Impact of number of nodes retrieved on outcome in patients with rectal cancer

Size and distribution of lymph nodes in rectal cancer resection specimens

BACKGROUND

The detection of lymph node involvement is fundamental to the staging of rectal cancer, and aids in prognostication and identification of patients who will benefit from adjuvant therapy. The anatomical variation in distribution and size of mesorectal lymph nodes has received scant attention.

OBJECTIVE

This study aimed to determine the size and distribution of lymph nodes in rectal cancer resection specimens.

DESIGN

This was a prospective, observational study of rectal cancer resection specimens analyzed by a single histopathologist.

SETTING

This study was conducted from January 2007 to July 2013 at the authors' institution.

PATIENTS

Two hundred forty-four consecutive patients underwent resection for rectal cancer.

MAIN OUTCOME MEASURES

The size and distribution of lymph nodes in the resection specimens and the anatomical position of mesorectal lymph nodes in relation to the peritoneal reflection, tumor, and anal verge were recorded.

RESULTS

A total of 10,473 lymph nodes were retrieved in 244 patients (75 women; median age, 68 years (interquartile range, 59-75 years)). One hundred seventy-three anterior resection and 71 abdominoperineal resection specimens were analyzed. Median lymph node yield was 41 lymph nodes (interquartile range, 31-52); 344 of 10,473 (3.2%) lymph nodes were positive. Lymph nodes were distributed in the mesorectum, sigmoid mesentery, and vascular pedicle in 40%, 32%, and 28% of the patients. Sixty-eight percent of mesorectal lymph nodes were above the peritoneal reflection. Mesorectal lymph node distribution in relation to the tumor was 53% above, 36% adjacent to, and only 11% below the tumor. Ninety-five of 334 (28%) positive nodes were ≤3 mm in diameter.

LIMITATIONS

Resection specimens analyzed by other pathologists (<5%) have not been included, and fat clearance techniques were not used to retrieve lymph nodes.

CONCLUSIONS

To ensure accurate nodal staging of rectal cancer, both resection and subsequent pathological evaluation should focus on the mesorectum in close proximity to the tumor and along the superior rectal artery. Small lymph nodes (<3 mm in size) should not be overlooked, and lymph node metastasis to the sigmoid mesentery is rare (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A177).

The multidisciplinary approach to the treatment of rectal cancer: 2015 update

The multidisciplinary approach to the management of rectal cancer continues to evolve with developments in surgery, radiation therapy as well as systemic chemotherapy. Refinement of surgical techniques to improve organ preservation, selective use of neoadjuvant (or adjuvant) therapies, improvements in staging modalities and emerging criteria for the selection of tailored therapies are some of the advancements made over the last three decades. In addition, neoadjuvant treatment alternatives, multimodality sequencing and adaptive therapies based on treatment response continue to be a subject of clinical investigation. The current article reviews the salient topics related to the multidisciplinary treatment of resectable rectal cancer.

Risk factors for recurrence after complete resection of pathological stage N2 non-small cell lung cancer

Background

Tumor recurrence is the most common cause of treatment failure, especially after complete resection of pathological stage N2 non-small cell lung cancer (NSCLC). In this study, we investigated the clinicopathological characteristics in order to identify independent risk factors for postoperative recurrence.

Methods

Between January 2001 and December 2013, 96 patients who underwent surgical resection for pathological N2 NSCLC were retrospectively reviewed. Recurrence-free survival (RFS) was calculated by the Kaplan-Meier method to explore risk factors, while the Cox proportional hazard model was used to assess independent predictors.

Results

The median and five-year RFS rates were 15 months and 27.4%, respectively. Univariate analysis showed a significantly poorer prognosis for non-regional N2 metastasis, more than three metastatic N2 lymph nodes, multiple N2 station, and multiple N2 zone involvement. Multivariate analysis demonstrated that non-regional N2 metastasis (hazard ratio [HR] 1.857, 95% confidence interval [CI] 1.061–3.249, P = 0.030) and more than three metastatic N2 lymph nodes (HR 2.555, 95% CI 1.164–5.606, P = 0.019) were independent risk factors for RFS. Additionally, the incidence of non-regional N2 metastasis was higher in patients with a primary tumor in the left lower (57.1%) or right lower lobe (48.1%), followed by left upper (31.8%), right middle (14.3%) and right upper lobe (7.7%).

Conclusion

The combination of the distribution and number of metastatic N2 lymph nodes provides a more accurate prediction for N2 NSCLC regarding recurrence. Non-regional N2 metastasis could occur with a primary tumor in any lobe, but occurs more frequently in the lower lobe.

Prognostic impact of lymphadenectomy in uterine clear cell carcinoma

Objective

The aim of this study was to estimate the survival impact of lymphadenectomy in patients diagnosed with uterine clear cell cancer (UCCC).

Methods

Patients with a diagnosis of UCCC were identified from Surveillance, Epidemiology, and End Results (SEER) program from 1988 to 2007. Only surgically treated patients were included. Statistical analysis using Student t-test, Kaplan-Meier survival methods, and Cox proportional hazard regression were performed.

Results

One thousand three hundred eighty-five patients met the inclusion criteria; 955 patients (68.9%) underwent lymphadenectomy. Older patients (≥65) were less likely to undergo lymphadenectomy compared with their younger cohorts (64.3% vs. 75.9%, p<0.001). The prevalence of nodal metastasis was 24.8%. Out of 724 women who had disease clinically confined to the uterus and underwent lymphadenectomy, 123 (17%) were found to have nodal metastasis. Lymphadenectomy was associated with improved survival. Patients who underwent lymphadenectomy were 39% (hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.52 to 0.72; p<0.001) less likely to die than patient who did not have the procedure. Moreover, more extensive lymphadenectomy correlated positively with survival. Compared to patients with 0 nodes removed, patients with more extensive lymphadenectomy (1 to 10 and >10 nodes removed) were 32% (HR, 0.68; 95% CI, 0.56 to 0.83; p<0.001) and 47% (HR, 0.53; 95% CI, 0.43 to 0.65; p<0.001) less likely to die, respectively.

Conclusion

The extent of lymphadenectomy is associated with an improved survival of patients diagnosed with UCCC.

Pre-operative predictive factors for intra-operative pathological lymph node metastasis in rectal cancers

BACKGROUND

A number of clinicopathologic factors have been found to be associated with pathological lymph node metastasis (pLNM) in rectal cancer; however, most of them can only be identified by expensive high resolution imaging or obtained after surgical treatment. Just like the Child-Turcotte-Pugh (CTP) and the model for end-stage liver disease (MELD) scores which have been widely used in clinical practice, our study was designed to assess the pre-operative factors which could be obtained easily to predict intra-operative pLNM in rectal cancer.

METHODS

A cohort of 469 patients who were treated at our hospital in the period from January 2003 to June 2011, and with a pathologically hospital discharge diagnosis of rectal cancer, were included. Clinical, laboratory and pathologic parameters were analyzed. A multivariate unconditional logistic regression model, areas under the curve (AUC), the Kaplan-Meier method (log-rank test) and the Cox regression model were used.

