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Wehrle CJ, Woo K, Chang J, Gamaleldin M, DeHaan R, Dahdaleh F, Felder S, Rosen DR, Champagne B, Steele SR, Naffouje SA. Impact of neoadjuvant therapy on nodal harvest in clinical stage III rectal cancer: Establishing optimum cut-offs by disease response. J Surg Oncol 2024; 129:945-952. [PMID: 38221655 DOI: 10.1002/jso.27586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION A minimum lymph node harvest (LNH) of 12 is the current standard for appropriate nodal staging in resectable rectal cancer. However, the rise of neoadjuvant chemoradiation (NCRT) and total neoadjuvant therapy (TNT) has been associated with decreasing number of LNH. We hypothesize that as tumor response to neoadjuvant therapy increases, the optimum for LNH to achieve appropriate nodal staging should decrease. METHODS Patients with clinical stage III rectal adenocarcinoma who underwent NCRT/TNT followed by resection were identified from the National Cancer Database. A JoinPoint regression analysis was used to determine the LNH for each tumor regression grade (TRG) category beyond which the rate of positive nodes does not significantly change. RESULTS Thirteen thousand four hundred and twenty-six patients met inclusion criteria. Of these, 2406 (17.9%) achieved TRG 0 or ypT0 and 8210 (61.2%) achieved ypN0. Collectively, 2043 patients (15.2%) were reported to have a pathologic complete response (ypT0 ypN0). Positive pathologic nodes were found in 15%, 23%, 31%, 54%, and 53% as ypT stage increased from ypT0 to ypT4, respectively. Similarly, ypN+ rates were 15%, 36%, 41%, and 55% in TRG 0-3. No JoinPoint was identified for TRG 0, whereas inflection points were found at 6-10 nodes for TRG1 (p = 0.002) and TRG 2 (p = 0.016), and at 11-15 nodes for TRG 3. CONCLUSION The benchmark of retrieving 12 nodes in resectable stage III rectal cancer is not consistently achieved after NCRT/TNT. We demonstrate that the LNH requirement to establish accurate pathologic nodal staging can vary depending on the tumor response to neoadjuvant therapies.
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Affiliation(s)
- Chase J Wehrle
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Kimberly Woo
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Jenny Chang
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Maysoon Gamaleldin
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Reece DeHaan
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Elmhurst, Illinois, USA
| | - Seth Felder
- Moffitt Cancer Center, GI Oncology Program, Tampa, Florida, USA
| | - David R Rosen
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Bradley Champagne
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Scott R Steele
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Samer A Naffouje
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
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Ryu HS, Park IJ, Ahn BK, Park MY, Kim MS, Kim YI, Lim SB, Kim JC. Prognostic significance of lymph node yield on oncologic outcomes according to tumor response after preoperative chemoradiotherapy in rectal cancer patients. Ann Coloproctol 2023; 39:410-420. [PMID: 35483697 PMCID: PMC10626326 DOI: 10.3393/ac.2022.00143.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/21/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE This study aimed to evaluate the predictive value of lymph node yield (LNY) for survival outcomes according to tumor response after preoperative chemoradiotherapy (PCRT) in patients with rectal cancer. METHODS This study was a retrospective study conducted in a tertiary center. A total of 1,240 patients with clinical stage II or III rectal cancer who underwent curative resection after PCRT between 2007 and 2016 were included. Patients were categorized into the good response group (tumor regression grade [TRG], 0-1) or poor response group (TRG, 2-3). Propensity score matching was performed for age, sex, and pathologic stage between LNY of ≥12 and LNY of <12 within tumor response group. The primary outcome was 5-year disease-free survival (DFS) and overall survival (OS). RESULTS LNY and positive lymph nodes were inversely correlated with TRG. In good responders, 5-year DFS and 5-year OS of patients with LNY of <12 were better than those with LNY of ≥12, but there was no statistical significance. In poor responders, the LNY of <12 group had worse survival outcomes than the LNY of ≥12 group, but there was also no statistical significance. LNY of ≥12 was not associated with DFS and OS in multivariate analysis. CONCLUSION LNY of <12 showed contrasting outcomes between the good and poor responders in 5-year DFS and OS. LNY of 12 may not imply adequate oncologic surgery or proper staging in rectal cancer patients treated by PCRT. Furthermore, a decrease in LNY should be comprehended differently according to tumor response.
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Affiliation(s)
- Hyo Seon Ryu
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo Kyung Ahn
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Young Park
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Sung Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Il Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Qu Y, Liu H. Construction of a predictive model for clinical survival in male patients with non-metastatic rectal adenocarcinoma. Asian J Surg 2023; 46:132-142. [PMID: 35227564 DOI: 10.1016/j.asjsur.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/15/2021] [Accepted: 02/11/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND No clinical prediction model is available for non-metastatic rectal adenocarcinoma in males. Based on demographic and clinicopathological characteristics, we constructed a survival prediction model for the study population. METHODS At a ratio of 7:3, 3450 eligible patients were divided into training and validation sets. Optimal cutoff values were calculated using X-tile software. Cox proportional hazards regression was used to find prognostic factors for cancer-specific survival (CSS) and overall survival (OS). Corresponding nomogram prognostic models were also constructed based on predictors.The validity, discriminative ability, predictability, and clinical usefulness of the model were analyzed and assessed. RESULTS We identified predictors of survival in the target population and successfully constructed nomograms. In the nomogram prediction model for OS and CSS, the C-index was 0.724 and 0.735, respectively, for the training group and 0.754 and 0.760, respectively, for the validation group. In the validation group, the area under the curve (AUC) of the receiver operating characteristic curve for OS and CSS nomograms was 0.768 and 0.769, respectively, for the 3-year survival rate and 0.755 and 0.747, respectively, for the 5-year survival rate. Kaplan-Meier Survival Curves showed excellent risk discrimination performance of the nomogram (P < 0.05) Calibration curves, time-dependent AUC and decision curve analysis showed that the prediction model constructed in this study had excellent clinical prediction and decision ability and performed better than the TNM staging system. CONCLUSION Our nomogram is helpful to evaluate the prognosis of non-metastatic male patients with rectal adenocarcinoma and has guiding significance for clinical treatment.
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Affiliation(s)
- Yidan Qu
- Department of Clinical Medicine, Qingdao University, 266000, Shandong, China
| | - Hao Liu
- Department of Clinical Medicine, Fudan University, 200032, Shanghai, China.
