Trends in lymph node excision and impact of positive lymph node ratio in patients with colectomy for primary colon adenocarcinoma: Population based study 1988 to 2011

Factors influencing lymph node yield in head and neck squamous cell carcinoma: A scoping review

OBJECTIVES

In head and neck cancer surgery, several studies have demonstrated the prognostic significance of lymph node yield (LNY). To our knowledge, no review has evaluated both the contributing factors to LNY and its impact on survival outcomes across all head and neck squamous cell carcinoma (HNSCC) subsites.

MATERIALS AND METHODS

A scoping review of LNY in HNSCC was conducted according to The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) framework to answer the following research questions: 1) Which surgeon, pathologist, and patient characteristics influence LNY? 2) Which anatomic subsites does LNY impact survival?

RESULTS

Surgeon experience and variation in pathology protocols and personnel can impact LNY. Extent of nodal dissection, advanced tumor characteristics, and treatment at an academic facility are associated with increased LNY. Patient characteristics such as age <40, male gender, and BMI > 30 are associated with increased LNY. In the oral cavity, LNY > 18 is an independent predictor of improved overall survival (OS), disease free survival (DFS), and disease-specific survival (DSS). In the oropharynx, published studies show mixed results with regards to the impact of LNY on OS, DFS, and DSS. LNY has not been associated with OS or DFS in the larynx, irrespective of nodal threshold.

CONCLUSIONS

Provider and patient characteristics may impact LNY. LNY ≥ 18 is associated with a survival benefit in the oral cavity and HNSCC overall. Further investigation of LNY particularly in prospective clinical trials is required prior to its adoption as a quality metric in HNSCC.

Standardization of Colon Resection for Cancer: An Overview of the American College of Surgeons Commission on Cancer Standard 5.6

The purpose of this editorial is to review the American College of Surgeons Commission on Cancer Standard 5.6, which pertains to curative intent colon resections performed for cancer. We first provide a broad overview of the Operative Standard, followed by the underlying rationale, technical components, and documentation requirements.

Lymph node retrieval colon cancer: Are we making the grade?

BACKGROUND

Adequate lymph node (LN) excision is imperative for pathologic staging and determination of adjuvant treatment.

METHODS

he 2004-2017 National Cancer Database (NCDB) was queried for curative colon cancer resections. Tumors were categorized by location: left, right, and transverse colon cancers. Adequate (12-20 LNs) vs. inadequate (<12 LNs) lymphadenectomy was examined and sub-analysis of <12 LNs, 12-20 LNs or >20 LNs. Primary outcome was predictors of inadequate lymph node retrieval.

RESULTS

Of 101,551 patients, 11.2% (11,439) had inadequate lymphadenectomy. The inadequate lymphadenectomy rate steadily decreased. On multivariable analysis, inadequate LN retrieval was associated with transverse (OR 1.49, CI [1.30-1.71]) and left colon cancers (OR 2.66, CI [2.42-2.93], whereas income >$63,333 had decreased likelihood of inadequate LN retrieval (OR 0.68, CI[0.56-0.82].

CONCLUSION

We are making the grade as NCDB data demonstrates a steady decrease in inadequate lymphadenectomy (2004-2017). There remain socioeconomic risk factors for inadequate lymphadenectomy that need to be addressed.

EWS-FLI1-targeting peptide identifies Ewing sarcoma tumor boundaries and lymph node metastasis via near-infrared imaging

Ewing sarcoma (ES) is one of the most aggressive types of pediatric tumors. The lack of tools for the identification of ES has largely hindered clinical diagnosis and the improvement of treatment. To address this challenge, we synthesized a near‐infrared (NIR) fluorescent probe (CS2‐N‐E9R) that targets the ES‐specific fusion protein EWS–FLI1 (E/F). This probe exhibited specific and high binding affinity to E/F. Further studies in animal models showed that CS2‐N‐E9R can be used to identify the boundaries of ES and lymph node metastases under a complex biological environment. These results demonstrate that CS2‐N‐E9R is a promising probe for early diagnosis and surgical guidance of ES through molecularly targeted NIR imaging.

