between both the groups (P<0.05). Among patients with metastatic lymph nodes, median LNR was lower in <12 lymph nodes group at 0.167 (range, 0.09-0.45) versus 0.187 (range, 0.05-0.54), difference was not statistically significant (P=0.81). CONCLUSIONS Retrieval of fewer than 12 lymph nodes in surgical specimen of rectal cancer who had received neo-adjuvant radiotherapy with or without chemotherapy should be considered as a good indicator of tumor response with better local disease control, and a good prognostic factor, rather than as a pointer of poor diligence of the surgical and pathological assessment.
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Affiliation(s)
- Jaiprakash Gurawalia
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
| | - Kapil Dev
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
| | - Sandeep P Nayak
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
| | - Vishnu Kurpad
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
| | - Arun Pandey
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
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25
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Marks JH, Montenegro GA, Salem JF, Shields MV, Marks GJ. Transanal TATA/TME: a case-matched study of taTME versus laparoscopic TME surgery for rectal cancer. Tech Coloproctol 2016; 20:467-73. [PMID: 27178183 DOI: 10.1007/s10151-016-1482-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 04/08/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Natural orifice translumenal endoscopic surgery (NOTES) has always made more sense in the colorectal field where the target organ for entry houses the pathology. To address the question whether an adequate total mesorectal excision (TME) for rectal cancer can be performed from a transanal bottoms-up approach, we performed a case-matched study. METHODS Starting in 2009, transanal TME (taTME) surgery was selectively used for rectal cancer after neoadjuvant therapy and prospectively entered into a database. Between March 2012 and February 2014, 17 consecutive taTME rectal cancer patients were identified and case-matched to multiport laparoscopic TME (MP TME) based on age, body mass index, uT stage, radiation dose, level in the rectum, and procedure. Perioperative outcomes, morbidity, mortality, local recurrence, completeness of TME, and radial and distal margins were analyzed. Statistically significant differences were identified using Student's t test. RESULTS There were 12 transanal abdominal transanal (TATA)/5 abdominoperineal resection procedures in each group. Data regarding overall/taTME/MP TME are as follows: % positive-circumferential margin: 2.9/0/5.9 % (p = 0.32). Distal margin: 0/0/0 %. Complete or near-complete TME: 97.1/100/94.1 % (p = 0.32). Incomplete TME 2.9/0/5.9 % (p = 0.32). Local recurrence: 2.9/5.9/0 % (p = 0.32). There were no perioperative mortalities. Morbidity in each group: 26.4/23.5/29.4 % (p = 0.79). There were no differences in perioperative or postoperative outcomes except days to clear liquids (1/2 days, p = 0.03) and largest incision length (1.3/2.6 cm, p = 0.05). CONCLUSIONS We demonstrated no differences in perioperative/postoperative outcomes or pathologic TME outcomes of transanal or bottoms-up TME compared to standard laparoscopic TME. TaTME is a promising progressive approach to NOTES and deserves additional evaluation.
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Affiliation(s)
- J H Marks
- Division of Colorectal Surgery, Lankenau Medical Center, Medical Office Building West, Suite 330, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA.
| | - G A Montenegro
- Division of Colorectal Surgery, Lankenau Medical Center, Medical Office Building West, Suite 330, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA.,Division of Colorectal Surgery, Saint Louis University Hospital, Saint Louis, MO, USA
| | - J F Salem
- Division of Colorectal Surgery, Lankenau Medical Center, Medical Office Building West, Suite 330, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA
| | - M V Shields
- Division of Colorectal Surgery, Lankenau Medical Center, Medical Office Building West, Suite 330, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA
| | - G J Marks
- Division of Colorectal Surgery, Lankenau Medical Center, Medical Office Building West, Suite 330, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA
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26
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Guedj N, Maggiori L, Poté N, Norkowski E, Cros J, Bedossa P, Panis Y. Distal intramural and tumor spread in the mesorectum after neoadjuvant radiochemotherapy in rectal cancer: about 124 consecutive patients. Hum Pathol 2016; 52:164-72. [PMID: 27210028 DOI: 10.1016/j.humpath.2016.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 01/15/2016] [Accepted: 01/24/2016] [Indexed: 02/07/2023]
Abstract
This observational prospective study aimed to assess the distribution of intramural and mesorectal tumor spread in mid/low rectal cancer after neoadjuvant radiochemotherapy. Distribution of mesorectal metastatic lymph nodes (MLNs) and mesorectal extranodal cancer tissue (EX), according to the tumor location, were analyzed. Distal intramural tumor spread was also performed. A total of 1676 LNs, 135 MLNs, and 69 EX were detected on 124 consecutive surgical specimens. Forty-two patients (34%) had MLNs. Six patients (4.8%) were classified as ypN1c. Distal viable cancer spread was observed in 3 patients (2.4%), all with mid rectal carcinoma. Two patients (1.6%) presented distal direct intramural extension less than 1 cm; and 1 (0.8%), with EX localized no more than 2 cm from the lower edge of the tumor. MLNs (76%) and EX (94%) were preferentially localized in the peritumoral area and in the first 3 cm just above the tumor. No viable distal intramural or mesorectal spread was observed in low rectal carcinoma. Distal intramural and mesorectal cancer spread is a rare event after neoadjuvant RCT. These results suggest that the 1-cm distal margin recommended in patients with low rectal carcinoma could be reduced with insurance to obtain a negative distal margin. The knowledge of preferential localization of MLNs and EX would help the pathologist to improve patient's lymph node staging.
