Number of harvested lymph nodes is the main prognostic factor in Stage IIa colorectal cancer patients

Finding the minimum number of retrieved lymph nodes in node-negative colorectal cancer using Real-world Data and the SEER database

BACKGROUND

Current clinical guidelines recommend the removal of at least 12 lymph nodes (LNs) in resectable colorectal cancer (CRC). With advancements in lymphadenectomy technologies, the number of retrieved lymph nodes (rLNs) has markedly increased. This study aimed to investigate the lowest number of rLNs in node-negative patients.

MATERIALS AND METHODS

A total of 1103 N0 and 208 N1a stage patients were enrolled in our cohort, while 8503 N0 and 1276 N1a patients from the Surveillance, Epidemiology, and End Results CRC database were included. Propensity score matching and multivariate Cox regression analyses were performed to mitigate the influence of selection bias and control for potential confounding variables.

RESULTS

The median number of rLNs in N0 patients increased from 13.5 (interquartile range [IQR]: 9-18) in 2013 to 17 (IQR: 15-20) in 2019. The restrictive cubic spline illustrated a nonlinear relationship between rLNs and prognosis (nonlinearity, P =0.009), with a threshold ( N =16) influencing clinical outcomes. Patients at either N0 or N1a stage with sufficient rLNs (≥16) demonstrated superior prognoses to those with a limited rLNs (<16). After adjusting for clinical confounders, similar prognoses were observed in N0 limited and N1a adequate populations. Furthermore, Kaplan-Meier curves revealed that N0 limited patients who received chemotherapy exhibited better outcomes than those who did not.

CONCLUSIONS

Among patients with node-negative CRC, it is crucial to remove 16 or more LNs effectively. Fewer than 16 rLNs should be regarded as an independent risk factor, implying the need for adjuvant chemotherapy.

Extracellular vesicle expansion of PMIS-miR-210 expression inhibits colorectal tumour growth via apoptosis and an XIST/NME1 regulatory mechanism

BACKGROUND

Colorectal cancer (CRC) has a high mortality rate, and therapeutic approaches to treat these cancers are varied and depend on the metabolic state of the tumour. Profiles of CRC tumours have identified several biomarkers, including microRNAs. microRNA-210 (miR-210) levels are directly correlated with CRC survival. miR-210 expression is higher in metastatic colon cancer cells versus non-metastatic and normal colon epithelium. Therefore, efficient methods to inhibit miR-210 expression in CRC may provide new advances in treatments.

METHODS

Expression of miRs was determined in several metastatic and non-metastatic cell lines. miR-210 expression was inhibited using PMIS-miR-210 in transduced cells, which were transplanted into xenograft mice. In separate experiments, CRC tumours were allowed to grow in xenograft mice and treated with therapeutic injections of PMIS-miR-210. Molecular and biochemical experiments identified several new pathways targeted by miR-210 inhibition.

RESULTS

miR-210 inhibition can significantly reduce tumour growth of implanted colon cancer cells in xenograft mouse models. The direct administration of PMIS-miR-210 to existing tumours can inhibit tumour growth in both NSG and Foxn1nu/j mouse models and is more efficacious than capecitabine treatments. Tumour cells further transfer the PMIS-miR-210 inhibitor to neighbouring cells by extracellular vesicles to inhibit miR-210 throughout the tumour. miR-210 inhibition activates the cleaved caspase 3 apoptotic pathway to reduce tumour formation. We demonstrate that the long non-coding transcript XIST is regulated by miR-210 correlating with decreased XIST expression in CRC tumours. XIST acts as a competing endogenous RNA for miR-210, which reduces XIST levels and miR-210 inhibition increases XIST transcripts in the nucleus and cytoplasm. The increased expression of NME1 is associated with H3K4me3 and H3K27ac modifications in the NME1 proximal promoter by XIST.

CONCLUSION

Direct application of the PMIS-miR-210 inhibitor to growing tumours may be an effective colorectal cancer therapeutic.