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Clinical Safety and Effectiveness of Robotic-Assisted Surgery in Patients with Rectal Cancer: Real-World Experience over 8 Years of Multiple Institutions with High-Volume Robotic-Assisted Surgery. Cancers (Basel) 2022; 14:cancers14174175. [PMID: 36077712 PMCID: PMC9454525 DOI: 10.3390/cancers14174175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/17/2022] [Accepted: 08/25/2022] [Indexed: 12/15/2022] Open
Abstract
Simple Summary The aim of this retrospective observational study was to evaluate perioperative and short-term oncological outcomes of robotic-assisted rectal surgery (RRS) in hospitals with a high-volume of robotic-assisted surgeries. This study enrolled patients with rectal adenocarcinoma undergoing RRS from three high-volume institutions from December 2011 to June 2020. Compared with other studies, our results revealed the equivalent or superior perioperative and short-term oncological outcomes. Hence, RRS is an effective, safe, and feasible technique for patients with rectal cancers in high-volume hospitals. Abstract The perioperative and short-term oncological outcomes of robotic-assisted rectal surgery (RRS) are unclear. This retrospective observational study enrolled patients with rectal adenocarcinoma undergoing RRS from three high-volume institutions in Taiwan. Of the 605 enrolled patients, 301 (49.75%), 176 (29.09%), and 116 (19.17%) had lower, middle, and upper rectal cancers, respectively. Low anterior resection (377, 62.31%) was the most frequent surgical procedure. Intraoperative blood transfusion was performed in 10 patients (2%). The surgery was converted to an open one for one patient (0.2%), and ten (1.7%) patients underwent reoperation. The overall complication rate was 14.5%, including 3% from anastomosis leakage. No deaths occurred during surgery and within 30 days postoperatively. The positive rates of distal resection margin and circumferential resection margin were observed in 21 (3.5%) and 30 (5.0%) patients, respectively. The 5-year overall and disease-free survival rates for patients with stage I–III rectal cancer were 91.1% and 86.3%, respectively. This is the first multi-institutional study in Taiwan with 605 patients from three high-volume hospitals. The overall surgical and oncological outcomes were equivalent or superior to those estimated in other studies. Hence, RRS is an effective and safe technique for rectal resection in high-volume hospitals.
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Liu S, Yang S, Yu H, Luo H, Chen G, Gao Y, Sun R, Xiao W. A nomogram for predicting 10-year cancer specific survival in patients with pathological T3N0M0 rectal cancer. Front Med (Lausanne) 2022; 9:977652. [PMID: 36072948 PMCID: PMC9441689 DOI: 10.3389/fmed.2022.977652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/02/2022] [Indexed: 12/03/2022] Open
Abstract
Background The pathological T3N0M0 (pT3N0M0) rectal cancer is the earliest stage and has the best prognosis in the locally advanced rectal cancer, but the optimal treatment remains controversial. A reliable prognostic model is needed to discriminate the high-risk patients from the low-risk patients, and optimize adjuvant chemotherapy (ACT) treatment decisions by predicting the likelihood of ACT benefit for the target population. Patients and methods We gathered and analyzed 276 patients in Sun Yat-sen University Cancer Center from March 2005 to December 2011. All patients underwent total mesorectal excision (TME), without preoperative therapy, and were pathologically proven pT3N0M0 rectal cancer with negative circumferential resection margin (CRM). LASSO regression model was used for variable selection and risk factor prediction. Multivariable cox regression was used to develop the predicting model. Optimum cut-off values were determined using X-Tile plot analysis. The 10-fold cross-validation was adopted to validate the model. The performance of the nomogram was evaluated with its calibration, discrimination and clinical usefulness. Results A total of 188 patients (68.1%) had ACT and no patients had adjuvant radiotherapy. Age, monocyte percentage, carbohydrate antigen 19–9, lymph node dissection numbers and perineural invasion (PNI) were identified as significantly associated variables that could be combined for an accurate prediction risk of Cancer Specific Survival (CSS) for pT3N0M0 patients. The model adjusted for CSS showed good discrimination with a C-index of 0.723 (95% CI: 0.652–0.794). The calibration curves showed that the nomogram adjusted for CSS was able to predict 3-, 5-, and 10-year CSS accurately. The corresponding predicted probability was used to stratify high and low-risk patients (10-year CSS: 69.1% vs. 90.8%, HR = 3.815, 95%CI: 2.102–6.924, P < 0.0001). ACT improved overall survival (OS) in the low-risk patients (10-year OS: 91.9% vs. 83.3%, HR = 0.338, 95% CI: 0.135–0.848, P < 0.0001), while it did not exhibit a significant benefit in the high-risk patients. Conclusion The present study showed that age, monocyte percentage, carbohydrate antigen 19–9, lymph node dissection numbers and PNI were independent prognostic factors for pT3N0M0 rectal cancer patients. A nomogram based on these prognostic factors effectively predicts CSS in patients, which can be conveniently used in clinical practice. ACT may improve overall survival in the low-risk patients. But the benefit of ACT was not seen in the high-risk patients.
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Affiliation(s)
- Shuang Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shanfei Yang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Haina Yu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Huilong Luo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Gong Chen
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yuanhong Gao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Rui Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- *Correspondence: Rui Sun,
| | - Weiwei Xiao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Weiwei Xiao,
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He L, Xiao J, Zheng P, Zhong L, Peng Q. Lymph node regression grading of locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. World J Gastrointest Oncol 2022; 14:1429-1445. [PMID: 36160739 PMCID: PMC9412927 DOI: 10.4251/wjgo.v14.i8.1429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/30/2022] [Accepted: 07/06/2022] [Indexed: 02/05/2023] Open
Abstract
Neoadjuvant chemoradiotherapy (nCRT) and total rectal mesenteric excision are the main standards of treatment for locally advanced rectal cancer (LARC). Lymph node regression grade (LRG) is an indicator of prognosis and response to preoperative nCRT based on postsurgical metastatic lymph node pathology. Common histopathological findings in metastatic lymph nodes after nCRT include necrosis, hemorrhage, nodular fibrosis, foamy histiocytes, cystic cell reactions, areas of hyalinosis, residual cancer cells, and pools of mucin. A number of LRG systems designed to classify the amount of lymph node regression after nCRT is mainly concerned with the relationship between residual cancer cells and regressive fibrosis and with estimating the number of lymph nodes existing with residual cancer cells. LRG offers significant prognostic information, and in most cases, LRG after nCRT correlates with patient outcomes. In this review, we describe the systematic classification of LRG after nCRT, patient prognosis, the correlation with tumor regression grade, and the typical histopathological findings of lymph nodes. This work may serve as a reference to help predict the clinical complete response and determine lymph node regression in patients based on preservation strategies, allowing for the formulation of more accurate treatment strategies for LARC patients, which has important clinical significance and scientific value.