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Affiliation(s)
- Nathalie Guedj
- Department of Pathology, Beaujon Hospital, 92110 Clichy, France.
| | - Léon Maggiori
- Department of Colo-rectal Surgery, Beaujon Hospital, 92110 Clichy, France
| | - Nicolas Poté
- Department of Pathology, Beaujon Hospital, 92110 Clichy, France
| | - Emma Norkowski
- Department of Pathology, Beaujon Hospital, 92110 Clichy, France
| | - Jérôme Cros
- Department of Pathology, Beaujon Hospital, 92110 Clichy, France
| | - Pierre Bedossa
- Department of Pathology, Beaujon Hospital, 92110 Clichy, France
| | - Yves Panis
- Department of Colo-rectal Surgery, Beaujon Hospital, 92110 Clichy, France
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27
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Rottoli M, Hanna L, Kukreja N, Pancholi A, Wegstapel H. Is transanal total mesorectal excision a reproducible and oncologically adequate technique? A pilot study in a single center. Int J Colorectal Dis 2016; 31:359-63. [PMID: 26490054 DOI: 10.1007/s00384-015-2418-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE An oncologically effective total mesorectal excision (TME) still represents a technical challenge, especially in the presence of a low rectal cancer and anatomical restraints such as obesity or narrow pelvis. Recently, few reports have shown that transanal TME was feasible and associated with good outcomes. Nevertheless, a widespread employment of the technique has yet to happen due to the doubts about the reproducibility of the results outside a tertiary specialized center. METHODS Between February 2014 and June 2015, patients with low rectal cancer underwent a transanal TME with laparoscopic assistance. The end points included the oncologic adequacy of the mesorectal excision and the perioperative outcomes. RESULTS Eleven patients (9 male, median age 70.5 years) with proven low rectal cancer were enrolled in the study. The median distance of the tumor from the anal verge was 5 cm (2-7). Four patients (36.4 %) received preoperative chemoradiation. The median operative time was 360 min (275-445). Postoperative morbidity (36.4 %) included one (9.1 %) anastomotic leak requiring a reoperation. The median length of hospital stay was 8 days (3-28). The median distance from the circumferential and distal resection margins were, respectively, 5 (1-20) and 10 (5-20) mm, and the mean number of harvested lymph nodes was 21.7 (11-50). All cases had a complete or nearly complete mesorectal plane of surgery. CONCLUSIONS Although technically challenging, the initial results suggest that transanal TME could be a feasible, oncologically safe, and reproducible operation. However, more robust studies are required to assess the short- and long-term outcomes.
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28
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Horne J, Carr NJ, Bateman AC, Kandala N, Adams J, Silva S, Ryder I. A comparison of formalin and GEWF in fixation of colorectal carcinoma specimens: rates of lymph node retrieval and effect on TNM staging. J Clin Pathol 2015; 69:511-7. [PMID: 26621110 DOI: 10.1136/jclinpath-2015-203281] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 10/28/2015] [Indexed: 01/26/2023]
Abstract
AIMS The Royal College of Pathologists recommend that a median of at least 12 lymph nodes should be harvested during pathological staging of colorectal cancer. It is not always easy to harvest the required number, especially in patients with rectal cancer receiving neoadjuvant therapy. Lymph node revealing solutions, for example, GEWF, may improve nodal yield. GEWF is safe, cheap and easy to use. METHODS In a controlled trial, lymph node yields were compared after secondary specimen dissection following either 24 h of further fixation in formalin (n=101) or GEWF immersion (n=99). The number, size and tumour status of additional lymph nodes identified were compared between groups. Twenty-seven cases that received long-course neoadjuvant therapy were also assessed. RESULTS Median lymph node yield at primary dissection met national standards overall (19) but also in the long-course neoadjuvant therapy group (13). Lymph nodes were smaller in neoadjuvant cases compared with non-neoadjuvant cases (mean size range 1.3-5.6 mm vs 1.5-8.9 mm). The use of further fixation and GEWF detected more nodes at secondary dissection. The mean number of additional nodes harvested was greater with formalin (8.3) than GEWF (7.3). There was no significant difference in the mean size of the additional lymph nodes detected between groups (point estimate 1.02; 95% CI -0.58 to 2.63; p=0.211). Upstaging triggering adjunct chemotherapy occurred in 1% (2/200) of cases. CONCLUSIONS The routine use of adjunct techniques to identify additional lymph nodes is unnecessary with underlying high-quality dissection practice. Emphasis should be placed upon education and training, spending appropriate time dissecting and ensuring specimens are sufficiently fixed beforehand.
