Assessing the effectiveness of mesorectal excision in rectal cancer: prognostic value of the number of lymph nodes found in resected specimens

INFLUENCE OF NEOADJUVANT THERAPY ON THE RATIO OF LYMPH NODES

BACKGROUND

To evaluate the relationship between the ratio of affected lymph nodes (LNR) and clinical and anatomopathological variables in patients with rectal adenocarcinoma submitted or not to neoadjuvant chemoradiotherapy.

METHODS

The LNR was determined by dividing the number of compromised LNR by the total number of LNR dissected in the surgical specimen. Patients were divided into two groups: with QRT and without QRT. In each group, the relationship between LNR and the following variables was evaluated: degree of cell differentiation, depth of invasion in the rectal wall, angiolymphatic /perineural invasion, degree of tumor regression and occurrence of metastases. The LNR was evaluated in patients with more than 1, LNR (LNR >12) or less (LNR<12) in the surgical specimen with overall survival (OS) and disease-free survival (DFS). The results were expressed as the mean with the respective standard deviation. Qualitative variables were analyzed using Fisher's exact test, while quantitative variables were analyzed using the Kruskal -Wallis and Mann-Whitney tests. The significance level was 5%.

RESULTS

We evaluated 282 patients with QRT and 114 without QRT, between 1995-2011. In the QRT Group, LNR showed a significant association with mucinous tumors (P=0.007) and degree of tumor regression (P=0.003). In both groups, LNR was associated with poorly differentiated tumors (P=0.001, P=0.02), presence of angiolymphatic invasion (P<0.0001 and P=0.01), perineural (P=0.0007, P=0.02), degree of rectal wall invasion (T3>T2; P<0.0001, P=0.02); Compromised LNR (P<0.0001, P<0.01), metastases (P<0.0001, P<0.01). In patients with QRT, LNR<12 was associated with DFS (5.889; 95%CI1.935-19.687; P=0.018) and LNR>12 with DFS and OS (17.984; 95%CI5.931-54.351; P<0.001 and 10.286; 95%CI 2.654-39.854; P=0.007, respectively).

CONCLUSION

LNR was associated with histological aspects of poor prognosis, regardless of the use of QRT. In the occurrence of less than 12 evaluated LNR, the LNR was associated only with the DFS.

BACKGROUND

• Assessment of the lymph nodes during pathological analysis of the surgical specimen is crucial to determine treatment and prognosis.

BACKGROUND

• Neoadjuvance therapy reduces the number of lymph nodes, being lower than recommended, therefore the lymph node ratio can be an alternative analysis for a better prognosis.

Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice.

OBJECTIVES

The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence.

METHODS

Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts.

RESULTS

The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients.

CONCLUSION

These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.

Prognostic significance of lymph node yield in patients with synchronous colorectal carcinomas

BACKGROUND

The National Comprehensive Cancer Network (NCCN) guidelines recommend examination of a minimum of 12 lymph nodes (LNs) for accurate staging of a single case of colorectal cancer. However, the guidelines do not support the examination of LNs in synchronous colorectal carcinoma (SCC). This study aimed to investigate the association between lymph node yield and the prognosis of SCC patients.

METHODS

Synchronous colorectal carcinoma patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database over a 10-year interval (2004 to 2013). Systematic dichotomization for optimal cut-off point identification was performed using X-tile. The baseline for the two LNs groups generated was balanced using the propensity score matching (PSM) method.

RESULTS

A total of 4616 patients met the inclusion criteria. The cut-off number for lymph node retrieved from a single patient was 15 and 12 for the first- and second-time diagnosis of SCC, respectively. Age, T category, N category, tumor grade, tumor site, tumor size, and radiation sequence were not balanced in the two groups. After adjusting the baseline in the two groups, the same results were observed. Age, T category, N category, tumor site had a partial effect on lymph node yield. There might be some biological characteristics of the tumor that influence lymph node yield.

CONCLUSIONS

Retrieval of fewer than 15 LNs at the first time of SCC diagnosis indicates worse SCC prognosis. Because factors such as manner of surgical examination influence SCC prognosis, specimens should be preserved for at least 6 months to enable reevaluation should there be a need. Irb: IRB approval is not required because the SEER data are freely accessible.

Prognostic accuracy of different lymph node staging systems in rectal adenocarcinoma with or without preoperative radiation therapy

Background and objective

A variety of different lymph node (LN) staging systems have been developed to describe the lymph node status accurately. We aim to compare the prognostic accuracy of American Joint Committee on Cancer seventh N stage relative to negative number of lymph node (nLN), lymph node ratio (LNR) and log odds of metastatic lymph nodes (LODDS) in rectal adenocarcinoma (RC).

Methods

A total of 19 167 Stage II-III rectal cancer patients who underwent surgical resection of rectal adenocarcinoma were identified from Surveillance, Epidemiology and End Results database. Akaike's Information Criterion (AIC) and the Harrell's concordance index (c statistic) were used to evaluate the relative discriminative power of the different LN staging systems.

Results

Of the 19 167 patients, 10 958 received preoperative radiotherapy (pre-RT cohort) and 8209 patients were treated with surgical resection directly (SURG cohort). When assessed using categorical cutoff values, LNR has a somewhat better prognostic accuracy both in pre-RT (c-index: 0.62; AIC: 2988.6) and SURG groups (c-index: 0.60; AIC: 3359.8). Further analysis based on different total number of lymph node (TNLN) suggested that when less than 10 lymph nodes were retrieved, LNR exhibited significant superiority (pre-RT: c-index: 0.597, AIC: 1006.8; SURG: c-index: 0.560, AIC: 810.5). When analyzed as a continuous variable, the LODDS system performed the best and was not impacted by TNLN.

Conclusion

When assessed as a categorical variable, LNR was the most powerful method to predict survival for Stage II-III RC patients with limited TNLN. Rather, LODDS was the most accurate staging system regardless of the TNLN when LN status was modeled as continuous variable.

Role of "Second Look" Lymph Node Search in Harvesting Optimal Number of Lymph Nodes for Staging of Colorectal Carcinoma

As with other malignancies, lymph node metastasis is an important staging element and prognostic factor in colorectal carcinomas. The number of involved lymph nodes is directly related to decreased 5-year overall survival for all pT stages according to United States Surveillance, Epidemiology, and End Results (SEER) cancer registry database. The National Quality Forum specifies that the presence of at least 12 lymph nodes in a surgical resection is one of the key quality measures for the evaluation of colorectal cancer. Therefore, the harvesting of a minimum of twelve lymph nodes is the most widely accepted standard for evaluating colorectal cancer. Since this is an accepted quality standard, a second attempt at lymph node dissection in the gross specimen is often performed when the initial lymph node count is less than 12, incurring a delay in reporting and additional expense. However, this is an arbitrary number and not based on any hard scientific evidence. We decided to investigate whether the additional effort and expense of submitting additional lymph nodes had any effect on pathologic lymph node staging (pN). We identified a total of 99 colectomies for colorectal cancer in which the prosector subsequently submitted additional lymph nodes following initial review. The mean lymph node count increased from 8.3 ± 7.5 on initial search to 14.6 ± 8.0 following submission of additional sections. The number of cases meeting the target of 12 lymph nodes increased from 14 to 69. Examination of the additional lymph nodes resulted in pathologic upstaging (pN) of five cases. Gross reexamination and submission of additional lymph nodes may provide more accurate staging in a limited number of cases. Whether exhaustive submission of mesenteric fat or fat-clearing methods is justified will need to be further investigated.