RESULTS

Of the 469 patients, 231 were diagnosed with pLNM (49.3%). Four variables were associated with pLNM by multivariate logistic analysis, age<60 yr (OR=1.819; 95% CI, 1.231-2.687; P=0.003), presence of abdominal pain or discomfort (OR=1.637; 95% CI, 1.052-2.547; P=0.029), absence of allergic history (OR=1.879; 95% CI, 1.041-3.392; P=0.036), and direct bilirubin ≥ 2.60 μmol/L (OR=1.540; 95% CI, 1.054-2.250; P=0.026). The combination of all 4 variables had the highest sensitivity (98.7%) for diagnostic performance. In addition, age<60 yr and direct bilirubin ≥ 2.60 μmol/L were found to be associated with prognosis.

CONCLUSION

Age, abdominal pain or discomfort, allergic history and direct bilirubin were associated with pLNM, which may be helpful for preoperative selection.

Lymph node count after preoperative radiotherapy is an independently prognostic factor for pathologically lymph node-negative patients with rectal cancer

Recent studies indicated that preoperative radiotherapy significantly reduces the lymph nodes (LNs) harvest from patients with rectal cancer. This may weaken the prognostic value of current standard of LNs retrieval (≥12 LNs). This study investigates the prognostic impact of the LN counts on pathologically LN-negative (ypN0) after preoperative radiotherapy for patients with rectal cancer.Surveillance, Epidemiology and End Results (SEER) registered nonmetastatic rectal cancer patients diagnosed between 1998 and 2005 were included in this study. Optimal cutoff value for number of LNs retrieved was determined by X-tile program. Log-rank tests were adopted to compare the rectal cause specific survival (RCSS) for ypN0 patients using separated cutoff value of LN counting from 2 to 20. Correlation between LN count and tumor regression was investigated in an additional 221 patients from Fudan University Shanghai Cancer Center (FUSCC).The results showed that there were fewer number of LNs examined in patients with preoperative radiotherapy than those without (8.9 vs 10.9, P < 0.001). X-tile program identified the difference in survival was most significant (maximum of χ log-rank values) for the number 4. And 5-year RCSS increased accordingly with the cutoff values ranging from 4 to 15, which were confirmed as optimal cutoff and validated as independent prognostic factors in multivariate regression analysis (χ = 50.65, P < 0.001). Patients in FUSCC set were found to have fewer LNs retrieval in group of good tumor regression than in that of poor one (P = 0.01).These results confirmed the reduced number of LN retrieval in patients with rectal cancer treated with preop-RT. LN count is still an independently prognostic factor for ypN0 rectal cancer.

Clinical implications of microsatellite instability in T1 colorectal cancer

PURPOSE

The estimation of regional lymph node metastasis (LNM) risk in T1 colorectal cancer is based on histologic examination and imaging of the primary tumor. High-frequency microsatellite instability (MSI-H) is likely to decrease the possibility of metastasis to either regional lymph nodes or distant organs in colorectal cancers. This study evaluated the clinical implications of MSI in T1 colorectal cancer with emphasis on the usefulness of MSI as a predictive factor for regional LNM.

MATERIALS AND METHODS

A total of 133 patients who underwent radical resection for T1 colorectal cancer were included. Genomic DNA was extracted from normal and tumor tissues and amplified by polymerase chain reaction (PCR). Five microsatellite markers, BAT-25, BAT-26, D2S123, D5S346, and D17S250, were used. MSI and clinicopathological parameters were evaluated as potential predictors of LNM using univariate and multivariate analyses.

RESULTS

Among 133 T1 colorectal cancer patients, MSI-H, low-frequency microsatellite instability (MSI-L), and microsatellite stable (MSS) colorectal cancers accounted for 7.5%, 6%, and 86.5%, respectively. MSI-H tumors showed a female predominance, a proximal location and more retrieved lymph nodes. Twenty-two patients (16.5%) had regional LNM. Lymphovascular invasion and depth of invasion were significantly associated with LNM. There was no LNM in 10 MSI-H patients; however, MSI status was not significantly correlated with LNM. Disease-free survival did not differ between patients with MSI-H and those with MSI-L/MSS.

CONCLUSION

MSI status could serve as a negative predictive factor in estimating LNM in T1 colorectal cancer, given that LNM was not detected in MSI-H patients. However, validation of our result in a different cohort is necessary.

Effect of the number of positive lymph nodes and lymph node ratio on prognosis of patients after resection of pancreatic adenocarcinoma

BACKGROUND

The prognostic factors related to lymph node involvement [lymph node status, the number of positive lymph nodes, lymph node ratio (LNR)] and the number of nodes evaluated in patients with pancreatic adenocarcinoma after pancreatectomy are poorly defined.

METHODS

A total of 167 patients who had undergone resection of pancreatic adenocarcinoma from February 2010 to August 2011 were included in this study. Histological examination was performed to evaluate the tumor differentiation and lymph node involvement. Univariate and multivariate analyses were made to determine the relationship between the variables related to nodal involvement and the number of nodes and survival.

RESULTS

The median number of total nodes examined was 10 (range 0-44) for the entire cohort. The median number of total nodes examined in node-negative (pN0) patients was similar to that in node-positive (pN1) patients. Patients with pN1 diseases had significantly worse survival than those with pN0 ones (P=0.000). Patients with three or more positive nodes had a poorer prognosis compared with those with the negative nodes (P=0.000). The prognosis of the patients with negative nodes was similar to that of those with one to two positive nodes (P=0.114). The median survival of patients with an LNR ≥0.4 was shorter than that of patients with an LNR <0.4 in the pN1 cohort (P=0.014). No significance was found between the number of total nodes examined and the prognosis, regardless of the cutoff of 10 or 12 and in the entire cohort or the pN0 and pN1 groups. Based on the multivariate analysis of the entire cohort and the pN1 group, the nodal status, the number of positive nodes and the LNR were all associated with survival.

CONCLUSIONS

In addition to the nodal status, the number of positive nodes and the LNR can serve as comprehensive factors for the evaluation of nodal involvement. This approach may be more effective for predicting the survival of patients with pancreatic adenocarcinoma after pancreatectomy.

Low Lymph Node Retrieval After Preoperative Chemoradiation for Rectal Cancer is Associated with Improved Prognosis in Patients with a Good Tumor Response

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.

The prognostic value of the number of lymph nodes removed in patients with node-negative colorectal cancer

BACKGROUND

To investigate the prognostic significance of the number of lymph nodes removed in colorectal cancer (CRC) patients with no metastatic lymph node.

PATIENTS AND METHODS

The clinicopathological data of 461 CRC patients was analyzed. In order to compare the survival of patients who had fewer lymph nodes removed versus the survival of patients who had 1-3 metastatic lymph node(s), a separate group of 74 N1 disease patients were also included in the study. All patient data were collected prospectively. Kaplan-Meier method was used for calculation and plotting of the survival curves of the patient groups, and log-rank test was used for the comparison of the survival curves.