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Affiliation(s)
- Joanne Horne
- Cellular Pathology Department, University Hospital Southampton NHS Foundation Trust Southampton General Hospital, Southampton, Hampshire, UK
| | - Norman J Carr
- Cellular Pathology Department, University Hospital Southampton NHS Foundation Trust Southampton General Hospital, Southampton, Hampshire, UK
| | - Adrian C Bateman
- Cellular Pathology Department, University Hospital Southampton NHS Foundation Trust Southampton General Hospital, Southampton, Hampshire, UK
| | - Ngianga Kandala
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
| | - Jody Adams
- Cellular Pathology Department, University Hospital Southampton NHS Foundation Trust Southampton General Hospital, Southampton, Hampshire, UK
| | - Sónia Silva
- Cellular Pathology Department, University Hospital Southampton NHS Foundation Trust Southampton General Hospital, Southampton, Hampshire, UK
| | - Isobel Ryder
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
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29
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Zhou D, Ye M, Bai Y, Rong L, Hou Y. Prognostic value of lymph node ratio in survival of patients with locally advanced rectal cancer. Can J Surg 2015; 58:237-44. [PMID: 26022151 DOI: 10.1503/cjs.001515] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The lymph node ratio (LNR) has been shown to be an important prognostic factor in patients with gastric, breast, pancreatic and colorectal cancer. We investigated the prognostic impact of the LNR in addition to TNM classification in patients with locally advanced rectal cancer. METHODS We retrospectively analyzed patients who underwent curative resection for locally advanced rectal cancer between July 2005 and December 2010. We determined the LNR cutoff value using a receiver operating characteristic curve. The Kaplan-Meier method was used to estimate survival curves, while Cox regression analyses were used to evaluate the relationship between LNR and survival. RESULTS We included 180 patients aged 28-83 years with median follow-up of 41.8 months. The median number of lymph nodes examined and lymph nodes involved were 11.5 and 4, respectively, and the median LNR was 0.366. An LNR of 0.19 (19%) was the cutoff point to separate patients with regard to median overall survival. Median overall survival was 64.2 months for patients with an LNR of 0, 59.1 for an LNR of 0.19 or less and 37.6 for an LNR greater than 0.19 (p = 0.004). The median disease-free survival was 32.9 months for patients with an LNR of 0, 30.4 for an LNR of 0.19 or less and 17.8 for an LNR greater than 0.19 (p = 0.002). CONCLUSION Our results suggest that LNR should be considered an additional prognostic factor in patients with locally advanced rectal cancer.
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Affiliation(s)
- Di Zhou
- The Department of Radiation Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ming Ye
- The Department of Radiation Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yongrui Bai
- The Department of Radiation Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ling Rong
- The Department of Radiation Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yanli Hou
- The Department of Radiation Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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30
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García-Flórez LJ, Gómez-Álvarez G, Frunza AM, Barneo-Serra L, Fresno-Forcelledo MF. Response to chemoradiotherapy and lymph node involvement in locally advanced rectal cancer. World J Gastrointest Surg 2015; 7:196-202. [PMID: 26425268 PMCID: PMC4582237 DOI: 10.4240/wjgs.v7.i9.196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/15/2015] [Accepted: 08/11/2015] [Indexed: 02/07/2023] Open
Abstract
AIM: To establish the association between lymph node involvement and the response to neoadjuvant therapy in locally advanced rectal cancer.
METHODS: Data of 130 patients with mid and low locally advanced rectal adenocarcinoma treated with neoadjuvant chemoradiation followed by radical surgery over a 5-year period were reviewed. Tumor staging was done by endorectal ultrasound and/or magnetic resonance imaging. Tumor response to neoadjuvant therapy was determined by T-downstaging and tumor regression grading (TRG). Pathologic complete response (pCR) is defined as the absence of tumor cells in the surgical specimen (ypT0N0). The varying degrees TRG were classified according to Mandard’s scoring system. The evaluation of the response is based on the comparison between previous clinico-radiological staging and the results of pathological evaluation. χ2 and Spearman’s correlation tests were used for the comparison of variables.
RESULTS: Pathologic complete response (pCR, ypT0N0, TRG1) was observed in 19 cases (14.6%), and other 18 (13.8%) had only very few residual malignant cells in the rectal wall (TRG2). T-downstaging was found in 63 (48.5%). Mean lymph node retrieval was 9.4 (range 0-38). In 37 cases (28.5%) more than 12 nodes were identified in the surgical specimen. Preoperative lymph node involvement was seen in 77 patients (59.2%), 71 N1 and 6 N2. Postoperative lymph node involvement was observed in 41 patients (31.5%), 29 N1 and 12 N2, while the remaining 89 were N0 (68.5%). In relation to ypT stage, we found nodal involvement of 9.4% in ypT0-1, 22.2% in ypT2 and 43.7% in ypT3-4. Of the 37 patients considered “responders” to neoadjuvant therapy (TRG1 and 2), there were only 4 N+ (10.8%) and the remainder N0 (89.2%). In the “non responders” group (TRG 3, 4 and 5), 37 cases were N+ (39.8%) and 56 (60.2%) were N0 (P < 0.001).
CONCLUSION: Response to neoadjuvant chemoradiation in rectal cancer is associated with lymph node involvement.