Lymph node regression grading of locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy

Neoadjuvant chemoradiotherapy (nCRT) and total rectal mesenteric excision are the main standards of treatment for locally advanced rectal cancer (LARC). Lymph node regression grade (LRG) is an indicator of prognosis and response to preoperative nCRT based on postsurgical metastatic lymph node pathology. Common histopathological findings in metastatic lymph nodes after nCRT include necrosis, hemorrhage, nodular fibrosis, foamy histiocytes, cystic cell reactions, areas of hyalinosis, residual cancer cells, and pools of mucin. A number of LRG systems designed to classify the amount of lymph node regression after nCRT is mainly concerned with the relationship between residual cancer cells and regressive fibrosis and with estimating the number of lymph nodes existing with residual cancer cells. LRG offers significant prognostic information, and in most cases, LRG after nCRT correlates with patient outcomes. In this review, we describe the systematic classification of LRG after nCRT, patient prognosis, the correlation with tumor regression grade, and the typical histopathological findings of lymph nodes. This work may serve as a reference to help predict the clinical complete response and determine lymph node regression in patients based on preservation strategies, allowing for the formulation of more accurate treatment strategies for LARC patients, which has important clinical significance and scientific value.

A retrospective study on the impact of the number of resected lymph nodes on the survival outcome of stage IV rectal cancer patients after preoperative therapy

Background

There is no consensus on the optimal number of examined LNs for stage IV rectal cancer patients after preoperative therapy. We aimed to explore the impact of the number of resected lymph nodes (LNs) on the survival outcomes of stage IV rectal cancer patients after preoperative therapy.

Methods

Clinicopathologic data of 556 patients diagnosed with stage IV rectal cancer between 1st January, 2010 and 31st December, 2015 from the Surveillance, Epidemiology, and End Results (SEER) database after preoperative therapy were reviewed. The patients were further divided into two groups: the ≥15 resected LNs group and <15 resected LNs group based on the X-tile software analysis results of the number of resected LNs.

Results

Both univariate and multivariate regression analyses revealed that the number of resected LNs and N status were significantly positively correlated with the survival outcome of the patients. Patients in the ≥15 resected LNs group had a significant better cancer-specific survival (CSS) (P=0.003) than those in the <15 resected LNs group. The 3-year CSS rate was 63.2% for patients with ≥15 resected LNs compared with 55.7% for those with <15 resected LNs. The 5-year CSS rate was 50.2% and 30.5% for patients in the ≥15 resected LNs group and those in the <15 resected LNs group, respectively.

Conclusions

The number of resected LNs is an important independent prognostic factor that influences the survival outcome of stage IV rectal cancer patients after receiving preoperative therapy.

Prognostic Performance of Different Lymph Node Staging Systems in Patients With Small Bowel Neuroendocrine Tumors

Background: The prognostic significance of the lymph node (LN) classification for small bowel neuroendocrine tumors (SBNETs) remains unknown. The aim of the present study was to evaluate and compare the prognostic assessment of different LN staging systems. Methods: Patients with SBNETs were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The X-tile program was used to determine the cutoff value of the resected lymph nodes (RLNs), negative lymph nodes (NLNs), lymph node ratio (LNR), and the log odds of positive lymph nodes (LODDS). Survival analyses were performed using Kaplan-Meier curves with log-rank test. Logistic regression analysis was used to evaluate the differences between different periods. Univariate and multivariate Cox proportional hazards models were used to assess the prognostic value of different LN staging systems on cause-specific survival (CSS). The relative discriminative abilities of the different LN staging systems were assessed using the Akaike information criterion (AIC) and the Harrell consistency index (HCI). Result: A total of 3,680 patients were diagnosed with SBNETs between 1988 and 2014 from the SEER database. A significant difference over time (1988-1999 vs. 2000-2014) was seen in age (P <0.001), tumor differentiation (P <0.001), T stage (P <0.001), and RLN (P <0.001) subgroups. Multivariate Cox survival analysis identified that LN status stratified by the number of RLNs, NLNs, LNR, and LODDS all predicted CSS in patients with SBNETs (all P <0.05), whereas the number of positive lymph nodes (PLNs) failed (P = 0.452). When assessed using categorical variables, LODDS staging systems showed the best prognostic performance (HCI: 0.766, AIC: 7,575.154) in the whole population. Further analysis based on different RLNs after eliminating the missing data showed that when the RLNs are <12, the LODDS (HCI: 0.769, AIC: 1,088.731) maintained the best prognostic performance as well when the RLNs are ≥12 (HCI: 0.835, AIC: 825.692). Among patients with LNR scores of 0 or 1, there was a residual heterogeneity of outcomes that were better stratified and characterized by the LODDS. Conclusion: LODDS was a better predicator of survival when LN status was stratified as a categorical variable and should be considered when assessing the prognosis of patients with SBNETs to allow a more reliable means to stratify patient survival.

