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Campos FG, Martinez CAR, Bustamante-Lopez LA, Mendonça RLDS, Kanno DT. Intra-abdominal desmoid tumors in familial adenomatous polyposis: How much do clinical and surgical variables interfere with their development? Clinics (Sao Paulo) 2023; 78:100144. [PMID: 36476966 PMCID: PMC9723922 DOI: 10.1016/j.clinsp.2022.100144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 12/07/2022] Open
Abstract
OBJECTIVE Familial Adenomatous Polyposis is a complex hereditary disease that exposes the carrier to a great risk of Colorectal Cancer (CRC). After prophylactic surgery, intra-abdominal desmoid tumors are known to be one the most important cause of death. Therefore, recognition of increased-risk patients and modification of operative strategy may be crucial. AIM The objective of this study was to estimate the desmoid tumor risk in relation to various surgical and clinical variables. METHODS Patients who had undergone polyposis since 1958 were included in the study. After exclusion criteria were met, those who had developed desmoid tumors were selected to undergo further evaluation. RESULTS The study revealed that the risk of developing desmoid tumors was associated with various factors such as sex ratio, colectomy, and reoperations. On the other hand, the type of surgery, family history, and surgical approach did not affect the risk of developing desmoid tumors. The data collected from 146 polyposis patients revealed that 16% had desmoid polyps. The sex ratio was 7:1, and the median age at colectomy was 28.6 years. Family history, multiple abdominal operations, and reoperations were some of the characteristics that were common in desmoid patients. CONCLUSION Recognition of clinical (female sex) and surgical (timing of surgery and previous reoperations) data as unfavorable variables associated with greater risk may be useful during the decision-making process.
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Affiliation(s)
- Fábio Guilherme Campos
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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Yang H, Xing J, Zhang C, Yao Z, Wu X, Jiang B, Cui M, Su X. Lymph node yield less than 12 is not a poor predictor of survival in locally advanced rectal cancer after laparoscopic TME following neoadjuvant chemoradiotherapy. Front Oncol 2022; 12:1080475. [PMID: 36568169 PMCID: PMC9773987 DOI: 10.3389/fonc.2022.1080475] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Purpose Previous studies have confirmed that neoadjuvant chemoradiotherapy (nCRT) may reduce the number of lymph nodes retrieved in rectal cancer. However, it is still controversial whether it is necessary to harvest at least 12 lymph nodes for locally advanced rectal cancer (LARC) patients who underwent nCRT regardless of open or laparoscopic surgery. This study was designed to evaluate the relationship between lymph node yield (LNY) and survival in LARC patients who underwent laparoscopic TME following nCRT. Methods Patients with LARC who underwent nCRT followed by laparoscopic TME were retrospectively analyzed. The relationship between LNY and survival of patients was evaluated, and the related factors affecting LNY were explored. To further eliminate the influence of imbalance of clinicopathological features on prognosis between groups, propensity score matching was conducted. Results A total of 257 consecutive patients were included in our study. The median number of LNY was 10 (7 to 13) in the total cohort. There were 98 (38.1%) patients with 12 or more lymph nodes harvested (LNY ≥12 group), and 159 (61.9%) patients with fewer than 12 lymph nodes retrieved (LNY <12 group). There was nearly no significant difference between the two groups in clinicopathologic characteristics and surgical outcomes except that the age of LNY <12 group was older (P<0.001), and LNY <12 group tended to have more TRG 0 cases (P<0.060). However, after matching, when 87 pairs of patients obtained, the clinicopathological features were almost balanced between the two groups. After a median follow-up of 65 (54 to 75) months, the 5-year OS was 83.9% for the LNY ≥12 group and 83.6% for the LNY <12 group (P=0.893), the 5-year DFS was 78.8% and 73.4%, respectively (P=0.621). Multivariate analysis showed that only patient age, TRG score and ypN stage were independent factors affecting the number of LNY (all P<0.05). However, no association was found between LNY and laparoscopic surgery-related factors. Conclusions For LARC patients who underwent nCRT followed by laparoscopic TME, the number of LNY less than 12 has not been proved to be an adverse predictor for long-term survival. There was no correlation between LNY and laparoscopic surgery-related factors.