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Affiliation(s)
- Lei He
- School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, Sichuan Province, China
| | - Juan Xiao
- School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, Sichuan Province, China
| | - Ping Zheng
- Department of Pathology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, Sichuan Province, China
| | - Lei Zhong
- Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu 610072, Sichuan Province, China
| | - Qian Peng
- Radiation Therapy Center, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, Sichuan Province, China
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Zhang X, Xu F, Bin Y, Liu T, Li Z, Guo D, Li Y, Huang Q, Lyu J, He S. Nomogram to predict cause-specific mortality of patients with rectal adenocarcinoma undergoing surgery: a competing risk analysis. BMC Gastroenterol 2022; 22:57. [PMID: 35144545 PMCID: PMC8832791 DOI: 10.1186/s12876-022-02131-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rectal adenocarcinoma is one of major public health problems, severely threatening people's health and life. Cox proportional hazard models have been applied in previous studies widely to analyze survival data. However, such models ignore competing risks and treat them as censored, resulting in excessive statistical errors. Therefore, a competing-risk model was applied with the aim of decreasing risk of bias and thereby obtaining more-accurate results and establishing a competing-risk nomogram for better guiding clinical practice. METHODS A total of 22,879 rectal adenocarcinoma cases who underwent primary-site surgical resection were collected from the SEER (Surveillance, Epidemiology, and End Results) database. Death due to rectal adenocarcinoma (DRA) and death due to other causes (DOC) were two competing endpoint events in the competing-risk regression analysis. The cumulative incidence function for DRA and DOC at each time point was calculated. Gray's test was applied in the univariate analysis and Gray's proportional subdistribution hazard model was adopted in the multivariable analysis to recognize significant differences among groups and obtain significant factors that could affect patients' prognosis. Next, A competing-risk nomogram was established predicting the cause-specific outcome of rectal adenocarcinoma cases. Finally, we plotted calibration curve and calculated concordance indexes (c-index) to evaluate the model performance. RESULTS 22,879 patients were included finally. The results showed that age, race, marital status, chemotherapy, AJCC stage, tumor size, and number of metastasis lymph nodes were significant prognostic factors for postoperative rectal adenocarcinoma patients. We further successfully constructed a competing-risk nomogram to predict the 1-year, 3-year, and 5-year cause-specific mortality of rectal adenocarcinoma patients. The calibration curve and C-index indicated that the competing-risk nomogram model had satisfactory prognostic ability. CONCLUSION Competing-risk analysis could help us obtain more-accurate results for rectal adenocarcinoma patients who had undergone surgery, which could definitely help clinicians obtain accurate prediction of the prognosis of patients and make better clinical decisions.
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Affiliation(s)
- Xu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Fengshuo Xu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong Province, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, Shaanxi Province, China
| | - Yadi Bin
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Tianjie Liu
- Department of Urology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Zhichao Li
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Dan Guo
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yarui Li
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qiao Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong Province, China
| | - Shuixiang He
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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Li T, Yang Y, Wu W, Fu Z, Cheng F, Qiu J, Li Q, Zhang K, Luo Z, Qiu Z, Huang C. Prognostic implications of ENE and LODDS in relation to lymph node-positive colorectal cancer location. Transl Oncol 2021; 14:101190. [PMID: 34403906 PMCID: PMC8367836 DOI: 10.1016/j.tranon.2021.101190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/15/2021] [Accepted: 07/29/2021] [Indexed: 02/07/2023] Open
Abstract
This is the first study on LODDS and ENE together. The current study showed that LODDS and ENE are liable prognostic parameters of CRC or CC. ENE is an independent influencing factor on the prognosis of both CRC and CC, and the prognostic impact of ENE was observed in both CRC and CC. The frequency of ENE increases from the proximal (right) to the distal (left) colon as well as the rectum.
Background Extranodal extension (ENE) and log odds of positive lymph nodes (LODDS) are associated with the aggressiveness of both colon and rectal cancers. The current study evaluated the clinicopathological significance and the prognostic impact of ENE and LODDS in the colon and rectal patients independently. Methods The clinical and histological records of 389 colorectal cancer (CRC) patients who underwent curative surgery were reviewed. Results For the ENE system, 244 patients were in the ENE1 group and 145 in the ENE2 system. Compared with the ENE1 system, the patients included in the ENE2 system were prone to nerve invasion (P < 0.001) and vessel invasion (P < 0.001) with higher TNM (P = 0.009), higher T category (P = 0.003), higher N category (P < 0.001), advanced differentiation (P = 0.013), more number of positive lymph nodes (NPLN) (P < 0.001), more lymph node ratio (LNR) (P < 0.001), and a higher value of LODDS (P < 0.001). ENE was more frequent in patients with left and rectal than right cancer. For the LODDS system, 280 patients were in the LODDS1 group, and 109 in the LODDS2 group. Compared to the LODDS1 group, the patients included in the LODDS2 group were more prone to nerve invasion (P = 0.0351) and vessel invasion (P < 0.001) with a higher rate of N2 stage, less NDLN (P < 0.001), more NPLN (P < 0.001), more LNR (P < 0.001), and a higher value of ENE (P < 0.001). Based on the results in the univariable analysis, the N, NPLN, LNR, LODDS, and ENE were separately incorporated into five different Cox regression models combined with the same confounders. The multivariable Cox regression analysis demonstrated that all the five staging systems were independent prognostic factors for overall survival. Conclusion The current study confirmed that the LODDS stage is an independent influence on the prognosis of both CRC and CC patients. ENE is an independent influencing factor on the prognosis of both CRC and CC patients, and the prognostic impact of extracapsular lymph node was observed in both CRC and CC. The frequency of ENE increases from the proximal (right) to the distal (left) colon as well as the rectum. Therefore, combining ENE and LODDS into the current TNM system to compensate for the inadequacy of pN staging needs further investigation.
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Affiliation(s)
- Tengfei Li
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai 201600, China
| | - Yan Yang
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai 201600, China; Graduate School of Bengbu Medical College, Bengbu 233000, China
| | - Weidong Wu
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai 201600, China
| | - Zhongmao Fu
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai 201600, China
| | - Feichi Cheng
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai 201600, China; Graduate School of Bengbu Medical College, Bengbu 233000, China
| | - Jiahui Qiu
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai 201600, China; Shanghai General Hospital Affiliated to Nanjing Medical University, Shanghai 200080, China
| | - Qi Li
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200021, China
| | - Kundong Zhang
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai 201600, China
| | - Zai Luo
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai 201600, China
| | - Zhengjun Qiu
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai 201600, China
| | - Chen Huang
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, 100 Haining Road, Hongkou District, Shanghai 201600, China.