RESULTS

Cancer-specific survival (CSS) rates of patients who had 1-7 lymph node(s) and 8-11 lymph nodes removed were significantly worse than those who had 12 or more lymph nodes removed (p = 0.006 and p = 0.037, respectively), while CSS was not significantly different between those who had 1-7 versus 8-11 lymph node(s) removed (p = 0.647); this grouping had independent prognostic significance in Cox analysis (p = 0.006). CSS of patients with N1 disease was not significantly different from those who had 1-7 and 8-11 lymph node(s) removed (p = 0.312 and p = 0.165, respectively), while it was significantly worse than CSS of patients who had 12 or more lymph nodes removed (p = 0.001).

CONCLUSION

In colorectal cancer patients whose removed lymph nodes are non-metastatic, removal of at least 12 lymph nodes will determine the lymph node status reliably.

Nodal counts and lymph node ratio impact survival after distal pancreatectomy for pancreatic adenocarcinoma

BACKGROUND

The number of lymph nodes required for accurate staging after distal pancreatectomy for pancreatic adenocarcinoma is unknown.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 1,473 patients who underwent distal pancreatectomy for pancreatic adenocarcinoma from 1998 to 2010. We evaluated the influence of the total number of lymph nodes examined (NNE) and the lymph node ratio (LNR-positive nodes/total nodes examined) on survival.

RESULTS

The median NNE was 8. No nodes were examined in 232 (16%) of the patients, and 843 (57%) had <10 NNE. Of the patients who had at least one node examined, 612 (49%) were node positive. In the node-negative subset, the median and 5-year overall survival for patients with ≤10 NNE was significantly worse than patients with >10 NNE (16 vs. 20 months and 13 vs. 19%, respectively, p < 0.011). For node-positive patients, those with LNR ≤0.1 had better 5-year overall survival compared with LNR >0.1 (17 vs. 6%, p = 0.002).

DISCUSSION

Patients with pancreatic cancer undergoing distal pancreatectomy should ideally have at least 11 lymph nodes examined to avoid understaging. For node-positive patients, LNR may be a better prognostic indicator than the total number of positive nodes.

Prognostic implications of the number of retrieved lymph nodes of patients with rectal cancer treated with preoperative chemoradiotherapy

BACKGROUND

The impact of the number of retrieved lymph nodes (LNs) on oncological outcomes in patients with rectal cancer remains unclear. This study was designed to evaluate the prognostic implications of the number of retrieved LNs in patients with rectal cancer receiving preoperative chemoradiotherapy (CRT).

METHODS

The study cohort consisted of 859 patients with locally advanced (cT3-4 or cN+) mid to low rectal cancer that had been treated with preoperative CRT and radical resection between 2000 and 2009. Multivariate analysis and the Kaplan-Meier method were used to evaluate the influence of the number of retrieved LNs on disease-free survival (DFS).

RESULTS

The median number of LNs retrieved from included patients was 13 (interquartile range [IQR] 9-17). Multivariate analysis confirmed the independent prognostic importance of the number of retrieved LNs on DFS (hazard ratio = 0.97, 95% confidence interval = 0.95-0.99, p = 0.029). The 3-year DFS rate in patients with yp stage II rectal cancer was associated with the total number of retrieved LNs.

CONCLUSIONS

DFS was associated with the number of LNs retrieved from patients with rectal cancer who received preoperative CRT, especially among patients with ypT3-4 N0 stage tumors. The oncological importance of the number of retrieved LNs should be considered when treating these patients.

Lymph node ratio improves TNM and Astler-Coller's assessment of colorectal cancer prognosis: an analysis of 761 node positive cases

BACKGROUND

Prognosis assessment of node-positive colorectal cancer patients by Astler-Coller (AC) and TNM classifications is suboptimal. Recently, several versions of lymph node ratio (LNR; ratio metastatic/examined nodes) have been proposed but are still mostly unused.

METHODS

The prognostic value of several criteria, including LNR (two classes-LNR1 and LNR2-identified by a 15% cut-off) was studied in 761 consecutive patients, from 2000 through 2010. The relationships between total examined nodes, N, T and LNR were also analysed. LNR1 and LNR2 patients' survival was analysed within AC and TNM subgroups, and then coupled with them.

RESULTS

Age, tumour location and LNR are independent factors predicting survival. The relationships between LNR, N stage and T stage with examined nodes suggest confusing factors. LNR allows for identification of subgroups with different survival within AC and TNM classifications (p < 0.0001). Patients with LNR class discordant from AC stage (LNR1-C2 and LNR2-C1) have a similar 5-year survival (54 and 57%, respectively). LNR2 and TNM stage IIIC define a poor 5-year prognosis (33%).

CONCLUSIONS

LNR is a powerful prognosis predictor, easily integrated with TNM and AC classifications to improve prognosis assessment and facilitate clinical use. Possible confusing factors should be considered in future studies.

Intra-arterial methylene blue injection into ex vivo colorectal cancer specimens improves lymph node staging accuracy: a randomized controlled trial

AIM

A randomized controlled trial was carried out to study the effect of a recently proposed technique of ex vivo intra-arterial methylene blue injection of the surgical specimen removed for colorectal cancer on lymph node harvest and staging.

METHOD

Between May 2012 and February 2013, 100 consecutive colorectal cancer resection specimens in a single institution were randomly assigned to intervention (methylene blue injection) and control (standard manual palpation technique) groups before formalin fixation. The specimen was then examined by the histopathologist for lymph nodes.

RESULTS

Both groups were similar for age, sex, site of tumour, operation and tumour stage. In the intervention group, a higher number of nodes was found [median 23 (5-92) vs. 15 (5-37), P < 0.001], with only one specimen not achieving the recommended minimum standard of 12 nodes [1/50 (2%) vs. 8/50 (16%), P = 0.014]. However, there was no upstaging effect in the intervention group [23/50 (46.0%) vs. 20/50 (40.0%); P = 0.686]. With a significantly lower number of nodes harvested in rectal cancer, the positive effect of the intervention was particularly observed in the patients who underwent preoperative neoadjuvant radiotherapy [median 30 nodes (12-57) vs. 11 (7-15); P = 0.011; proportion of cases with < 12 nodes 0/5 vs. 5/8 (62.5%), P = 0.024].

CONCLUSION

Ex vivo intra-arterial methylene blue injection increases lymph node yield and can help to reduce the number of cases with a lower-than-recommended number of nodes, particularly in patients with rectal cancer having neoadjuvant treatment. The technique is easy to perform, cheap and saves time.

Drug allergy and the risk of lymph node metastasis in rectal cancer

Background

Previous epidemiologic studies have reported that a history of allergy is associated with reduced risk of colorectal cancer and other malignancies. However, no information is available for the association between allergy and the risk of lymph node metastasis. Our study was designed to determine this association in rectal cancer.

Methods

Patients who were treated at our hospital in the period from January 2003 to June 2011, and with a pathologically hospital discharge diagnosis of rectal adencarcinoma, were included. The clinical, laboratory, and pathologic parameters were analyzed. A multivariate logistic regression model was used to determine the association. Moreover, for type of allergic drug, sub-group analysis was performed.