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Kim WR, Han YD, Cho MS, Hur H, Min BS, Lee KY, Kim NK. Oncologic Impact of Fewer Than 12 Lymph Nodes in Patients Who Underwent Neoadjuvant Chemoradiation Followed by Total Mesorectal Excision for Locally Advanced Rectal Cancer. Medicine (Baltimore) 2015; 94:e1133. [PMID: 26181550 PMCID: PMC4617087 DOI: 10.1097/md.0000000000001133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
A minimum of 12 harvested lymph nodes (hLNs) are recommended in colorectal cancer. However, a paucity of hLNs is frequently presented after preoperative chemoradiation (pCRT) in rectal cancer and the significance of this is still uncertain. The aim of this study is to analyze the impact of hLNs on long-term oncologic outcomes. A total of 302 patients with locally advanced rectal cancer who underwent pCRT and curative resection between 1989 and 2009 were reviewed. Patients were categorized into 2 groups according to the number of hLNs: <12 versus ≥12 LN. The 2 groups were compared with respect to 5-year disease-free and overall survival. The optimal number or ratio of hLNs was investigated in subgroup analysis according to LN status. The median follow-up was 57 months. Patient characteristics other than age did not differ between the 2 groups. The group with <12 LNs had more favorable ypTNM and ypN stage than those with ≥12 LNs. However, the long-term oncologic outcomes were not significantly different between the 2 groups. In subgroup analysis of ypN(-), the group with <5 hLNs had the most favorable oncologic outcomes. In ypN(+) cases, a higher LN ratio tended to be associated with poorer 5-year overall survival. The paucity of hLNs in locally advanced rectal cancer after chemoradiation did not imply poor oncologic outcomes in this study. In addition, <5 hLNs in ypN(-) patients could reflect a good tumor response rather than suboptimal radicality.
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Affiliation(s)
- Woo Ram Kim
- From the Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Hall MD, Schultheiss TE, Smith DD, Fakih MG, Kim J, Wong JYC, Chen YJ. Impact of Total Lymph Node Count on Staging and Survival After Neoadjuvant Chemoradiation Therapy for Rectal Cancer. Ann Surg Oncol 2015; 22 Suppl 3:S580-7. [PMID: 25956577 DOI: 10.1245/s10434-015-4585-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Indexed: 01/04/2023]
Abstract
PURPOSE Current guidelines recommend that a minimum of 12 lymph nodes (LNs) be dissected to accurately stage rectal cancer patients. Neoadjuvant chemoradiation therapy (CRT) decreases the number of LNs retrieved at surgery. The purpose of this study was to assess the impact of the number of LNs dissected on overall survival (OS) for localized rectal cancer patients treated with neoadjuvant CRT. METHODS Treatment data were obtained on all patients treated for rectal cancer (2000-2013) in the National Oncology Data Alliance™, a proprietary database of merged tumor registries. Eligible patients were treated with neoadjuvant CRT followed by surgery and had complete data on number of positive LNs, number of LNs examined, and treatment dates (n = 4565). RESULTS Hazard ratios for OS decreased sequentially with increasing number of LNs examined until a maximum benefit was achieved with examination of eight LNs. On multivariate analysis, age, sex, race, marital status, grade, ypT stage, ypN stage, type of surgery, margin status, presence of pathologically confirmed metastasis at surgery, and number of LNs examined were significant predictors of OS. CONCLUSIONS Examination of eight or more LNs in rectal cancer patients treated with neoadjuvant CRT resulted in accurate staging and assignment into prognostic groups with an ensuing improvement in OS by stage. This study suggests that eight LNs is the threshold for an adequate lymph node dissection after neoadjuvant CRT.
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Affiliation(s)
- Matthew D Hall
- Department of Radiation Oncology, City of Hope National Medical Cancer, Duarte, CA, USA.
| | - Timothy E Schultheiss
- Department of Radiation Oncology, City of Hope National Medical Cancer, Duarte, CA, USA
| | - David D Smith
- Division of Biostatistics, City of Hope National Medical Cancer, Duarte, CA, USA
| | - Marwan G Fakih
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Cancer, Duarte, CA, USA
| | - Joseph Kim
- Department of Surgery, City of Hope National Medical Cancer, Duarte, CA, USA
| | - Jeffrey Y C Wong
- Department of Radiation Oncology, City of Hope National Medical Cancer, Duarte, CA, USA
| | - Yi-Jen Chen
- Department of Radiation Oncology, City of Hope National Medical Cancer, Duarte, CA, USA
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Rectal Cancer. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bhatti ABH, Akbar A, Hafeez A, Syed AA, Khattak S, Jamshed A, Kazmi AS. Impact of lymph node ratio and number on survival in patients with rectal adenocarcinoma after preoperative chemo radiation. Int J Surg 2015; 13:65-70. [PMID: 25475873 DOI: 10.1016/j.ijsu.2014.11.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/26/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Retrieval of <12 lymph nodes after proctectomy and preoperative chemoradiation (C-XRT) may improve survival in good risk patients. The objective of this study was to determine impact of <12 retrieved lymph nodes and lymph node ratio (LNR) on survival in a population with certain poor prognostic features for rectal cancer. METHODS Patients who underwent surgery for rectal adenocarcinoma between 2005 and 2011 were divided them into <12 or >12 lymph node groups. The LNR groups were based on interquartile range. Clinicopathological and treatment outcomes were compared. Expected 5 year disease free and overall survival was calculated. Cox proportional hazard model was used to determine independent predictors. RESULTS More patients in <12 lymph nodes removed group had low tumors (<5 cm from anal verge) (75.5% versus 60.7%) (P=0.03) and underwent abdominoperineal resection (59.1% versus 42.9%) (P=0.02). Overall survival (OS) and disease free survival (DFS) was not different [(56% and 52% (P=0.7)] [(50% and 57% (P=0.5)]. LNR<0.15 was independent predictor of DFS while LNR ratio<0.12 for OS on multivariate analysis. CONCLUSION LNR and not number of retrieved nodes impacts survival in younger patients with predominance of anorectal tumors after C-XRT. A specific LNR cutoff remains to be defined.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan.