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Advanced Lymph Node Staging With Ex Vivo Intra-arterial Indigo Carmine Injection After Transanal Total Mesorectal Excision for Rectal Cancer: A Retrospective Cohort Study. Dis Colon Rectum 2022; 65:1015-1024. [PMID: 34856584 DOI: 10.1097/dcr.0000000000002058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Exact lymph node staging is essential in rectal cancer therapy. OBJECTIVE The aim of the study was to assess the impact of intra-arterial indigo carmine injection after transanal total mesorectal excision on the number of retrieved lymph nodes. DESIGN This was a retrospective, nonrandomized study. SETTINGS The study was conducted at a tertiary hospital by a multidisciplinary team. PATIENTS Patients who underwent transanal total mesorectal excision for suspected rectal cancer between 2013 and 2019 were included. INTERVENTIONS Rectal cancer specimens received ex vivo intra-arterial indigo carmine injection to stain lymph nodes. MAIN OUTCOME MEASURES Outcome measures included the number of retrieved lymph nodes with or without staining. RESULTS Specimens of 189 patients were analyzed, of which 108 (57.1%) were stained with indigo carmine. A mean of 19.8 ± 6.1 lymph nodes was identified in stained samples compared to 16.0 ± 4.9 without staining ( p < 0.001). Multivariable analysis showed that 3.2 additional lymph nodes were found in stained specimens (95% CI: 1.0 to 5.3; p = 0.02). In stained specimens the adequate lymph node count (≥12) was increased in univariable (odds ratio: 3.24, 95% CI: 1.13 to 10.65; p = 0.03) but not in multivariable analysis. Indigo carmine injection had no effect on the number of positive lymph nodes or the nodal stage. Chemoradiotherapy reduced the lymph node count by 2.5 ( p = 0.008). After staining, 95.0% of patients with chemoradiotherapy had ≥12 lymph nodes retrieved. The median follow-up of patients was 24.2 months with a local recurrence rate of 3.3%. LIMITATIONS The study is limited by its retrospective design and the nonrandomized allocation. CONCLUSIONS Ex vivo intra-arterial indigo carmine injection increases the number of isolated lymph nodes after transanal total mesorectal excision regardless of neoadjuvant chemoradiotherapy. Indigo carmine injection is not associated with nodal upstaging or an increased number of tumor-positive lymph nodes. See Video Abstract at http://links.lww.com/DCR/B839 . ESTADIFICACIN AVANZADA DE LOS GANGLIOS LINFTICOS CON INYECCIN INTRAARTERIAL EX VIVO,DE NDIGO CARMN,DESPUS DE LA ESCISIN TOTAL DEL MESORRECTO POR VA TRANSANAL PARA CNCER DE RECTO UN ESTUDIO DE COHORTE RETROSPECTIVO ANTECEDENTES:La estadificación exacta de los ganglios linfáticos es esencial en la tratamiento del cáncer de recto.OBJETIVO:El objetivo del estudio fue evaluar el impacto de la inyección intraarterial de índigo carmín después de la escisión total del mesorrecto por vía transanal con relación al número de ganglios linfáticos recuperados en el espécimen quirúrgico..DISEÑO:Estudio retrospectivo no aleatorizado.AJUSTE:El estudio se llevó a cabo en un hospital de tercer nivel por un equipo multidisciplinario.PACIENTES:Pacientes a quienes se les practicó escisión total del mesorrecto por vía transanal por sospecha de cáncer de recto entre 2013 y 2019.INTERVENCIONES:Al espécimen quirúrgico que se obtuvo, se le practicó inyección intraarterial ex vivo, de índigo carmín para teñir los ganglios linfáticos.PRINCIPALES MEDIDAS DE RESULTADO:El número de ganglios linfáticos recuperados con o sin tinción.RESULTADOS:Se analizaron muestras de 189 pacientes, de los cuales 108 (57,1%) fueron teñidos con índigo carmín. Se identificó una media de 19,8 ± 6,1 ganglios linfáticos en las muestras teñidas en comparación con 16,0 ± 4,9 sin tinción ( p < 0,001). El análisis multivariado mostró que se encontraron 3.2 ganglios linfáticos adicionales en las muestras teñidas (intervalo de confianza del 95%: 1,0 a 5,3; p = 0,02). En las muestras teñidas, el recuento adecuado de ganglios linfáticos (≥12) aumentó en el análisis univariado (razón de posibilidades: 3,24, intervalo de confianza del 95%: 1,13 a 10,65; p = 0,03) pero no en el multivariado. La inyección de índigo carmín no tuvo ningún efecto sobre el número de ganglios linfáticos positivos o el estadio ganglionar. La quimiorradioterapia redujo el recuento de ganglios linfáticos en 2,5 ( p = 0,008). Después de la tinción, en el 95,0% de los pacientes con quimiorradioterapia se recuperaron ≥12 ganglios linfáticos. La mediana de seguimiento de los pacientes fue de 24,2 meses con una tasa de recurrencia local del 3,3%.LIMITACIONES:El estudio está limitado por su diseño retrospectivo y la asignación no aleatoria.CONCLUSIONES:La inyección ex vivo de índigo carmín intraarterial aumenta el número de ganglios linfáticos aislados después de la escisión total del mesorrectal por vía transanal a pesar de la quimiorradioterapia neoadyuvante. La inyección de índigo carmín no se asocia con un aumento del estadio de los ganglios ni con un mayor número de ganglios linfáticos positivos para tumor. Consulte Video Resumen en http://links.lww.com/DCR/B839 . (Traducción-Eduardo Londoño-Schimmer ).
