Prognostic evaluation of stage B colon cancer patients is improved by an adequate lymphadenectomy: results of a secondary analysis of a large scale adjuvant trial

Factors affecting lymph node yield from patients undergoing colectomy for cancer

PURPOSE

Lymph node (LN) yield is a critical component of colon cancer staging and is often a surrogate for quality assessment in surgery. We investigated the impact of pathologists' training on LN harvest.

METHODS

This is a retrospective review on 137 patients undergoing elective colectomy for adenocarcinoma at a single institution from 2008 to 2009. We studied surgeon-, patient- and pathologist-derived factors, and identified independent variables affecting LN yield using logistic regression.

RESULTS

LN yield was similar between open and laparoscopic resections (21 versus 23, p = 0.54). Similarly, nodal counts were independent of tumor location (p = 0.08) and no difference was noted between colorectal and general surgeons (24 versus 21, p = 0.31). Strikingly, the number of LNs reported by PGY-1 pathology residents was significantly higher than those with two or more years of training (24 versus 19, p = 0.02). On logistic regression, only the reporting pathologists' year in training remained a significant predictor of the number of nodes reported (OR = 5.28, p = 0.0001).

CONCLUSIONS

LN retrieval in patients with colon cancer is inversely related to the interpreting pathologists' level of training.

Learning curves in laparoscopic right-sided colon cancer surgery: a comparison of first-generation colorectal surgeon to advance laparoscopically trained surgeon

BACKGROUND

We aimed to evaluate the learning curve (LC) for laparoscopic right-sided colon cancer surgery (LRCCS) by comparing the results between two surgeons (first-generation colorectal surgeon versus laparoscopically trained surgeon).

METHODS

The study was a retrospective analysis that evaluated 117 consecutive LRCCSs performed by two surgeons, the first-generation surgeon (Surgeon A) and laparoscopically trained surgeon (Surgeon B), from April 1995 to August 2006. Patients were divided into two groups; patients included in groups I and II received LRCCSs from surgeons A and B, respectively.

RESULTS

The moving average method revealed that the operation times of surgeons A and B began to shorten after the 9th case. The cumulative sum (CUSUM) analysis of group I data showed that the 24th case was the peak point of conversion. The 35th case was the peak for intraoperative complications, and the 17th case was the peak for postoperative complications. There was only one case of conversion in group II. The peak points for inadequate lymph node dissection were the 37th case in group I and the 8th case in group II. The CUSUM analysis for surgeons A and B showed that the 18th case and the 8th case, respectively, were the overall peak points in the failure of LRCCS.

CONCLUSIONS

We suggest that careful observation of a laparoscopic procedure, such as acting as the scope operator for a certain amount of time, may help in shortening the LC of the actual procedure.

Factors predicting oncologic outcomes in patients with fewer than 12 lymph nodes retrieved after curative resection for colon cancer

PURPOSE

The aim of this study was to determine which clinicopathological factors influenced the long-term survival after potentially curative resection of patients with colon cancer having fewer than 12 retrieved lymph nodes.

METHODS

Prospective data were collected from 179 patients who had fewer than 12 resected lymph nodes after curative resection for stages I-III colon cancer. The oncological outcomes and the risk factors for recurrence were analyzed, focusing on lymph node ratio (LNR).

RESULTS

The median number of harvested lymph nodes was 7 (range, 1-11). The LNR was associated significantly with T category and lymphovascular invasion. Multivariate analysis revealed that tumor diameter (P = 0.006), perineural invasion (P = 0.043), LNR (P = 0.002), and preoperative carcinoembryonic antigen (CEA) level (P = 0.013) were the independent predictors for 5-year disease-free survival; T category (P = 0.032), postoperative chemotherapy (P = 0.001), LNR (P = 0.007), and preoperative CEA level (P = 0.023) were the independent predictors for 5-year overall survival.

CONCLUSIONS

The LNR and preoperative CEA level may be reliable predictors of recurrence and survival after curative surgery in patients with colon cancer who have less than 12 lymph nodes examined.

Evaluation of quality indicators following implementation of total mesorectal excision in primarily resected rectal cancer changed future management

BACKGROUND AND AIMS

We evaluated the outcome of primarily resected rectal cancer patients immediately after the implementation of total meserectal excision (TME) based on potential quality indicators.

PATIENTS AND METHODS

Following initial teaching of two staff surgeons (PMS and AHH) by RJ Heald, 164 consecutive patients were analyzed. The following quality indicators were evaluated: (a) frequency of local recurrence, (b) number of resected lymph nodes, (c) selection of operative technique depending on tumor localization, (d) use of a protective loop ileostomy, and (e) frequency and type of adjuvant therapy.

RESULTS

Local recurrence rate was 8.5% after a minimum follow-up of 5 years. An increasing pT category (p < 0.02) and the presence of lymph node metastases (pN+, p < 0.05) were significantly associated with local recurrence rates. The number of resected lymph nodes was significantly associated with nodal metastases rate (p < 0.02). Patients with distal third rectal cancer underwent significantly more often an abdominoperineal amputation (p < 0.0001). Clinical course, but not the rate of anastomotic leakage (9.5%) itself was influenced by using a protective loop ileostomy. Forty-two (29.7%) patients received adjuvant therapy; however, local recurrence rate was higher in patients with adjuvant chemo-/radiotherapy (14.2% vs. 6.1%).

CONCLUSIONS

The local recurrence rate of 8.5% demonstrates that through consequent implementation of TME excellent onclogical results can be achieved. The number of resected lymph nodes significantly influenced the pN category. The primary construction of a protective loop ileostomy after TME became standard. Neoadjuvant chemoradiation was systematically introduced in order to improve local tumor control and prevent abdominoperineal amputations. No conclusions can be drawn concerning adjuvant therapy.

Role of radiation in intermediate-risk rectal cancer

The treatment of rectal cancer has greatly evolved during the last several decades as a result of the understanding of the pathways of cancer spread, natural history of the disease, stages prognosis and prognostic markers. The tendency is clearly to move toward a more personalized approach to these patients based on preoperative staging and response to therapy. Although in the past we have been adding more treatment modalities to surgery to the point that every stage II/III cancer was treated with neoadjuvant chemo and radiotherapy followed by radical surgery by total mesorectal excision with or without sphincter preservation and more chemotherapy to follow, more recently this algorithm has been under discussion and scrutiny. Two of the major topics of controversy are: the use of local excision or even a watch-and-wait approach after a clinical complete response and the need for radiotherapy in the intermediate risk group. In this manuscript we will present the historical perspective that has brought the treatment of rectal cancer to the current standard of care and present the evidence supporting further investigation in the intermediate risk group.

Evaluation of lymph node numbers for adequate staging of Stage II and III colon cancer

BACKGROUND

Although evaluation of at least 12 lymph nodes (LNs) is recommended as the minimum number of nodes required for accurate staging of colon cancer patients, there is disagreement on what constitutes an adequate identification of such LNs.

METHODS

To evaluate the minimum number of LNs for adequate staging of Stage II and III colon cancer, 490 patients were categorized into groups based on 1-6, 7-11, 12-19, and ≥ 20 LNs collected.

RESULTS

For patients with Stage II or III disease, examination of 12 LNs was not significantly associated with recurrence or mortality. For Stage II (HR = 0.33; 95% CI, 0.12-0.91), but not for Stage III patients (HR = 1.59; 95% CI, 0.54-4.64), examination of ≥20 LNs was associated with a reduced risk of recurrence within 2 years. However, examination of ≥20 LNs had a 55% (Stage II, HR = 0.45; 95% CI, 0.23-0.87) and a 31% (Stage III, HR = 0.69; 95% CI, 0.38-1.26) decreased risk of mortality, respectively. For each six additional LNs examined from Stage III patients, there was a 19% increased probability of finding a positive LN (parameter estimate = 0.18510, p < 0.0001). For Stage II and III colon cancers, there was improved survival and a decreased risk of recurrence with an increased number of LNs examined, regardless of the cutoff-points. Examination of ≥7 or ≥12 LNs had similar outcomes, but there were significant outcome benefits at the ≥20 cutoff-point only for Stage II patients. For Stage III patients, examination of 6 additional LNs detected one additional positive LN.

