Preoperative Submucosal Injection of Carbon Nanoparticles Improves Lymph Node Staging Accuracy in Rectal Cancer after Neoadjuvant Chemoradiotherapy

Convenient method to improve efficiency of lymph node examination after gastrectomy with D2 lymphadenectomy for gastric cancer

BACKGROUND

The D2 procedure has been accepted as the standard treatment for advanced gastric cancer (GC) in East Asia. Determination of the number of lymph nodes (LNs) after gastrectomy may influence the pathological stage assessment of lymph node metastasis, significantly influencing prognostic evaluations and formulation of chemotherapy regimens.

METHODS

Between January 2020 and January 2022, the medical files of 312 patients with clinical stage T0-4aN0-3M0 gastric cancer were reviewed retrospectively, and the patients were assigned to the normal group (lymph nodes were examined roughly), manual group (lymph nodes were manually examined meticulously), and device group (lymph nodes were examined by device). The clinical and pathologic characteristics, number of lymph nodes harvested, and the time required for lymph node examination was compared.

RESULTS

A total of 312 gastric cancer patients (mean age 65.8 ± 10.3 years, 85 females and 227 males) underwent gastrectomy with curative intent at our department. Sex, age, body mass index (BMI), tumor size, clinical TNM stage, and pathologic TNM stage in the three groups showed no statistically significant differences (P > 0.05). The mean number of harvested lymph nodes in the normal, manual, and device group was 24.2, 36.6 and 35.2, respectively, which showed significant differences (P < 0.0001). The mean number of positive lymph nodes in the normal, manual, and device group was 3.5, 3.9 and 3.9, respectively (P = 0.99). The mean time consumption in device group was 15 min while the time consumption in manual group was 52.3 min, which showed a significant difference (P < 0.0001).

CONCLUSION

This improved lymph node examination method offers a simple approach that is worth promoting, and it can improve the number of harvested lymph nodes efficiently.

A retrospective study analyzing if lymph node ratio carbon nanoparticles predict stage III rectal cancer recurrence

Background

Lymph node ratio has garnered increasing attention as a prognostic marker for rectal cancer; however, few studies have investigated the relationship between lymph node ratio and rectal cancer recurrence. Additionally, Carbon Nanoparticle tracking is a safe and effective strategy for locating tumors and tracking lymph nodes. However, no studies have reported the relationship between Carbon Nanoparticles and rectal cancer recurrence.

Methods

Patients with stage III rectal cancer who underwent radical resection between January 2016 and 2020 were analyzed. The primary outcome was tumor recurrence. 269 patients with stage III rectal cancer were included in this study. The effects of lymph node ratio, Carbon Nanoparticles, and other clinicopathological factors on rectal cancer recurrence were assessed using univariate, multivariate analyses and the t-test.

Results

Univariate analysis determined tumor recurrence using cytokeratin 19 fragment, CA-199, CEA, N-stage, positive lymph nodes, total lymph nodes, and lymph node ratio(positive/total); with the lymph node ratio being the most relevant. Receiver operating characteristic (ROC) analysis determined lymph node ratio =0.38 as the optimal cutoff value. The analysis of lymph node ratio ≥0.38 and <0.38 showed statistical differences in three indicators: tumor recurrence, CEA, and use of Carbon Nanoparticles.

Conclusion

Lymph node ratio is a strong predictor of stage III rectal cancer recurrence and may be considered for inclusion in future tumor-node-metastasis staging and stage III rectal cancer stratification. In addition, we found that Carbon Nanoparticles use significantly increased total lymph nodes and decreased lymph node ratio.