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Liu H, Li Y, Qu YD, Zhao JJ, Zheng ZW, Jiao XL, Zhang J. Construction of a clinical survival prognostic model for middle-aged and elderly patients with stage III rectal adenocarcinoma. World J Clin Cases 2021; 9:1563-1579. [PMID: 33728300 PMCID: PMC7942048 DOI: 10.12998/wjcc.v9.i7.1563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/10/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nomograms for prognosis prediction in colorectal cancer patients are few, and prognostic indicators differ with age.
AIM To construct a new nomogram survival prediction tool for middle-aged and elderly patients with stage III rectal adenocarcinoma.
METHODS A total of 2773 eligible patients were divided into the training cohort (70%) and the validation cohort (30%). Optimal cutoff values were calculated using the X-tile software for continuous variables. Univariate and multivariate Cox proportional hazards regression analyses were used to determine overall survival (OS) and cancer-specific survival (CSS)-related prognostic factors. Two nomograms were successfully constructed. The discriminant and predictive ability and clinical usefulness of the model were also assessed by multiple methods of analysis.
RESULTS The 95%CI in the training group was 0.719 (0.690-0.749) and 0.733 (0.702-0.74), while that in the validation group was 0.739 (0.696-0.782) and 0.750 (0.701-0.800) for the OS and CSS nomogram prediction models, respectively. In the validation group, the AUC of the three-year survival rate was 0.762 and 0.770, while the AUC of the five-year survival rate was 0.722 and 0.744 for the OS and CSS nomograms, respectively. The nomogram distinguishes all-cause mortality from cancer-specific mortality in patients with different risk grades. The time-dependent AUC and decision curve analysis showed that the nomogram had good clinical predictive ability and decision efficacy and was significantly better than the tumor-node-metastases staging system.
CONCLUSION The survival prediction model constructed in this study is helpful in evaluating the prognosis of patients and can aid physicians in clinical diagnosis and treatment.
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Affiliation(s)
- Hao Liu
- Department of Colonrectal Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Yu Li
- Department of Colonrectal Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Yi-Dan Qu
- Rheumatology and Immunology Department, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Jun-Jiang Zhao
- Department of Colonrectal Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Zi-Wen Zheng
- Department of Colonrectal Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Xue-Long Jiao
- Department of Colonrectal Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Jian Zhang
- Department of Colonrectal Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
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10
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Wu Z, Qin G, Zhao N, Jia H, Zheng X. A statistical tool for risk assessment as a function of the number of lymph nodes retrieved from rectal cancer patients. Colorectal Dis 2018; 20:O199-O206. [PMID: 29768703 DOI: 10.1111/codi.14264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 04/23/2018] [Indexed: 01/14/2023]
Abstract
AIM Although a minimum of 12 lymph nodes (LNs) has been recommended for examination in colorectal cancer patients there remains considerable debate with regard to rectal cancer. Inadequacy of examined LNs could lead to understaging and inappropriate treatment as a consequence. We describe a statistical tool that allows an estimate of the probability of false-negative nodes. METHOD A total of 26 778 patients diagnosed between 2004 and 2013 with rectal adenocarcinoma [tumour stage (T stage) 1-3] who did not receive neoadjuvant therapies and had at least one histologically assessed LN were extracted from the Surveillance, Epidemiology and End Results (SEER) database. A statistical tool using beta-binomial distribution was developed to estimate the probability of missing a positive node as a function of the total number of LNs examined and T stage. RESULTS The probability of falsely identifying a patient as node-negative decreased with increasing number of nodes examined for each stage. It was estimated to be 72%, 66% and 52% for T1, T2 and T3 patients, respectively, with a single node examined. To confirm an occult nodal disease with 90% confidence, 5, 9 and 29 nodes need to be examined for patients from stages T1, T2 and T3, respectively. CONCLUSION The false-negative rate of the examined LNs in rectal cancer was verified to be dependent preoperatively on the clinical T stage. A more accurate nodal staging score was developed to recommend a threshold for the minimum number of examined nodes with regard to the favoured level of confidence.
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Affiliation(s)
- Z Wu
- Department of Biostatistics, School of Public Health, Key Laboratory of Public Health Safety and Collaborative Innovation Center of Social Risks Governance in Health, Fudan University, Shanghai, China
| | - G Qin
- Department of Biostatistics, School of Public Health, Key Laboratory of Public Health Safety and Collaborative Innovation Center of Social Risks Governance in Health, Fudan University, Shanghai, China
| | - N Zhao
- Department of Biostatistics, School of Public Health, Key Laboratory of Public Health Safety and Collaborative Innovation Center of Social Risks Governance in Health, Fudan University, Shanghai, China
| | - H Jia
- Center for Biomedical Statistics, Fudan University Shanghai Cancer Center, Shanghai, China
| | - X Zheng
- Department of Biostatistics, School of Public Health, Key Laboratory of Public Health Safety and Collaborative Innovation Center of Social Risks Governance in Health, Fudan University, Shanghai, China
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11
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Shen F, Cui J, Cai K, Pan H, Bu H, Yu F. Prognostic accuracy of different lymph node staging systems in rectal adenocarcinoma with or without preoperative radiation therapy. Jpn J Clin Oncol 2018; 48:625-632. [PMID: 29788392 DOI: 10.1093/jjco/hyy070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 05/04/2018] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Feng Shen
- Department of Colorectal Surgery, Tongde Hospital of Zhejiang Province, Hangzhou Zhejiang, China
| | - Junhui Cui
- Department of Colorectal Surgery, Tongde Hospital of Zhejiang Province, Hangzhou Zhejiang, China
| | - Ke Cai
- Department of Colorectal Surgery, Tongde Hospital of Zhejiang Province, Hangzhou Zhejiang, China
| | - Haiqiang Pan
- Department of Colorectal Surgery, Tongde Hospital of Zhejiang Province, Hangzhou Zhejiang, China