Results

469 patients were included, including 231 with pathological lymph node metastasis (pLNM) (49.3%) and 238 without pLNM. Univariate analysis showed, compared with patients without pLNM, patients with pLNM had a younger age (60.6±12.8 yr vs. 63.6±12.2 yr, P = 0.012), a lower percentage of drug allergy (8.7% vs. 16.0%, P = 0.016), an increased CEA (median/interquartile-range 5.40/2.40–13.95 vs. 3.50/2.08–8.67, P = 0.009), and a lower serum sodium (141±3.1 mmol/L vs. 142±2.9 mmol/L, P = 0.028). Multivariate analysis showed that drug allergy was associated with a reduced risk of pLNM (OR = 0.553; 95% CI, 0.308–0.994; P = 0.048). In addition, our results showed that: (1) for tumor classification, patients with drug allergy had a higher percentage of group patients with pT1/pT2; and (2) for type of allergic drug, this inverse association was found for penicillins, not for other allergic drugs.

Conclusion

Drug allergy is associated with a reduced risk of pLNM in rectal cancer.

A modified GEWF solution is cost-saving and effective for lymph node retrieval in resected colorectal carcinoma specimens

Lymph node (LN) retrieval is important for proper staging of colorectal carcinoma. Although various assistant techniques were recommended to facilitate LN identification, most of them were unavoidably time-consuming, resource intensive and costly. We prepared a modified GEWF solution (RE-GEWF) by use of recycled alcohol and a familiar dye, eosin and investigated its efficacy on 55 colorectal carcinoma specimens. Of the 55 studied cases, 33 of them with <12 LNs (Group A) and 22 with ≥12 LNs were detected (Group B) before RE-GEWF treatment. All were subsequently treated with RE-GEWF for 14-16h and were inspected again for LNs. The number of LNs revealed before and after RE-GEWF treatment was 539 and 476 respectively. The mean number of LNs per cases increased from 9.80±6.27 to 18.43±8.77. Twelve accessory LN metastases were found in 9 cases. Upgrade of pN stage was only present in 7 of the Group A cases. The results show that RE-GEWF is as effective as other reported LN revealing solutions. Use of RE-GEWF not only can assure the quality of LN detection, but also minimize the cost and reduce the release of waste.

Laparoscopic right hemicolectomy with complete mesocolic excision

BACKGROUND

Complete mesocolic excision (CME) has recently been reemphasized as a technical approach for anatomical dissection during colon cancer surgery. Although a laparoscopic approach for right colon cancer is performed frequently, identifying an adequate dissection plane is not always easy. In our practice, the patient lies in a modified lithotomy position. The first step is ileocolic area mobilization, followed by adequate retraction of the cecum laterally. This procedure enables discrimination of the ileocolic vessels and superior mesenteric vessels. Importantly, this method facilitates identification of the superior mesenteric vein (SMV), followed by the identification of the root of ileocolic pedicles. After that, sharp dissection along the SMV in an upward direction helps to safely identify the middle colic artery (MCA). Dissection then continues to the level of the origin of MCA, after which the right branch of MCA can be divided.

METHODS

A total of 128 consecutive patients (63 males) who underwent laparoscopic CME for right colon cancer by a single surgeon were analyzed in this study.

RESULTS

There was no conversion to open surgery. The median operation time was 192 min (interquartile range [IQR] 118-363 min). The median proximal and distal resection margins were 11 and 10 cm, respectively. The median number of harvested lymph nodes was 28 (IQR 3-88). There were six postoperative complications (4.6 %). The median hospital stay was 5 days (IQR 4-37 days). The video demonstrates a laparoscopic CME for a patient who had advanced distal ascending colon cancer.

CONCLUSION

In conclusion, identifying the anatomical location of the SMV and performing meticulous dissection along the SMV is an essential procedure for containing all potential routes of metastatic tumors. Initial ileocecal mobilization with adequate counter traction of the cecum may be useful for novice surgeons attempting to identify the location of SMV during laparoscopic CME for right colon cancer.

Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery

SUMMARY 

The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.

Does reevaluation of colorectal cancers with inadequate nodal yield lead to stage migration or the identification of metastatic lymph nodes?

BACKGROUND

The National Comprehensive Cancer Network recommends routine reevaluation of all stage II colon cancer specimens with fewer than 12 lymph nodes. However, there are few data demonstrating the effect of reevaluation on stage.

OBJECTIVE

The aim of this study was to demonstrate the effect of pathologic reevaluation for colorectal cancers with fewer than 12 lymph nodes on stage.

DESIGN

This study entailed a retrospective review of pathology reports.

SETTINGS

This study was conducted at 2 large multispecialty referral centers.

INTERVENTIONS

Pathologic reevaluation was performed to look for additional lymph nodes.

PATIENTS

All patients with stage I through III colorectal cancers with inadequate lymph node yields who underwent reevaluation from January 1, 2007 through March 31, 2011 were identified.

MAIN OUTCOME MEASURES

We recorded initial pathologic stage and new stage following reevaluation. The following variables before and after reevaluation were also recorded: 1) total lymph node count, 2) metastatic node count, 3) negative node count, and 4) lymph node ratio.

RESULTS

Eighty-three patients underwent pathologic reevaluation from a total of 1682 cancer specimens. Mean nodal yields were 7.2 ± 2.6 on the first pathologic review. On reevaluation, 80% of patients had one or more newly identified nodes. On average, 6.9 ± 9.6 more lymph nodes were identified with a metastatic node detected in 4 of 83 patients (4.8%). After pathologic reevaluation, 1 patient (1.2%) had a change in TNM stage from N1 to N2 disease. The lymph node ratio changed in 13 of 15 patients (87% of stage III cancers). Only 4 of these had a change in lymph node quartile.

LIMITATIONS

The study was limited by its retrospective nature and small sample size.

CONCLUSION

Few patients have a newly discovered metastatic node or stage change following pathologic reevaluation. The effect of pathologic reevaluation on treatment and outcome should be further investigated.

The impact of visceral obesity on surgical outcomes of laparoscopic surgery for colon cancer

PURPOSE

Although obesity is considered as a risk factor for postoperative morbidity in abdominal surgery, its effect on the outcomes of laparoscopic-assisted colectomy (LAC) is still unclear. The technical difficulty and risk factor for postoperative complication in LAC are thought to be influenced by visceral obesity. The aim of this prospective study was to evaluate the impact of visceral fat on the surgical outcomes of LAC.

METHODS

Between April 2005 and December 2010, consecutive patients with preoperatively diagnosed colon cancer, excluding medium and low rectal cancer, who underwent LAC, were enrolled. Their visceral fat area (VFA) and body mass index (BMI) were prospectively collected. The VFA was assessed by Fat Scan software. The patients were classified into two groups as follows: VFA nonobese with VFA <100 cm(2) (VNO) and VFA obese with VFA ≧100 cm(2) (VO). The predictive factors for surgical complications of LAC were evaluated by univariate and logistic regression analyses.

RESULTS

A total of 338 consecutive patients were enrolled in this study. Of the 338 patients, 194 (57.4 %) and 138 (42.6 %) were classified into the VNO and VO groups, respectively. Logistic regression analysis showed that high BMI (≧25 kg/m(2)) and VO independently predicted the incidence of overall postoperative complications (p = 0.040 and 0.007, respectively). VO was more highly related to the incidence of overall postoperative complications, anastomotic leakage (p = 0.021), and surgical site infection (SSI) (p = 0.013) than high BMI.