Extra nodular metastasis is a poor prognostic factor for overall survival in node-positive patients with colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is the second leading cause for cancer-related death in industrialized nations. Nodal involvement has been identified as a relevant prognostic feature in CRC. Extra nodal metastasis (ENM) describes the spread of malignant cells beyond the nodal capsule. ENM is thought to be an independent risk factor for poor survival. This study examined ENM as an independent risk factor for poor overall survival in patients with node-positive CRC.

MATERIALS AND METHODS

Data from a prospectively maintained CRC database was retrospectively analyzed. Blinded slides of patients with stage III and IV CRC following radical surgical resection were re-examined for the presence of ENM. The effect of ENM on overall survival was examined using Kaplan-Meier curves.

RESULTS

One hundred forty-seven cases with node-positive CRC (UICC stages III and IV) including 78 cases with ENM were included for analysis. ENM was seen in 60 patients with colon cancer (58.8%) and in 18 patients with rectal cancer (40%), p = 0.033. ENM-positive patients had a significantly higher odd for cancer-related death compared to ENM-negative patients ratio of [OR 0.44: 0.22-0.88, CI 95%, p = 0.021], p = 0.02. The median overall survival was significantly longer in patients without ENM, 51.0 ± 33 vs. 30.5 ± 42 months, p = 0.02.

CONCLUSION

Extra nodal metastasis is an independent prognostic factor in patients with node-positive colorectal cancer. Extra nodal metastasis is associated with high odds of tumor-related mortality and poor overall survival.

Tumor Size as an Independent Risk Factor for Postoperative Complications in Laparoscopic Low Anterior Resection for Advanced Rectal Cancer: A Multicenter Japanese Study

This study aimed to identify the risk factors for postoperative complications after laparoscopic low anterior resection for the treatment of advanced rectal cancers. A prospectively maintained database was retrospectively analyzed. Oncological parameters in resected specimens and clinical risk factors for postoperative complications, including anastomotic leakage, were examined in patients with clinical stage II and III upper rectal cancer who underwent laparoscopic low anterior resection, including total mesorectal excision. Pathologic resection margins were negative in all patients. Postoperative complications occurred in 22 patients (25.9%), which is similar to incidence rates in previous studies. In multivariate analysis, tumor size (≥4 cm) and tumor category (T4) were independent risk factors for postoperative complications. Precise pretreatment diagnoses with locoregional evaluations are essential for the selection of appropriate patients for laparoscopic rectal resection. Despite quality results from laparoscopic low anterior resection for the treatment of advanced rectal cancer, we must attempt to reduce postoperative complications.

The size of retrieved lymph nodes correlates with the number of retrieved lymph nodes and is an independent prognostic factor in patients with stage II colon cancer

PURPOSE

In stage II colon cancer, patients with many retrieved lymph nodes (LNs) have been reported to have better oncological outcomes. We tested the hypothesis that the greater number of retrieved LNs is related to a larger LN size.

METHODS

The subjects comprised 320 patients with stage II colon cancer who underwent curative resection. All operations were elective and were performed by the same surgeons. The maximum long axis and short axis diameters of LNs were measured on hematoxylin-eosin-stained specimens.

RESULTS

A total of 4,744 LNs were evaluated. The number of retrieved LNs was 14.8 ± 10.1 (mean ± SD). The long axis diameter was 4.8 ± 2.6 mm, with a median value of 4.3 mm, a maximum value of 20.4 mm, and a minimum value of 0.6 mm. The corresponding short axis diameters were 3.4 ± 1.7, 3.0, 15.1, and 0.5 mm, respectively. The highest correlation coefficient for the association with the number of LNs was obtained for the maximum value of the long axis diameter (0.59). Multivariate analysis revealed that age, tumor location, pathological T stage, and the maximum long axis diameter were independent prognostic factors. The number of LNs was not a significant factor. Patients with less than 12 LNs and a maximum long axis diameter of less than 10 mm had significantly poorer outcomes (p < 0.001).

CONCLUSION

In patients with stage II colon cancer, the maximum long axis diameter of LNs correlated with the number of LNs and was an independent prognostic factor.

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.

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 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.

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.

Neoadjuvant treatment of mid-to-lower rectal cancer with oxaliplatin plus 5-fluorouracil and leucovorin in combination with radiotherapy: a Korean single center phase II study

PURPOSE

To evaluate the safety and efficacy of neoadjuvant chemoradiation with oxaliplatin and 5-fluorouracil (5-FU) in advanced mid-to-lower rectal cancer.

METHODS

This was a single-arm, open-label phase II study conducted between August 2008 and August 2010. Thirty-one patients (n = 31) with clinical stage T3/T4 or lymph node positive rectal adenocarcinoma located in the middle or lower rectum without metastasis were enrolled onto the study. Data were analyzed according to the intention-to-treat principle.

RESULTS

Thirty-one patients were enrolled into the study. Six patients (19.4%) experienced grade 3 diarrhea. Grade 2 nausea and vomiting occurred in 5 and 2 patients, respectively. Severe neurotoxicity was not observed. Grade 1 sensory neuropathy occurred in 10 patients (32.3%). Sphincter-saving surgery was performed in 29 patients (93.5%). The mean distance of the tumor from the anal verge was 4.9 cm. Anastomotic leakage occurred in 4 of 29 (13.8%) patients. The circumferential resection margin was involved in 2 patients (6.5%). Overall, 23 patients (77.4%) responded to treatment. The complete pathologic response (ypCR) rate was 12.9%. There was no death secondary to toxicity, and the mean follow-up time was 12.3 months.

CONCLUSION

The overall toxicity of oxaliplatin and continuous 5-FU/leucovorin infusion in combination with radiation was well tolerated. Neoadjuvant chemoradiation for patients with locally advanced rectal cancer was associated with higher rates of sphincter preservation and downstaging, but did not significantly increase ypCR. The impact of this neoadjuvant chemoradiation regimen on survival will be determined by longer follow-up studies.