The Role of Carbon Nanoparticles as Lymph Node Tracers in Colorectal Cancer: A Systematic Review and Meta-Analysis

Colorectal malignancies are the third-most common malignancies worldwide, with a rising incidence. Surgery remains the treatment of choice and adequate lymph node dissection is required for accurate staging. The objective of this study is to assess the use of carbon nanoparticles in lymph node tracing and resection in cases of colorectal cancer. For that purpose, we conducted a systematic review and meta-analysis of studies included in Medline, Scopus, Embase, Cochrane Library, and Google Scholar databases. In the end, ten studies with a total number of 1418 patients were included in the final statistical analysis. The meta-analysis carried out showed that the use of carbon nanoparticles results in an increased number of lymph nodes harvested (WMD 6.15, 95% CI 4.14 to 8.16, p < 0.001) and a higher rate of cases with more than 12 lymph nodes harvested (OR 9.57, 95% CI 2.87 to 31.96, p = 0.0002). As a consequence, we suggest that carbon nanoparticles are used on a wider scale and that future research focuses on assessing the association between their use and overall patient survival. This study is limited by the fact that all included studies originate from China and by the fact that certain oncologic parameters and long-term outcomes have not been taken into account in the analysis.

Use of Carbon Nanoparticles to Improve the Efficiency of Harvesting Lymph Nodes in Rectal Cancer

BACKGROUND

The accurate determination of lymph node status in patients with rectal cancer requires harvesting a certain number of lymph nodes. This study investigated whether using carbon nanoparticles (CNs) could improve the efficiency of harvesting lymph nodes in rectal cancer patients.

MATERIALS AND METHODS

Data from patients with rectal cancer treated with radical resection were collected from Nanfang Hospital between January 2014 and June 2021. Patients in the CN group received a CN suspension 1 day before surgery, which was endoscopically injected around the tumor. A 1:1 case-matched study was performed using the propensity score. The efficiency of harvesting lymph nodes was investigated by comparing the number of total nodes, total time, and percentage of nodes <5 mm in size between the CN and non-CN groups.

RESULTS

A total of 768 patients were included, with 246 patients who underwent CN injection and 522 patients who did not. After matching, 246 pairs of patients were analyzed. After matching, the number of total nodes of each sample was significantly higher in the CN group than in the non-CN group ( P <0.001). The total time for node detection ( P <0.001) was significantly shorter in the CN group. The percentage of nodes <5 mm in size was increased significantly in the CN group ( P <0.001). Among patients with clinical staging I/II, the difference in positive LNs was significant (21.79% vs. 11.95%, P =0.029).

CONCLUSIONS

The application of CNs improved the efficiency of harvesting lymph nodes during rectal cancer surgery.

Carbon nanoparticle suspension could help get a more accurate nodal staging for patient with rectal cancer

This study aimed to evaluate whether carbon nanoparticles could improve the accuracy of nodal staging in colorectal cancer (CRC). We performed a randomized controlled trial with CRC at the department of general surgery, the affiliated hospital of Nanjing University Medical School. A total of 160 patients were recruited in this research and 132 patients were included in the safety analyses. Among these patients, 72 cases were classified into control group and 60 cases into study group. The mean number of lymph nodes harvested from patients in study group was 19.3 ± 6.7 (range from 4 to 38), which was higher than that in control group (15.1 ± 5.7 (range from 3 to 29)) (p < 0.001). The mean number of positive lymph nodes got from patients in study group was 1.7 ± 3.5 (range from 0 to 22), which was also higher than that in control group (0.7 ± 1.4 (range from 0 to 7)) (p = 0.045). In study group, there were 30 patients (50%) proved to be N0, and remaining 30 patients (50%) were N1 or N2. However, 50 patients (69.4%) were N0 and 22 patients (30.6%) were N1 or N2 in control group. The rate of N0 in control group was significantly higher than that in study group (p = 0.023). Injecting carbon nanoparticle suspension could get a more accurate nodal staging to receive enough chemoradiotherapy, improving prognosis. Besides, injecting carbon nanoparticles suspension at four points 5 cm, 10 cm, 15 cm and 20 cm away from the anus by “sandwich” method was a new try.

Trial registration: This study was registered with ClinicalTrials.gov, number ChiCTR1900025127 on 12/8/2019.