CONCLUSIONS

Thus, the 12 LN cut-off point cannot be supported as requisite in determining adequate staging of colon cancer based on current data. However, a minimum of 6 LNs should be examined for adequate staging of Stage II and III colon cancer patients.

Laparoscopic radical correction combined with extensive lymphadenectomy and pelvic autonomic nerve preservation for mid-to-low rectal cancer

OBJECTIVE

The purposes of this study were to confirm the definite metastasis and micrometastasis rate of upward and lateral lymph nodes of mid-to-low rectal cancer at stage II and stage III, and to evaluate the feasibility and safety of laparoscopic radical correction combined with extensive lymphadenectomy and pelvic autonomic nerve preservation (PANP).

METHODS

The study was performed in 68 patients who were diagnosed with mid-to-low rectal cancer at stage II or stage III and received laparoscopic radical correction combined with extensive lymphadenectomy and PANP from June 2006 to June 2008 in the General Surgery Department of Southwest Hospital. All lymph nodes resected in the surgeries were examined by hematoxylin and eosin (H & E) stain and immunohistochemistry with an antibody against cytokeratin 20 (CK20) to confirm the conditions of metastasis and micrometastasis. We compared the postoperative complications with those of traditional surgeries.

RESULTS

In 1571 lymph nodes, 16 lymph nodes were found to have definite metastasis in 6 patients (8.8%) and in 41 lymph nodes we found micrometastasis in 12 patients (17.6%). The total metastasis rate of upward and lateral lymph nodes was 19.1%. Compared with traditional surgeries, the new surgery had less blood loss and short convalescence and postoperative complications were not increased.

CONCLUSION

The total metastasis rate of upward and lateral lymph nodes is 19.1%. The laparoscopic radical correction combined with extensive lymphadenectomy and PANP is feasible and safe.

Lymph node harvest in colorectal adenocarcinoma specimens: the impact of improved fixation and examination procedures

A review of 1050 pathology reports from colorectal adenocarcinoma specimens examined at the Department of Pathology, Sørlandet sykehus HF, Kristiansand, Norway during the period 1995-2006 revealed a poor performance of most doctors concerning lymph node harvest. A mean of 8.1 nodes per specimen (range 12.3-2.1) and a mean proportion of 22.3% of specimens with ≥12 lymph nodes (range 47.1-0%) were found. A small pilot study was undertaken in 2007 to evaluate the effect of prolonged formalin fixation and the use of a special lymph node fixative [glacial acetic acid, ethanol, water and formaldehyde (GEWF) solution] with regard to the number of retrieved nodes. This showed that one extra day formalin fixation and the use of GEWF solution considerably enhanced the detection of lymph nodes, particularly those of smaller size. Based on these findings, our routines concerning handling of colorectal cancer specimens were changed during 2007. After this time all specimens have been fixed in a mixture of GEWF solution and formalin for at least 48 h and the doctors have been encouraged to find as many lymph nodes as possible. In cases revealing <12 nodes after microscopical examination, the specimens have been re-examined and searched for additional nodes. A review of lymph node retrieval in 423 cases of colorectal cancer during the period 2008-2010 showed that the mean number of nodes per specimen had increased to 16.8 (range 29.0-13.3) and the proportion of specimens with ≥12 nodes to 78.0% (range 96.8-63.6%). Thus, these changes of routines which were easy to implement without significant extra costs have considerably improved lymph node harvest at our department. The use of a special lymph node fixative (e.g. GEWF solution) is highly recommended not only for detection of nodes in colorectal specimens, but also for retrieval of lymph nodes embedded in fat tissue generally.

Same Surgeon: Different Centre Equals Differing Lymph Node Harvest following Colorectal Cancer Resection

Introduction. The aim of this study was to examine the effect of surgeon relocation on lymph node (LN) retrieval in colorectal cancer (CRC) resection. Methods. The study population was 213 consecutive patients undergoing CRC resection by a single surgeon, at two units: unit one 110 operations (2002-2005) and unit two 103 (2005-2009). LN yields and case mix were compared. Results. Median LN harvests were significantly different between the two centres: unit 1: 13 nodes/patient and unit 2: 22 nodes/patient (P < .001). In unit one 42% of cases were LN positive and in unit two 48% (P = .398). There was no difference in case mix. Multivariate analysis identified unit (P < .001) and pathologist (P = .007) as independent predictors of harvest. Conclusions. A surgeon moving units can experience significantly different LN yield following CRC resection. Both units comply with national standards, but the "surgeon's results" at the two units appear to be pathologist dependent. This has implications for nodal harvest as a surrogate marker of surgical quality.

Lymph node ratio as a quality and prognostic indicator in stage III colon cancer

BACKGROUND

The presence and number of nodal metastasis significantly impact colon cancer prognosis. Similarly, the number of resected/evaluated nodes impacts staging accuracy. This ratio of metastatic to examined nodes or lymph node ratio (LNR) may have independent prognostic value in colon carcinoma.

PURPOSE

: To evaluate the impact of LNR on overall survival in colon cancer patients with fewer than 12 or 12 examined nodes or more.

METHODS

Patients (n = 36,712) with node-positive nonmetastatic colon cancer diagnosed between 1992 and 2004 were identified from the Surveillance, Epidemiology, and End Results database and stratified according to LNR and number of nodes examined. Survival was estimated by Kaplan-Meier method, and differences analyzed by log-rank test. A Cox proportional hazards model was used for multivariate analysis.

RESULTS

Patients with fewer than 12 nodes were older and male and had lower primary tumor stage, grade, and N stage (P < 0.01). Survival appeared greater with 12 total nodes examined or more (median 53 vs. 66 months, P < 0.001). Within each LNR stratum, survival with 12 nodes or more was improved for those with less than 10% of nodes positive for cancer, but was worse with higher LNRs (P < 0.01). Lymph node ratio was significantly associated with survival independent of total nodes (HR 1.24-5.12, P < 0.001). Other significant factors included age, race, tumor grade, stage, location, and N stage.

CONCLUSION

Metastatic LNR independently estimates survival in Stage III colon cancer, irrespective of number of nodes examined. However, statistically significant differences in each LNR stratum between those with resection of fewer than 12 or 12 nodes or more would indicate that a 12-node minimum may still be necessary for accurate staging.

Comparison of nodal positivity between SLNM vs conventional surgery in colon cancer patients with <12 and ≥12 lymph nodes harvested

BACKGROUND

Examination of ≥12 lymph nodes (LNs) ensures accurate staging in colon cancer. The aim of this study was to compare nodal positivity between sentinel LN mapping (SLNM) and conventional surgery in patients with <12 and ≥12 LNs harvested.

METHODS

From 1993 to 2008, 407 and 380 patients with colon cancer underwent SLNM and conventional surgery, respectively. Total LNs harvested and nodal positivity were analyzed. Patients were grouped according to number of LNs harvested: 2 to 11, 12 to 25, or >25.

RESULTS

The average numbers of LNs harvested in the groups with 2 to 11, 12 to 25, and >25 LNs harvested for SLNM and conventional surgery, respectively, were 8.3 and 7.1 (P < .0001), 17.2 and 16.5 (P = .09), and 34.2 and 32.1 (P = .40). Nodal positivity for SLNM and conventional surgery in the groups with <12 and ≥12 LNs harvested was 42% and 29% (P = .01) and 50% and 36% (P = .003), respectively. Overall nodal positivity was 47% for SLNM and 32% for conventional surgery (P < .0001). When SLNM with 2 to 11 LNs was compared with conventional surgery with 12 to 25 LNs, nodal positivity was 42% versus 36% (P = .35).

CONCLUSIONS

SLNM possessed higher nodal positivity compared with conventional surgery. SLNM is a valuable adjunct to accurate nodal staging in colon cancer.

Nodal yield and survival in oral squamous cancer: Defining the standard of care

BACKGROUND

Elective neck dissection (END) is commonly used as a staging and therapeutic procedure for oral squamous cell carcinoma (SCC) at high risk of nodal metastases. The authors aimed to determine whether the extent of lymphadenectomy, as defined by nodal yield, is a prognostic factor in this setting.