| | - Heqi Bu
- Department of Colorectal Surgery, Tongde Hospital of Zhejiang Province, Hangzhou Zhejiang, China
| | - Feng Yu
- Department of Colorectal Surgery, Tongde Hospital of Zhejiang Province, Hangzhou Zhejiang, China
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12
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Zhou YY, Zhang QW, Huang J, Yan XL, Chen C, Xu FF, Du XJ, Jin R. Additional lymphadenectomy might not improve survival of patients with resectable metastatic colorectal adenocarcinoma of T4 stage, proximal location, poor/undifferentiation, or N3/N4 stages: a large population-based study. J Cancer 2018; 9:2428-2435. [PMID: 30026839 PMCID: PMC6036890 DOI: 10.7150/jca.24675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 05/15/2018] [Indexed: 12/27/2022] Open
Abstract
This study was performed to evaluate the prognostic effect of lymphadenectomy on outcomes in patients with resectable metastatic colorectal adenocarcinoma (mCRC). We selected patients with mCRC from 2004 to 2013 from Surveillance, Epidemiology, and End Results Program (SEER) database. Kaplan-Meier analysis, univariate Cox regression and multivariate Cox regression analysis were performed to assess the clinical value of lymphadenectomy on overall survival (OS) and cause-specific survival (CSS) of patients with resectable mCRC. A total 24178 eligible patients were included, 23056 (95.36%) of which received lymphadenectomy. Results showed that lymphadenectomy was an independent protective factor for survival of patients with mCRC overall [OS (HR: 0.86, 95%CI: 0.79-0.93, P=0.002) and CSS (HR: 0.85, 95%CI: 0.78-0.93, P<0.001)]. Further analysis showed that lymphadenectomy improved survival of patients with T1 stage [OS (HR: 0.51, 95%CI: 0.39-0.66, P<0.001); CSS (HR: 0.48, 95%CI: 0.36-0.65, P<0.001)], distal [OS (HR: 0.65, 95%CI: 0.56-0.75, P<0.001); CSS (HR: 0.65, 95%CI: 0.65-0.75, P<0.001)], rectal [OS (HR: 0.60, 95%CI: 0.52-0.70, P<0.001); CSS (HR: 0.59, 95%CI: 0.51-0.69, P<0.001)] , well/moderately differentiated [OS (HR: 0.62, 95%CI: 0.56-0.70, P<0.001); CSS (HR: 0.62, 95%CI: 0.55-0.69, P<0.001)], N1 stage [OS (HR: 0.76, 95%CI: 0.67-0.85, P<0.001); CSS (HR: 0.74, 95%CI: 0.65-0.84, P<0.001)] and N2 stage [OS (HR: 0.63, 95%CI: 0.54-0.74, P<0.001; CSS (HR: 0.65, 95%CI: 0.55-0.77, P<0.001)) mCRC. While lymphadenectomy might not improve survival of patients with T4 stage, proximal, poor or undifferentiated, N3 and N4 stage mCRC. In general, Additional lymphadenectomy was suggested for patients with mCRC overall. However, lymphadenectomy might not improve survival of patients with mCRC of higher malignancy tendency, such as T4 stage, proximal location, poor or undifferentiation, N3 and N4 stages.
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Affiliation(s)
- Yang-Yang Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou325000, Zhejiang, China
| | - Qing-Wei Zhang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University; Shanghai Institute of Digestive Disease;145 Middle Shandong Road, Shanghai 200001, China
| | - Jian Huang
- Department of Gastroenterology, Yuyao People's Hospital of Zhejiang Province, The Affiliated Yangming Hospital of Ningbo University, Ningbo 315400, Zhejiang, China
| | - Xia-Lin Yan
- Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin 2nd Rd, Shanghai 200025, China
| | - Chao Chen
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou325000, Zhejiang, China
| | - Fan-Fan Xu
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou325000, Zhejiang, China
| | - Xiao-Jing Du
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou325000, Zhejiang, China
| | - Rong Jin
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou325000, Zhejiang, China.,Department of Epidemiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou325000, Zhejiang, China
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13
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Keikes L, Koopman M, Tanis PJ, Lemmens VE, Punt CJ, van Oijen MG. Evaluating the scientific basis of quality indicators in colorectal cancer care: A systematic review. Eur J Cancer 2017; 86:166-177. [DOI: 10.1016/j.ejca.2017.08.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/22/2017] [Accepted: 08/30/2017] [Indexed: 12/31/2022]
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14
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Xu Z, Berho ME, Becerra AZ, Aquina CT, Hensley BJ, Arsalanizadeh R, Noyes K, Monson JRT, Fleming FJ. Lymph node yield is an independent predictor of survival in rectal cancer regardless of receipt of neoadjuvant therapy. J Clin Pathol 2016; 70:584-592. [PMID: 27932667 DOI: 10.1136/jclinpath-2016-203995] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 11/08/2016] [Accepted: 11/13/2016] [Indexed: 01/05/2023]
Abstract
AIMS Lymph node yield (LNY) is used as a marker of adequate oncological resection. The American Joint Committee on Cancer (AJCC) currently recommends that at least 12 nodes are necessary to confirm node-negative disease for rectal cancer. A LNY of 12 is not always achieved, particularly in patients who have undergone neoadjuvant treatment. This study attempts to examine factors associated with LNY and its prognostic impact following neoadjuvant chemoradiation in rectal cancer. METHODS The 2006-2011 National Cancer Data Base was queried for patients with clinical stage I-III rectal cancer who underwent a proctectomy. Suboptimal LNY was defined as <12 lymph nodes examined. A mixed-effects multinomial logistic regression model was used to identify independent factors associated with LNY. Mixed-effects Cox proportional hazards models were used to estimate the adjusted effect of LNY on 5-year overall survival. RESULTS 25 447 patients met inclusion criteria. Overall, 62% of the cohort received neoadjuvant chemoradiation and 32% had suboptimal LNY. The median LNY for patients who received neoadjuvant therapy was 13 (IQR: 9-18) and for patients who did not receive neoadjuvant therapy was 15 (IQR: 12-21). After risk adjustment, there was a 3.5-fold difference in the rate of suboptimal LNY among individual hospitals (27%-95%). Suboptimal LNY was independently associated with an 18% increased hazard of death among patients who did not receive neoadjuvant treatment and a 20% increased hazard of death among those who did receive neoadjuvant treatment when controlled for adjuvant treatment, staging, proximal/distal margins and other patient factors. CONCLUSIONS Suboptimal LNY is independently associated with worse overall survival regardless of neoadjuvant therapy, pathological staging and patient factors in rectal cancer. This finding underlies the importance and challenge of an optimal lymph node evaluation for prognostication, especially for patients receiving neoadjuvant therapy.