Application of Carbon Nanoparticles in Tracing Lymph Nodes and Locating Tumors in Colorectal Cancer: A Concise Review

Background

Accurate lymph node (LN) staging has considerably prognostic and therapeutic value in patients with colorectal cancer (CRC). The purpose of this study is to evaluate the feasibility of applying carbon nanoparticles (CNPs) to track LN metastases in CRC.

Methods

Two researchers independently screened publications in PubMed, EMBASE, Cochrane and Ovid MEDLINE databases. The keywords were (carbon nanoparticles OR activated carbon nanoparticles) AND (colon cancer OR rectal cancer OR colorectal cancer). Titles and abstracts of the articles were meticulously read to rule out potential publications. Next, full texts of the ultimately obtained eligible publications were retrieved and analyzed in detail.

Results

The search produced 268 publications, and 140 abstracts were identified after a bibliographic review. Finally, 20 studies relevant to our subject were obtained; however, only 14 papers met our inclusion criteria and were included for final review. All studies included have compared the control group with carbon nanoparticles group (control group, defined as nontattooed group; and carbon nanoparticles group, defined as administering carbon nanoparticles during surgery) for their efficacy in intraoperative detecting and positioning. After analysis, appreciably less amount of bleeding (3/5 trials), shorter operation time (2/4 trials), and shorter time to detect lesions and dissect LNs (2/2 trials) were revealed in CNPs group compared to control group. Thirteen studies have recorded the numbers of the harvested LNs in both groups; meanwhile, CNPs group shows superiority to control group in LN retrieval as well (11/13 trials), which also could effectively aid in locating and harvesting more LNs with diameter below 5 mm.

Conclusion

The tracing technique for CNPs is a safe and useful strategy both in localizing tumor and tracing LNs in CRC surgery. But there is still a need for more randomized controlled trials to further establish its contribution to patient survival.

Clinical application of carbon nanoparticles in lymphatic mapping during colorectal cancer surgeries: A systematic review and meta-analysis

OBJECTIVE

To investigate the overall performance of carbon nanoparticles (CNs) for detecting lymph nodes (LNs) and node metastasis during colorectal cancer surgery.

METHODS

The English and Chinese literature was searched until 29 April 2020. Studies were included if they were randomized controlled trials (RCTs) for colorectal resection and LN dissection that compared the use of CNs with a blank control in colorectal cancer surgery. Quality assessment and data extraction were performed, and a meta-analysis was conducted using ReviewManager 5.3 and Stata 15.1 software.

RESULTS

A total of 17 RCTs comprising 1241 patients were included for analysis. Compared with the outcomes of the blank controls, the use of CNs resulted in an average of 5.21 more LNs per patient (weighted mean difference = 5.21, 95% confidence interval [CI] = 4.14-6.29, p < 0.001) and a 68% higher detection rate of micro LNs (relative risk [RR] = 1.68, 95% CI = 1.38-2.04, p < 0.001). In addition, more metastatic LNs were identified in stained nodes (RR = 1.56, 95% CI = 1.40-1.75, p < 0.001), but the total detection rate of metastatic nodes did not differ between the groups.

CONCLUSION

CN is an effective lymphatic tracer in colorectal cancer surgeries. Further studies with larger sample sizes are needed to validate these findings.

The safety and effectiveness of carbon nanoparticles suspension in tracking lymph node metastases of colorectal cancer: a prospective randomized controlled trial

OBJECTIVE

This study was to evaluate the safety and effectiveness of carbon nanoparticles suspension in tracking lymph node metastases of colorectal cancer.

METHODS

Eligible patients diagnosed with stages I-III colorectal cancer in Fudan University Shanghai Cancer Center between 1 May 2017 and 31 May 2018 fulfilling the inclusion criteria were included in this prospective randomized controlled study. All the patients were randomly allocated to two groups: the nanocarbon group and the control group. Patients' clinicopathological characteristics were compared between the nanocarbon group and the control group. For continuous variables, data were presented as mean (±SD) and differences between the two groups were compared by the Mann-Whitney U test; for categorical variables, data was presented as frequency (%) and the Pearson's chi-squared test was used to compare the differences between two groups.