METHODS

A retrospective database review identified 225 patients undergoing END with curative intent for oral SCC between 1987 and 2009. Nodal yield was studied as a categorical variable for association with overall, disease-specific, and disease-free survival in univariate and multivariate analyses.

RESULTS

Nodal yield <18 was associated with 5-year overall survival of 51% compared with 74% in those with nodal yield ≥ 18 (P = .009). Five-year disease-specific survival rates were 69% in those with <18 nodes and 87% in patients with ≥ 18 nodes (P = .022). Similar results were obtained for disease-free survival, with 5-year rates of 44% with <18 nodes versus 71% with ≥ 18 nodes (P = .043). After adjusting for the effect of age, nodal status, T stage, and adjuvant radiotherapy on multivariate analysis, nodal yield <18 was associated with reduced overall (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.1-3.6; P = .020), disease-specific (HR, 2.2; 95% CI, 1.1-4.5; P = .043), and disease-free survival (HR, 1.7; 95% CI, 1.1-2.8; P = .040). In the pathologically lymph node-negative subgroup (n = 148), similar results were obtained.

CONCLUSIONS

Nodal yield is an independent prognostic factor in patients undergoing END for oral SCC. These results suggest that an adequate lymphadenectomy in this setting should include at least 18 nodes.

A multidisciplinary cancer center maximizes surgeons' impact

BACKGROUND

Colorectal cancer patients require care across different disciplines. Integration of multidisciplinary care is critical to accomplish excellent oncologic results. We hypothesized that the establishment of a dedicated colorectal cancer center (CRCC) around specialty-trained surgeons will lead to increased multidisciplinary management and improved outcomes in colorectal cancer patients.

METHODS

We analyzed data from three periods: a baseline group, a period after the recruitment of specialty-trained surgeons, and a period after the creation of a dedicated multidisciplinary cancer center. Data analyzed included surrogate markers of surgical oncologic care, multidisciplinary integration, and oncologic outcomes.

RESULTS

Recruitment of specialized surgeons led to improvements in surgical oncologic care; the establishment of the CRCC resulted in further improvements in surgical oncologic care and multidisciplinary integration.

CONCLUSION

Our study suggests that although the recruitment of specialty-trained surgeons in a high volume center leads to improvement in surgical oncologic care, it is the establishment of a multidisciplinary center around the surgeons that leads to integrated care and improvements in oncologic outcomes.

The impact of audit and feedback on nodal harvest in colorectal cancer

BACKGROUND

Adequate nodal harvest (≥ 12 lymph nodes) in colorectal cancer has been shown to optimize staging and proposed as a quality indicator of colorectal cancer care. An audit within a single health district in Nova Scotia, Canada presented and published in 2002, revealed that adequate nodal harvest occurred in only 22% of patients. The goal of this current study was to identify factors associated with adequate nodal harvest, and specifically to examine the impact of the audit and feedback strategy on nodal harvest.

METHODS

This population-based study included all patients undergoing resection for primary colorectal cancer in Nova Scotia, Canada, from 01 January 2001 to 31 December 2005. Linkage of the provincial cancer registry with other databases (hospital discharge, physician claims data, and national census data) provided clinicodemographic, diagnostic, and treatment-event data. Factors associated with adequate nodal harvest were examined using multivariate logistic regression. The specific interaction between year and health district was examined to identify any potential effect of dissemination of the previously-performed audit.

RESULTS

Among the 2,322 patients, the median nodal harvest was 8; overall, 719 (31%) had an adequate nodal harvest. On multivariate analysis, audited health district (p < 0.0001), year (p < 0.0001), younger age (p < 0.0001), non-emergent surgery (p < 0.0001), more advanced stage (p = 0.008), and previous cancer history (p = 0.03) were associated with an increased likelihood of an adequate nodal harvest. Interaction between year and audited health district was identified (p = 0.006) such that the increase in adequate nodal harvest over time was significantly greater in the audited health district.

CONCLUSIONS

Improvements in colorectal cancer nodal harvest did occur over time. A published audit demonstrating suboptimal nodal harvest appeared to be an effective knowledge translation tool, though more so for the audited health district, suggesting a potentially beneficial effect of audit and feedback strategies.

Overall survival after resection for colon cancer in a national cohort study was adversely affected by TNM stage, lymph node ratio, gender, and old age

BACKGROUND

A national surveillance program of colon cancer treatment was introduced in 2007. We examined prognostic factors for colon cancer operated in 2000 with an aim of improving survival in the new program and a special focus on the merit of lymph node yield.

METHODS

A cohort of 269 patients, 152 women (56.5%), with a mean age of 71 years, was operated for colon cancer in 2000 at three teaching hospitals and followed up for 7 years.

RESULTS

Overall 5-year survival was 58.0%, and overall hospital mortality was 5.2%, with 4.5% in elective cases and 12.5% after urgent surgery. In only 41.1% of the specimens were 12 or more lymph nodes retrieved, but this did not affect survival in the combined cohort, although one of the hospitals achieved a significantly better result with a harvest of 12 or more lymph nodes. In a multivariate analysis, old age, gender, a high lymph node ratio (LNR) at stage III, and tumor-node-metastasis stage were adverse factors for survival.

CONCLUSIONS

The operative mortality was high and should be reassessed. The lymph node count did not have a significant impact on outcome overall, whereas the LNR proved significant for stage III. A prospective protocol using overall lymph node yield as a surrogate measure for more radical surgery, nevertheless, seems warranted to improve the lymph node harvest according to international recommendations.

Lymph node harvest in colon cancer specimens depends on tumour factors, patients and doctors, but foremost on specimen handling

There are good indications that the number of lymph nodes found in the specimen after resections for colon cancer somehow has a bearing on prognosis. Many factors have been reported in the literature to influence lymph node retrieval. We wanted to assess these closer with special focus on the pathology handling process in our own practice. A range of international literature was reviewed to study what has been found to influence lymph node harvest. A questionnaire was sent to 13 renowned national and international institutions to explore their handling of the colon cancer specimens to obtain a histological diagnosis. A retrospective, hospital audit was undertaken to examine if the number of lymph nodes and staging after examinations of the specimens varied between individual pathologists. In the literature, tumour and patient characteristics, as well as the surgeon and the pathologist, are found to be influential, but it is difficult to ascertain which ones are truly essential. Fat solvents were found by several to increase the lymph node yield, although some also opposed this finding. Our questionnaire showed some variations in the routines of each Department. A junior pathologist was more likely to inspect the specimen first hand and not more than half employed specific lymph node detection strategies while three of 13 did not seek a minimum number of lymph nodes. Still every department had implemented a standard procedure for such examinations. The internal audit showed without doubt that the devotion of the pathologist secured significantly more lymph nodes from the specimen and this may also have detected more stage III cancers. Several tumour and individual patient characteristics, surgical approach and specimen handling may influence lymph node yield and theoretically, TNM staging. Our investigation specifically suggests that tissue handling by pathologists may be a prominent factor in lymph node harvest from colon cancer specimens.

Lymph node yield following colorectal cancer surgery

BACKGROUND

Lymph node yield (LNY) is a measure of quality of care and a strong prognostic factor for outcome from colorectal cancer (CRC). The main aims of this study were to determine LNY across multiple Australian centres and the clinico-pathologic factors that influence yield.

METHODS

Analysis of data from prospective CRC databases at 11 Australian centres between January 1988 and May 2008 was undertaken utilizing the linkage and analysis resources of BioGrid Australia. The LNY depending on different clinico-pathologic patient characteristics was evaluated.

RESULTS

In total, 10,082 cases (54.1% men, 45.9% women) were identified. Median LNY was 12 (range 0-174). LNY increased significantly (P < 0.001) over time, from a mean of 8.5 in 1988 to 13 in 2008. LNY also varied significantly between surgical centres. Female gender, younger age, right-sided disease, higher T and N stage, specific operation types and absence of preoperative radiotherapy were all significantly associated with higher LNY.

CONCLUSIONS

While varying across centres, the median LNYs in Australia are acceptable and have improved significantly over recent years. Multiple clinico-pathologic factors significantly influence the number of nodes retrieved.

Predictive factors affecting survival in stage II colorectal cancer: is lymph node harvesting relevant?