Lymph node harvest in colon and rectal cancer: Current considerations

The prognostic significance of identifying lymph node (LN) metastases following surgical resection for colon and rectal cancer is well recognized and is reflected in accurate staging of the disease. An established body of evidence exists, demonstrating an association between a higher total LN count and improved survival, particularly for node negative colon cancer. In node positive disease, however, the lymph node ratios may represent a better prognostic indicator, although the impact of this on clinical treatment has yet to be universally established. By extension, strategies to increase surgical node harvest and/or laboratory methods to increase LN yield seem logical and might improve cancer staging. However, debate prevails as to whether or not these extrapolations are clinically relevant, particularly when very high LN counts are sought. Current guidelines recommend a minimum of 12 nodes harvested as the standard of care, yet the evidence for such is questionable as it is unclear whether an increasing the LN count results in improved survival. Findings from modern treatments, including down-staging in rectal cancer using pre-operative chemoradiotherapy, paradoxically suggest that lower LN count, or indeed complete absence of LNs, are associated with improved survival; implying that using a specific number of LNs harvested as a measure of surgical quality is not always appropriate. The pursuit of a sufficient LN harvest represents good clinical practice; however, recent evidence shows that the exhaustive searching for very high LN yields may be unnecessary and has little influence on modern approaches to treatment.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of preoperative chemoradiotherapy on the number of lymph nodes retrieved in rectal cancer

OBJECTIVE

To evaluate the relation of preoperative chemoradiotherapy to the number of lymph nodes retrieved in curative intent surgery for rectal cancer.

SUMMARY BACKGROUND DATA

Current guidelines recommend evaluation of least 12 to 14 lymph nodes in rectal cancer. It is well known that lymph nodes retrieval is affected by many factors.

METHODS

This was a retrospective study of 615 patients who underwent curative intent surgery for primary rectal cancer. Preoperative chemoradiotherapy involving 50.4 Gy fractionated radiotherapy and concurrent chemotherapy was performed in patients with locally advanced rectal cancer (clinically T3 or T4). We explored associations between the number of lymph nodes retrieved in the pathologic specimen and patient demographics (age, gender, body mass index [BMI]), treatment (surgeon, sphincter-saving, preoperative chemoradiotherapy), and tumor-related variables (location, stage, histology). After adjustment for other factors, we compared the mean number of obtained lymph nodes between patients treated with preoperative chemoradiotherapy and those treated without preoperative chemoradiotherapy.

RESULTS

Univariate analysis demonstrated that age, BMI, preoperative chemoradiotherapy, location, and stage significantly related the number of lymph nodes retrieved. Multivariate analysis revealed age, BMI, preoperative chemoradiotherapy, and stage as independent factors influencing the number of lymph nodes retrieved. The mean number of lymph nodes adjusted for age, BMI, and stage was significantly lower in patients treated with preoperative chemoradiotherapy than in those treated without preoperative chemoradiotherapy (14.5 vs. 21.5, P < 0.001). The reduction rate by preoperative chemoradiotherapy was 32.6% (7/21.5). In patients who underwent preoperative chemoradiotherapy, advanced age (P < 0.001) and high BMI (P = 0.037) were associated with decreased number of retrieved lymph nodes.

CONCLUSIONS

Preoperative chemoradiotherapy significantly decreased the number of retrieved lymph nodes by approximately 33%. Therefore, the recommended number of retrieved lymph nodes should be adjusted when rectal cancer is treated with preoperative chemoradiotherapy.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Lymph node yield in rectal cancer surgery: effect of preoperative chemoradiotherapy

AIM

Adequate lymph node resection in rectal cancer is important for staging and local control. This study aims to verify the effect of neoadjuvant chemoradiation, as well as some clinicopathological features, on the yield of lymph nodes in rectal carcinoma.

METHODS

Data on consecutive patients who had total mesorectal excision for rectal adenocarcinoma at a single cancer center between January 2003 and July 2008 were reviewed. No patient had any prior pelvic surgery or radiotherapy. Patients had neoadjuvant chemoradiotherapy if they were stage II or III.

RESULTS

A total of 116 patients were included. The mean age was 53 years (range 29-83). Fifty-nine patients (51%) received neoadjuvant therapy before resection. The mean number of lymph nodes removed was 18 (range 4-67) per specimen. There was less lymph node yield in patients who received neoadjuvant therapy (16 vs. 19, p = 0.008). Only 64% of patients who had preoperative therapy had 12 lymph nodes or more in the specimen as opposed to 88% of those who had surgery upfront (p = 0.003). Other factors associated with lower lymph node yield included: female sex (p = 0.03) and tumour location in the lower rectum (p = 0.002). Age, tumour stage and grade, type of operation and surgical delay did not affect the number of lymph nodes removed.

CONCLUSION

Preoperative chemoradiotherapy for rectal cancer results in reduction in lymph node yield. Female sex and lower rectal tumours are also associated with retrieval of fewer lymph nodes.

The prognostic impact of the number of lymph nodes retrieved after neoadjuvant chemoradiotherapy with mesorectal excision for rectal cancer

BACKGROUND

We aimed to assess factors associated with the number of nodes retrieved and the impact of the number of lymph nodes in rectal cancer patients who underwent neoadjuvant chemoradiation with radical surgery.

METHODS

A total of 258 patients were enrolled. Lymph nodes were retrieved from specimens using a manual dissection technique.

RESULTS

Of the 258 patients, nine patients had an absence of lymph nodes (ypNx), 150 patients had a node-negative status (ypN(-)) and 99 patients had node-positive disease (ypN(+)). An advanced ypT classification (ypT3,4) and larger tumor (>4 cm) were associated with an increased number of nodes retrieved. The pretreatment CEA level (>5 ng/ml) and ypN(+) classification were significant risk factors for cancer specific and recurrence free survival. There was no significant difference of oncological outcomes among ypNx patients and a subset of ypN(-) patients based on the number of nodes retrieved using three cutoff values (1-11, 12-25, and 25-65 nodes).

CONCLUSIONS

In a neoadjuvant setting, ypN(+) disease was an independent risk factor for oncological outcomes. An absence of nodes does not represent an inferior oncological outcome. The number of nodes does not seen to impact survival and recurrence in ypN(-) patients.

The influence of the number of retrieved lymph nodes on staging and survival in patients with stage II and III rectal cancer undergoing tumor-specific mesorectal excision

OBJECTIVE

This study was designed to determine whether the number of lymph nodes retrieved influence staging and survival in patients with stage II and III rectal cancer that undergo tumor-specific mesorectal excision.

SUMMARY BACKGROUND DATA

The prognostic impact of the retrieved nodes has been emphasized in patients with colorectal cancer, but few studies have focused on patients with rectal cancer.

METHODS

A total of 900 patients who underwent tumor-specific mesorectal excision with curative intent and adjuvant chemoradiation therapy for stage II and III rectal cancer from January 1989 to December 2006 were analyzed.

RESULTS

Cancer-specific survival (CSS) of stage II patients with less than 15 nodes (25th percentile) was not different from stage III patients, but CSS was better in stage II patients with more than 15 nodes. When using cutoff values of the 25th and 50th percentiles (22 and 31 nodes), recurrence-free survival (RFS) was statistically different among subgroups of stage II and III patients. In multivariate analysis, stage II disease with less than 15 nodes retrieved was an adverse factor for CSS and RFS. In Kaplan-Meier survival analysis, using cutoff values, the difference for CSS was not significant with 22 and more nodes and the difference for RFS was not observed with 23 and more nodes.