RESULTS

All the patients' characteristics between two groups did not achieve statistical significance (P > 0.05). Patients in nanocarbon group were more likely to be associated with more lymph nodes retrieved totally compared with control group (19.84 ± 6.428 vs. 17.41 ± 7.229, P < 0.001). The number of lymph nodes retrieved in nanocarbon group were more likely to be ≥12 than that in the control group (P = 0.005).

CONCLUSIONS

Our study confirmed the safety of using carbon nanoparticles suspension as a tracer in colorectal cancer. More importantly, nanocarbon could significantly increase the detected number of lymph nodes in colorectal cancer, which can help improve the accuracy of lymph node staging and even improve patients' survival.

Application of carbon nanoparticles in localization of parathyroid glands during total parathyroidectomy for secondary hyperparathyroidism

BACKGROUND

Intraoperative imaging is used to address the challenges of parathyroidectomy, but no standard modality has been established. This study aimed to assess whether carbon nanoparticle injection is useful in localizing parathyroid glands (PGs) during parathyroidectomy.

METHODS

Patients who underwent total parathyroidectomy (TPTX) between September 2015 and November 2018 were included. The operative duration and intact parathyroid hormones (iPTH) were analyzed.

RESULTS

A total of 61 patients were included; of these, 32 with carbon nanoparticle injection (TPTX + CN group) and 29 without (TPTX group). The operative duration in the TPTX + CN group was significantly shorter (90.6 ± 21.2 vs 101.4 ± 19.4 min, P = 0.042), which is more apparent in those with normal sized PGs. For those with four enlarged PGs, iPTH levels on 1 day and 1 year postoperatively were significantly lower in the TPTX + CN group (P = 0.032 and P = 0.036, respectively).

CONCLUSION

Carbon nanoparticles are useful in the identification normal sized PGs and complete resection of enlarged PGs.

The Methods of Lymph Node Examination Make a Difference to Node Staging and Detection of N3b Node Status for Gastric Cancer

Background: The number of retrieved lymph nodes (RLNs) affects the likelihood of detecting metastatic lymph nodes (MLNs) for gastric cancer (GC), but the retrieval of LNs is not satisfactory worldwide. There is no standard for LN examination.

Methods: We retrospectively analyzed 2,163 patients diagnosed with GC who underwent surgery at Nanfang Hospital between October 2004 and September 2016. According to the methods of LN examination, patients were classified into two groups: LN detection by pathologists (pathologist group) and LN examination by surgicopathologic team (surgicopathologist group). The relationship between RLNs and LN staging accuracy as well as the factors influencing the detection of MLNs were evaluated.

Results: There were 472 males in pathologist group and 467 males in surgicopathologist group. The number of RLNs and MLNs in surgicopathologist group was significantly higher than that in pathologist group (RLNs: 53.8 ± 20.9 vs. 18.8 ± 11.5, p < 0.001; MLNs: 5.6 ± 9.8 vs. 3.9 ± 5.7, p < 0.001). Notably, the detection of N3b node status was significantly improved in surgicopathologist group [83 (11.9%) vs. 34 (4.8%), p < 0.001]. Additionally, the detection rate of N3b status gradually increased from 0 in patients with 1-16 RLNs to 16.6% in patients with more than 49 RLNs. The MLNs detected increased gradually from 2.3 ± 3.0 in patients with 1-16 RLNs to 7.3 ± 11.7 in patients with more than 49 RLNs. Univariate and multivariate analyses indicated that LN examination by surgicopathologic team, more advanced pT, tumor size ≥5 cm and combined organ(s) resection were related to detecting more MLNs.

Conclusions: The retrieval of nodes immediately postoperatively by the surgicopathologic team could significantly improve the number of RLNs, detect more MLNs, and screen more patients with N3b node status.