Toll-Like Receptor 4 and Matrix Metalloproteases 11 and 13 as Predictors of Tumor Recurrence and Survival in Stage II Colorectal Cancer

Current clinical-pathologic stratification factors do not allow clear identification of high-risk stage II colorectal cancer (CRC) patients. Therefore, the identification of additional prognostic markers is desirable. Toll-like receptor (TLR)-4 is activated during tumorigenesis and matrix metalloproteases (MMPs) are involved in invasion and metastasis. We aimed to evaluate the expression and clinical relevance of TLR4, MMP11 and MMP13 for patients with stage II CRC. Immunohistochemistry was used to study the expression of TLR4, MMP11 and MMP13 in 96 patients with stage II CRC. We measured the global expression and the expression by different cell types (tumor cells, cancer-associated fibroblasts (CAFs) and mononuclear inflammatory cells (MICs)). The potential relationship between expressions of factors and different prognostic variables were evaluated. Our results show significant relationships between either TLR4 expression by tumor cells and MMP11 expression by CAFs and high risk of tumor recurrence. In addition, the concurrence of age ≥ 75 years and the non-expression of MMP11 by CAFs identify a subgroup of patients with a good prognosis. Our results show that TLR4 expression by tumor cells and MMP11 expression by CAFs may to improve the identification of patients with stage II CRC with a high-risk of relapse.

Emergency surgery for colorectal cancer does not affect nodal harvest comparing elective procedures: a propensity score-matched analysis

PURPOSE

About 30% of colorectal cancers (CRCs) present with acute symptoms. The adequacy of oncologic resections is a matter of concern since few authors reported that emergency surgery in these patients results in a lower lymph node harvest (LNH). In addition, emergency resections have been reported with a longer hospital stay and higher morbidity rate. We thus conducted a propensity score-matched analysis with the aim of investigating LNH in emergency specimens comparing with elective ones. Secondary aim was the comparison of morbidity and hospital stay.

METHODS

Eighty-seven consecutive R0 emergency surgical procedures were matched with elective CRCs using the propensity score method and the following covariates: age, sex, stage, and localization. Groups were compared using univariate and multivariate analyses. Outcome measures were LNH, nodal ratio, Clavien's morbidity grades, and hospital stay.

RESULTS

Emergency patients presented more metastatic nodes compared with elective ones (p 0.017); however, both presented a comparable mean LNH. Multivariate analysis documented that a T stage ≥3 was the only variable correlated with a nodal positivity (OR 6.3). On univariate analysis, emergency CRCs had a longer mean hospital stay compared with elective resections (p 0.006) and a higher rate of Clavien ≥4 events (p 0.0173). Finally, emergency resection and an age >66 years were variables independently correlated with a mean hospital stay >10 days (OR, respectively, 3.7 and 3.5).