PURPOSE

Lymph node status is important in colorectal cancer. Multiple studies indicate a relationship between the number of nodes harvested and survival. This is important in patients with stage II disease where the role of adjuvant therapy is unclear. This study sought to analyze the impact of lymph node harvest on survival in patients with stage II colorectal cancer.

METHODS

The data of our hospital's colorectal tumor registry from 1997 to 2008 was reviewed. The records of 3534 patients of all stages were analyzed; of these patients, 913 patients with stage II colorectal cancer underwent curative resection. A univariate analysis estimated 5-year survival by Kaplan-Meier analysis based on various lymph node groupings. Patients were further analyzed with respect to sex, age, tumor grade, and tumor location. Multivariate linear regression analysis by the Cox proportional hazards model was performed using these variables to analyze survival relative to lymph node harvesting.

RESULTS

Of 913 stage II patients, the mean age was 71 years and 48% were male. Univariate analysis of the number of lymph nodes harvested found that ≥24 nodes removed was a significant and independent factor for improved survival in stage II (P = .009) and ≥36 nodes in stage III cancers (P = .008). Cox proportional hazards ratios found male sex (P < .03) and poorly differentiated tumors (P < .015) to be negative independent risk factors for survival. Tumor location in the sigmoid was associated with improved survival (P < .02).

CONCLUSION

Patients with stage II disease had an improved survival when ≥24 lymph nodes were harvested, and patients with stage III disease had improved survival with up to a 36 node harvest. Male sex and poorly differentiated tumors had a worse prognosis, and tumors located in the sigmoid were associated with improved survival in stage II cancers. An increased lymph node harvest is recommended to improve survival in these stages.

Pathological examination of 12 regional lymph nodes and long-term survival in stages I-III colon cancer patients: an analysis of 2,056 consecutive patients in two branches of same institution

PURPOSE

Pathologic examination of at least 12 lymph nodes (LNs) is widely accepted as a standard for colon cancer surgery. We sought to address its association with patient source, other clinicopathological factors, and survival by comparing information from two branches in a large single institution.

METHODS

Patients with stages I-III adenocarcinoma of the colon between 1998 and 2003 were identified from the Chang Gung Colorectal Tumor Registry in two branches (Linkou and Kaohsiung branches) of same institution. We used multivariate analysis to adjust for variables with P < 0.1 in univariate analyses.

RESULTS

A minimum of 12 examined nodes were observed in 80% of patients in Linkou branch versus 25% in Kaohsiung branch (P < 0.0001). Younger age, right hemicolectomy, larger tumor, higher tumor stage, higher caseload of surgeons, and patients at Linkou branch with an odds ratio (OR) as high as 23 (95% CI, 17-31) were independently associated with a higher frequency of ≥12 examined nodes. Patients with examined node number of <12 had a greater risk of recurrence within stages II and III (stage II: adjusted OR 1.88, 95% CI 1.27-2.79; stage III: adjusted OR 1.58, 95% CI 1.15-2.17) but not within stage I (OR 0.73, 95% CI 0.23-2.24).

CONCLUSIONS

The results confirm that factors influencing nodal harvest are multifactorial and the examined LN number of 12 or more is associated with an increased long-term survival in stages II-III colon cancer. It is possible to adequately sample and examine a sufficient number of nodes in the majority of colon cancer specimens by standardized conventional methods.

Surgical quality and nodal ultrastaging is associated with long-term disease-free survival in early colorectal cancer: an analysis of 2 international multicenter prospective trials

BACKGROUND

The National Quality Forum has endorsed a minimum of 12 lymph node (LN) as a surrogate measure of quality in colorectal cancer (CRC). The prognostic value of ultrastaging hematoxylin and eosin (H&E) negative LNs (N0) using pan-cytokeratin immunohistochemistry (pan-CK-IHC) is unknown.

PURPOSE

To assess the effect on survival of surgical quality and focused pathologic analysis.

PATIENTS AND METHODS

Between 2001 and 2007, 253 evaluable patients with resectable CRC were enrolled. Multiple sectioning and pan-CK-IHC were performed on N0 LNs (American Joint Commission on Cancer Stage II). Follow-up was performed at 6-month intervals with a 4-year disease-free survival (DFS) primary end-point.

RESULTS

There were 253 patients, 177 N0 and 76 N1/N2 patients, staged conventionally. Thirty-six (20%) N0 patients were upstaged using ultrastaging (N0-->N0i+ [n = 27] and N0-->N1mi [n = 9]). At a mean follow-up of 3.4 +/- 1.6 years, 38 (15%) have recurred. Only 3% (3/108) of patients with > or =12 LNs, negative by H&E and pan-CK-IHC (N0i-), compared with 18% (6/33) with <12 LNs/N0i- (6/33; P = 0.0015) have recurred. Four-year DFS differed significantly according to surgical quality (<12 vs. > or =12 LNs) among Stage II patients only (DFS, <12 vs. > or =12 LNs: Stage I, 90.5% vs. 97.7%, P = 0.22; Stage II, 67.5% vs. 94.7%, P = 0.0036; Stage III, 61% vs. 61%, P = 0.61).

CONCLUSION

This represents the first prospective report demonstrating that both surgical quality and nodal ultrastaging impacts survival in Stage II CRC. Patients with Stage II CRC having > or =12 LNs negative for micrometastases (N0i-) are likely cured by surgery alone. Both surgical and pathologic quality measures are imperative in early CRC to improve patient selection for adjuvant chemotherapy.

The number of lymph nodes in colon cancer specimens: what do the numbers really mean?

AIM

Stage-specific survival for colon cancer is improved when more lymph nodes are identified in the surgical specimen. This association is typically attributed to staging effect, but may instead be a surrogate for tumour biology.

METHOD

We retrospectively studied a cohort of 48 consecutively treated patients with Stage II colon cancer who underwent complete resection between January 2000 and December 2002. Archived H&E slides were reviewed for lymphocytic infiltration at the leading edge, presence and degree of sinus histiocytosis in the largest node and the presence of lymph node hyperplasia.

RESULTS

The mean number of lymph nodes identified was 14.1 +/- 9.4. T stage was strongly associated with the number of nodes identified (P = 0.01) and the presence of a significant degree of sinus histiocytosis approached statistical significance (P = 0.077). No statistically significant relationship existed between number of lymph nodes in a specimen and tumour location (P = 0.44), grade (P = 0.56) or lymphovascular invasion (P = 0.64).

CONCLUSIONS

T stage is highly associated with the number of nodes found in a colon cancer specimen; a significant degree of sinus histiocytosis may also be predictive. Finding more nodes may be a surrogate for tumour or host-related factors that impact prognosis.

Can adequate lymphadenectomy be obtained by laparoscopic resection in rectal cancer? Results of a case-control study in 200 patients

AIM

The aim of this study is to compare pathological findings in rectal cancer specimens obtained by laparoscopy or laparotomy.

MATERIALS AND METHODS

Bowel length, distal and circumferential margins, and number of total and positive nodes harvested were prospectively recorded in specimens obtained from 100 consecutive patients who had a laparoscopic total mesorectal excision for cancer. These data were compared with those extracted from a well-matched group of 100 patients who had an open procedure.

RESULTS

The mean length of the specimens was 31.04 cm in the case group and 29.45 cm in the control group (not significant (NS)). All distal margins in both groups were negative. The circumferential margin was positive in four cases in the case group and nine cases in the control group (NS). The mean number of lymph nodes harvested was 13.76 nodes/patient in the case group and 12.74 nodes/patient in the control group (NS). The mean number of involved lymph nodes was 1.18 node/case in the case group and 1.96 node/case in group 2 (NS).

CONCLUSION

There is no difference between laparoscopic or open approaches concerning specimen's length, distal margin, circumferential margin, and total and positive lymph nodes. Laparoscopic rectal resection is not only technically feasible but it seems also oncologically safe.

Prognostic factors in node-negative colorectal cancer: a retrospective study from a prospective database

PURPOSE

There is a need to identify a subgroup of high-risk patients with node-negative colorectal cancer who have a poor long-term prognosis and may benefit from adjuvant therapies. The aim of this study was to evaluate the prognostic impact of clinical and pathological parameters in a retrospective study from a prospective, continuous database of homogenously treated patients.