Nanovectors Design for Theranostic Applications in Colorectal Cancer

Colorectal cancer (CRC) is a diffused disease with limited therapeutic options, none of which are often curative. Based on the molecular markers and targets expressed by the affected tissues, numerous novel approaches have been developed to study and treat this disease. In particular, the field of nanotechnology offers an astonishingly wide array of innovative nanovectors with high versatility and adaptability for both diagnosis and therapy (the so called “theranostic platforms”). However, such complexity can make the selection of a specific nanocarrier model to study a perplexing endeavour for the biomedical scientist or clinician not familiar with this field of inquiry. This review offers a comprehensive overview of this wide body of knowledge, in order to outline the essential requirements for the clinical viability evaluation of a nanovector model in CRC. In particular, the differences among the foremost designs, their specific advantages, and technological caveats will be treated, never forgetting the ultimate endpoint for these systems development: the clinical practice.

A case-control study of using carbon nanoparticles to trace decision-making lymph nodes around inferior mesenteric artery in rectal cancer

BACKGROUND

Accurate identification of lymph nodes localized around inferior mesenteric artery (IMA), with or without metastasis, is of crucial importance for surgeons when dissecting D2 or D3 lymph nodes in patients with rectal cancer (RC). The following study evaluates whether carbon nanoparticles can be used for detection of decision-making lymph nodes (DLNs) in station 253 lymph nodes found around IMA during RC surgery.

METHODS

A total of 66 patients with rectal adenocarcinomas were recruited between January 2014 and August 2017. Patients were divided into carbon nanoparticle (CN) group and control (CL) group; for the CN group, 1 ml nanoparticles were endoscopically injected into submucosal layer of primary tumor 1 day before surgery. DLNs were defined as black-dyed nodes in CN group or macroscopic lymph nodes in CL group localized along the IMA, proximal to the origin of the left colic artery. D3 lymph nodes were dissected using laparoscopic radical resection, and then examined using pathological approach. Intra-operative and post-operative data were compared between the two groups.

RESULTS

In CN group, black-dyed DLNs were easily found under laparoscopy; the median number of DLNs was 3 (range 1-9). In CL group, the median number of DLNs was 0 (range 0-3). Consistency between intra-operative DLNs and post-operative station 253 nodes were confirmed by pathological examination. Significant higher number of DLNs in station 253 nodes (2.91 ± 2.47 vs 0.58 ± 0.75, p < 0.001), number of station 251 nodes (12.85 ± 8.99 vs 8.09 ± 5.85, p = 0.014), number of station 253 nodes (5.21 ± 5.26 vs 3.15 ± 2.32, p = 0.045), and the number of total lymph nodes (24.06 ± 13.20 vs 16.21 ± 9.09, p = 0.007) were found in the CN group compared to CL group.

CONCLUSIONS

Carbon nanoparticles are useful for identifying DLNs in station 253 LNs around IMA in RC. It is not necessary to perform D3 lymph node dissection if there are no intra-operative DLNs metastases in RC.

A study of using carbon nanoparticles to improve lymph nodes staging for laparoscopic-assisted radical right hemicolectomy in colon cancer

PURPOSE

This study aimed to analyze and evaluate the feasibility of using carbon nanoparticles (CNs) to track lymph nodes (LNs) metastases in right colon tumors, especially for patients who underwent laparoscopic-assisted radical right hemicolectomy.

METHOD

A total of 99 patients were enrolled in this retrospective study between November 2015 and September 2017 (control group n = 47). One day before surgery, 1 ml of CNs suspension was injected into the submucosal layer around the site of the primary lesions by colonoscopy. Then complete mesocolic excision (CME) of laparoscopic right hemicolectomy was performed. CNs-stained LNs were identified and counted from all dissected LNs after surgery.

RESULTS

The dates showed that the number of total harvested LNs and the number of positive patients in the experimental group increased significantly compared with the control group (respectively, P < 0.01 and P < 0.05). The increase of positive percentage shifted some patients toward higher stage, although the total number of positive LNs changed a little bit. In addition, the duration for pathologist to dissect LNs became shorter (26.4 vs. 31.1 min, P < 0.05).