CONCLUSIONS

Emergency CRC resections were equivalent to the elective procedures with respect to LNH. However, emergency surgery correlated with a longer mean hospital stay. Graphical abstract Emergency and Elective resections for CRC provide similar LNH.

Inferior Mesenteric Artery Lymph Node Metastasis Is an Independent Prognostic Factor for Stage III Sigmoid Colon and Rectal Cancer

It is unclear whether the number or distribution of lymph node metastases can provide a more accurate prognosis. The aim of this study was to evaluate the prognostic impact of inferior mesenteric artery (IMA) lymph node metastasis (LNM) in sigmoid colon and rectal cancer. We included 188 patients who underwent curative resection for stage III sigmoid colon and rectal cancer between January 2001 and December 2012. Patients were divided into 2 groups based on the presence of IMA-LNM (LNM-positive versus LNM-negative group). Clinicopathologic characteristics, 3-year recurrence-free survival and 5-year overall survival rates, and recurrence patterns were compared between the 2 groups. Of 188 patients, 9 patients (4.79%) were in the LNM-positive group. After curative resection, 3-year recurrence-free survival and 5-year overall survival rates were significantly lower in the LNM-positive group compared to the LNM-negative group (44.44% versus 69.98%, P = 0.016 for 3-year recurrence-free survival and 48.61% versus 81.73%, P = 0.018 for 5-year overall survival). Multivariate analysis revealed that the presence of IMA-LNM (P = 0.04), not the number of LNMs (P = 0.153), was an independent prognostic factor for recurrence-free survival. The para-aortic LNM rate was significantly higher in the LNM-positive group (P = 0.0078). IMA-LNM is an independent predictor of survival for stage III sigmoid colon and rectal cancer patients. Evaluation of IMA-LNM enables accurate estimation of patient prognosis and enhances appropriate postoperative therapy.

Lymph node yield after rectal resection in patients treated with neoadjuvant radiation for rectal cancer: A systematic review and meta-analysis

BACKGROUND

The lymph node status represents a major prognostic factor in colorectal cancer. However, it was demonstrated that neoadjuvant chemoradiotherapy (CRT) decreases the numbers of lymph nodes in the specimen. Several studies describe less than 12 lymph nodes in the resected specimen of rectal cancer patients after neoadjuvant radiation. This meta-analysis quantifies the influence of neoadjuvant CRT or radiotherapy (RT) only on the lymph node yield in rectal cancer patients.

METHODS

We performed a systematic review and searched PubMed, EMBASE and the Cochrane Library without any language restriction from 1st of January 1980 until 31st March 2015. Two reviewers examined all publications independently and extracted the relevant data if the study assessed lymph node counts or positive lymph node yields of patients who received neoadjuvant treatment compared with patients who did not receive neoadjuvant treatment. Meta-analyses were conducted to quantify the mean difference in lymph node yield.

RESULTS

A total of 34 articles (including 37 datasets) were included in the meta-analyses. Neoadjuvant CRT resulted in a mean reduction of 3.9 lymph nodes (95% confidence interval [CI] 3.7-4.1) and an average reduction in harvested positive lymph nodes of 0.7 (95% CI 0.2-1.2) compared with patients who received no neoadjuvant therapy. Individuals who received neoadjuvant RT had, in average, 2.1 lymph node less (95% CI 1.7-2.5) resected compared with their counterparts who received no neoadjuvant treatment.

CONCLUSIONS

Neoadjuvant CRT or RT only in rectal cancer patients leads to a decrease in lymph node harvest of approximately four and two lymph nodes, respectively. We therefore stress the importance of intensifying all efforts from involved subspecialities (i.e. surgeons and pathologists) to reach the benchmark harvest of 12 resected lymph nodes according to current guidelines.