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Lin Z, Li X, Song J, Zheng R, Chen C, Li A, Xu B. The Effect of Lymph Node Harvest on Prognosis in Locally Advanced Middle-Low Rectal Cancer After Neoadjuvant Chemoradiotherapy. Front Oncol 2022; 12:816485. [PMID: 35242710 PMCID: PMC8886163 DOI: 10.3389/fonc.2022.816485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/24/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the relationship between lymph node harvest and the prognosis in locally advanced rectal cancer (LARC) patients after neoadjuvant chemoradiotherapy (nCRT). METHODS Patients who were diagnosed with clinical LARC and treated with nCRT and radical surgery between June 2008 and July 2017 were included in this study. The relationship between lymph node retrieval and prognosis was analyzed. Other lymph node-related indicators were explored. RESULTS A total of 837 patients with a median follow-up of 61 (7-139) months were included in the study. The five-year DFS and OS rates of all patients were 74.9% and 82.3%, respectively. Multivariate survival analysis suggested that dissection of ≥ 12 lymph nodes did not improve OS or DFS. 7 was selected as the best cutoff value for the total number of lymph nodes retrieved by Cox multivariate analysis (χ2 = 10.072, HR: 0.503, P=0.002). Dissection of ≥ 5 positive lymph nodes (PLNs) was an independent prognostic factor for poorer DFS (HR: 2.104, P=0.004) and OS (HR: 3.471, p<0.001). A positive lymph node ratio (LNR) of more than 0.29 was also an independent prognostic factor for poorer DFS (HR: 1.951, P=0.002) and OS (HR: 2.434, p<0.001). CONCLUSION The recommends that at least 7 harvested lymph nodes may be more appropriate for LARC patients with nCRT. PLN and LNR may be prognostic factors for LARC patients with ypN+ after nCRT.
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Affiliation(s)
- Zhuangbin Lin
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,The Graduate School, Fujian Medical University, Fuzhou, China.,Department of Radiation Oncology, Fujian Branch of Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, Fuzhou, China.,Department of Radiation Oncology, Fujian Children's Hospital, Fuzhou, China
| | - Xiaobo Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China
| | - Jianyuan Song
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China
| | - Rong Zheng
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Cheng Chen
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China
| | - Anchuan Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Benhua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China.,Union Clinical Medicine College, Fujian Medical University, Fuzhou, China.,School of Clinical Medicine, Fujian Medical University, Fuzhou, China
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Detering R, Meyer VM, Borstlap WAA, Beets-Tan RGH, Marijnen CAM, Hompes R, Tanis PJ, van Westreenen HL. Prognostic importance of lymph node count and ratio in rectal cancer after neoadjuvant chemoradiotherapy: Results from a cross-sectional study. J Surg Oncol 2021; 124:367-377. [PMID: 33988882 DOI: 10.1002/jso.26522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/08/2021] [Accepted: 04/24/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to determine the prognostic value of lymph node count (LNC) and lymph node ratio (LNR) in rectal cancer after neoadjuvant chemoradiotherapy (CRT). METHODS Patients who underwent neoadjuvant CRT and total mesorectal excision (TME) for Stage I-III rectal cancer were selected from a cross-sectional study including 71 Dutch centres. Primary outcome parameters were disease-free survival (DFS) and overall survival (OS). Prognostic significance of LNC and LNR (cut-off values 0.15, 0.20, 0.30) was tested for different (sub)groups. RESULTS From 2095 registered patients, 458 were included, of which 240 patients with LNC < 12 and 218 patients with LNC ≥ 12. LNC was not significantly associated with DFS (p = 0.35) and OS (p = 0.59). In univariable analysis, LNR was significantly associated with DFS and OS in the whole cohort and LNC subgroups, but not in multivariable analysis. CONCLUSIONS LNC was not associated with long-term oncological outcome in rectal cancer patients treated with CRT, nor was LNR when corrected for N-stage. However, LNR might be used to identify subgroups of node-positive patients with a favourable outcome.