| | - Ali Akbar
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | | | - Aamir Ali Syed
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Shahid Khattak
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Arif Jamshed
- Department of Radiation Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Ather Saeed Kazmi
- Department of Medical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
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Robotic-assisted laparoscopic transanal total mesorectal excision for rectal cancer: a prospective pilot study. Dis Colon Rectum 2015; 58:145-53. [PMID: 25489707 DOI: 10.1097/dcr.0000000000000265] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We performed a prospective pilot study of robotic-assisted laparoscopic transanal proctectomy with total mesorectal excision for the surgical treatment of rectal cancer. This study was to assess the feasibility and safety of robotic-assisted laparoscopic transanal total mesorectal excision. TECHNIQUE All patients underwent robotic-assisted laparoscopic left colon mobilization, robotic-assisted laparoscopic transanal total mesorectal excision, ultralow mechanical colorectal or handsewn coloanal anastomosis, and a diverting loop ileostomy. Four patients with stage III disease received long-course preoperative chemoradiation before surgery. MAIN OUTCOME MEASURES Primary and secondary end points included the assessment of pathological examination and postoperative morbidity. RESULTS Between August 2013 and January 2014, 4 men and 1 woman underwent robotic-assisted laparoscopic transanal total mesorectal excision. Patient age and BMI were 57 ± 13.9 years and 25.8 ± 2,7 kg/m. Tumors were located an average of 5 ± 1 cm from the anal verge and were preoperatively staged as T2N0M0 (1 patient) and T2N1M0 (4 patients). Mean operative time was 398 ± 88 minutes with no intraoperative complications. Mean length of hospital stay was 6 ± 1 days. A Clavien II, grade B anastomotic leakage developed in 1 patient postoperatively. In all cases, pathological examination of the total mesorectal excision specimens showed complete mesorectal excision with negative proximal, distal, and circumferential margins. All patients were disease-free at their initial 3-month follow-up. CONCLUSIONS Robotic-assisted laparoscopic transanal total mesorectal excision is a feasible and safe option for the surgical management of early-stage rectal cancers. Robotic technology with endowristed instruments and 3-dimensional high-definition imaging are of great help in overcoming the limitations of traditional laparoscopic transanal surgery. Long-term functional and oncological assessments of outcome are needed.
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Kim HJ, Jo JS, Lee SY, Kim CH, Kim YJ, Kim HR. Low Lymph Node Retrieval After Preoperative Chemoradiation for Rectal Cancer is Associated with Improved Prognosis in Patients with a Good Tumor Response. Ann Surg Oncol 2014; 22:2075-81. [PMID: 25395150 DOI: 10.1245/s10434-014-4235-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Indexed: 12/28/2022]
Abstract
PURPOSE To examine the association between the number of lymph nodes retrieved and oncologic outcome after preoperative chemoradiation for rectal cancer according to tumor regression grade. METHODS Patients with rectal cancer who underwent curative surgery between May 2004 and December 2012 were analyzed retrospectively. Using multivariate analysis, the correlation between clinicopathologic variables and the number of lymph nodes retrieved was evaluated. The associations between the oncologic outcome and number of lymph nodes retrieved were also investigated according to the tumor regression grade. RESULTS In total, 1,332 patients were identified, of whom 433 (32.8 %) received preoperative chemoradiation. Multivariate analysis revealed that preoperative chemoradiation was an independent predictor of the number of lymph nodes retrieved (P = 0.002). After chemoradiation, the number of total and positive lymph nodes retrieved was inversely correlated with tumor regression. Retrieval of ≥12 lymph nodes was not an independent prognostic factor for disease-free survival; however, among patients with a good tumor response, those with <12 lymph nodes retrieved had a significantly better 3-year disease-free survival (P = 0.030) than those with ≥12 lymph nodes retrieved. CONCLUSIONS Reduced lymph node yield after preoperative chemoradiation for rectal cancer does not indicate inadequate oncologic surgery. It may represent good treatment response and better prognosis, especially in patients with good pathologic tumor regression after chemoradiation.
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Affiliation(s)
- Hun Jin Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, 519-763, Jeonnam, Korea
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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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Chen H, Zhao L, An S, Wu J, Zou Z, Liu H, Li G. Laparoscopic versus open surgery following neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and meta-analysis. J Gastrointest Surg 2014; 18:617-626. [PMID: 24424713 DOI: 10.1007/s11605-014-2452-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 01/02/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND This meta-analysis aimed to evaluate the short-term and pathological outcomes of laparoscopic surgery (LS) versus open surgery (OS) following neoadjuvant chemoradiotherapy (NCRT) for rectal cancer. METHODS PubMed, Embase, Web of Science, Cochrane Library, and Chinese Biomedicine Literature databases were searched for eligible studies published up to July 2013. The rates of postoperative complication, positive circumferential resection margin (CRM), and the number of lymph nodes harvested were evaluated. RESULTS Three randomized controlled trials (RCTs) and five non-RCTs enrolling 953 patients were included. Compared to OS, LS had similar rate of postoperative complication [odds ratio (OR) 0.86; 95% confidence interval (CI), 0.60 to 1.22], comparable rate of positive CRM (OR 0.41; 95% CI, 0.16 to 1.02), and smaller number of lymph nodes (weighted mean difference -0.8; 95% CI, -1.1 to -0.5). LS also had significantly less blood loss, faster bowel movement recovery, and shorter postoperative hospitalization than those of OS. CONCLUSION LS is associated with favorable short-term benefits, similar postoperative complication rate, and comparable pathological outcomes for rectal cancer after NCRT compared to OS despite a slight difference in the number of lymph nodes. Additional high-quality studies are needed to validate long-term outcomes of LS following NCRT.