CONCLUSION

Therefore, the CNs are not only a good tattoo in laparoscopic-assisted operation, but could be regarded as a better pathological evaluating tool for tumor treatment.

Effect of pathologist's dedication on lymph node detection rate and postoperative survival in colorectal cancer

AIM

As adjuvant chemotherapy in colorectal cancer relies on the identification of lymph node metastases, the pathologist's dedication may have a considerable influence on postoperative survival.

METHOD

The aim of this retrospective study was to assess the impact of the pathologist's dedication on lymph node detection rate and postoperative survival in patients operated on by a single experienced colorectal surgeon within a 5-year period. We assessed 229 patients undergoing total mesorectal excision or complete mesocolic excision by the senior author between 1 January 2009 and 31 December 2013. Pathologists were grouped as 'general pathologist' or 'dedicated pathologist' depending on their dedication/specialization.

RESULTS

Dedicated pathologists found statistically significantly more lymph nodes in colorectal specimens than general pathologists [23 (interquartile range 24) vs 14 (interquartile range 11), respectively; P < 0.001]. The detection rate of ≥ 12 lymph nodes per specimen was significantly higher in the dedicated pathologist group [65/74 (87.8%) vs 105/155 (67.7%); P = 0.016]. However, postoperative survival did not differ in the respective subgroups. In the multivariable analysis by Cox proportional hazard model, International Union against Cancer Stage IV was the only factor associated with decreased disease-specific survival (hazard ratio 28.257; 95% CI 3.850-207.386; P = 0.001).

CONCLUSION

In our centre, the pathologist's dedication has an impact on lymph node detection rate but does not influence postoperative disease-specific survival.

Lower lymph node yield following neoadjuvant therapy for rectal cancer has no clinical significance

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.

Tattooing improves the detection of small lymph nodes and increases the number of retrieved lymph nodes in patients with rectal cancer who receive preoperative chemoradiotherapy: A randomized controlled clinical trial

BACKGROUND

In rectal cancer who received chemoradiotherapy, the number of Lymph nodes (LNs) required remains unclear. We conducted a randomized controlled trial to determine whether preoperative tattooing increases the number of LNs and enhances the detection rate of metastatic LNs.

METHODS

Eighty patients with rectal cancer who received chemoradiotherapy were randomly assigned to receive no tattooing (C group) or to receive tattooing (T group).

RESULTS

The number of LNs was significantly higher in the T group (13.3 ± 7.4, mean ± SD) than in the C group (8.8 ± 5.9, p < 0.001), however, the number of positive LNs did not differ (0.5 ± 1.3 vs. 0.5 ± 1.1, p = 0.882). The long-axis diameter of LNs was significantly smaller in the T group than in the C group (3.4 ± 1.8 vs. 3.9 ± 2.3 mm, p < 0.001), however, the long-axis diameter of positive LNs did not differ.

CONCLUSIONS

Tattooing increased the number of retrieved LNs by 51%, however, there was no increase in the number of positive LNs.

One-pot synthesis of dextran-coated iron oxide nanoclusters for real-time regional lymph node mapping

The intraoperative precision cleaning of lymph nodes (LNs) is an essential component of treating neoplastic disease. To develop efficient probes for the targeted detection of LNs that could act as carriers for the specific diagnosis and treatment of metastatic LNs in the future, dextran-coated iron oxide nanoclusters (DIONs) were synthesized using a one-pot coprecipitation procedure. These modified DIONs have good water dispersibility, cytocompatibility, an optimum size, and a stable, dark brown color for LN imaging. In this study, cytotoxicity was evaluated using lymphatic endothelial cells (LECs) to predict biosafety and biocompatibility. Most importantly, the effectiveness of DIONs in mapping perigastric LNs in Sprague Dawley rats following injection into the gastric submucosal layer was demonstrated. In addition, a long-term tracing in vivo (from 4 days to 3 months) indicated that the DIONs had good biosafety and biocompatibility according to an evaluation of the behavior and blood biochemistry of the rat and a histopathological examination of the important organs.