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Affiliation(s)
- Robin Detering
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Vincent M Meyer
- Department of Surgery, Isala Hospital Zwolle, Zwolle, the Netherlands
| | - Wernard A A Borstlap
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiotherapy, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Roel Hompes
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Association of certification, improved quality and better oncological outcomes for rectal cancer in a specialized colorectal unit. Int J Colorectal Dis 2021; 36:517-533. [PMID: 33165684 DOI: 10.1007/s00384-020-03792-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Centralization of cancer care is expected to yield superior results. In Germany, the national strategy is based on a voluntary certification process. The effect of centre certification is difficult to prove because quality data are rarely available prior to certification. This observational study aims to assess outcomes for rectal cancer patients before and after implementation of a certified cancer centre. PATIENTS AND METHODS All consecutive patients treated for rectal cancer in our certified centre from 2009 to 2017 were retrieved from a prospective database. The dataset was analyzed according to a predefined set of 19 quality indicators comprising 36 quality goals. The results were compared to an identical cohort of patients, treated from 2000 to 2008 just before centre implementation. RESULTS In total, 1059 patients were included, 481 in the 2009-2017 interval and 578 in the 2000-2008 interval. From 2009 to 2017, 25 of 36 quality goals were achieved (vs. 19/36). The proportion of anastomotic leaks in low anastomoses was improved (13.5% vs. 22.1%, p = 0.018), as was the local 5-year recurrence rate for stage (y)pIII rectal cancers (7.7% vs. 17.8%, p = 0.085), and quality of mesorectal excision (0.3% incomplete resections vs. 5.5%, p = 0.002). Furthermore, a decrease of abdominoperineal excisions was noted (47.1% vs. 60.0%, p = 0.037). For the 2009-2017 interval, local 5-year recurrence rate in stages (y)p0-III was 4.6% and 5-year overall survival was 80.2%. CONCLUSIONS Certification as specialized centre and regular audits were associated with an improvement of various quality parameters. The formal certification process has the potential to enhance quality of care for rectal cancer patients.
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Yang H, Yao Z, Cui M, Xing J, Zhang C, Zhang N, Liu M, Xu K, Tan F, Su X. Influence of tumor location on short- and long-term outcomes after laparoscopic surgery for rectal cancer: a propensity score matched cohort study. BMC Cancer 2020; 20:761. [PMID: 32795280 PMCID: PMC7427716 DOI: 10.1186/s12885-020-07255-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the short- and long-term outcomes after laparoscopic resection for low rectal cancer (LRC) compared with mid/high rectal cancer (M/HRC). METHODS Patients with rectal cancer undergoing laparoscopic resection with curative intent were retrospectively reviewed between 2009 and 2015. After matched 1:1 by using propensity score analysis, perioperative and oncological outcomes were compared between LRC and M/HRC groups. Multivariate analysis was performed to identify independent factors of overall survival (OS) and disease-free survival (DFS). RESULTS Of 373 patients who met the criteria for inclusion, 198 patients were matched for the analysis. Laparoscopic surgery for LRC required longer operative time (P<0.001) and more blood loss volume (P = 0.015) compared with M/HRC, and the LRC group tended to have a higher incidence of postoperative complications (16.2% vs. 8.1%, P = 0.082). There was no significant difference in local recurrence between the two groups (9.1% vs. 4.0%, P = 0.251), whereas distant metastasis was inclined to be more frequent in LRC patients compared with M/HRC (21.2% vs. 12.1%, P = 0.086). The LRC group showed significantly inferior 5-year OS (77.0% vs. 86.4%, P = 0.033) and DFS (71.2% vs. 86.2%, P = 0.017) compared with the M/HRC group. Multivariate analysis indicated that tumor location was an independent predictor of DFS (HR = 2.305, 95% CI 1.203-4.417, P = 0.012). CONCLUSION Tumor location of the rectal cancer significantly affected the clinical and oncological outcomes after laparoscopic surgery, and it was an independent predictor of DFS.