Histologic prognostic markers in stage IIA colorectal cancer: a comparative study

OBJECTIVE

pTNM stage IIA colorectal cancer (CRC) is not currently submitted to any adjuvant treatment due to its good prognosis. Nevertheless, a percentage of cases unexpectedly recur. The aim of this study was to assess and compare the prognostic value and inter-observer agreement of a novel histological grading system based on the counting of poorly differentiated clusters (PDC) of cancer cells and that of conventional histological grade, lymphatic, venous and perineural invasion (LVI, VI, PNI), tumour budding (TB) and tumor border configuration in stage IIA CRC.

MATERIALS AND METHODS

the afore mentioned histological parameters were assessed in 82 stage IIA CRCs. Inter-observer agreement and correlation with tumour relapse were analyzed by using Fleiss-Cohen's weighted K statistics, Fisher exact test and Chi-squared test. The Mantel-Cox log-rank test was applied to assess the strength of association with disease-free interval (DFI).

RESULTS

inter-observer agreement was very good/good in the assessment of PDC presence and grade, while it was moderate at best in the evaluation of the other parameters. The presence of PDC, high PDC grade, LVI and TB were significantly associated with disease progression (p < 0.0001; p = 0.0012; p = 0.0308; p = 0.0002) and shorter DFI (p = 0.0001; p < 0.0001; p = 0.0129; p = 0.0008). PDC presence (p < 0.0001) and TB (p = 0.012) were independent prognostic factors in multivariate analysis.

CONCLUSIONS

our findings suggest that the assessment of PDC may be useful to stratify patients with stage IIA CRC for recurrence risk, and to identify high risk patients who could benefit from adjuvant chemotherapy.

Stage migration vs immunology: The lymph node count story in colon cancer

Lymph node staging is of crucial importance for the therapy stratification and prognosis estimation in colon cancer. Beside the detection of metastases, the number of harvested lymph nodes itself has prognostic relevance in stage II/III cancers. A stage migration effect caused by missed lymph node metastases has been postulated as most likely explanation for that. In order to avoid false negative node staging reporting of at least 12 lymph nodes is recommended. However, this threshold is met only in a minority of cases in daily practice. Due to quality initiatives the situation has improved in the past. This, however, had no influence on staging in several studies. While the numbers of evaluated lymph nodes increased continuously during the last decades the rate of node positive cases remained relatively constant. This fact together with other indications raised doubts that understaging is indeed the correct explanation for the prognostic impact of lymph node harvest. Several authors assume that immune response could play a major role in this context influencing both the lymph node detectability and the tumor’s behavior. Further studies addressing this issue are need. Based on the findings the recommendations concerning minimal lymph node numbers and adjuvant chemotherapy should be reconsidered.

Lymph Node Yield in Colon Cancer: Individuals Can Make the Difference

AIM

To investigate the influence of individual surgeons and pathologists on examining an adequate (i.e. ≥10) number of lymph nodes in colon cancer resection specimens.

PATIENTS AND METHODS

The number of lymph nodes was evaluated in surgically treated patients for colon cancer at our hospital from 2008 through 2010, excluding patients who had received neo-adjuvant treatment. The patient group consisted of 156 patients with a median age of 73 (interquartile range (IQR) 63-82 years) and a median of 12 lymph nodes per patient (IQR 8-15). In 106 patients (67.9%), 10 or more nodes were histopathologically examined.

RESULTS

At univariate analysis, the examination of ≥10 nodes was influenced by tumour size (p = 0.05), tumour location (p = 0.015), type of resection (p = 0.034), individual surgeon (p = 0.023), and pathologist (p = 0.005). Neither individual surgeons nor pathologists did statistically and significantly influence the chance of finding an N+ status. Age (p = 0.044), type of resection (p = 0.007), individual surgeon (p = 0.012) and pathologist (p = 0.004) were independent prognostic factors in a multivariate model for finding ≥10 nodes.

CONCLUSION

Though cancer staging was not affected in this study, individual efforts by surgeons and pathologists play a critical role in achieving optimal lymph node yield through conventional methods.

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.