CONCLUSIONS

The number of lymph nodes retrieved is closely associated with survival and recurrence in patients with stage II rectal cancer and, for more accurate prognostic stratification, at least 22 and 23 nodes seem to be necessary, respectively, for CSS and for RFS.

Injecting methylene blue into the inferior mesenteric artery assures an adequate lymph node harvest and eliminates pathologist variability in nodal staging for rectal cancer

PURPOSE

The American Joint Committee on Cancer recommends examination of a minimum of 12 lymph nodes in rectal cancer for accurate staging. Despite this, several studies have demonstrated that nodal harvest is highly variable and often inadequate. This study was designed to determine if staining the nodes with methylene blue dye produced a better and more accurate harvest in comparison with standard pathologic lymph node dissection.

METHODS

Fifty patients with primary resectable rectal cancer were randomly assigned to undergo a standard nodal harvest or a harvest after ex vivo injection of the inferior mesenteric artery with methylene blue. A fat clearance technique was subsequently used to identify the maximum possible number of lymph nodes and metastasis.

RESULTS

The average lymph node harvest was 30 +/- 13.5 in the stained group and 17 +/- 11 in the unstained group (P < 0.001). At least 12 nodes were identified in every case in the stained group. In the unstained group, 7 of 25 cases (28 percent) did not meet the minimum criteria of 12 nodes (P < 0.01). Among the pathologists for the stained group, no difference was found in the harvest (P < 0.05), but variability was detected between the pathologists in the unstained group (P = 0.6). After fat clearance, one case in the unstained group was upstaged, whereas no cases in the stained group were upstaged.

CONCLUSIONS

Staining the lymph nodes with methylene blue dye is an accurate staging technique and reliably produces an adequate harvest.

The ratio of metastatic to examined lymph nodes is a powerful independent prognostic factor in rectal cancer

OBJECTIVE

The aim of the study was to evaluate the prognostic value of the ratio of metastatic to examined lymph nodes (LNR) in patients with rectal cancer.

SUMMARY BACKGROUND DATA

Lymph nodes ratio (LNR) has been shown to have prognostic value in patients with colon cancer. The impact of LNR on disease-free and overall survival in patients with rectal cancer is unknown.

PATIENTS AND METHODS

From 1998 to 2004, 307 patients underwent rectal resection for adenocarcinoma. The relationships between overall and disease-free survival at 3 years and 15 variables, including the presence or absence of metastatic lymph nodes, the total number of lymph nodes examined, and LNR, were analyzed by multivariate analysis. Patients were then assigned to 4 groups based on LNR: LNR = 0 (N0 patients), LNR = 0.01 to 0.07, LNR >0.07 to 0.2, LNR >0.2.

RESULTS

The mean number of lymph nodes examined was 22 +/- 12. In the multivariate analysis, LNR was a significant prognostic factor for both disease-free (P = 0.006) and overall survival (P = 0.0003), whereas the presence or absence of metastatic lymph nodes was not. LNR remained a significant prognostic factor in the 59 patients in whom fewer than 12 lymph nodes were examined (P = 0.0058). According to LNR values, disease-free and overall survival decreased significantly with increasing LNR (P < 0.001).

CONCLUSIONS

LNR is the most significant prognostic factor for both overall and disease-free survival in patients with rectal cancer, even in patients with fewer than 12 lymph nodes examined.

The impact of T and N stage on long-term survival of rectal cancer patients in the community

BACKGROUND AND OBJECTIVES

Use of the TNM staging system has been encouraged for rectal cancer patients. This study examined the impact of T and N stages on long-term survival as well as the performance of associated risk classification systems.

METHODS

Patients who underwent surgery for rectal adenocarcinoma from 1988 to 2004 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier survival analysis was performed for subgroups of patients defined by T and N stage.

RESULTS

For the overall population of 30,826 patients, both T and N stage significantly impacted overall survival (P < 0.001). N stage variably affected survival for subgroups of patients based on T stage, whereas T stage significantly affected survival regardless of N stage. A previously developed risk classification system that assigns one of four risk levels outperformed AJCC group staging in this cohort. Based on long-term outcomes, a modified risk classification system was constructed which was highly prognostic for long-term overall survival (P < 0.001).

CONCLUSIONS

Rectal cancer patients experience widely varying survival rates based on extent of disease. A new risk classification system is proposed that provides better prognostic information than AJCC group staging, suggesting current rectal cancer staging systems may be improved with appropriate revisions.

American Society of Clinical Oncology/National Comprehensive Cancer Network Quality Measures

PURPOSE

The National Cancer Policy Board recommended the creation of quality measures and a national reporting system in 1999. Representatives from the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) collaborated to create metrics suitable for national performance measurement.

METHODS

Content and methodology experts nominated by ASCO and NCCN met to select and refine metrics for breast, colon, and rectal cancer based on National Initiative for Cancer Care Quality and NCCN measures and NCCN and ASCO guidelines. Measures were selected based on their impact on disease free and overall survival, the degree to which opportunities for improvement exist, and the feasibility of data collection.

RESULTS

Three breast cancer measures and four colorectal cancer measures were chosen. Measures for breast cancer included adjuvant hormone therapy for hormone receptor-positive tumors, chemotherapy for hormone receptor-negative cancer, and radiation after lumpectomy. Colorectal measures included adjuvant radiation and chemotherapy for rectal cancer, and adjuvant chemotherapy for colon cancer. All but one were recommended as accountability measures and one for quality improvement (removal and examination of 12 or more lymph nodes in colon cancer). Specifications were developed for each measure using tumor registries as the data source.

CONCLUSION

ASCO/NCCN measures can be implemented by health systems, provider groups or payors for improvement or accountability using local tumor registries to furnish data on staging and treatment.

Absence of lymph nodes in the resected specimen after radical surgery for distal rectal cancer and neoadjuvant chemoradiation therapy: what does it mean?

PURPOSE

The number of retrieved lymph nodes during radical surgery has been considered of great importance to ensure adequate staging and radical resection. However, this finding may not be applicable after neoadjuvant therapy in which, not only is there a decrease in lymph nodes recovered, but also a subgroup of patients with absence of lymph nodes in the resected specimen.

METHODS

Patients with absence of lymph nodes were compared with patients with ypN0 disease and patients with ypN+ disease.

RESULTS

Thirty-two patients (11 percent) had absence of lymph nodes, 171 patients (61 percent) had ypN0 disease, and 78 patients (28 percent) had ypN+ disease. Patients with absence of lymph nodes had significantly lower ypT status (ypT0-1, 40 vs. 13 percent; P<0.001) and decreased risk of perineural invasion (6 vs. 21 percent; P=0.04) compared with ypN0 patients. Five-year disease-free survival (74 percent) was similar to patients with ypN0 (59 percent; P=0.2), and both were significantly better than patients with ypN+ disease (30 percent; P<0.001).