CONCLUSIONS

VFA is a more useful parameter than BMI in predicting surgical outcomes after LAC.

Prognostic biomarkers in colorectal cancer: where do we stand?

Colorectal cancer remains a major cause of cancer-related death worldwide. One way to reduce its staggering mortality rate and socio-economic burden is to predict outcome based on the aggressiveness of the tumor biology in order to treat patients accordingly to their risk profile. As such, it comes as no surprise that prognostic biomarker discovery is a hot topic in colorectal cancer research. The last two decades have literally produced tons of new data and an avalanche of potential clinically applicable biomarkers. This review explores and summarizes data concerning the prognostic strength and clinical utility of current and future tissue biomarkers in the diagnosis and treatment of colorectal cancer.

Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES)

The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision (TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery (NOTES) has been held as the next revolution in surgical techniques, offering the possibility of 'incisionless' TME. Early clinical series of transanal TME with laparoscopic assistance (n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average-risk patients at short-term follow up, and 2-year survival rates in high-risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future.

The effect of preoperative chemoradiotherapy on lymph nodes harvested in TME for rectal cancer

BACKGROUND

Adequate lymph nodes resection in rectal cancer is important for staging and local control. This retrospective analysis single center study evaluated the effect of neoadjuvant chemoradiation on the number of lymph nodes in rectal carcinoma, considering some clinicopathological parameters.

METHODS

A total of 111 patients undergone total mesorectal excision for rectal adenocarcinoma from July 2005 to May 2012 in our center were included. No patient underwent any prior pelvic surgery or radiotherapy. Chemoradiotherapy was indicated in patients with rectal cancer stage II or III before chemoradiation.

RESULTS

One-hundred and eleven patients were considered. The mean age was 67.6 yrs (range 36 - 84, SD 10.8). Fifty (45.0%) received neoadjuvant therapy before resection. The mean number of removed lymph nodes was 13.6 (range 0-39, SD 7.3). In the patients who received neoadjuvant therapy the number of nodes detected was lower (11.5, SD 6.5 vs. 15.3, SD 7.5, p = 0.006). 37.4% of patients with preoperative chemoradiotherapy had 12 or more lymph nodes in the specimen compared to the 63.6% of those who had surgery at the first step (p: 0.006).Other factors associated in univariate analysis with lower lymph nodes yield included stage (p 0.005) and grade (p 0.0003) of the tumour. Age, sex, tumor site, type of operation, surgeons and pathologists did not weight upon the number of the removed lymph nodes.

CONCLUSION

In TME surgery for rectal cancer, preoperative CRT results into a reduction of lymph nodes yield in univariate analisys and linear regression.

Lymph node evaluation in stage IIA colorectal cancer and its impact on patient prognosis: a population-based study

BACKGROUND

The analysis of regional lymph nodes is particularly relevant in patients with stage II colorectal cancer, in whom the role of adjuvant chemotherapy remains unclear. The aim of this study was to assess the relationship between number of examined lymph nodes and survival in patients with stage IIA (pT3N0M0) colorectal cancer, and to determine the optimal number of lymph nodes that should be examined.

METHODS

The study group included all the surgically-treated colorectal cancer patients in stage IIA (n = 657) who were identified through the population-based Cancer Registry of the Province of Modena (Northern Italy), during the period 2002-2006.

RESULTS

The median number of harvested lymph nodes was 19 (range 1-68). Considering, as a reference point, patients with 12 or less lymph nodes, subjects with n ≥ 20 lymph nodes examined showed, in univariate analysis, a significantly higher cancer specific (p = 0.01) and relapse-free survival (p = 0.003). The results were confirmed by multivariate analysis (Cox model).

CONCLUSION

The result suggests that colorectal cancer patients in stage IIA with n ≥ 20 lymph nodes examined exhibit better survival when compared with subjects in whom fewer lymph nodes were examined. The number of 20 lymph nodes is the essential requirement for an oncologic resection of the large bowel.

What does absence of lymph node in resected specimen mean after neoadjuvant chemoradiation for rectal cancer

Background

The effect of insufficient node sampling in patients with rectal cancer managed by neoadjuvant chemoradiation followed by surgery has not been clearly determined. We evalulated the impact of insufficient sampling or even abscence of lymph nodes in the specimen on survival in patients at high-risk (T3, T4 or node positive) for rectal cancer.

Methods

We conducted a single institution, retrospective analysis of all patients who underwent surgical rectal resection following neoadjuvant chemoradiation for treatment of mid to lower rectal cancer between 1997 and 2009. ypNX was defined as the absence of lymph nodes retrieved in the resected specimen.

Results

A total of 132 patients underwent resection for treatment of rectal cancer following neoadjuvant chemoradiation. Ninety four patients (71.2%) were considered as having node-negative disease, including ypNx and ypN0. In 38 patients (28.8%), the primary tumor was associated with regional lymph node metastases (ypNpos). The mean number of retrieved nodes per specimen was 14.2, respectively. The five-year overall survival from initial operation for the ypNx group was 100%, respectively. The estimated five-year overall survival for ypN0 and ypNpos was 84.0% and 60.3%, respectively (P =0.001). No significant differences in overall survival were observed between the ypNx and ypN0 group (P =0.302).

Conclusion

Absence of recovered LN in resected specimens after neoadjuvant chemoradiation was observed in 7.6% of specimens. Absence of LN should not be regarded as a risk factor for poor survival or as a sign of less radical surgery.

Cancer concepts and principles: primer for the interventional oncologist-part II

This is the second of a two-part overview of the fundamentals of oncology for interventional radiologists. The first part focused on clinical trials, basic statistics, assessment of response, and overall concepts in oncology. This second part aims to review the methods of tumor characterization; principles of the oncology specialties, including medical, surgical, radiation, and interventional oncology; and current treatment paradigms for the most common cancers encountered in interventional oncology, along with the levels of evidence that guide these treatments.

Discordance between conventional and detailed lymph node analysis in resected biliary carcinoma at or above the cystic duct: are we understaging patients?

BACKGROUND

Analysis of portal lymph node (LN) metastases following resection of biliary carcinomas at or above the cystic duct (BC) is used to select patients for adjuvant therapy, but no guidelines exist and LN yield is low. Some consider analysis of 7 LNs necessary for accurate staging. Conventional LN analysis may understage patients.

METHODS

Portal LNs from 38 node-negative patients following resection of BC from 2000 to 2008 were re-examined in detail for occult metastases (OM) using a modified Weaver protocol. Outcomes measured were discordance in LN positivity and patient survival.

RESULTS

On detailed examination, 5 of 38 patients had OM. There was no difference in survival between patients with and without OM (24 vs 17 months; p = .382). There was no association between OM and patient demographics or adverse tumor characteristics. The median LN yield was 3. Of the 27 patients with <7 LNs retrieved, 1 had OM, compared with 4 of 11 patients with ≥7 LNs retrieved (p = .030). OM in these well-staged patients were associated with reduced survival (9 vs 41 months; p = .032).