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Affiliation(s)
- Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Mariana E Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, Florida, USA
| | - Adan Z Becerra
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Christopher T Aquina
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Bradley J Hensley
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Reza Arsalanizadeh
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Katia Noyes
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida, College of Medicine, Orlando, Florida, USA
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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15
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Han J, Noh GT, Yeo SA, Cheong C, Cho MS, Hur H, Min BS, Lee KY, Kim NK. The number of retrieved lymph nodes needed for accurate staging differs based on the presence of preoperative chemoradiation for rectal cancer. Medicine (Baltimore) 2016; 95:e4891. [PMID: 27661032 PMCID: PMC5044902 DOI: 10.1097/md.0000000000004891] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The aim of this study is to investigate if retrieval of 12 lymph nodes (LNs) is sufficient to avoid stage migration as well as to evaluate the prognostic impact of insufficient LN retrieval in different treatment settings of rectal cancer, particularly in the case of preoperative chemoradiotherapy (pCRT).The data of all patients with biopsy proven rectal adenocarcinoma who underwent curative surgery between January 2005 and December 2012 were analyzed. Univariate and multivariate analyses for oncologic outcomes were performed in LN metastasis or no LN metastasis (LN-) group. Subgroup analyses were performed according to whether a patient had received pCRT.A total of 1825 patients were enrolled into the study. The maximal Chi-square method revealed the minimum number of harvested LNs required to be 12. Univariate and multivariate analyses found LNs ≥ 12 to be an independent prognostic factor for both overall survival (OS) (hazard ratio [HR] = 0.5, 95% confidence intervals [CIs]: 0.3-0.8; P = 0.002) and disease-free survival (DFS) (HR = 0.6, 95% CI: 0.4-0.7; P < 0.001) in the LN- group. In the LN- group, LNs ≥ 12 continued to be a significant prognostic factor both for OS and DFS in the subgroup of patients who did not undergo pCRT. However, in the subgroup of the LN- patients who underwent pCRT, LN ≥ 8 was significant for DFS and OS.Retrieval of LNs ≥ 12 and LNs ≥ 8 should be achieved to obtain accurate staging and optimal treatment for the non-pCRT and pCRT groups in rectal cancer, respectively.
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Affiliation(s)
| | | | | | | | | | | | - Byung Soh Min
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Correspondence: Byung Soh Min, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-Ku, 120-752 Seoul, South Korea (e-mail: )
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16
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Lykke J, Jess P, Roikjaer O. The prognostic value of lymph node ratio in a national cohort of rectal cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:504-12. [PMID: 26856955 DOI: 10.1016/j.ejso.2016.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/13/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To analyze the prognostic implications of the lymph node ratio (LNR) in curative resected rectal cancer. SUMMARY BACKGROUND DATA It has been proposed that the LNR has a high prognostic impact in colorectal cancer, but the lymph node ratio has not been evaluated exclusively for rectal cancer in a large national cohort study. METHODS All 6793 patients in Denmark diagnosed with stage I to III adenocarcinoma of the rectum, and so treated in the period from 2003 to 2011, were included in the analysis. The cohort was divided into two groups according to whether or not neo-adjuvant treatment had been given. RESULTS In a multivariate analysis the pN status, ypN status and lymph node yield were found to be independent prognostic factors for overall survival, irrespective of neo-adjuvant therapy. The LNR was also found to be a significant prognostic factor with a Hazard Ratio ranging from 1.154 (95% CI: 0.930-1.432) (LNR: 0.01-0.08) to 2.974 (95% CI: 2.452-3.606) (LNR > 0.5) in the group of patients who had surgery to begin with and from 1.381 (95% CI: 0.891-2.139) (LNR: 0.01-0.08) to 2.915 (95% CI: 2.244-3.787) (LNR > 0.5) in the group of patients who had neo-adjuvant treatment. CONCLUSIONS The LNR reflects the influence on survival from N-status and the lymph node yield and since LNR was shown to be a significant prognostic predictor for overall survival in patients with curatively resected stage III rectal cancer irrespective of neo-adjuvant therapy we recommend that the introduction of LNR should be considered for rectal cancer in a revised TNM classification.
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Affiliation(s)
- J Lykke
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark.
| | - P Jess
- Department of Surgery, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark
| | - O Roikjaer
- Department of Surgery, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark
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17
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Ecker BL, Paulson EC, Datta J, Jeganathan AN, Aarons C, Kelz RR, Mahmoud NN. Lymph node identification following neoadjuvant therapy in rectal cancer: A stage-stratified analysis using the surveillance, epidemiology, and end results (SEER)-medicare database. J Surg Oncol 2015; 112:415-20. [DOI: 10.1002/jso.23991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/17/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Brett L. Ecker
- Department of Surgery; University of Pennsylvania; Philadelphia Pennsylvania
| | - Emily C. Paulson
- Department of Surgery; University of Pennsylvania; Philadelphia Pennsylvania
- Department of Surgery; Philadelphia Veterans Affairs Medical Center; Philadelphia Pennsylvania
| | - Jashodeep Datta
- Department of Surgery; University of Pennsylvania; Philadelphia Pennsylvania
| | - Arjun N. Jeganathan
- Department of Surgery; University of Pennsylvania; Philadelphia Pennsylvania
| | - Cary Aarons
- Department of Surgery; University of Pennsylvania; Philadelphia Pennsylvania
| | - Rachel R. Kelz
- Department of Surgery; University of Pennsylvania; Philadelphia Pennsylvania
| | - Najjia N. Mahmoud
- Department of Surgery; University of Pennsylvania; Philadelphia Pennsylvania
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18
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Gill A, Brunson A, Lara P, Khatri V, Semrad TJ. Implications of lymph node retrieval in locoregional rectal cancer treated with chemoradiotherapy: a California Cancer Registry Study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2015; 41:647-52. [PMID: 25800934 PMCID: PMC4406634 DOI: 10.1016/j.ejso.2015.01.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/22/2014] [Accepted: 01/29/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND In contrast to colon cancer, the implications of reduced lymph node retrieval in rectal cancer are unclear. METHODS Using the California Cancer Registry, we performed a retrospective cohort study of 4790 patients with stage I - III rectal cancer diagnosed from 2000 to 2007 who underwent tri-modality therapy. Using multivariate Cox proportional hazards models adjusted for age, sex, race, socioeconomic status, T-stage, and lymph node numbers, we evaluated rectal cancer specific survival (RC-SS) in neoadjuvant and adjuvant cohorts in the overall population and amongst those without involved lymph nodes (pN0). RESULTS Sixty one percent of evaluable patients were treated with neoadjuvant chemoradiation. Although there was no difference in RC-SS between neoadjuvant and adjuvant chemoradiation cohorts, the median number of lymph nodes examined was reduced after neoadjuvant therapy (8 vs. 11, p < 0.0001). Positive lymph nodes were associated with worse RC-SS regardless of sequence, although the effect was numerically stronger for residual lymph nodes in the neoadjuvant cohort. Compared to at least 12, eight or fewer lymph nodes retrieved was associated with worse outcome in both neoadjuvant and adjuvant cohorts. However, no association between reduced lymph nodes examined and RC-SS was seen in the neoadjuvant cohort when the analysis was restricted to pN0 patients. CONCLUSIONS In this large cohort of rectal cancer patients treated with tri-modality therapy, reduced lymph node retrieval in node negative patients did not provide additional prognostic information in patients treated with neoadjuvant therapy.