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Affiliation(s)
- Hao Chen
- Department of General Surgery, Nanfang Hospital, Southern Medical University, No.1838, North Guangzhou Avenue, Guangzhou, 510515, China
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Destri GL, Carlo ID, Scilletta R, Scilletta B, Puleo S. Colorectal cancer and lymph nodes: The obsession with the number 12. World J Gastroenterol 2014; 20:1951-1960. [PMID: 24587671 PMCID: PMC3934465 DOI: 10.3748/wjg.v20.i8.1951] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 01/06/2014] [Indexed: 02/06/2023] Open
Abstract
Lymphadenectomy of colorectal cancer is a decisive factor for the prognostic and therapeutic staging of the patient. For over 15 years, we have asked ourselves if the minimum number of 12 examined lymph nodes (LNs) was sufficient for the prevention of understaging. The debate is certainly still open if we consider that a limit of 12 LNs is still not the gold standard mainly because the research methodology of the first studies has been criticized. Moreover many authors report that to date both in the United States and Europe the number “12” target is uncommon, not adequate, or accessible only in highly specialised centres. It should however be noted that both the pressing nature of the debate and the dissemination of guidelines have been responsible for a trend that has allowed for a general increase in the number of LNs examined. There are different variables that can affect the retrieval of LNs. Some, like the surgeon, the surgery, and the pathology exam, are without question modifiable; however, other both patient and disease-related variables are non-modifiable and pose the question of whether the minimum number of examined LNs must be individually assigned. The lymph nodal ratio, the sentinel LNs and the study of the biological aspects of the tumor could find valid application in this field in the near future.
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Nadoshan JJ, Omranipour R, Beiki O, Zendedel K, Alibakhshi A, Mahmoodzadeh H. Prognostic value of lymph node ratios in node positive rectal cancer treated with preoperative chemoradiation. Asian Pac J Cancer Prev 2014; 14:3769-72. [PMID: 23886180 DOI: 10.7314/apjcp.2013.14.6.3769] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the impact of the lymph node ratio (LNR) on the prognosis of patients with locally advanced rectal cancer undergoing pre-operative chemoradiation. METHODS Clinicopathologic and follow up data of 128 patients with stage III rectal cancer who underwent curative resection from 1996 to 2007 were reviewed. The patients were divided into two groups according to the lymph node ratio: LNR ≤ 0.2 (n=28), and >0.2 (n=100). Kaplan-Meier and the Cox proportional hazard regression models were used to evaluate the prognostic effects according to LNR. RESULTS Median numbers of lymph nodes examined and lymph nodes involved by tumour were 10.3 (range 2-28) and 5.8 (range 1-25), respectively, and the median LNR was 0.5 (range, 0-1.6). The 5-year survival rate significantly differed by LNR (≤ 0.2, 69%; >0.2, 19%; Log-rank p value < 0.001). LNR was also a significant prognostic factor of survival adjusted for age, sex, post-operative chemotherapy, total number of examined lymph nodes, metastasis and local recurrence (≤ 0.2, HR=1; >0.2, HR=4.8, 95%CI=2.1-11.1) and a significant predictor of local recurrence and distant metastasis during follow-up independently of total number of examined lymph node. CONCLUSIONS Total number of examined lymph nodes and LNR were significant prognostic factors for survival in patients with stage III rectal cancer undergoing pre-operative chemoradiotherapy.