Changes in the surgical approach to colonic emergencies during a 15-year period

PURPOSE

The present study aims to determine the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any change in incidence of the different types of pathological conditions and in the surgical approach over the last 15 years.

MATERIALS AND METHODS

A total of 319 patients who underwent emergency colonic surgery between January 1997 and December 2011 were retrospectively analyzed. Patients were divided into two groups according to the date of surgery, namely group 1, between 1997 and 2006, and group 2, between 2006 and 2011. The differences in terms of postoperative outcomes between the groups were analyzed.

RESULTS

Overall postoperative morbidity and mortality rates were 25.3 and 17.2%, respectively; no differences were found between the groups. Group 2 showed a significantly increased rate of primary resection and anastomosis (p < 0.001), as well as an increase in laparoscopic approach compared with group 1 (p < 0.001).

CONCLUSIONS

Emergency colon surgery is today primarily performed for benign diseases, of these the most common is diverticular disease followed by ischemic colitis. Age, comorbidities, and ischemic colon disease are predictors of adverse outcomes, while the surgical procedure per se is not.

Prognostic assessment of different lymph node staging methods for pancreatic cancer with R0 resection: pN staging, lymph node ratio, log odds of positive lymph nodes

BACKGROUND AND AIMS

Survival after surgical resection of pancreatic adenocarcinoma is poor. Several prognostic factors such as the status of the resection margin, lymph node status, or tumour grading have been identified. The aims of the present study were to evaluate and compare the prognostic assessment of different lymph nodes staging methods: standard lymph node (pN) staging, metastatic lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) in pancreatic cancer after pancreatic resection.

MATERIALS AND METHODS

Data were retrospectively collected from 143 patients who had undergone R0 pancreatic resection for pancreatic ductal adenocarcinoma. Survival curves (Kaplan-Meier and Cox proportional hazard models), accuracy, and homogeneity of the 3 methods (LNR, LODDS, and pN) were compared to evaluate the prognostic effects.

RESULTS

Multivariate analysis demonstrated that LODDS and LNR were an independent prognostic factors, but not pN classification. The scatter plots of the relationship between LODDS and the LNR suggested that the LODDS stage had power to divide patients with the same ratio of node metastasis into different groups. For patients in each of the pN or LNR classifications, significant differences in survival could be observed among patients in different LODDS stages.

CONCLUSION

LODDS and LNR are more powerful predictors of survival than the lymph node status in patients undergoing pancreatic resection for ductal adenocarcinoma. LODDS allows better prognostic stratification comparing LNR in node negative patients.

Prognostic criteria in colorectal carcinoma constructed by the combination of tumor-related and host-related factors

BACKGROUND

The significance of prognostic criteria based on a combination of tumor-related and host-related factors for patients with colorectal carcinoma has not been appreciated fully.

METHODS

Correlation of tumor-related and host-related score (TRHRS), which are constructed by the combination of serum elevation of C-reactive protein and pathologic lymph node metastasis (scores ranging 0 to 2), with clinicopathologic features including prognosis was studied in 271 patients with colorectal carcinoma who had been treated with curative resection.

RESULTS

Significant difference regarding survival was observed both between TRHRS 0 and 1 (P = .028) and between TRHRS 1 and 2 (P < .0001). Multivariate analysis showed that histologic types (P = .040) and TRHRS (P < .0001) were independent prognostic indicators.

CONCLUSION

Criteria for the prediction of prognosis in colorectal carcinoma treated with curative resection based on both tumor-related and host-related factors could provide a strict stratification.