CONCLUSIONS

There is discordance between conventional and detailed LN analysis in resected BC. LN yield ≥7 was associated with OM. The presence of OM may be associated with decreased survival. Conventional LN analysis may understage patients with resected BC.

The importance of lymph node retrieval and lymph node ratio following preoperative chemoradiation of rectal cancer

AIM

Preoperative chemoradiation (CRT) for rectal cancer decreases the number of examined lymph nodes (NELN) found in the resected specimen. However, the prognostic role of lymph node evaluation including overall numbers and the lymph node ratio (LNR) in patients having preoperative CRT have not yet been defined. The study has assessed the influence of CRT on the NELN and on lymph node number and LNR on the survival of patients with rectal cancer.

METHOD

Between 2003 and 2011, 508 patients with nonmetastatic rectal cancer underwent mesorectal excision. Of these 123 (24.2%) received preoperative CRT. Univariate and multivariate analysis was performed to define the role of NELN and LNR as prognostic indicators of survival.

RESULTS

Neoadjuvant CRT significantly reduced the NELN (P < 0.0001). Disease-free survival (DFS) and overall survival (OS) of patients with fewer or more than 12 nodes retrieved did not differ statistically. Node-negative patients with six or fewer lymph nodes were significantly associated with a poor DFS and OS on univariate analysis (P = 0.03 and P = 0.03). LNR significantly influenced the DFS and OS on multivariate analysis [DFS, P = 0.0473, hazard ratio (HR) 2.4980, 95% confidence interval (CI) 1.2631-9.4097; OS, P = 0.0419, HR 1.1820, 95% CI 1.1812-10,710].

CONCLUSION

The cut-off of 12 lymph nodes does not influence survival and should not be considered for cancer-specific prediction of patients having neoadjuvant CRT. In contrast LNR is an independent prognostic predictor of DFS and OS in such patients.

Differential lymph node retrieval in rectal cancer: associated factors and effect on survival

BACKGROUND

Recent publications have identified positive associations between numbers of lymph nodes pathologically examined and five-year overall survival (5-yr OS) in colon cancer. However, focused examinations of relationships between survival of rectal cancer and lymph node counts are less common. We conducted a single institution, retrospective review of rectal cancer resections to determine whether lymph node counts correlated with 5-yr OS and to explore the relationship between lymph node counts and various clinical and pathologic factors.

METHODS

A retrospective review of our institutional tumor registry identified 159 patients with AJCC Stage 1, 2, or 3 rectal cancers that underwent surgical resection at our institution over eleven years. Univariate analysis was used to explore the relationship between lymph node counts and age, AJCC Stage, time period of diagnosis, preoperative radiotherapy, and performance of TME. Survival analysis was performed by the Kaplan-Meier method and the Cox proportional hazards model.

RESULTS

In univariate analysis, there was an association between increased lymph node counts and age <70, higher stage, and diagnosis during the later portion of the study period [all P-values <0.05]. Lymph node counts were not associated with survival in Kaplan-Meier analysis or in multivariate Cox proportional hazards analysis.

CONCLUSIONS

Increasing lymph node counts improve survival and the accuracy of colorectal cancer staging. The body of literature recommends identical minimum lymph node counts in both colon and rectal cancer. In our study, which exclusively examined rectal cancer, we could not demonstrate that increased lymph node counts were associated with improved survival.

A comparative study of colorectal surgical outcome in a national audit separated by 15 years

AIM

The Wales-Trent Bowel Cancer Audit (WTBA) was carried out in 1993, and since 2001 Welsh Bowel Cancer Audits (WBCA) have taken place annually. Screening for bowel cancer in Wales was introduced in 2008. This study compared patient variables, the role of surgery and operative mortality rates over the 15-year interval between the WTBA and the last WBCA before the introduction of population screening.

METHOD

Data from the WTBA in 1993 were compared with those of the WBCA including patients diagnosed between April 2007 and March 2008.

RESULTS

In 1993, 1536 patients were diagnosed with colorectal cancer (CRC) compared with 1793 in 2007-2008. Patient demographics and American Society of Anesthesiology (ASA) score did not change during these periods. Surgical treatment for CRC decreased (93% in 1993 vs 80% in 2007-2008; P < 0.001) particularly in the use of resectional surgery (84% in 1993 vs 71% in 2007-2008; P < 0.001). The 30-day postoperative mortality rate fell from 7.4% in 1993 to 5.9% in 2007-2008 (P = 0.097). Advanced disease at operation was more prevalent in the WTBA (25% of all operated patients were Stage IV in 1993 vs 13% in 2007-2008; P < 0.001). The use of surgery in patients with metastatic disease also declined over this period.

CONCLUSION

Surgery is used less frequently in the management of CRC compared with 15 years previously, and is a factor in the reduction of the interpreted 30-day operative mortality.

Assessment of nodal status for perihilar cholangiocarcinoma: location, number, or ratio of involved nodes

OBJECTIVE

To analyze lymph node status in resected perihilar cholangiocarcinoma, to clarify which index (ie, location, number, or ratio of involved nodes) is better for staging, and to determine the minimum requirements for node examination.

BACKGROUND

In the TNM classification for perihilar cholangiocarcinoma, the number or ratio of involved nodes is not considered for nodal staging. The minimum requirement for histologic examination of lymph nodes is arbitrary.

METHODS

This study involved 320 patients with perihilar cholangiocarcinoma who underwent resection from January 2000 to December 2009 at Nagoya University Hospital. The relationship between lymph node status and patient survival was retrospectively analyzed.

RESULTS

Total lymph node counts (TLNCs), ie, the number of lymph nodes examined histologically, averaged 12.9 ± 8.3 (range: 1-59). Lymph node metastasis was found in 146 (45.6%) patients and was an independent, powerful prognostic factor. The survival rates were not significantly different between patients with regional node metastasis alone and those with distant node metastasis (19.2% vs 11.5% at 5 years, P = 0.058). The survival for patients with multiple node metastases was significantly worse than that for patients with single metastasis (12.1% vs 27.6% at 5 years, P = 0.002), regardless of the presence or absence of distant lymph node metastasis. The survival for patients with lymph node ratios (LNRs) of 0.2 or less was significantly better than that for patients with LNRs greater than 0.2 (21.4% vs 13.5% at 5 years, P = 0.032). Upon multivariate analysis of the 146 patients with lymph node metastasis, the number of involved nodes (single vs multiple) was identified as an independent prognostic factor (RR of 1.61, P = 0.045), whereas the locations (regional alone vs distant) and ratios (LNR ≤ 0.2 vs LNR > 0.2) of involved nodes were not. When the 148 pN0-R0 patients were divided into 3 groups (ie, those with TLNC ≥ 8, with TLNC = 5, 6, or 7, and with TLNC ≤ 4), survivals were identical between the first and second groups, whereas they were largely different between the former two and the third.

CONCLUSIONS

Lymph node metastasis is a powerful, independent prognostic factor in perihilar cholangiocarcinoma and is better classified based not on location but on the number of involved nodes. To adequately assess nodal status, histologic examination of 5 or more nodes is recommended.