CONCLUSIONS

Absence of lymph nodes retrieved from the resected specimen is associated with favorable pathologic features (ypT and perineural invasion status) and good disease-free survival rates. In this setting, absence of retrieved lymph nodes may reflect improved response to neoadjuvant chemoradiation therapy rather than inappropriate or suboptimal oncologic radicality.

The validity of the Royal College of Pathologists' colorectal cancer minimum dataset within a population

Quality of colorectal cancer pathology reports is related to individual patient prognosis and future treatment options. This study sought to validate the prognostic utility of the Royal College of Pathologists minimum pathology dataset (MPD), regarded as the ‘gold standard’, within a population. Retrospective study of the survival of 5947 surgically resected colorectal cancer patients for whom an MPD had been collected. Variables were related to survival. The study population was representative of the Yorkshire colorectal cancer population. Survival was poorer in older patients and colonic tumours and improved over the study period. Local invasion, total number of lymph nodes retrieved, nodal stage, extramural vascular invasion, peritoneal involvement, distance of invasion beyond the muscularis propria, and in rectal cancers, circumferential resection margin involvement and distance to this margin were all validated as of prognostic significance within a population. Failure to report extramural vascular invasion, peritoneal involvement or circumferential resection margin status was associated with a worse survival than absence of the factor. All variables within the Royal College of Pathologists MPD are of prognostic significance. High-quality pathology reports are essential in providing accurate prognostic information and guiding optimal patient management.

Number and size of lymph nodes recovered from dukes B rectal cancers: correlation with prognosis and histologic antitumor immune response

PURPOSE

In rectal cancer variation in lymph node recovery influences the detection of nodal metastases and prognosis among Dukes B (Stage II) cases. However, the possible prognostic importance of node size and inherent patient/tumor characteristics in determining node recovery has not been studied.

METHODS

We examined 269 Dukes B (Stage II) rectal tumors, with a mean of 12 nodes per case. Primary tumor characteristics were correlated with the number and size of recovered nodes. Clinical follow-up permitted determination of long-term survival.

RESULTS

The five-year survival of 94 Dukes B cases with nine or fewer nodes was 69.4 percent vs. 87.6 percent in 175 cases with ten or more nodes (P = 0.001). Lymph nodes were smaller in patients dying of recurrence; among 130 Dukes B patients whose mean node diameter was <4 mm, survival was 73.3 vs. 88 percent when mean nodal diameter was > or =4 mm. The number and size of recovered nodes was related to patient age, histologic antitumor immune response, and tumor growth pattern. By combining the number and size of nodes, a poor prognosis subgroup of 98 Dukes B patients with relatively few large nodes (no more than 5 measuring > or =4 mm) was identified with a five-year survival of 65.6 percent compared with 89.6 percent for the remaining 158 Dukes B cases (P < 0.0001).

CONCLUSIONS

In Dukes B rectal tumors, the number and size of lymph nodes are related to inherent patient and tumor characteristics and permit the identification of Dukes B cases at increased risk of recurrence. A valid comparison of nodal sampling efficiency between centers necessitates measuring and counting harvested lymph nodes.

Identifying Stage III Colorectal Cancer Patients: The Influence of the Patient, Surgeon, and Pathologist

Purpose

Nodal yields from resected colorectal cancers vary greatly. This study sought to determine what patient, tumor, and management factors influence the number of nodes retrieved and to determine if the extent of lymphadenectomy affects stage allocation and influences survival.

Patients and Methods

Retrospective study of the nodal yields of 7,062 surgically resected colorectal cancer patients for whom colorectal pathology minimum data sets had been collected. The percentage of patients diagnosed as stage III was compared across nodal yield categories. A threshold for an adequate lymphadenectomy was defined as retrieval of 12 nodes. Binary logistic regression was used to determine factors associated with obtaining an adequate lymphadenectomy.

Results

Median nodal yields increased over the study period from 7 (interquartile range [IQR], 4 to 11) in 1995 to 13 (IQR 8 to 19) in 2003. There was no difference in yield by cancer site or sex, but yields were lower in older patients. Yields increased with increasing local invasion and stage of tumor. The percentage of patients diagnosed as stage III increased as yields increased. Five-year survival was lower in those patients who did not have an adequate lymphadenectomy. Adequate lymphadenectomy was significantly more likely in patients with advanced tumors and when the surgery and pathology was undertaken by a specialist. Older patients were significantly less likely to receive an adequate lymphadenectomy.

Conclusion

Variations in nodal yield are due to idiosyncratic patient and tumor characteristics and differences in the quality of surgery and pathology undertaken. Adequate lymphadenectomy is essential to ensure correct stage allocation and optimal survival.

A systematic review on the significance of extracapsular lymph node involvement in gastrointestinal malignancies

AIMS

The impact of extracapsular lymph node involvement (LNI) has been studied for several malignancies, including gastrointestinal malignancies. Aim of this study was to assess the current evidence on extracapsular LNI as a prognostic factor for recurrence in gastrointestinal malignancies.

METHODS

The Cochrane Database of systematic reviews, the Cochrane central register of controlled trials, and MEDLINE databases were searched using a combination of keywords relating to extracapsular LNI in gastrointestinal malignancies. Primary outcome parameters were incidence of extracapsular LNI and overall five-year survival rates.

FINDINGS

Fourteen manuscripts were included, concerning seven oesophageal, three gastric, one colorectal, and three rectal cancer series with a total of 1528 node positive patients. The pooled incidence of extracapsular LNI was 57% (95% CI: 53-61%) for oesophageal cancer, 41% (95% CI: 36-47%) for gastric cancer, and 35% (95% CI: 31-40%) for rectal cancer. In nine of the 14 studies a multivariate analysis was performed. In eight of these nine studies extracapsular LNI was identified as an independent risk factor for recurrence.

CONCLUSION

Extracapsular LNI is a common phenomenon in patients with gastrointestinal malignancies. It identifies a subgroup of patients with a significantly worse long-term survival. This systematic review highlights the importance of assessing extracapsular LNI as a valuable prognostic factor. Pathologists and clinicians should be aware of this important feature.

Increasing negative lymph node count is independently associated with improved long-term survival in stage IIIB and IIIC colon cancer

PURPOSE

The purpose of this study was to examine the impact of the number of negative lymph nodes on survival in patients with stage III colon cancer.

PATIENTS AND METHODS

Patients who underwent surgery for stage III colon cancer between January 1988 and December 1997 were identified from the Surveillance, Epidemiology and End Results cancer registry. The number of negative and positive nodes was determined for 20,702 eligible patients. Disease-specific survival was examined by substage according to the number of negative nodes identified. A proportional hazards model was constructed to determine the effect of the number of negative nodes on survival.