METHODS

This study included 362 patients operated in a single institution for Dukes A and B (node-negative) colorectal cancer. The median follow-up was 140 months. The prognostic value of 13 clinical and pathological parameters was investigated.

RESULTS

Multivariate analysis identified six independent prognostic factors: age at time of diagnosis (hazard ratio (HR) = 1.076), number of lymph nodes removed (HR = 0.948), perineural invasion (HR = 2.173), venous invasion (HR = 1.959), lymphatic vessel invasion (HR = 2.126), and T4 stage (HR = 5.876).

CONCLUSION

These parameters could be useful in identifying patients with high-risk node-negative colorectal cancer who should be presented to adjuvant therapy.

Combination therapy in high-risk stage II or stage III colon cancer: current practice and future prospects

Colon cancer represents the second leading cause of cancer-related deaths. For patients who have undergone curative surgery, adjuvant therapy can reduce the risk of recurrence and death from relapsed or metastatic disease. Postoperative chemotherapy with a 5-fluorouracil-based regimen combined with oxaliplatin is the current standard of care for stage III patients. However, there is still controversy in stage II disease about the real impact of adjuvant monotherapy or combined therapy on survival. Better identification of a subgroup of patients with a higher risk of recurrence can select patients who might benefit from adjuvant therapy. For the elderly population, there is a well-established role for postoperative therapy, although the most appropriate regimen remains to be defined. Targeted agents for combined adjuvant therapy in stage II and III colon cancer is a promising area, but to date, there is no evidence supporting its use in this setting. Results from large prospective trials with targeted therapy have been disappointing and new drugs and strategies are needed to define the role of these types of agents in the adjuvant scenario of colon cancer.

Clinical and pathologic factors that predict lymph node yield from surgical specimens in colorectal cancer: a population-based study

BACKGROUND

The National Quality Forum endorses the recommendation of examining at least 12 lymph nodes (LNs) from colorectal cancer (CRC) specimens. However, heterogeneity in LN harvest exists. The objective of this study was to investigate the clinicopathologic factors that influence LN yield.

METHODS

The authors used the Surveillance, Epidemiology, and End Results database to identify patients who were diagnosed with stage I, II, and III CRC between 1994 and 2005. Poisson regression was used to model the number of LNs examined as a function of individual clinicopathologic factors, including age, sex, race, year of diagnosis, geographic region, anatomic site, preoperative radiation, tumor size, tumor classification, tumor differentiation, and LN positivity.

RESULTS

In total, 153,483 patients with CRC were identified. The mean number of LNs examined (+/- standard deviation) was 12 (+/-9.3). Separate multivariate analyses revealed that age, year of diagnosis, tumor size, and tumor classification were significant predictors of LN yield for colon and extraperitoneal rectal cancers (P < .01 for all covariates). Tumor location and radiotherapy were significant predictors of LN yield in patients with colon cancer and rectal cancer, respectively. Overall LN yields increased between 2% and 3% annually.

CONCLUSIONS

Despite the increasing yields observed over time, patients with rectal cancer and older patients who had distally located, early colon cancer were less likely to meet the benchmark yield of 12 LNs. Further investigation into how LN yield is influenced by alterable factors, such as the extent of mesenteric resection and the pathologic technique, as well as nonalterable factors, such as patient age and tumor location, may reveal innovative ways to improve current staging methods.

The prognostic value of lymph node ratio in a population-based collective of colorectal cancer patients

OBJECTIVE

We analyzed 3 previously identified cut-off values of lymph node ratios (0.17, 0.41, and 0.69) in a large population-based collective of patients with colorectal cancer for their prognostic value.

SUMMARY BACKGROUND DATA

The lymph node ratio (LNR) (relation of tumor-infiltrated to total examined lymph nodes) has a high prognostic impact, but the relevant cut-off values are not determined.

METHODS

Patients (N = 27,803) with a primary colorectal cancer diagnosed and operated in the Munich region between 1991 and 2006 were registered in the Munich Cancer Registry. Lymph node numbers and survival data were available for 17,309 patients with a mean follow-up of 5.9 years.

RESULTS

The mean number (+/-SD) of resected lymph nodes was 16.8 +/- 8.4. Twelve or more lymph nodes were resected in 76.8%. Estimated 5-year overall survival decreased significantly with increasing LNR: LNR = 0 in 71.4%, LNR 0.01 to 0.17 in 52.4%, LNR 0.18 to 0.41 in 33.3%, LNR 0.42 to 0.69 in 19.8%, and LNR > or = 0.70 in 8.3% (P < 0.001). Multivariable survival analyses identified separately both LNR and pN- category, as well as number of resected lymph nodes, patient's age, tumor location, pT-category, pM-status, R-status, tumor grade, and year of operation as independent prognostic factors.

CONCLUSION

: The 3 cut-off values of LNRs had strong independent prognostic value in a population-based collective of patients with colorectal cancer. The LNR should be routinely reported and included in the American Joint Committee on Cancer staging system. Nevertheless, the benefit of lymphadenectomy on survival is still unclear.

Análise do número de linfonodos em espécimes de ressecções colorretais por neoplasia entre a cirurgia aberta e videolaparoscópica

Introdução: o estadiamento patológico com a análise do número de linfonodos dissecados é fator importante na determinação da segurança oncológica das ressecções por câncer colorretal, independentemente da via de acesso. Em fase inicial de curva de aprendizado em laparoscopia colorretal, a equivalência entre a cirurgia convencional e laparoscópica pode ser comprometida. O objetivo do presente estudo foi analisar o número de linfonodos dissecados em espécimes de ressecções por câncer colorretal pela via convencional e laparoscópica, e verificar a equivalência oncológica entre ambas. Método: estudo retrospectivo de uma série de casos de pacientes submetidos a ressecções por câncer colorretal por via convencional e laparoscópica. Variáveis analisadas: idade, sexo, via de acesso, tipo de procedimento, estadiamento de Dukes e número de linfonodos dissecados nas peças. Análise estatística pelo método de Mann-Whitney. Resultados: 50 pacientes foram analisados (33 operados por via convencional, 17 por via laparoscópica). Houve maior número de colectomias direitas e retossigmoidectomias altas nos dois grupos. O número médio de linfonodos dissecados foi de 10,35 no grupo laparoscópico e de 10,15 no grupo de acesso convencional (p=0,859). Conclusões: não houve diferença estatística entre o número médio de linfonodos dissecados entre os espécimes ressecados por via convencional e laparoscópica, numa fase inicial de curva de aprendizado.

Prognostic significance of the number of lymph nodes examined in colon cancer surgery: clinical application beyond simple measurement

OBJECTIVE

To identify an optimal cutoff value for the number of lymph node examined (NLNE) to distinguish the prognoses in patients following a curative resection for advanced colon cancer, to clarify the mechanism of the difference, and to suggest the integration of NLNE to colon cancer staging.

PATIENTS AND METHODS

A total of 859 patients who had undergone surgical treatment for localized colon cancer from 1980 to 2000 were reviewed. This was a cohort from a single institution with mean NLNE of 20.7 and more than 12 NLNE in 77% of the patients. The optimal breakpoint for NLNE was calculated by a receiver operating characteristic curve (ROC) analysis. The patients were stratified into groups based on various parameters and underwent univariate and multivariate analyses with respect to survival.

RESULTS

The ROC analysis identified NLNE as a significant prognostic factor with cutoff value of 18 for node-negative and 20 for node-positive patients. A multivariate analysis with these cutoff values identified NLNE as a significant prognostic factor independent of tumor depth and the number of lymph nodes involved. The 5-year cause-specific survival of stage IIB patients was 96.5% with 18 or more NLNE and 67.5% with NLNE less than 18 (P[r]=0.0067). Similarly, a cutoff value of 20 NLNE for node-positive patients separated the 5-year cause-specific survival of stage IIIB patients into 79.3% with 20 or more NLNE and 63.3% with less than 20 NLNE (P=0.0052).

CONCLUSIONS

The clinical significance of NLNE is not limited to being a benchmark for quality care, but has a definite benefit as a prognostic indicator across the stages. Patients could be stratified more efficiently by the integration of NLNE to TNM staging.