Evaluation of preoperative C-reactive protein aids in predicting poor survival in patients with curative colorectal cancer with poor lymph node assessment

Lymph node status is the most significant prognostic factor of colorectal cancer. However, there is a risk of disease understaging if the extent of lymph node assessment is sub-optimal. Preoperative C-reactive protein (CRP) is known to be a useful tool in predicting postoperative outcomes in patients with colorectal cancer. We retrospectively evaluated whether CRP adds to prognosis information in stage I-III colorectal cancer patients with poor lymph node assessment. In stages I-III, multivariate analysis revealed that CRP-positive status and advanced T-stage were factors that independently affected survival. In stage III, univariate analysis revealed that lymph node number retrieval and lymph node ratio were factors that affected survival. However, CRP positivity was the only independent factor for survival. CRP positivity did not predict poor prognosis in stage II or III patients with adequate lymph node retrieval. By contrast, the prognosis of CRP-positive patients was poorer than that of CRP-negative patients in stage II and III, with inadequate lymph node retrieval. CRP is an independent prognostic marker in patients with stage I-III, II or III colorectal cancer. The evaluation of CRP may provide useful information on prognosis in curative patients with an inadequate examination of lymph nodes.

Lymph node evaluation for resected colorectal cancer

SUMMARY The negative impact of regional lymph node metastasis on survival from nonmetastatic colorectal cancers is proportional to the number of nodes harvested. A thorough lymph node examination by the pathologist is essential for accurate staging. Recommendations in the USA and Europe stipulate that a minimum of 12–15 lymph nodes must be examined to accurately predict regional node negativity. The prognostic separation for stage III colorectal cancer obtained by the lymph node ratio is superior to that of the absolute number of positive nodes. The extent of mesenteric resection, pathologic technique, age or tumor location may influence lymph node yield. In the future, biological significance and clinical impact on outcome of very small amounts of tumor in regional nodes could help in staging patients. The current data are considered insufficient to recommend either the routine examination of multiple tissue levels of paraffin blocks or the use of special/ancillary techniques.

Determinants of lymph node count in endometrial cancer surgical staging

OBJECTIVE

Lymphadenectomy is a fundamental procedure in gynecologic oncology, but there is an ongoing debate concerning its indication in endometrial cancer. Lymph node (LN) count has been used as a surrogate marker for quality of staging in endometrial cancer. Because of variability in reported LN counts in the literature and within our practice, we aimed to better understand the factors that influence the final LN count in endometrial cancer staging.

METHODS

We conducted a retrospective case study of patients with endometrial cancer who underwent surgical staging at our institution between April 1, 2005, and February 3, 2007. Linear regression was used to determine the association between LN count and a series of predictor variables.

RESULTS

Of 131 patients, 100 patients (76%) had stage I disease and 9 patients (7%) had LN metastasis. The mean (SD) LN count was 9.5 (7.8). We found no significant difference in LN count according to age, tumor histology, stage, or surgeon. Lymph node count decreased by 1 for each 5-unit (kg/m(2)) increase in body mass index (coefficient, -0.2; P = 0.038). The strongest predictor associated with LN count was the pathologist, with 2 groups of pathologists counting an average 7.7 (P < 0.001) and 6.42 (P = 0.001) fewer LNs per case compared to the referent group.

CONCLUSIONS

Our study confirms that LN count varies markedly. Although not the only contributor, the pathologist, we found, was the most significant determining factor in LN count variation. This highlights the need to exercise caution when drawing conclusions from published LN counts in endometrial cancer research.

Contributing factors on lymph node yield after surgery for mid-low rectal cancer

PURPOSE

The purpose of the present study was to evaluate the contributing factors to the lymph node status as well as to define the impact of preoperative concurrent chemoradiotherapy (CCRT) on the number of lymph nodes retrieved in mid-low rectal cancer.

MATERIALS AND METHODS

We retrospectively analyzed 277 patients who underwent curative surgical resection for mid-low rectal cancer between 1998 and 2007. Eighty-two patients received long course preoperative CCRT followed by surgery.

RESULTS

A mean of 13.12±9.28 lymph nodes was retrieved. In a univariate analysis, distance from the anal verge, pT stage, pN stage, lymphovascular invasion, preoperative CCRT had significant influence on the number of lymph nodes retrieved. In a multivariate model, patients in the CCRT group had fewer retrieved lymph nodes than the non-CCRT group (p<0.001). Both univariate and multivariate analyses showed that the ypN0 group had fewer retrieved lymph nodes than the ypN1-2 group (p=0.027) in the CCRT group.

CONCLUSION

Preoperative CCRT was an independent risk factor for failure to harvest an appropriate number of lymph nodes, and node-negative patients who received CCRT had fewer lymph nodes harvested.

The role of para-aortic lymphadenectomy in endometrial cancer

Endometrial cancer (EC) is the most common malignancy of the female reproductive tract and the fourth most common cancer overall. Approximately 20 % of patients with EC harbor disease outside the uterus, and 10 % of patients initially diagnosed with cancer confined to the uterus are found to have lymph node metastases. Para-aortic lymph node involvement occurs in approximately 7-8 % of EC patients overall and in about 50 % of patients with positive pelvic nodes. Metastases to the para-aortic lymph nodes are associated with poor prognosis. Factors associated with para-aortic lymph node dissemination include advanced stage, high histological grade, deep myometrial invasion, cervical involvement, lymphovascular space involvement, and the presence of pelvic lymph node metastases. Approximately 77 % of patients with para-aortic nodal involvement are found to have metastases above the level of the inferior mesenteric artery. Systematic pelvic and para-aortic lymphadenectomy with dissection optimally carried out to the renal vessels is important in high-risk patients in order to identify nodes present at distant sites, particularly above the inferior mesenteric artery (IMA). While the definitive management of EC varies widely across the gynecological oncology community, there is a consensus that patients at risk for lymphatic metastases (high and intermediate risk) who are targeted with systematic lymphadenectomy may have an improved prognosis. Well-designed prospective studies evaluating the therapeutic role of systematic lymphadenectomy in EC are needed. Herein, we describe the role of para-aortic lymphadenectomy in the surgical staging of EC emphasizing its prerequisites, extent, and diagnostic and potential therapeutic advantages.

Laparoscopic rectal cancer surgery: Where do we stand?

Large comparative studies and multiple prospective randomized control trials (RCTs) have reported equivalence in short and long-term outcomes between the open and laparoscopic approaches for the surgical treatment of colon cancer which has heralded widespread acceptance for laparoscopic resection of colon cancer. In contrast, laparoscopic total mesorectal excision (TME) for the treatment of rectal cancer has been welcomed with significantly less enthusiasm. While it is likely that patients with rectal cancer will experience the same benefits of early recovery and decreased postoperative pain from the laparoscopic approach, whether the same oncologic clearance, specifically an adequate TME can be obtained is of concern. The aim of the current study is to review the current level of evidence in the literature on laparoscopic rectal cancer surgery with regard to short-term and long-term oncologic outcomes. The data from 8 RCTs, 3 meta-analyses, and 2 Cochrane Database of Systematic Reviews was reviewed. Current data suggests that laparoscopic rectal cancer resection may benefit patients with reduced blood loss, earlier return of bowel function, and shorter hospital length of stay. Concerns that laparoscopic rectal cancer surgery compromises short-term oncologic outcomes including number of lymph nodes retrieved and circumferential resection margin and jeopardizes long-term oncologic outcomes has not conclusively been refuted by the available literature. Laparoscopic rectal cancer resection is feasible but whether or not it compromises short-term or long-term results still needs to be further studied.