RESULTS

For stage IIIB and IIIC patients, there was a significant decrease in disease-specific mortality as the number of negative nodes increased; cumulative 5-year cancer mortality was 27% in stage IIIB patients with 13 or more negative nodes identified versus 45% in those with three or fewer negative lymph nodes evaluated (P < .0001). In patients with stage IIIC cancer, those with 13 or more negative nodes had a 5-year mortality of 42% versus 65% in those with three or fewer negative lymph nodes evaluated (P < .0001). There was no association between the number of negative nodes identified and disease-specific survival for patients with stage IIIA disease. After controlling for the number of positive nodes, a higher number of negative nodes was found to be independently associated with improved disease-specific survival.

CONCLUSION

The number of negative nodes is an important independent prognostic factor for patients with stage IIIB and IIIC colon cancer.

Distribution of lymph node metastasis is a prognostic index in patients with stage III colon cancer

BACKGROUND

In the TNM classification of colorectal carcinoma, N-staging is dependent on the number of metastases; in the Japanese classification system, staging usually has been based on the distribution of metastases (N1, paracolic; N2, along the major vessels; N3, at the root of major vessels). The aim of our study was to examine whether the concept of the distribution of nodal metastasis could improve the TNM classification for colorectal cancer.

METHODS

We studied the survival rates of 485 and 136 patients with stage III colonic and rectal cancer, respectively, who underwent curative surgery between 1979 and 1998. The patients were categorized into 4 groups: group 1, TNM-N1 classified in J-N1; group 2, TNM-N2 in J-N1; group 3, TNM-N1 in J-N2-3; and group 4, TNM-N2 in J-N2-3.

RESULTS

In the colon cancer arm, the 5-year survival rates of the patients in groups 1 to 4 were 74%, 51%, 52%, and 54%, respectively. There was a significant difference in survival rate between groups 1 and 3 (P = .0002). Thus, in colon cancer, nodal metastasis along the major vessels was a bad prognostic factor, even though the number of nodes that were involved was <4. In the rectum cancer arm, the 5-year survival rates of the patients in each group were 65%, 39%, 60%, and 32%, respectively. Only the number of nodal metastases was an independently significant prognostic variable.

CONCLUSION

This study suggests that adding the concept of nodal distribution to the conventional TNM staging of colon cancer will improve the accuracy in the evaluation of the nodal status.

The Reliability of Lymph-node Staging in Rectal Cancer After Preoperative Chemoradiotherapy

AIMS

To determine the prognostic significance of the nodal stage and number of nodes recovered in the surgical specimen after preoperative synchronous chemoradiation (SCRT) and surgery for locally advanced or unresectable rectal cancer.

MATERIALS AND METHODS

One hundred and eighty-two consecutive patients with locally advanced or unresectable (T3/T4) rectal carcinomas were entered on a prospective database and treated in this department with preoperative chemoradiation, followed 6-12 weeks later by surgical resection. Most patients received chemotherapy in the form of low-dose folinic acid and 5-fluorouracil (5-FU) 350 mg/m2 via a 60-min infusion on days 1-5 and 29-33 of a course of pelvic radiotherapy delivered at a dose of 45 Gy in 25 fractions over 33 days to a planned volume. After resection, patients with a positive circumferential margin (< or = 1 mm), extranodal deposits or Dukes' C histology received adjuvant 5-FU-based-chemotherapy (n = 40).

RESULTS

After SCRT, 161 patients underwent resection. Twenty-one patients remained unresectable or refused an exenterative operation. Median follow-up is 36 months. Down-staging was achieved in most patients, with 19 having a complete pathological response (pT0). The median number of lymph nodes recovered for all patients was five (range 0-21). The 3-year survival rate for node-positive patients is 47%, for node-negative patients with less than three lymph nodes recovered is 62% and for node-negative patients with three or more lymph nodes recovered is 70%. Compared with node-positive patients, simple regression models revealed a reduced hazard ratio (HR) of 0.72 (0.36-1.43) for node-negative patients with less than three nodes recovered and 0.48 (0.26-0.89) for node-negative patients with three or more lymph nodes recovered. In a multivariate model, including nodal status, excision status, age and sex only positive excision margins significantly predicted a poor outcome: HR = 3.05 (1.55-5.97).

CONCLUSIONS

The number of nodes found after preoperative chemoradiation is a significant prognostic factor by univariate analysis. In this study, patients with node-negative histology, and at least three nodes recovered, had better long-term survival than patients in whom two or less nodes were recovered or with positive nodes. This effect was attenuated by the inclusion of excision status in multivariate models.

Ex Vivo Sentinel Lymph Node Study For Rectal Adenocarcinoma: Preliminary Study

Intraoperative sentinel lymph node (SLN) detection has been reported for colon cancer, but no study has focused on rectal cancer. Only an ex vivo technique can be performed easily in this location. We evaluated SLN detection using blue dye injection in patients with rectal adenocarcinoma. This prospective study included 31 patients. Preoperative radiotherapy (45 Gy) was done in 15 cases. After proctectomy the surgical specimen was examined in the operating room. Submucosal peritumoral injections were done. One to three SLNs were retrieved. The SLNs were sectioned at three levels and examined histologically and then, if negative by hematoxylin-eosin (H&E) staining and immunohistochemistry (IHC). There were 7 abdominoperineal resections, 12 colorectal anastomoses, 11 coloanal anastomoses, and 1 Hartmann procedure. The median number of lymph nodes harvested was 21 (7-38). A SLN was identified in 30 cases (feasibility 97%). The mean number of SLNs was 2 (0-3). A micrometastasis was discovered in 3 of 23 pNO cases when H&E was used on multisection levels, thus changing the stage to pN1. Each time the only positive lymph node was the SLN. IHC evaluation did not change the result, as only isolated tumor cells were discovered in one case. Only four of seven N+ patients had a positive SLN, resulting in a false-negative rate of 43%. Ex vivo detection of SLNs is possible for rectal cancer and is a simple technique. Classic analysis using H&E remains the gold standard. However, SLNs detection can change the tumor stage by upstaging nearly 15% of the tumors from T2-3N0 to T2-3 N+.

Impact of preoperative radiation for rectal cancer on subsequent lymph node evaluation: a population-based analysis

PURPOSE

To determine the impact of preoperative radiotherapy (RT) on the accuracy of lymph node staging (LNS). Preoperative RT is a well-established component of rectal cancer treatment but its impact on LNS is unknown.

METHODS AND MATERIALS

The Surveillance, Epidemiology and End Results (SEER) registry, representing 14% of the U.S. population, was used to assess the impact of preoperative RT on LNS. Our study population consisted of adults with rectal cancer between 1998 and 2000 who underwent radical resection.

RESULTS

In our 3-year study period, 5647 patients met the selection criteria and 1034 (19.5%) underwent preoperative RT. The preoperative RT group was younger (average age, 61 years) than those who did not undergo preoperative RT (average age, 69 years) and more likely to be male (22% of men vs. 16% of women). On average, fewer nodes were examined in patients who underwent preoperative RT (7 nodes) vs. those who did not (10 nodes); this difference was statistically significant, controlling for potential confounders (p < or = 0.0001). In 16% of the preoperative RT patients (vs. 7.5% without), no nodes were identified (p < or = 0.0001). If one used a minimum of 12 nodes as the standard, only 20% of patients who underwent preoperative RT underwent adequate LNS.