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Affiliation(s)
- A Gill
- Division of Hematology/Oncology, Department of Internal Medicine, University of California, Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - A Brunson
- Division of Hematology/Oncology, Department of Internal Medicine, University of California, Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - P Lara
- Division of Hematology/Oncology, Department of Internal Medicine, University of California, Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - V Khatri
- Division of Surgical Oncology, Department of Surgery, University of California, Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - T J Semrad
- Division of Hematology/Oncology, Department of Internal Medicine, University of California, Davis Comprehensive Cancer Center, Sacramento, CA, USA.
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Campa-Thompson M, Weir R, Calcetera N, Quirke P, Carmack S. Pathologic processing of the total mesorectal excision. Clin Colon Rectal Surg 2015; 28:43-52. [PMID: 25733973 DOI: 10.1055/s-0035-1545069] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Total mesorectal excision (TME) is the current optimal surgical treatment for patients with rectal carcinoma. A complete TME is related to lower local recurrence rates and increased patient survival. Many confounding factors in the patient's anatomy and prior therapy can make it difficult to obtain a perfect plane, and thus a complete TME. The resection specimen can be thoroughly evaluated, grossly and microscopically, to identify substandard surgical outcomes and increased risk of local recurrence. Complete and accurate data reporting is critical for patient care and helps surgeons improve their technique.
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Affiliation(s)
- Molly Campa-Thompson
- Department of Pathology, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Robert Weir
- Department of Pathology, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Natalie Calcetera
- Department of Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Philip Quirke
- Department of Pathology and Tumor Biology, Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Susanne Carmack
- Department of Pathology, Baylor University Medical Center at Dallas, Dallas, Texas
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Lykke J, Jess P, Roikjaer O. A minimum yield of twelve lymph nodes in rectal cancer remains valid in the era of neo-adjuvant treatment : results from a national cohort study. Int J Colorectal Dis 2015; 30:347-51. [PMID: 25652878 DOI: 10.1007/s00384-015-2145-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of the study was to examine if a minimum of 12 lymph nodes (LNs) is still valid in rectal cancer after neo-adjuvant treatment. METHODS An analysis was carried out in a nationwide Danish cohort of 6793 patients, treated by curative resection of stage I-III rectal cancer during the period 2003-2011. The cohort was divided into two groups according to whether neo-adjuvant treatment had been given. The groups were analysed separately and were further analysed according to four lymph node yield (LNY) groups 0-5, 6-11, 12-17 and ≥18. RESULTS Two thousand one hundred twenty-three patients (31.0 %) received neo-adjuvant treatment. A median LNY of 10 and 15 (p < 0.0001) and rates of node-positive (N-positive) disease of 31.6 and 36.7 % (p < 0.001) were observed with and without (+/-) neo-adjuvant treatment, respectively. The rate of N-positive disease according to tumour stage ranged from 4.8 %/11.4 % (ypT0/pT1) to 42.1 %/64.1 % (ypT4/pT4). The rate of N-positive disease according to LNY ranged from 19.5 %/16.8 % (0-5 LNs) to 42.6 %/37.9 % (≥18 LNs) (-/+neo-adjuvant treatment). In a logistic regression analysis, a significant association was found between N-positive disease and pT/ypT stage as well as between N-positive disease and LNY. CONCLUSIONS A significantly smaller ratio of N-positive disease was observed in the group of patients who had received neo-adjuvant treatment. The ratio of N-positive disease increased significantly with more advanced tumour stage and increasing LNY irrespective of neo-adjuvant treatment. A minimum of 12 LNs is needed to ensure N-negative disease, irrespective of neo-adjuvant treatment.
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Affiliation(s)
- Jakob Lykke
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark,
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Bhatti ABH, Akbar A, Hafeez A, Syed AA, Khattak S, Jamshed A, Kazmi AS. Impact of lymph node ratio and number on survival in patients with rectal adenocarcinoma after preoperative chemo radiation. Int J Surg 2014; 13:65-70. [PMID: 25475873 DOI: 10.1016/j.ijsu.2014.11.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/26/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Retrieval of <12 lymph nodes after proctectomy and preoperative chemoradiation (C-XRT) may improve survival in good risk patients. The objective of this study was to determine impact of <12 retrieved lymph nodes and lymph node ratio (LNR) on survival in a population with certain poor prognostic features for rectal cancer. METHODS Patients who underwent surgery for rectal adenocarcinoma between 2005 and 2011 were divided them into <12 or >12 lymph node groups. The LNR groups were based on interquartile range. Clinicopathological and treatment outcomes were compared. Expected 5 year disease free and overall survival was calculated. Cox proportional hazard model was used to determine independent predictors. RESULTS More patients in <12 lymph nodes removed group had low tumors (<5 cm from anal verge) (75.5% versus 60.7%) (P=0.03) and underwent abdominoperineal resection (59.1% versus 42.9%) (P=0.02). Overall survival (OS) and disease free survival (DFS) was not different [(56% and 52% (P=0.7)] [(50% and 57% (P=0.5)]. LNR<0.15 was independent predictor of DFS while LNR ratio<0.12 for OS on multivariate analysis. CONCLUSION LNR and not number of retrieved nodes impacts survival in younger patients with predominance of anorectal tumors after C-XRT. A specific LNR cutoff remains to be defined.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan.