Lymphatic drainage of the rectum, preoperative assessment and its relevance to malignant polyp and rectal cancer management

SUMMARY The importance of lymph node metastasis in rectal cancer is well recognized with regards to prognosis, staging and treatment. Accurate staging is particularly important where neoadjuvant treatment has been shown to downsize and downstage locally advanced tumors. Vascular invasion, poor differentiation and increasing depth of invasion are related to a higher risk of lymph node metastasis in early cancers while advanced, poorly differentiated and low rectal cancers are more likely to have lateral pelvic sidewall nodal involvement. Nodal staging is crucial in the management of malignant rectal polyps, as is the deferral of surgery in patients who have a complete clinical and radiological response to chemoradiotherapy. In all of these situations nodal staging is vital and warrants ongoing evaluation to improve its accuracy.

The complexity of the count: considerations regarding lymph node evaluation in colorectal carcinoma

In patients with colorectal carcinoma, studies have reported improved survival with increasing numbers of retrieved lymph nodes. These findings are puzzling, as increased node sampling was not correlated with significant change in disease staging. Although the physiologic processes underlying this correlation between number of lymph nodes sampled and survival remain unknown, the reported correlation has caused modifications to clinical and non-clinical practices. Herein, we review the literature and discuss potential etiologies responsible for the observed increased survival statistics. Literature regarding colorectal lymph node anatomy, molecular aspects of colorectal cancer, changes in tumor characteristics and utilization of lymph node sample numbers are evaluated. In addition, we present the mathematical concepts available for probabilistic prediction of diagnostic confidence based upon sample size. From evaluation of the aggregate literature, certain facts emerge which are not easily identified within the individual studies. Colorectal carcinoma appears to encompass a number of individual disease entities with different physiologic characteristics and likelihoods of metastasis. In addition, it appears the improved survival is likely multifactorial including effects from intrinsic tumor biology and tumor-host interactions along with ever changing clinical practices. Finally, because lymph node count is dependent on a number of variables and is correlated, but unlikely to be causally associated with survival, use of this number as a quality indicator is unwarranted. Based on statistical considerations, the current recommended goal of 12-15 recovered lymph nodes without evidence of metastatic disease provides approximately 80% negative predictive value for colorectal carcinoma metastasis.

Different approaches for complete mobilization of the splenic flexure during laparoscopic rectal cancer resection

PURPOSE

Laparoscopic resection of rectal cancer has already become the standard procedure in many hospitals. The splenic flexure mobilization (SFM) is an important preparational step. Several methods are used for laparoscopic SFM; however, studies comparing different approaches are lacking. In the present study, three different approaches for SFM have been compared to each other.

METHODS

Between January 1998 and December 2010, 415 patients with rectal adenocarcinoma underwent laparoscopic rectal resection at one center. Of these, 303 patients received complete splenic flexure mobilization. The SFM was performed using either a medial (SFM-M; n = 41), lateral (SFM-L; n = 214), or anterior (SFM-A; n = 48) approach.

RESULTS

There was a significantly higher rate of intraoperative complications in the SFM-L group as compared to the SFM-M or the SFM-A group (p = 0.038). Postoperative surgical complications occurred in 5 (10.6 %) patients of the SFM-A group compared to 38 patients (17.7 %) in the SFM-L group (p = 0.002) and 5 (12.1 %) patients in the SFM-M group (p = 0.037). SFM-L was also associated with a higher frequency of overall postoperative morbidity which was mainly due to wound infection rates (p = 0.001).

CONCLUSIONS

The anterior approach for SFM in laparoscopic surgery seems to be associated with lower frequency of intra- and postoperative morbidity.

The relationship of lymph node evaluation and colorectal cancer survival after curative resection: a multi-institutional study

BACKGROUND

Esophagectomy remains the mainstay treatment for clinical T1bN0M0 esophageal cancer because pathologic lymph node metastases in these patients are not negligible. Recently, chemoradiotherapy (CRT), which can preserve the esophagus, has been reported to be a promising therapeutic alternative to esophagectomy. However, to our knowledge, no comparative studies of esophagectomy and CRT have been reported in clinical T1bN0M0 esophageal cancer.

METHODS

A total of 173 patients with clinical T1bN0M0 squamous cell carcinoma of the thoracic esophagus were enrolled in this study, 102 of whom were treated with radical esophagectomy (S group) and 71 with definitive CRT (CRT group). Treatment results of both groups were retrospectively compared.

RESULTS

No statistically significant difference was found in overall survival, but the S group displayed significantly better progression-free survival than the CRT group. Disease recurrence was observed in 12 S group patients and 20 CRT group patients. The incidence of distant recurrence was similar, while local recurrence and lymph node recurrence were significantly more frequent in the CRT group. In the S group, 20 patients had pathologic lymph node metastasis. The progression-free survival of patients with pathologic lymph node metastasis did not differ from those without nodal metastasis. In the CRT group, local recurrence could be controlled by salvage esophagectomy, but treatment results of lymph node recurrence were poor; only 4 of 12 patients with lymph node recurrences were cured.

CONCLUSIONS

Selection of patients at high risk of pathologic lymph node metastasis is essential when formulating treatment decisions for clinical T1bN0M0 esophageal cancers.

Lymph node ratio and preoperative CA 19-9 levels predict overall survival and recurrence-free survival in patients with resected pancreatic adenocarcinoma

AIM: Clinicopathologic factors predicting overall survival (OS) would help identify a subset to benefit from adjuvant therapy.

METHODS: One hundred and sixty-nine patients patients from 1984 to 2009 with curative resections for pancreatic adenocarcinoma were included. Tumors were staged by American Joint Committee on Cancer 7th edition criteria. Univariate and multivariable analyses were performed using Kaplan-Meier methodology or Cox proportional hazard models. Log-rank tests were performed. Statistical inferences were assessed by two-sided 5% significance level.

RESULTS: Median age was 67.1 (57.2-73.0) years with equal gender distribution. Tumors were in the head (89.3%) or body/tail (10.7%). On univariate analysis, adjuvant therapy, lymph node (LN) ratio, histologic grade, negative margin status, absence of peripancreatic extension, and T stage were associated with improved OS. Adjuvant therapy, LN ratio, histologic grade, number of nodes examined, negative LN status, and absence of peripancreatic extension were associated with improved recurrence-free survival (RFS). On multivariable analysis, LN ratio and carbohydrate antigen (CA) 19-9 levels were associated with OS. LN ratio was associated with RFS.

CONCLUSION: The LN ratio and CA 19-9 levels are independent prognostic factors following curative resections of pancreatic cancer.