CONCLUSION

Lymph node staging in patients who undergo preoperative RT must be interpreted with caution. Studies are needed to evaluate the clinical relevance of node number and pathologic staging after preoperative RT for rectal cancer.

Lymph Node Evaluation in Colorectal Cancer Patients: A Population-Based Study

BACKGROUND

Adequate lymph node evaluation is required for proper staging of colorectal cancer, and the number of lymph nodes examined is associated with survival. According to current guidelines, the recommended minimum number of lymph nodes examined to ensure adequate sampling is 12. We used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program to determine the proportion of colorectal cancer patients in the United States who receive adequate lymph node evaluation.

METHODS

For 116,995 adults with colorectal adenocarcinoma, diagnosed from 1988 through 2001, who underwent radical surgery and did not receive neoadjuvant radiation, we evaluated the number of lymph nodes, the likelihood of receiving adequate lymph node evaluation (i.e., at least 12 lymph nodes examined), and the influence of tumor and patient factors on lymph node evaluation. All statistical tests were two-sided.

RESULTS

Among all patients, the median number of lymph nodes examined was nine. Only 37% of all patients received adequate lymph node evaluation. The proportion of patients receiving adequate lymph node evaluation increased from 32% in 1988 to 44% in 2001 (P(trend)<.001, Cochran-Armitage test). Advanced tumor stage was statistically significantly associated with adequate lymph node evaluation (odds ratio [OR] of receiving adequate lymph node evaluation=2.27, 95% confidence interval [CI] = 2.18 to 2.35). Older patients (> or =71 years, OR = 0.45, 95% CI = 0.44 to 0.47) were less likely to receive adequate lymph node evaluation than younger patients, and those with left-sided (OR = 0.45, 95% CI = 0.44 to 0.47) or rectal (OR = 0.52, 95% CI = 0.50 to 0.54) cancers were less likely to receive adequate lymph node evaluation than patients with right-sided cancers. In all analyses, geographic location was an important predictor of adequate lymph node evaluation, which ranged from 33% to 53%, depending on geographic location.

CONCLUSIONS

In 2001, the majority of patients with colorectal cancer still received inadequate lymph node evaluation. The association of demographic variables, particularly patient age and geographic location, with adequate lymph node evaluation indicates that local surgical and pathology practice patterns may affect adequacy of lymph node evaluation.

Management of colorectal cancers

The management of colorectal cancers, published in a recent issue of Effective Health Care, is reviewed.

What factors affect lymph node yield in surgery for rectal cancer?

OBJECTIVE

The detection of lymph node metastases is of vital importance in patients undergoing excisional surgery for rectal cancer as it provides important prognostic information and facilitates decision-making with regards to adjuvant therapy. It has been suggested that patients in whom only a small number of nodes are present in the excised specimen have a worse prognosis, presumably due to inadequate lymphadenectomy and consequent understaging of the disease. The aim of this study was to determine which factors affect the yield of lymph nodes.

METHODS

This was a retrospective study of patients who had undergone a resection for histologically proven adenocarcinoma of the rectum. The total number of lymph nodes identified in the excised specimen was recorded in each case. A multivariate analysis was performed to ascertain whether this number was significantly influenced by any of several variables.

RESULTS

A total of 167 patients were studied (M:F ratio 107 : 60, median age 70 years). The median number of lymph nodes contained within the resected specimen was 16 (interquartile range 10-21). On univariate analysis a significantly higher yield of lymph nodes was obtained with tumours in the middle third of the rectum (P=0.007), larger tumours (P < 0.001), more locally advanced tumours according to both pT staging (P=0.001) and Dukes' staging (P=0.020), an increased number of involved nodes (P=0.003) and examination by a specialist histopathologist (P=0.003). On multivariate analysis the only significant variables were tumour size (P=0.021), number of positive nodes (P=0.007) and histopathologist (P=0.021).

CONCLUSIONS

The number of lymph nodes identified within the excised specimen in patients undergoing resection of a rectal cancer positively correlates with the size of the tumour and is also dependent on the examining histopathologist. In addition, in node-positive patients the number of involved nodes increases with increasing lymph node yield.

Postoperative Adjuvant Radio(Chemo)Therapy for Rectal Cancer: An Appraisal

Aims and background

Rectal cancer can be considered a broad-spectrum disease, where the surgeon, radiation oncologist and medical oncologist have a peculiar and specific place in order to work harmoniously as a good orchestra. The reality in common general hospitals is far from that of comprehensive cancer centers, particularly for postoperative approaches. The adjuvant therapy of rectal cancer is not codified worldwide, and it is strongly dependent on preoperative staging procedures, surgeon's acts and pathologist's decisions. Starting from our 10-year experience, we analyzed the various steps of postoperative approaches, defining possible decision errors, the incongruity of some attitudes, and the lack of knowledge of recent achievements of science in this disease.

Methods

A total of 194 patients with advanced surgically removed rectal cancer (pT3-4 pNO - any pT pN+) treated with postoperative radio(chemo)therapy was reviewed retrospectively. Anterior resection was performed in 126, abdominoperineal resection in 48, and other surgical procedures in 20 patients. Irradiation was conducted with a single daily fraction of 1.8 Gy until 45 Gy, and chemotherapy consisted of the combination of 5-fluorouracil and folinic acid (Machover schedule): 47% of patients with positive nodes did not receive chemotherapy.

Results

Five-year overall survival was 60.6% and relapse-free survival was 55.5%. The main prognostic factors were pathological T and N stages. The principal route of progression was distant metastases. Acute toxicity was severe in 1 case (drug toxic hepatitis) and very severe in 16 patients, and late severe sequelae appeared in 13 patients.

Conclusions

The outcome of rectal cancer patients has not changed during the last decade, and this was confirmed in our study. The improvement of radiotherapy techniques has reduced the adverse acute and late toxicity. The best postsurgical approach for pT3pN0 cancer remains unsolved, as the good chemotherapy combination and the real solution could be the application of a new Consensus Conference.

Emerging standards of radiotherapy combined with radical rectal cancer surgery

For patients with resectable rectal cancer treated with total mesorectal excision, the routine use of radiotherapy should be omitted for stage I of the disease and for lesions located higher than 10 cm from the anal verge. Preoperative radiotherapy may be considered for all patients with a lesion with deep perirectal fat infiltration located in the lower two thirds of the rectum. The other option is to offer postoperative radiotherapy for patients with a positive surgical margin, N+ stage disease, mesorectal tumour implants, high tumour grade, perineural invasion, extramuscular blood and lymphatic vessel invasion and with inadvertent tumour perforation. The lower risk of small bowel damage and probable higher efficacy are arguments for the use of preoperative radiotherapy instead of postoperative radiotherapy. The impairment of anorectal function appears to be most frequent late postirradiation sequel. The analysis of acute complications (including toxic deaths) compliance, cost and convenience favours 5 x 5 Gy preoperative irradiation with immediate surgery for patients with resectable tumours in comparison to other commonly used schemes of radiotherapy. These advantages should be weighed against approximately 1.5% risk of late neurotoxicity. There is no clear answer to the question whether preoperative conventional radio(chemo)therapy offers an advantage in sphincter preservation. To answer this question, the results of two ongoing randomised trials are awaited. For patients with unresectable cancers, long-term preoperative radio(chemo)therapy with delayed surgery is a preferable scheme. The total mesorectal irradiation should be employed for mid- and low-lying lesions. Therefore, during radiotherapy planning, a contrast enema should be used to identify the anorectal ring, anatomically corresponding with the lowest edge of the mesorectum.