Number of retrieved lymph nodes and survival in node-negative patients undergoing laparoscopic colorectal surgery for cancer

BACKGROUND

The number of retrieved lymph nodes in colorectal cancer resection may have an impact on staging and survival. Examination of at least 12 nodes has become a quality measure for adequate surgical practice. To evaluate the impact of the number of retrieved lymph nodes in laparoscopic colorectal surgery for cancer on node-negative patients' survival.

METHODS

Evaluation of our prospective in-hospital collected data of patients that underwent laparoscopic surgery for curable colorectal cancer over a 5-year period. Long-term data were collected from our outpatient's clinic data and personal contact when necessary.

RESULTS

During a 5-year period since September 2003,173 patients were operated laparoscopically for curable colorectal cancer. Of the 117 patients who were node negative, 85 node-negative patients (72%) had 12 or more evaluated lymph nodes (mean, 18.3 + 2.4), while 32 node-negative patients had less than 12 (mean, 8.3 + 6.2). Patients with fewer than 12 nodes evaluated had significantly more left-sided tumors, while patients with 12 nodes or more had more right-sided tumors. A comparison of 5-year disease free and overall Kaplan-Meier survival curves revealed no statistically significant difference between the two groups.

CONCLUSIONS

Evaluation of less than 12 nodes may not necessarily impact patients' survival in node-negative patients undergoing laparoscopic resection for curable colorectal cancer. A lower number of nodes may be sufficient.

Impact of metastatic lymph node ratio in node-positive colorectal cancer

Colorectal cancer (CRC) is one of the most common malignant diseases in the world. Presently, the most widely used staging system for CRC is the tumor nodes metastasis classification system, which classifies patients into prognostic groups according to the depth of the primary tumor, presence of regional lymph node (LN) metastases, and evidence of distant metastatic spread. The number of LNs with confirmed metastasis is related to the severity of the disease, but this number depends on the number of LNs retrieved, which varies depending on patient age, tumor grade, surgical extent, and tumor site. Numerous studies and a recent structured review have demonstrated associated improvements in the survival of CRC patients with increasing numbers of LNs retrieved for examination. Hence, the impact of lymph node ratio (LNR), defined as the number of metastatic LNs divided by the number of LNs retrieved, has been investigated in various malignancies, including CRC. In this editorial, we review the literature demonstrating the clinicopathological significance of LNR in CRC patients. Some reports have indicated the advantage of considering the LNR compared to the number of LNs retrieved and/or LN status. When the LNR is taken into consideration for survival analysis, the number of LNs retrieved and/or the LN status is not always found to be a prognostic factor. The cut-off points for LNRs were proposed in numerous studies. However, optimal thresholds for LNRs have not yet received consensus. It is still unclear whether the LNR has more prognostic validity than N stage. For all these reasons, the potential advantages of LNRs in the staging system should be investigated in large prospective data sets.

Colorectal cancer

Substantial progress has been made in colorectal cancer in the past decade. Screening, used to identify individuals at an early stage, has improved outcome. There is greater understanding of the genetic basis of inherited colorectal cancer and identification of patients at risk. Optimisation of surgery for patients with localised disease has had a major effect on survival at 5 years and 10 years. For rectal cancer, identification of patients at greatest risk of local failure is important in the selection of patients for preoperative chemoradiation, a strategy proven to improve outcomes in these patients. Stringent postoperative follow-up helps the early identification of potentially radically treatable oligometastatic disease and improves long-term survival. Treatment with adjuvant fluoropyrimidine for colon and rectal cancers further improves survival, more so in stage III than in stage II disease, and oxaliplatin-based combination chemotherapy is now routinely used for stage III disease, although efficacy must be carefully balanced against toxicity. In stage II disease, molecular markers such as microsatellite instability might help select patients for treatment. The integration of targeted treatments with conventional cytotoxic drugs has expanded the treatment of metastatic disease resulting in incremental survival gains. However, biomarker development is essential to aid selection of patients likely to respond to therapy, thereby rationalising treatments and improving outcomes.

Prognostic value of perineural invasion in patients with stage II colorectal cancer

BACKGROUND

Perineural invasion (PNI) may influence the prognosis after resection of colorectal cancer (CRC); whether this is a definite prognostic factor remains controversial. This study determined the clinicopathologic factors associated with oncologic outcome after radical resection of stage II CRC, focusing on PNI.

MATERIALS AND METHODS

We retrospectively reviewed 341 consecutive patients who underwent curative surgery for stage II CRC between January 2001 and December 2006. Of these, 278 patients (81.5%) received postoperative 5-fluorouracil-based chemotherapy. The oncologic outcomes and the risk factors for recurrence were analyzed.

RESULTS

PNI was detected in 57 of 341 patients (16.7%) and was significantly associated with depth of tumor invasion (P = .035) and positive lymphovascular invasion (P < .001). Multivariate analyses revealed that PNI was a significant independent prognostic factor for disease-free survival, not for overall survival. With a median follow-up period of 57.6 months, the 5-year disease-free and overall survival rates of the patients were 80.2 and 82.6%, respectively. The 5-year disease-free survival of the PNI-negative group was significantly higher than that of the PNI-positive group (P < .001). Within the PNI-positive patients, those receiving chemotherapy had significantly higher 5-year disease-free survival than the others (P = .023).

CONCLUSION

This study illustrates the value of PNI as a prognostic factor for stage II CRC. Moreover, PNI-positive patients should be considered for postoperative chemotherapy.

Negative lymph node count is associated with survival of colorectal cancer patients, independent of tumoral molecular alterations and lymphocytic reaction

OBJECTIVES

The number of recovered lymph nodes is associated with good prognosis among colon cancer patients undergoing surgical resection. However, little has been known on prognostic significance of lymph node count after adjusting for host immune response to tumor and tumoral molecular alterations, both of which are associated with the lymph node count and patient survival.

METHODS

Among 716 colorectal cancers (stages 1-4) in two independent prospective cohorts, we examined patient survival in relation to the negative lymph node count and lymph node ratio (LNR; positive to total lymph node counts). Cox proportional hazard models were used to compute hazard ratio of deaths, adjusted for patient, specimen, and tumoral characteristics, including lymphocytic reactions, KRAS and BRAF mutations, p53 expression, microsatellite instability (MSI), the CpG island methylator phenotype (CIMP), and LINE-1 methylation.

RESULTS

Compared with patients with 0-3 negative lymph nodes, patients with 7-12 and > or =13 negative nodes experienced a significant reduction in cancer-specific and overall mortality in Kaplan-Meier analysis (log-rank P<0.0001), univariate Cox regression (P(trend)<0.0001), and multivariate analysis (P(trend)<0.0003), independent of potential confounders examined. The benefit associated with the negative node count was apparent across all stages, although the effect was significantly greater in stages 1-2 than stages 3-4 (P(interaction)=0.002). In both stage 3 and stage 4, smaller LNR was associated with improved survival (log-rank P<0.0001).

CONCLUSIONS

The negative lymph node count is associated with improved survival of colorectal cancer patients, independent of lymphocytic reactions to tumor and tumoral molecular features including MSI, CIMP, LINE-1 hypomethylation and BRAF mutation.

Extended lymph node dissection in colorectal cancer surgery. Reliability and reproducibility in assessments of operative reports

BACKGROUND

Stratification of surgical strategies or techniques by operative reports is rarely validated. This study evaluates the assessment of lymph node dissection from operative reports and the possible survival benefit of extended lymph node dissection.

METHODS

The operative reports of 342 colorectal resections (R0) were assessed twice by two surgeons. The lymph node dissection was classified as limited or extended according to a novel scheme. Intraobserver reproducibility and interobserver reliability were evaluated by kappa (kappa) statistics and a Cox model.

RESULTS

For colonic resections, the reproducibility of assessments was moderate or substantial (kappa: 0.42-0.75), and the reliability was moderate (kappa: 0.54-0.58). For rectal resections, reproducibility was moderate (kappa: 0.45-0.58), and reliability was fair (kappa: 0.29-0.36; all kappa values: p < 0.001). The 5-year survival rates of colonic cancer patients subject to a limited or extended procedure were 52% (45-60%, 95% confidence interval) and 69% (53-84%; p = 0.034), respectively. The hazard ratios of extended lymph node dissection (limited as reference) were 0.34 (0.14-0.86; p = 0.023) for stage I and II and 1.11 (0.50-2.44) for stage III. In rectal cancer patients, the 5-year survival rates of a limited or extended procedure were 63% (54-72%) and 55% (37-73), respectively.