| | - Ali Akbar
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | | | - Aamir Ali Syed
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Shahid Khattak
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Arif Jamshed
- Department of Radiation Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Ather Saeed Kazmi
- Department of Medical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
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22
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Wu W, Hong X, Tian R, You L, Dai M, Liao Q, Zhang T, Zhao Y. An increased total resected lymph node count benefits survival following pancreas invasive intraductal papillary mucinous neoplasms resection: an analysis using the surveillance, epidemiology, and end result registry database. PLoS One 2014; 9:e107962. [PMID: 25264746 PMCID: PMC4179272 DOI: 10.1371/journal.pone.0107962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 08/16/2014] [Indexed: 12/30/2022] Open
Abstract
Background The therapeutic effect of lymph node dissection for pancreas invasive intraductal papillary mucinous neoplasms (IPMN) remains unclear. The study investigated whether cancer-specific survival (CSS) and overall survival (OS) rates among invasive IPMN patients improve when more lymph nodes are harvested during surgery. Study Design The study cohort was retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. The lymph node count was categorized into quartiles. The relationship between lymph node count and survival was analyzed using Kaplan–Meier curves and a Cox proportional-hazards model. The stage migration was assessed by Chi-square tests. Propensity score matching (PSM) was used to minimize confounding variables between groups. Results In total, 1,080 patients with resected invasive IPMNs from 1992 to 2011 were included. Univariate and multivariate Cox models indicated that an increased lymph node count independently improves survival. The Kaplan-Meier and log-rank tests identified 16 nodes as an optimal cut-off value that yielded a significant survival benefit for all invasive IPMN patients. The stage migration effect existed in this cohort. After PSM, the 5-year CSS increased from 36% to 47%, and the median survival rate increased from 30 months to 40 months by increasing the lymph node count to over 16, alone. The 5-year OS rate also provided additional support for this result. Conclusion Increased lymph node counts were associated with improved survival in invasive IPMN patients. One cut-off value of lymph node count was 16 for this improvement.
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Affiliation(s)
- Wenming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Xiafei Hong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Rui Tian
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Lei You
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
- * E-mail:
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23
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Hayes BD, O’Riordan JM, Stuart C, Muldoon C. Rectal Site and Suboptimal Nodal Yield Predict Systemic Recurrence in Resected Colorectal Carcinoma. Int J Surg Pathol 2014; 22:505-11. [DOI: 10.1177/1066896914534464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We assessed the contribution of histopathological features to systemic recurrence (SR) in patients with colorectal cancer, using a case-control design: 71 cases and 184 controls were included, with a mean time until SR of 1.4 ± 0.1 years and a mean follow-up of controls of 1.6 ± 0.06 years. Cases had significantly greater odds of rectal site (odds ratio [OR] = 1.82), stage ≥pT3 (OR = 2.11), suboptimal (<12) lymph node yield (OR = 4.6), stage ≥pN1 (OR = 2.46), KRAS mutation (OR = 2.76), and extramural venous invasion (OR = 1.97). By multiple regression analysis, rectal site, stage ≥pT3, suboptimal lymph node yield, and lymph node positivity independently predicted SR. Rectal cancers were more likely to have a suboptimal node yield than nonrectal cancers (relative risk = 1.6) among the entire cohort. We conclude that rectal cancers have greater risk of SR than colon cancers. A lower yield of lymph nodes in rectal cancer specimens may contribute to this.
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Affiliation(s)
- Brian D. Hayes
- St James’s Hospital, Dublin, Ireland
- Trinity College Dublin, Ireland
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24
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Persiani R, Biondi A, Gambacorta MA, Bertucci Zoccali M, Vecchio FM, Tufo A, Coco C, Valentini V, Doglietto GB, D'Ugo D. Prognostic implications of the lymph node count after neoadjuvant treatment for rectal cancer. Br J Surg 2014; 101:133-42. [PMID: 24375303 DOI: 10.1002/bjs.9341] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of this study was to investigate the effect of neoadjuvant chemoradiotherapy on the lymph node yield of rectal cancer surgery. METHODS Data for patients who underwent neoadjuvant chemoradiotherapy followed by surgery for resectable rectal cancer from June 1992 to June 2009 were reviewed. The primary outcomes measured were the number of lymph nodes retrieved, their status, and patient survival. RESULTS In total, 345 patients underwent neoadjuvant chemoradiotherapy followed by surgery, and 95 patients had surgery alone. Neoadjuvant chemoradiotherapy decreased both the median (range) number of lymph nodes retrieved (7 (1-33) versus 12.5 (0-44) respectively; P < 0.001) and the number of positive lymph nodes (0 (0-11) versus 0 (0-16); P = 0.001). After neoadjuvant chemoradiotherapy, the number of retrieved lymph nodes was inversely correlated with tumour regression, and with the interval between treatment and surgery. The 5-year overall and disease-free survival rates were 86.5 and 79.1 per cent respectively. After neoadjuvant therapy, lymph node status was found to be an independent predictor of survival, whereas the number of retrieved lymph nodes did not represent a prognostic factor for either overall or disease-free survival. CONCLUSION Low lymph node count after neoadjuvant chemoradiotherapy for rectal cancer does not signify an inadequate resection or understaging, but represents an increased sensitivity to the treatment.
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Affiliation(s)
- R Persiani
- Department of Surgery, Catholic University School of Medicine, Rome, Italy
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25
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Märkl B, Schaller T, Krammer I, Cacchi C, Arnholdt HM, Schenkirsch G, Kretsinger H, Anthuber M, Spatz H. Methylene blue-assisted lymph node dissection technique is not associated with an increased detection of lymph node metastases in colorectal cancer. Mod Pathol 2013; 26:1246-54. [PMID: 23599158 DOI: 10.1038/modpathol.2013.61] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 02/09/2013] [Accepted: 02/09/2013] [Indexed: 12/12/2022]
Abstract
Lymph node staging is of paramount importance for prognosis estimation and therapy stratification in colorectal cancer. A high number of harvested lymph nodes is associated with an improved outcome. Methylene blue-assisted lymph node dissection effectively improves the lymph node harvest and ensures sufficient staging. Now, the effect on node positivity rate and stage-related outcome was investigated. The study cohort with advanced lymph node dissection consisted of 669 colorectal cancer cases of all stages, which were collected between 2007 and 2012. A historical collection of 663 cases investigated with conventional techniques between 2002 and 2004 served as control. Lymph node harvest was dramatically improved in the study group with mean lymph node numbers of 34 ± 17 vs 13 ± 5 (P<0.001) and sufficient staging rates of 98% vs 62% (P<0.001). However, neither the rate of nodal positive cases (37% vs 37%; P = 0.98) nor the rate of N2 cases differed between the two groups (14% vs 13%; P = 0.80). Furthermore, no differences were found concerning the outcome in both groups. The advanced lymph node dissection technique guarantees adequate histopathological lymph node staging in virtually all cases of colorectal cancer and is therefore extremely helpful. The hypothesis that it also provides a higher sensitivity in detecting metastases, however, could be not proved.
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Affiliation(s)
- Bruno Märkl
- Institute of Pathology, Klinikum Augsburg, Augsburg, Germany.
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