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Affiliation(s)
- Hong Yang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Zhendan Yao
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Ming Cui
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Jiadi Xing
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Chenghai Zhang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Nan Zhang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Maoxing Liu
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Kai Xu
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Fei Tan
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China
| | - Xiangqian Su
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, PR China.
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The prognostic impact of neoadjuvant chemoradiotherapy on lymph node sampling in patients with locally advanced rectal cancer. Updates Surg 2020; 72:793-800. [PMID: 32632764 PMCID: PMC7481149 DOI: 10.1007/s13304-020-00841-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/21/2020] [Indexed: 02/06/2023]
Abstract
According to the American Joint Committee on Cancer, at least 12 lymph nodes are required to accurately stage locally advanced rectal cancer (LARC). Neoadjuvant chemoradiation therapy (NACRT) reduces the number of lymph nodes retrieved during surgery. In this study, we evaluated the effect of NACRT on lymph node retrieval and prognosis in patients with LARC. We performed an observational study of 142 patients with LARC. Although our analysis was retrospective, data were collected prospectively. Half the patients were treated with NACRT and total mesorectal excision (TME) and the other half underwent TME only. The number of lymph nodes retrieved and the number of metastatic lymph nodes were significantly reduced in the NACRT group (P > 0.001). In the univariate and multivariate analyses, only NACRT and patient age were significantly associated with reduced lymph node retrieval. The number of metastatic lymph nodes and the lymph node ratio (LNR) both had a significant effect on prognosis when the patient population was examined as a whole (P = 0.003 and P = 0.001, respectively). However, the LNR was the only significant, independent prognostic factor in both treatment groups (P = 0.007 for the NACRT group; P = 0.04 for the no-NACRT group). NACRT improves patient prognosis only when the number of metastatic lymph nodes is reduced. The number of metastatic lymph nodes and the LNR are important prognostic factors. Lymph node retrieval remains an indispensable tool for staging and prognostic assessment of patients with rectal carcinoma treated with NACRT.
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Narayanan S, Attwood K, Gabriel E, Nurkin S. Pathologic Complete Response Despite Nodal Yield Has Best Survival in Locally Advanced Rectal Cancer. J Surg Res 2020; 251:220-227. [PMID: 32172008 DOI: 10.1016/j.jss.2020.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/05/2019] [Accepted: 01/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Controversy exists regarding the ability of neoadjuvant chemoradiation (nCR) to diminish lymph node yield (LNY) and how that relationship is influenced by tumor response in patients undergoing proctectomy for locally advanced rectal cancer. MATERIALS AND METHODS The National Cancer Database was used to identify patients with rectal adenocarcinomas from 2004 to 2014. Patients that received nCR were compared with those that underwent surgery alone. LNY was stratified into <12 and ≥12 groups to determine their differences in stage specific overall survival. RESULTS Of 56,812 patients 46.5% underwent surgery alone and 53.5% were administered nCR. There were more patients with LNY<12 in the nCR group compared to surgery alone, across all stages (44.1% versus 36.5%, P < 0.001). nCR improved OS regardless of LNY (P < 0.001). Although patients with LNY≥12 had improved overall survival, patients who had a pathologic complete response (pCR) achieved the greatest survival. In patients that did not achieve a pCR, LNY≥12 was a marker of improved OS but LNY did not impact OS in patients that attained pCR (P < 0.001). CONCLUSIONS Although nCR diminished LNY, LNY≥12 improved OS demonstrating the importance of quality total mesorectal excision. However, LNY did not impact patients that achieved pCR. These patients, who achieved the best OS, demonstrated that tumors' biologic response to nCR had the greatest impact on patient outcomes.
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Affiliation(s)
- Sumana Narayanan
- Department of Surgical Oncology, Mount Sinai Medical Center, Miami Beach, Florida
| | - Kristopher Attwood
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Emmanuel Gabriel
- Department of Surgery, Section of Surgical Oncology, Mayo Clinic, Jacksonville, Florida
| | - Steven Nurkin
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York.