CONCLUSIONS

Valid assessment of lymph node dissection can be obtained from operative reports. Extended lymph node dissection improves long-term survival rates of colonic cancer patients.

Staging error does not explain the relationship between the number of lymph nodes in a colon cancer specimen and survival

BACKGROUND

Survival in colon cancer is greater in those patients who have more lymph nodes identified at resection and may be due to stage migration, confounding by treatment, social, or clinical characteristics. Identifying factor(s) responsible for the effect may represent an opportunity to improve quality of care for patients with colon cancer by increasing node counts in specimens.

METHODS

Cox proportional hazards models were created to analyze survival of 11,399 patients with stage I-III colon cancer from the Surveillance, Epidemiology and End Results (SEER)-Medicare database. The primary predictor variable was the number of lymph nodes identified. The models allowed adjustment for patient factors, use of chemotherapy, surgical specialty, and the average number of nodes identified by surgeon and hospital pathologist.

RESULTS

The number of nodes identified was related to survival. Compared to those with less than 7 nodes, patients with 7 to 11 nodes had a 13% lesser risk of death (hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.76-0.99; P = .037). Patients with more than 12 nodes had a 17% lesser risk (HR, 0.83; 95% CI, 0.73-0.95; P = .005). Adjusting for selected patient demographic characteristics, receipt of chemotherapy, surgical specialty, and the average number of nodes identified per specimen by the surgeon or hospital did not significantly alter the relationship between number of nodes and survival.

CONCLUSION

These findings argue against understaging or confounding as the explanation for the inferior survival observed in patients with fewer nodes identified. National initiatives to increase the number of nodes identified in colon cancer specimens may not improve substantially the cancer-specific outcomes.

Nodal staging score: a tool to assess adequate staging of node-negative colon cancer

PURPOSE

Adequate nodal staging of colon cancer has been defined as pathologic examination of at least 12 lymph nodes. We sought to refine this definition by quantifying the likelihood that a pathologically node-negative patient has, indeed, no positive nodes.

PATIENTS AND METHODS

Patients with stage I-III adenocarcinoma of the colon between 1994 and 2005 and had at least one lymph node pathologically examined were identified from the Surveillance, Epidemiology and End Results (SEER) database (n = 131,953). We estimated the sensitivity of the pathologic staging of locoregional spread using a beta-binomial model and developed the nodal staging score (NSS), which is the probability that a patient is correctly staged as node negative. NSS is a function of T stage and the number of examined nodes.

RESULTS

The probability of missing a positive node that is in fact truly present is 29.7% if five nodes are examined, 20.0% if eight are examined, and drops to 13.6% for 12 nodes are examined. An NSS of 90% can be achieved by examining a single node for T1 and four nodes for T2 tumors. To maintain similar levels of NSS for T3, 13 nodes need to be examined and for T4 lesions, 21 nodes need to be examined. Graphical and tabular tools are provided to facilitate calculation of NSS and treatment decision making in practice.

CONCLUSION

The minimum number of examined nodes for adequate staging depends on the T stage. The score we developed indicates the adequacy of nodal staging for patients with no positive nodes and can assist clinical decision making in the patient without nodal metastasis.

Metastatic lymph node ratio is a more precise predictor of prognosis than number of lymph node metastases in stage III colon cancer

OBJECTIVE

The objective of this study is to assess the value of metastatic lymph node ratio (LNR) in predicting disease-free survival (DFS) in patients with stage III adenocarcinoma of the colon.

MATERIALS AND METHODS

From 1995 to 2003 inclusively, a total of 624 patients featuring stage III adenocarcinoma of the colon underwent curative resection. Of the 624 patients, an adequate number of lymph nodes (n > or = 12) had been harvested in 490 patients. These patients were stratified into LNR groups 1 (LNR < or = 0.4), 2 (0.4 < LNR < or = 0.7), and 3 (LNR > 0.7). Kaplan-Meier survival curve and log-rank test were used to evaluate the prognostic value of LNR. A Cox regression model was used for multivariate analyses.

RESULTS

The 5-year DFS rate was 66.7% for patients with LNR1, 35.1% for those with LNR2, and 0% for patients with LNR3 (p < 0.0001). In T3/4LNR1 patients (n = 411), there was no difference in survival between those with N1 stage and those with N2 stage. Cox proportional hazards regression analysis revealed that N stage (number of positive lymph nodes) was not a significant factor when LNR was taken into consideration.

CONCLUSIONS

LNR is a more precise predictor of 5-year DFS than number of positive lymph nodes (N stage) in patients with stage III colon cancer.

Does Specialized Surgical Training Increase Lymph Node Yield in Colon Cancer?

Most colon cancer resections do not meet the 12-lymph node minimum recommended in 2001 National Cancer Institute (NCI) panel guidelines. Previous reports suggest surgical training influences lymph node recovery. We hypothesized that recent trends show improved results for lymphadenectomy regardless of specialty. The cancer registry database at a large community hospital with an academic surgical oncology training program was queried to identify resections performed for colon cancer before (1995 to 2000) and after (2001 to 2006) NCI guideline publication. There were no changes in pathology procedures between 374 early and 411 later procedures. The later period brought increases in mean total lymph nodes (15.4 vs 10.4, P < 0.0001), total positive nodes (1.8 vs 1.2, P = 0.005), and the percentage of procedures yielding 12 or more nodes (overall: 65.9 vs 36.0%, P < 0.0001; Stage II and III disease: 73.0 vs 41.4%, P < 0.003). In addition, mean nodal yield increased (P < 0.0001) for fellowship-trained surgeons (16.7 vs 11.2) and nonfellowship-trained surgeons (14.9 vs 10.2). Single-registry data show that since 2001, most colon resections exceed minimum recommendations for lymph node recovery regardless of surgical training. The increased rate of adequate lymphadenectomy for Stage II and III disease is encouraging because this patient population will benefit most by accurate staging of colon cancer.

Nodal stage of stage III colon cancer: the impact of metastatic lymph node ratio

PURPOSE

We assessed which classification of lymph node metastasis better predicted outcomes in patients with colorectal carcinoma.

METHODS

We identified 318 patients (176 men) with stage III colon cancer who underwent curative resection. The number of LNs dissected, LNR, and disease-free survival time, were analyzed. Lymph node disease was stratified by the American Joint Committee on Cancer staging and LNR, with the latter categorized into groups with LNR <0.059 (n = 67), 0.059-0.23 (n = 171), and >0.23 (n = 80). Median follow-up time was 37 (range, 1-122) months.

RESULTS

LNR significantly increased with the number of metastatic LNs (P < 0.0001). Three-year disease-free survival (DFS) rates differed significantly in the three LNR groups. Within each TNM stage, 3-year DFS rates differed according to LNR, but, within each LNR subgroup, 3-year DFS did not differ according to TNM stage. When both TNM stage and LNR subgroup were considered, 3-year DFS was stratified into four groups, which differed significantly (P < 0.0001). Considering number of retrieved lymph nodes, this stratification was not found when <12 lymph nodes retrieved.

CONCLUSIONS

Re-stratified lymph node staging, reflecting both LNR and TNM stage, can predict survival in patients with LN-positive colon cancer, especially when more than 12 lymph nodes harvested.