Digestive cancer surgery in the era of sentinel node and epithelial-mesenchymal transition

Lymph node involvement is one of the most important prognostic indicators of carcinoma of the digestive tract. Although the therapeutic impact of lymphadenectomy has not been proven and the number of retrieved nodes cannot be considered a measure of successful cancer surgery, an adequate lymph node count should be guaranteed to accurately assess the N-stage through the number of involved nodes, lymph node ratio, number of negative nodes, ratio of negative to positive nodes, and log odds, i.e., the log of the ratio between the number of positive lymph nodes and the number of negative lymph nodes in digestive carcinomas. As lymphadenectomy is not without complications, sentinel node mapping has been used as the rational procedure to select patients with early digestive carcinoma in whom nodal dissection may be omitted or a more limited nodal dissection may be preferred. However, due to anatomical and technical issues, sentinel node mapping and nodal basin dissection are not yet the standard of care in early digestive cancer. Moreover, in light of the biological, prognostic and therapeutic impact of tumor budding and tumor deposits, two epithelial-mesenchymal transition-related phenomena that are involved in tumor progression, the role of staging and surgical procedures in digestive carcinomas could be redefined.

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.

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.

Lymph node ratio is a stronger prognostic factor than microsatellite instability in colorectal cancer patients: results from a 7 years follow-up study

BACKGROUND

The presence of high microsatellite instability (MSI-H) in colorectal cancers has been generally associated with better survival, opposite an increased ratio between metastatic lymph-nodes and nodes sampled in the specimen (LNR) has been associated with a worse outcome. The study aims to detect the incidence and prognostic significance of MSI and LNR in a consecutive series of 119 colorectal cancers.

METHODS

119 consecutive colorectal cancer patients undergone resection at our Department were enrolled from 2000 to 2004. The MSI status has been evaluated by amplification of target sequences. The LNR has been calculated and patients stratified into 4 groups on the basis of the ratio values. Clinical/pathological data were collected and analyzed; the overall, disease free and disease specific survivals were analyzed by the Kaplan-Meier and Cox regression analyses (mean follow-up: 81 months).

RESULTS

MSI-H was detected in 11.7% of the cases and patients were compared with the microsatellite stable (MSS) group. We observed a higher prevalence of right colon localizations (p 0.01) and locally advanced tumors (p 0.0012) in the MSI-H subgroup. Kaplan-Meier analysis documented no significant difference comparing MSS patients vs MSI-H, although the latter showed a better survival trend (p ns); worse survivals were observed according with the LNR stratification (p < 0.0001). Multivariate analysis documented a statistical value associated with the LNR sub-groups in relationship with survival.

CONCLUSION

According to our results the MSI-H status was associated with particular features (right locations/locally advanced tumors). The results of a long-term follow-up indicate a trend for better survival in MSI-H vs MSS patients. Notably, an increased LNR is associated with worse survivals, both at the univariate and multivariate analysis, displaying this ratio as the strongest prognostic factor of cancer-related survival.

Malnutrition and pancreatic surgery: prevalence and outcomes

BACKGROUND

Pancreatic surgery is associated with severe postoperative morbidity. Identification of patients at high risk may provide a way to allocate resources objectively and focus care on those patients in greater need. The Authors evaluate the prevalence of malnutrition and its effect on the postoperative morbidity of patients undergoing pancreatic surgery for malignant tumors.

METHODS

Data were collected from 143 patients who had undergone pancreatic resection for cancer. Prevalence of malnutrition was evaluated by several validated screening tools and correlated to the incidence of surgical site infection, overall morbidity, mortality, and hospital stay.

RESULTS

Overall, 88% of patients were at medium-high risk of malnutrition. Patients at high risk of malnutrition presented a fourfold longer postoperative hospitalization period and a higher morbidity rate (53.2%) than those patients at low risk of malnutrition. Malnutrition, evaluated by MUST and NRI, was an independent predictor of overall morbidity using multivariate analysis (P = 0.00145, HR = 2.6581, 95% CI = 1.3589-8.5698, and P = 0.07129, HR = 1.9953, 95% CI = 0.9723-13.548, respectively).

CONCLUSION

Malnutrition is a relevant predictor of post-operative morbidity and mortality after pancreatic surgery. Patients underwent pancreatic resection for malignant tumors are usually malnourished. Preoperative malnutrition screening is mandatory in order to assess the risk and to treat the malnutrition.