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Kreis ME, Ruppert R, Kube R, Strassburg J, Lewin A, Baral J, Maurer CA, Sauer J, Winde G, Thomasmeyer R, Stelzner S, Bambauer C, Scheunemann S, Faedrich A, Junginger T, Hermanek P, Merkel S. MRI-Based Use of Neoadjuvant Chemoradiotherapy in Rectal Carcinoma: Surgical Quality and Histopathological Outcome of the OCUM Trial. Ann Surg Oncol 2019; 27:417-427. [PMID: 31414295 DOI: 10.1245/s10434-019-07696-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Preoperative magnetic resonance imaging (MRI) allows highly reliable imaging of the mesorectal fascia (mrMRF) and its relationship to the tumor. The prospective multicenter observational study OCUM uses these findings to indicate neoadjuvant chemoradiotherapy (nCRT) in rectal carcinoma. METHODS nCRT was indicated in patients with positive mrMRF (≤ 1 mm) in cT4 and cT3 carcinomas of the lower rectal third. RESULTS A total of 527 patients (60.2%) underwent primary total mesorectal excision, and 348 patients (39.8%) underwent long-term nCRT followed by surgery. The mrMRF was involved in 4.6% of the primary surgery group and 80.7% of the nCRT group. Rates of resections within the mesorectal plane (90.8%), sparing of pelvic nerves on both sides (97.8%), and number of regional lymph nodes (95.3% with ≥ 12 lymph nodes examined) are indicative of high-quality surgery. Resection was classified as R0 in 98.3%, the pathological circumferential resection margin (pCRM) was negative in 95.1%. Patients in the nCRT group had more advanced carcinomas with a significantly higher rate of abdominoperineal excision. Independent risk factors for pCRM positivity were advanced stage (T4), metastatic lymph nodes, resection in the muscularis propria plane, and location in the lower third. CONCLUSIONS The risk classification of rectal cancer patients by MRI seems to be highly reliable and allows the restriction of nCRT to approximately half of the patients with clinical stage II and III rectal carcinoma, provided there is a high-quality MRI diagnostic protocol, high-quality surgery, and standardized examination of the resected specimen.
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Affiliation(s)
- Martin E Kreis
- Department of Surgery, Campus Benjamin Franklin, Charité, University Medicine, Berlin, Germany
| | - Reinhard Ruppert
- Department of General and Visceral Surgery, Endocrine Surgery, and Coloproctology, Municipal Hospital of Munich-Neuperlach, Munich, Germany
| | - Rainer Kube
- Department of Surgery, Carl-Thiem-Klinik, Cottbus, Germany
| | - Joachim Strassburg
- Department of General and Visceral Surgery, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Andreas Lewin
- Department of General and Visceral Surgery, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Joerg Baral
- Department of General and Visceral Surgery, Municipal Hospital, Karlsruhe, Germany
| | - Christoph A Maurer
- Department of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland.,HIRSLANDEN Private Hospital Group, Clinic Beau-Site, Bern, Switzerland
| | - Joerg Sauer
- Department for General, Visceral and Minimal Invasive Surgery, Arnsberg, Germany
| | - Günther Winde
- Department for General and Visceral Surgery, Thoracic Surgery and Proctology University Medical Centre, Herford, Germany
| | - Rena Thomasmeyer
- Department for General, Visceral and Minimal Invasive Surgery, Municipal Hospital Wolfenbüttel, Wolfenbüttel, Germany
| | | | | | - Soenke Scheunemann
- Department for General and Visceral Surgery, Evangelisches Krankenhaus Lippstadt, Lippstadt, Germany
| | - Axel Faedrich
- Department for Genera- and Visceral Surgery, Brüderkrankenhaus St. Josef Paderborn, Paderborn, Germany
| | - Theodor Junginger
- Department of General and Abdominal Surgery, University Medical Centre at the Johannes Gutenberg-University, Mainz, Germany.