Impacto do uso da solução reveladora de linfonodos no estadiamento do câncer colorretal

INTRODUÇÃO: A avaliação anátomo-patológica do câncer colorretal (CCR) em relação ao acometimento linfonodal é fundamental para o prognóstico da doença e para a indicação de terapias adjuvantes. Tem sido considerado um número mínimo de 12 linfonodos na peça cirúrgica para que se obtenha adequado estadiamento linfonodal, embora se admita que quanto maior o número de linfonodos dissecados, maior é a probabilidade de se encontrar linfonodos metastáticos. OBJETIVOS: avaliar o número de linfonodos obtidos em peças cirúrgicas de CCR antes e após a utilização rotineira de solução reveladora de linfonodos na gordura mesocólica. MATERIAL E MÉTODOS: Foram avaliados 706 laudos anátomo-patológicos de CCR, sendo 582 sem tratamento do espécime cirúrgico com solução reveladora e 124 após uso de solução reveladora. Resultados: Houve predominância do sexo feminino (57,6%) e a média de idade foi de 61,36 anos. A maioria dos tumores localizava-se distalmente à flexura esplênica (60%). A média de linfonodos dissecados após uso da solução reveladora foi igual a 28,97, enquanto que no período anterior ao uso desta solução esta média foi de 16,73 (p < 0,001). A porcentagem de peças com 11 linfonodos dissecados ou menos (pNx) diminuiu significativamente após a utilização da solução reveladora (32,7 para 3,2%, com p < 0,0001). Ao contrário, houve aumento significativo do número de casos estadiados como pN0, pN1, pN2 e pN3 após o uso da solução reveladora. CONCLUSÃO: O uso da solução reveladora de linfonodos causa grande impacto no estudo anátomo-patológico das peças cirúrgicas do CCR, sendo altamente aconselhável sua introdução na rotina dos serviços de patologia cirúrgica.

The effect of preoperative chemoradiotherapy on lymph node harvest after total mesorectal excision for rectal cancer

PURPOSE

This study was designed to evaluate whether preoperative chemoradiotherapy reduces the number of lymph nodes harvested after total mesorectal excision of rectal cancer.

METHODS

From January 1995 to December 2007, 168 consecutive patients with rectal cancer underwent total mesorectal excision in the Department of Surgical Oncology at the University of Crete. The patients were divided into three groups (Group A, no chemoradiotherapy; Group B, short course of chemoradiotherapy; Group C, long course of chemoradiotherapy). The primary end points were the number of lymph nodes examined and the percentage of patients with fewer than 12 lymph nodes removed.

RESULTS

The overall number of lymph nodes retrieved was not significantly reduced by the use of preoperative chemoradiotherapy. The percentage of patients with fewer than 12 lymph nodes examined, however, was significantly higher in Group C. The leakage rate and the duration of hospital stay were not affected. The rate of wound infections was higher in Group C.

CONCLUSION

Preoperative chemoradiotherapy did not significantly decrease the overall number of lymph nodes retrieved but did increase the percentage of patients with fewer than 12 lymph nodes examined.

Multicentre review of lymph node harvest in colorectal cancer: are we understaging colorectal cancer patients?

BACKGROUND

Lymph node examination in colorectal cancer is of vital importance for accurate staging. Patients who have fewer nodes examined may be understaged and not offered adjuvant chemotherapy. The national institute of clinical excellence and the association of coloproctology of Great Britain and Ireland both recommend that 12 nodes should be examined for accurate staging. The aim of this study was to assess lymph node harvest at five hospitals in the northwest of England in respect to these guidelines.

MATERIALS AND METHODS

This study is a retrospective review of all colorectal cancer resections over a 1-year period at five hospitals.

RESULTS

Two hospitals met the national guidelines of a median of 12 or more nodes. Overall, over 50% of colorectal cancers contained fewer than 12 nodes. Fifty-three point seven percent (53.7%) of Dukes B patients did not have 12 nodes in their specimens and may therefore be understaged. There was a significant variation between hospitals in terms of the number of cancers with 12 or more nodes (P < 0.0001) and the number of Dukes B cancers with 12 or more nodes (P < 0.008).

CONCLUSION

Over 50% of all colorectal cancer specimens contain fewer than 12 lymph nodes despite clear national guidelines. This is of particular importance to Dukes B cancers where over 53% of cases may be understaged and not offered adjuvant therapy. Significant variation exists between hospitals within the same region.

Non-ampullary duodenal adenocarcinoma: factors important for relapse and survival

BACKGROUND

Duodenal adenocarcinoma (DA) is rare, but potentially curable. Prospective data on treatment outcomes is scarce and large retrospective studies show conflicting results on the impact of radical resection, node-status, and adjuvant therapy.

METHODS

In the past 17 years, 30 patients presented with resectable DA. Data on the aforementioned variables were acquired then analyzed for impact on recurrence and survival.

RESULTS

Overall-survival rates at 1, 2, and 3 years were 70.0%, 53.3%, and 33.3% respectively. Recurrence-free survival rates at 1, 2, and 3 years were 53.3%, 30.0%, and 26.7%. Overall-survival rates for patients with node-positive disease at 1, 2, and 3 years were 68.8%, 43.8%, 12.5%, and for node-negative 70%, 60%, 60%. Recurrence-free survival in node-positive disease at 1, 2, 3 years was 50%, 12.5%, 12.5%, and for node negative 50%, 50%, and 40%. Median survival from diagnosis was 27.5 months (0.5-226.7 months). Significant predictors of recurrence and survival were nodal-status and AJCC stage (P < 0.001). Adjuvant therapy, surgical-type, pathological tumor-stage, and surgical margins were not significant.

CONCLUSION

Nodal-status and overall pathological-stage significantly affect the prognosis for patients with DA, while resection-status and adjuvant therapy may not. The role of adjuvant therapy requires prospective trials for elucidation.

Lymph node evaluation of colon cancer and its association with improved staging and survival in the Department of Defense Health Care System

BACKGROUND

Improved survival is associated with an increased number of lymph nodes (LNs) examined. The aim of this study was to assess whether the examination of >or=12 LNs is associated with more accurate colon cancer staging.

METHODS

We queried the Department of Defense Automated Central Tumor Registry database for stage I-III colon cancer patients. Logistic regression analysis was performed to determine whether the examination of >or=12 LNs is associated with increased rates of LN-positive colon cancer. Kaplan-Meier and Cox proportional hazard analysis was performed to evaluate the effect of number of LNs examined on survival.

RESULTS

The rate of LN-positive colon cancer is significantly higher with increasing number of LNs examined (1-3 LNs examined: 31% vs. >12 LNs examined: 41%, P<.001). Logistic regression analysis adjusting for patients, tumor, and hospital characteristics showed that examination of >or=12 LNs is associated with a >30% increase in detecting a LN-positive colon cancer (odds ratio, 1.350; 95% confidence interval, 1.175-1.511). The evaluation of >or=12 LNs is associated with improved survival in LN-negative colon cancer patients (P<.001).

CONCLUSIONS

Our study demonstrates that the proportion of LN-positive colon cancer is far higher when >or=12 LNs are examined. Examination of >or=12 LNs may improve staging accuracy and outcome with optimal use of systemic chemotherapy.

Identification of 12 or more lymph nodes in resected colon cancer specimens as an indicator of quality performance

BACKGROUND

: Identification of > or =12 lymph nodes in resected colon cancer specimens has been endorsed as a quality indicator.

METHODS

: The Hoag Hospital cancer registry was used to identify patients diagnosed with colon cancer. The proportion of colon cancer specimens for which > or =12 lymph nodes were identified was determined by anatomic location, stage of disease, patient age, and operating surgeon. Survival was correlated with stage and with whether > or =12 lymph nodes were identified.

RESULTS

: Pathology procedural changes in 1998 were associated with an increase in the average number of lymph nodes identified from 8.0 to 14.5 (P < .0001); therefore, analysis was limited to 574 patients who underwent surgical resection of colon adenocarcinoma during 1998 to 2005. Identification of > or =12 lymph nodes varied from 57% to 83% by 7 anatomic locations (P < .0001), from 65% to 75% by 5 age cohorts (P = .027), from 59% to 73% by 4 general stages of disease (P = .004), and from 53% to 80% among 12 surgeons who performed at least 17 resections (P = .014). The proportion of resections in which > or =12 lymph nodes were identified was higher for 3 colorectal fellowship-trained surgeons compared with the other 9 surgeons (77% vs 63%, P = .0007), and with 30 surgeons who each performed <10 resections (77% vs 51%, P < .0001). Identification of > or =12 lymph nodes was associated with better survival for patients with stage I (P = .016) and stage II (P = .021) disease.

CONCLUSIONS

: Anatomic location, colorectal surgical training, and case volume were strongly correlated with the number of lymph nodes identified. Cancer 2009. (c) 2009 American Cancer Society.