Local recurrence after mesorectal excision for rectal cancer

AIMS

Controversy still exists about the optimal surgical treatment of rectal cancer. The main purpose of the present study was to compare local recurrence (LR) rates after mesorectal excision (ME) and conventional surgery (CS) technique.

METHODS

All rectal cancer patients from a defined catchment area were included. Outcome after ME in the period 1993-1999 (n=161) was compared with the outcome after CS (n=217) in the period 1983-1992. Partial ME (PME) was the routine in upper, and total ME the routine in mid- and low rectal cancer. The follow-up programmes were identical, and the median observation times very similar (37 and 38 months) in the two periods. Five-year actuarial LR rate and survival were estimated using the Kaplan-Meier method, and adjustment for prognostic factors was performed with Cox regression analysis.

RESULTS

Total LR rate after R0 resection was 7.7% crude and 9% 5 year actuarial in the ME period, as compared with 16.0% crude and 24% actuarial in the CS period (P=0.02). Cox regression analyses confirmed these differences with a hazard ratio of 0.40 for ME vs CS (P=0.02). Isolated LR rate was 2% after ME and 8% after CS. Five-year actuarial total LR rate after rectal resection with curative intent was 11% after ME and 27% after CS (P<0.01). Actuarial total LR rate after PME was 6%, and none of these patients developed isolated LR.

CONCLUSION

Standardization of surgical technique and application of ME resulted in a significant reduction of LRs. LR rate was low after PME, indicating that this procedure is adequate in upper rectal cancer.

Sphincter preservation after short-term preoperative radiotherapy for low rectal cancer--presentation of own data and a literature review

This report is based on a series of 108 patients with clinically staged T2 (9), T3 (94) and T4 (5) rectal cancer treated with preoperative irradiation with 25 Gy, 5 Gy per fraction given for one week. In 77% of patients. the tumour was located within 7 cm of the anal verge and in 15% the anal canal was involved. Surgery was usually undertaken during the week after irradiation. For low tumours, total mesorectal excision was performed, and for middle and upper cancers, the whole circumference of the mesorectum was excised at least 2 cm below the lower pole of a tumour. Tumour was resected in 103 patients, and sphincter-preserving surgery was performed in 73% of them. In the subgroup where the tumour was located higher than 4 cm from the anal verge, sphincter-preserving surgery was performed in 95%. The follow-up period ranged from 10 to 49 months, with a median of 25 months. Local recurrences were observed in 4% of patients. Anorectal dysfunction caused impairment of social life in 40% of patients and 18% admitted that their quality of life was seriously affected however, none of them stated that they would have preferred a colostomy. These preliminary data suggest that following high dose per fraction short-term preoperative radiotherapy a high rate of sphincter-preserving surgery can be reached, with acceptable anorectal function and an acceptable rate of local failure and late complications. The results of our own data and literature review indicate the need for a randomized clinical trial comparing high dose per fraction preoperative radiotherapy with immediate surgery with conventional preoperative radiochemotherapy with delayed surgery.

Identifying patients with T3-T4 node-negative colon cancer at high risk of recurrence

PURPOSE

Adjuvant chemotherapy is effective for node-positive colon cancer patients. In node-negative patients, it could be justified in high-risk patients. The purpose of this study was to determine clinical and pathological findings associated with tumor recurrence in T3-T4 node-negative colon cancer patients.

METHODS

From 1974 to 1993, 108 patients undergoing colectomy for T3-4N0M0 colon cancer, without adjuvant chemotherapy, followed until death or for a minimum of five years, were divided into two groups: patients without recurrence (n = 74) and those dead from colon cancer or alive with recurrence (n = 34). Thirty-three clinical and pathological findings were studied.

RESULTS

In univariate analysis, the following were significantly associated with a high risk of tumor recurrence: male patients (P = 0.006), bowel obstruction (P < 0.001), weight loss >5 Kg (P = 0.03), circumferential tumor (P = 0.02), macroscopic or microscopic pericolic organ invasion (T4 stage; P < 0.001), perineural invasion (P = 0.02), vascular invasion (P = 0.045), poor tumor differentiation (P = 0.005), mesocolic invasion >1 cm (P = 0.009), less than 14 uninvolved nodes on the specimen (P = 0.03), and visceral peritoneal invasion (T4; P < 0.001). In multivariate analysis, the following were independent prognostic factors of recurrence: male patients (P = 0.005), bowel obstruction (P = 0.002), pericolic organ invasion (i.e., T4 tumor; P = 0.02), and less than 14 uninvolved nodes on a specimen (P = 0.01). On the other hand, preoperative carcinoembryonic antigen serum level, size and tumor location, blood transfusion, and mucin production were not associated with higher risk of tumor recurrence.

CONCLUSION

Our study identifies a subgroup of patients with node-negative colon cancer at high risk of recurrence, who could be included in priority trials of adjuvant chemotherapy.

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

PURPOSE

We postulated that the pathologic evaluation of the lymph nodes of surgical specimens from patients with rectal cancer can have a substantial impact on time to relapse and survival.

PATIENTS AND METHODS

We analyzed data from 1,664 patients with T3, T4, or node-positive rectal cancer treated in a national intergroup trial of adjuvant therapy with chemotherapy and radiation therapy. Associations between the number of lymph nodes found by the pathologist in the surgical specimen and the time to relapse and survival outcomes were investigated.

RESULTS

Patients were divided into groups by nodal status and the corresponding quartiles of numbers of nodes examined. The number of nodes examined was significantly associated with time to relapse and survival among patients who were node-negative. For the first through fourth quartiles, the 5-year relapse rates were 0.37, 0.34, 0.26, and 0.19 (P: = .003), and the 5-year survival rates were 0.68, 0.73, 0.72, and 0.82 (P: = .02). No significant differences were found by quartiles among patients determined to be node-positive. We propose that observed differences are primarily related to the incorrect determination of nodal status in node-negative patients. Approximately 14 nodes need to be studied to define nodal status accurately.

CONCLUSION

These results suggest that the pathologic assessment of lymph nodes in surgical specimens is often inaccurate and that examining greater number of nodes increases the likelihood of proper staging. Some patients who might benefit from adjuvant therapy are misclassified as node-negative due to incomplete sampling of lymph nodes.