| | - Paul Hermanek
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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11
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Wang Y, Zhou M, Yang J, Sun X, Zou W, Zhang Z, Zhang J, Shen L, Yang L, Zhang Z. Increased lymph node yield indicates improved survival in locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. Cancer Med 2019; 8:4615-4625. [PMID: 31250569 PMCID: PMC6712464 DOI: 10.1002/cam4.2372] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/22/2019] [Accepted: 06/12/2019] [Indexed: 12/17/2022] Open
Abstract
PURPOSE It is recommended for colorectal cancer to harvest at least 12 lymph nodes (LNs) during surgery to avoid understaging of the disease. However, it is still controversial whether it is necessary to harvest from locally advanced rectal cancer (LARC) patients who underwent neoadjuvant chemoradiotherapy (neo-CRT). The impact of lymph node yield (LNY) on prognosis in LARC patients was analyzed. MATERIALS/METHODS In total, 495 LARC patients who underwent neo-CRT in 2006-2015 were analyzed. After examining clinicopathological distribution differences between the LNY subgroups (with the threshold of 12), univariate and multivariate Cox survival analyses were performed. Survival plots were obtained from Kaplan-Meier analyses. Similar subgroup analyses were performed according to the tumor regression grade (TRG) and metastatic status of post-operational LNs. RESULTS Of the 495 patients, 287 (57.98%) had an LNY of less than 12. Nearly no significant clinicopathological difference was found between the LNY subgroups, including the TRG scores. Multivariate survival analysis demonstrated that at least 12 LNs examined was an independent prognostic feature of good overall survival (OS), disease-free survival (DFS), and distant metastasis free survival (DMFS), but not local recurrence free survival (LRFS). However, in the subgroup analyses, no association was found between LNY and prognosis in patients with good TRG scores (0-1) or negative LNs. CONCLUSIONS For LARC patients treated with neo-CRT, an LNY of at least 12 indicated an improved survival. Decreased LNY was not related to better tumor regression. It suggests that a sufficiently high LNY is still required, especially in those with a potentially poor tumor response.
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Affiliation(s)
- Yaqi Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Menglong Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Jianing Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Xiaoyang Sun
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Wei Zou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Zhiyuan Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Jing Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Lijun Shen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Lifeng Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
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12
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Bustamante-Lopez L, Nahas CS, Nahas SC. Reply letter to: "Lymph node harvest in rectal cancer patients with good tumor regression grade following neoadjuvant chemoradiotherapy". Int J Surg 2019; 64:57-58. [PMID: 30772523 DOI: 10.1016/j.ijsu.2019.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Leonardo Bustamante-Lopez
- Department of Gastroenterology, Surgical Division, University of Sao Paulo, Medical School, Sao Paulo, Brazil.
| | - Caio S Nahas
- Department of Gastroenterology, Surgical Division, University of Sao Paulo, Medical School, Sao Paulo, Brazil
| | - Sergio C Nahas
- Department of Gastroenterology, Surgical Division, University of Sao Paulo, Medical School, Sao Paulo, Brazil
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13
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Bustamante-Lopez LA, Nahas CSR, Nahas SC, Marques CFS, Pinto RA, Cotti GC, Imperiale AR, de Mello ES, Ribeiro U, Cecconello I. Pathologic complete response implies a fewer number of lymph nodes in specimen of rectal cancer patients treated by neoadjuvant therapy and total mesorectal excision. Int J Surg 2018; 56:283-287. [PMID: 29981939 DOI: 10.1016/j.ijsu.2018.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/30/2018] [Accepted: 07/02/2018] [Indexed: 12/26/2022]
Abstract
Studies have suggested that the use of neoadjuvant chemoradiation results in a lower lymph nodes yield in rectal cancer patients. OBJECTIVE To evaluate factors associated with less than 12 lymph nodes harvested on patients with rectal cancer treated with preoperative chemoradiotherapy followed by total mesorectal excision. PATIENTS This was a cohort/retrospective single cancer center study. Low and mid locally advanced rectal cancer or T2N0 under risk of sphincter resection underwent chemoradiotherapy followed by total mesorectal excision with curative intent. Chemotherapy consisted of 5-FU and leucovorin IV. Total dose of pelvic radiation was 5040 Gys. All patients were staged and restaged by digital rectal examination, proctoscopy, colonoscopy, CT of abdomen and chest, and MRI of the pelvis. Patients were stratified in two groups: ≥12 and < 12 L N retrieved. The possible factors affecting number of LN were analyzed. RESULTS 95 patients met the inclusion criteria. Mean LN harvest was 23.2 (3-67). 81 patients (85%) had ≥12 L N. Gender, age, tumor size, tumor stage, tumor location, length of specimen, presence of LN involvement, type of surgery, and surgical access showed no association with number of LN retrieved. Only pathological complete response showed a statistically significant association with <12 L N on univariate (p = 0.004) and multivariate analyses (p = 0.002). LIMITATIONS Data were collected retrospectively. The number of patients disparity between the two groups. CONCLUSIONS Complete pathologic response is associated with <12 L N harvested. Thus, the number of lymph nodes should not be used as a surrogate for oncologic adequacy of resection in patients with pathologic complete response.