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Affiliation(s)
- Jamal Jafari Nadoshan
- Department of Surgical Oncology, Cancer Institute, Tehran University of Medical Science, Tehran, Iran
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Horne J, Bateman AC, Carr NJ, Ryder I. Lymph node revealing solutions in colorectal cancer: should they be used routinely? J Clin Pathol 2014; 67:383-8. [DOI: 10.1136/jclinpath-2013-202146] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Atallah S, Martin-Perez B, Albert M, deBeche-Adams T, Nassif G, Hunter L, Larach S. Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): results and experience with the first 20 patients undergoing curative-intent rectal cancer surgery at a single institution. Tech Coloproctol 2013; 18:473-80. [PMID: 24272607 DOI: 10.1007/s10151-013-1095-7] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 11/02/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transanal TME is a new approach to performing minimally invasive rectal resection. It is particularly well suited for patients with locally advanced distal rectal cancer and obesity, where the abdominal approach is challenging. Transanal TME can be performed with either TAMIS or TEM. Here, we report our initial experience with transanal TME using TAMIS (TAMIS-TME). METHODS Patients were selected to undergo transanal TME using the TAMIS platform (TAMIS-TME) primarily for malignant disease, but also for select cases of benign disease. Transanal TME defines a "bottom-up" approach to en bloc rectal cancer resection. Transanal TME requires abdominal access for proximal colonic mobilization and is often done in conjunction with a laparoscopic approach. RESULTS During a 32-month period, 20 patients underwent TAMIS-TME with curative intent. The primary indication for transanal TME was distal, locally advanced rectal cancer. The median age of rectal cancer patients at the time of surgery was 57 years (range 36-73 years) with 30% (6) female and 70% (14) male. The median body mass index (BMI) measured was 24 kg/m(2) (range 18-41 kg/m(2)); this included six patients (30%) with obesity (BMI ≥ 30 kg/m(2)). Mean operating time was 243 min (range 140-495 min) with blood loss averaging 153 ml. Postoperative length of stay averaged 4.5 days (range 3-24 days). There was no 30-day postoperative mortality. Surgical complications included wound infection (n = 2), pelvic abscess (n = 4), and prolonged ileus (n = 4). The anastomotic leak rate was 6.7% (1/15). Of the 20 patients who underwent resection, 90% (18/20) had negative margins. Pathologic grading of the TME specimen revealed that 85% (17/20) of transanal TME specimens were found to have "completely" or "near-completely" intact mesorectal envelopes. Data collected during the 6-month median follow-up period revealed that only one patient had developed distant metastasis. There was no locoregional recurrence in any of the patients. CONCLUSIONS Transanal TME is a feasible method for oncologic resection of locally advanced mid- and distal-rectal cancer with curative intent. It has special application for patients with obesity and anatomic constraints such as a narrow male pelvis.
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Affiliation(s)
- S Atallah
- Florida Hospital, Winter Park, FL, USA,
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Hu JJ, Liang JW, Wang Z, Zhang XM, Zhou HT, Hou HR, Zhou ZX. Short-term outcomes of laparoscopically assisted surgery for rectal cancer following neoadjuvant chemoradiotherapy: a single-center experience. J Surg Res 2013; 187:438-44. [PMID: 24252856 DOI: 10.1016/j.jss.2013.10.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 10/16/2013] [Accepted: 10/18/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The efficacy of laparoscopic treatment of rectal cancer remains unclear, and little is known about its effect on sphincter preservation. We compared short-term outcomes of laparoscopically assisted and open surgeries following neoadjuvant chemoradiotherapy (CRT) for mid and low rectal cancer. METHODS This study enrolled 137 patients with mid-low rectal cancer who underwent curative resection, 51 by laparoscopically assisted (Lap group) and 86 by conventional open (Open group) surgeries, following neoadjuvant CRT from July 2007 to July 2012. The clinical and surgical findings of the two groups of patients were prospectively collected and analyzed. RESULTS Three patients (5.9%) in the Lap group were converted to an open procedure. The mean operating times were similar in both groups. The Lap group had a significantly higher rate of sphincter preservation (62.7% versus 41.9%, P = 0.018) and significantly lower mean blood loss than the Open group. Mean times to first flatus, start of a normal diet, and overall postoperative hospitalization were longer for open surgery. The complication rate (11.8% versus 31.4%, P = 0.009) was significantly lower in the Lap group. Mean distal resection margin, involvement of the circumferential resection margin (2.0% versus 3.5%, P = 1.000), and mean lymph nodes harvested (12 versus 11; P = 0.242) were equivalent in the two groups. CONCLUSIONS Laparoscopically assisted surgery following neoadjuvant CRT is safe for patients with rectal cancer and provides favorable short-term benefits but without compromising oncologic outcomes. This sphincter-preserving procedure may be a treatment of choice for patients with lower rectal cancer.
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Affiliation(s)
- Jun-Jie Hu
- Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jian-Wei Liang
- Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zheng Wang
- Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xing-Mao Zhang
- Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hai-Tao Zhou
- Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hui-rong Hou
- Comprehensive Planning Office, Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhi-Xiang Zhou
- Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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Marks J, Nassif G, Schoonyoung H, DeNittis A, Zeger E, Mohiuddin M, Marks G. Sphincter-sparing surgery for adenocarcinoma of the distal 3 cm of the true rectum: results after neoadjuvant therapy and minimally invasive radical surgery or local excision. Surg Endosc 2013; 27:4469-77. [PMID: 24057070 DOI: 10.1007/s00464-013-3092-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 07/01/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ideal treatment of rectal cancer includes controlling the cancer; minimizing trauma, morbidity, and mortality; and avoiding a colostomy with preservation of adequate function. These goals become more challenging the further distal in the rectum the cancer is located. We sought to determine whether minimally invasive sphincter-preservation surgery (SPS) can accomplish good cancer control, maintaining sphincter function with minimal morbidity and mortality in rectal cancers of the distal 3 cm after receiving neoadjuvant chemoradiotherapy. METHODS We retrospectively reviewed a prospectively maintained rectal cancer database of a single colorectal surgeon to identify all patients with cancers of the distal 3 cm undergoing SPS via a laparoscopic total mesorectal excision or transanal endoscopic microsurgery (TEM). All patients received neoadjuvant chemoradiotherapy. Patient data, including demographics, initial tumor characteristics, staging, radiation dose, perioperative morbidity and mortality, and local recurrence (LR) and survival, were analyzed. RESULTS A total of 161 patients (108 men) underwent SPS via 3 techniques: transanal abdominal transanal proctosigmoidectomy (TATA, n = 106), TEM (n = 49), or ultralow anterior resection (LAR, n = 6). Average age was 62 years (range 22-90 years). The mean levels in rectum from the anorectal ring were as follows: TATA, 1.3 cm (range -1.0 to 3.0 cm), TEM, 1.5 cm (range -0.5 to -3.0 cm), and LAR, 2.9 cm (range 2.5-3.0 cm) (p > 0.05). Preoperative T stage was as follows: T3, n = 108 (TATA 83, TEM 20, LAR 5), T2, n = 48 (TATA 22, TEM 25, LAR 1), T1, n = 3 (TATA 1, TEM 2), and T4, n = 2 (both TEM). All patients received concomitant 5-fluorouracil-based chemotherapy and radiotherapy (mean, 5300 cGy; range 3,000-7,295 cGy). The mean estimated blood loss was 376 ml (range 10-3,600 ml). There were no mortalities. Morbidity rates were as follows: LAR, 0; TATA, 13.2%; and TEM, 32 % (wound disruption: major, 10%; minor, 16%). Pathologic staging was as follows: ypCR: uT2, 34%, and uT3, 19%. Overall LR was 3.7%. By procedure, the follow-up, LR, and KM5YAS, respectively, were: TATA, 37.9 months, 3 and 95%; TEM, 36.3 months, 6 and 88%; and LAR, 63.1 months, 0 and 75% (p > 0.05). CONCLUSIONS This study demonstrates positive oncologic outcomes, low LR rates, and high KM5YS after minimally invasive SPS. A colostomy-free lifestyle and cancer control make the minimally invasive surgical approach an excellent treatment option for complex distal rectal cancers.
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Affiliation(s)
- John Marks
- Section of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA,
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Histopathological regression grading matches excellently with local and regional spread after neoadjuvant therapy of rectal cancer. Pathol Res Pract 2013; 209:424-8. [DOI: 10.1016/j.prp.2013.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 12/12/2012] [Accepted: 04/19/2013] [Indexed: 02/06/2023]
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de Campos-Lobato LF, Stocchi L, de Sousa JB, Buta M, Lavery IC, Fazio VW, Dietz DW, Kalady MF. Less than 12 nodes in the surgical specimen after total mesorectal excision following neoadjuvant chemoradiation: it means more than you think! Ann Surg Oncol 2013; 20:3398-406. [PMID: 23812804 DOI: 10.1245/s10434-013-3010-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND A minimum of 12 examined lymph nodes (LN) is recommended to ensure adequate staging and oncologic resection of patients undergoing proctectomy for rectal adenocarcinoma. However, a decreased number of LN is not unusual in patients receiving neoadjuvant chemoradiation. PURPOSE We hypothesized that a decreased number of LN in the proctectomy specimen of these patients may be an indicator of tumor response and be associated with improved prognosis. METHODS A single-center colorectal cancer database was queried for c-stage II-III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized into two groups according to the number of LN retrieved from the proctectomy specimen: <12 LN versus ≥12 LN. Groups were compared with respect to demographics, tumor and treatment characteristics, and the following oncologic outcomes: overall-survival (OS), cancer-specific-mortality (CSM), cancer-free-survival (CFS), distant (DR), and local recurrences (LR). RESULTS The query returned 237 patients. There were 173 (73 %) males, and the median age was 57 years [interquartile range (IQR) 49-66 years]. The median number of LN retrieved was 15 (IQR 10-23) and 70 (30 %) patients had less than 12 nodes examined. The <12 nodes group was older [60 (IQR 51-71 years) vs. 55 (IQR 48-65 years), p = 0.009] and had more pathologic complete responders (36 vs. 19 %, p = 0.01). No <12 nodes patient experienced a LR, whereas the 5-year LR rate was 11 % in the ≥12 nodes group (p = 0.004). Other oncologic outcomes were not significantly different. CONCLUSIONS Retrieval of less than 12 nodes in the proctectomy specimen of rectal cancer patients treated with neoadjuvant chemoradiation does not affect OS, CSM, CFS, or DR and may be a marker of higher tumor response and, consequently, decreased LR rate.
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Amajoyi R, Lee Y, Recio PJ, Kondylis PD. Neoadjuvant therapy for rectal cancer decreases the number of lymph nodes harvested in operative specimens. Am J Surg 2013; 205:289-92; discussion 292. [DOI: 10.1016/j.amjsurg.2012.10.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 10/15/2012] [Accepted: 10/19/2012] [Indexed: 11/26/2022]
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Madariaga MLL, Berger DL. The quandary of N0 disease after neoadjuvant therapy for rectal cancer. J Gastrointest Oncol 2012. [PMID: 23205302 DOI: 10.3978/j.issn.2078-6891.2012.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Maria Lucia L Madariaga
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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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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Abstract
Colorectal carcinoma is one of the most common cancers and one of the leading causes of cancer-related death in the United States. Pathologic examination of biopsy, polypectomy and resection specimens is crucial to appropriate patient managemnt, prognosis assessment and family counseling. Molecular testing plays an increasingly important role in the era of personalized medicine. This review article focuses on the histopathology and molecular pathology of colorectal carcinoma and its precursor lesions, with an emphasis on their clinical relevance.
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Affiliation(s)
- Matthew Fleming
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles, California, USA
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