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Affiliation(s)
| | - Caio Sergio Rizkallah Nahas
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Rodrigo Ambar Pinto
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Guilherme Cutait Cotti
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Antonio Rocco Imperiale
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Evandro Sobroza de Mello
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
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14
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Number of lymph nodes assessed has no prognostic impact in node-negative rectal cancers after neoadjuvant therapy. Results of the "Italian Society of Surgical Oncology (S.I.C.O.) Colorectal Cancer Network" (SICO-CCN) multicentre collaborative study. Eur J Surg Oncol 2018; 44:1233-1240. [PMID: 29705284 DOI: 10.1016/j.ejso.2018.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/12/2018] [Accepted: 04/05/2018] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION We retrospectively investigated the impact of number or complete absence of nodes retrieved on survival of patients with rectal cancer (RC) treated with neoadjuvant radiation-therapy (NAT). METHODS All patients with RC treated with NAT followed by curative surgery from 2000 to 2014 in 14 Italian referral Centres for Colorectal Surgery were enrolled. Information about number of nodes harvested, node ratio, type of radiation therapy schedule and tumour stage were recorded. Impact of number or complete absence of nodes retrieved on overall survival (OS) and on cumulative incidence of death for disease (CIDD) was assessed and factors influencing node yield were investigated. RESULTS In total, 1407 patients were included. Mean number of nodes retrieved was 12.9, while no lymph nodes were found in only 32 patients (2%, ypNnull). Definite nodal stage was ypN0 in 1001 patients (71%) and ypN+ in 372 patients (27%). In multivariable analysis ypNnull patients showed worse OS and CIDD compared to both ypN0 and ypN+. In ypN0 patients, number of nodes assessed, stratified in 4 groups (<5, 5-10, 11-15 and > 15), did not significantly influence OS and CIDD. Long-course radiation schedule and early T stages negatively affected node assessment. CONCLUSION Complete absence of nodes assessed was associated with worse prognosis compared to node-negative and node-positive patients. In node-negative patients number of nodes was not associated to OS and CIDD. Based on data from this large population of irradiated RC, number of nodes assessed has no prognostic impact in node-negative patients.
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15
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Chan DKH, Tan KK. Lower lymph node yield following neoadjuvant therapy for rectal cancer has no clinical significance. J Gastrointest Oncol 2018; 10:42-47. [PMID: 30788158 DOI: 10.21037/jgo.2018.10.02] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background Obtaining 12 lymph nodes following resection for rectal cancer is an important prognostic marker. However, patients who have received neoadjuvant therapy are known to have a lower lymph node yield. We conducted this study to determine the clinical significance of evaluating <12 versus ≥12 lymph nodes in individuals who underwent surgery following neoadjuvant therapy for rectal cancer. Methods A retrospective analysis of all patients who received neoadjuvant therapy for locally advanced rectal cancer between January 2008 and December 2014 followed by proctectomy was conducted. Results In total, 217 patients were treated for rectal cancer. Mean follow-up was 23.4 (interquartile range, 9-40.5) months. Sixty-three (29.0%) patients received neoadjuvant therapy. There was a statistically significant difference in the number of patients with <12 lymph node yield between those who received neoadjuvant therapy and those who did not (27.0% vs. 9.1%, P=0.001). Amongst the 63 patients who received neoadjuvant therapy, lymph node yield of ≥12 was not associated with a statistically significant difference in time to recurrence [hazard ratio (HR) 0.17; 95% confidence interval (CI), 0.01-2.01, P=0.160] or time to death (HR 1.07; 0.15-7.90, P=0.946). Kaplan-Meier curves also did not show any significant difference between those with <12 lymph nodes and those with ≥12 lymph nodes in terms of recurrence and death (P=0.203 and P=0.762 respectively). Conclusions Although neoadjuvant therapy reduces the lymph node yield during surgery for locally advanced rectal cancer, this has no significance on the overall survival of the patient.
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Affiliation(s)
- Dedrick Kok Hong Chan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ker-Kan Tan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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