Modified complete mesocolic excision with central vascular ligation by the squeezing approach in laparoscopic right colectomy

PURPOSE

Complete mesocolic excision (CME) and central vascular ligation (CVL) are becoming the standard procedure in laparoscopic right-sided colectomy. However, the approach to CME and CVL has not been established, although several useful approaches have been reported. The squeezing approach described herein is a novel procedure to perform modified CME and CVL in laparoscopic right colectomy.

METHODS

The squeezing approach features retroperitoneal mobilization followed by cranial mesocolic mobilization and lymph node dissection using a cranial approach followed by a caudal approach. Dissection of the regional lymph nodes along with central vascular ligation was performed along the anterior wall of the superior mesenteric vein. In total, 177 patients (mean age, 70.6 years; male-to-female ratio, 90:87) who underwent laparoscopic right-sided colectomy were retrospectively assessed. Descriptive statistics for patient characteristics were calculated.

RESULTS

The mean operative time and blood loss were 169 min and 37 mL, respectively. Seven patients (4.0%) required conversion to open surgery, and major postoperative complications occurred in five patients (2.8%) with no anastomotic leakage. Histological R0 resection was achieved in all cases of stages 0-III colon cancer. The 5-year recurrence-free survival rates were 100% (n = 19), 100% (n = 40), 87% (n = 46), and 81% (n = 43) in pathological stages 0, I, II, and III, respectively. Node recurrence occurred in one case near the root of the middle colic artery.

CONCLUSION

The novel squeezing approach in laparoscopic right colectomy could be safely performed in terms of the technical and oncological aspects.

Colon cancer survival differs from right side to left side and lymph node harvest number matter

Background

Right-sided colorectal cancer (CRC) has worse survival than does left-sided CRC. The objective of this study was to further assess the impact of right-side location on survival and the role of the extent of lymphadenectomy.

Methods

All CRCs diagnosed between 2000 and 2012 in Emilia-Romagna Region, Italy, were included. Data for stage, grade, histology, screening history, and number of removed lymph nodes (LN) were collected. Multivariable Cox regression models were used to estimate hazard ratios (HR), with relative 95% confidence intervals (95%CI), of right vs. left colon and of removing < 12, 12–21 or > 21 lymph nodes by cancer site.

Results

During the study period, 29,358 patients were registered (8828 right colon, 18,852 left colon, 1678 transverse). Patients with right cancer were more often older, females, with advanced stage and high grade, and higher number of removed LNs. Five-year survival was lower in the right than in the left colon (55.2% vs 59.7%). In multivariable analysis, right colon showed a lower survival when adjusting for age, sex, and screening status (HR 1.12, 95%CI 1.04–1.21). Stratification by number of lymph nodes removed (12–21 or > 21) was associated with better survival in right colon (HR 0.54, 95%CI 0.40–0.72 and HR 0.40, 95%CI 0.30–0.55, respectively) compared to left colon (HR 0.89, 95%CI 0.76–1.06 and HR 0.83, 95%CI 0.69–1.01, respectively).

Conclusions

This study confirms that right CRC has worse survival; the association is not due to screening status. An adequate removal of lymph nodes is associated with better survival, although the direction of the association in terms of causal links is not clear.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10746-4.

Has the increase in the regional nodes evaluated improved survival rates for patients with locoregional colon cancer?

Background: The guidelines for colon cancer surgery have been evolving over the past three decades. The advances in colectomy have focused mainly on the number of regional nodes evaluated (RNE).

Methods: Data in this retrospective analysis were extracted from the Surveillance, Epidemiology, and End Results (SEER) linked database.

Results: Rapid growth of RNE (the median rising from 10 (6-16) to 17 (13-23)) occurred from 2000 to 2009. The rate of colon cancer patients with positive lymph nodes following colectomy was greatly decreasing only in the group with RNE greater than 12 after 2000. Patients with T4 and/or N+ cannot obtain survival benefit from the increasing trend of RNE. The apparent survival benefit for T1-3N0 patients may result from augmented false negatives in patients from previous periods.

Conclusions: The golden period of surgical development in colon cancer, using RNE as an alternative indicator, occurred in the first decade of the 21st century. Although a more extensive lymph node evaluation is able to reduce the risk of underestimated staging, the increase of RNE does not provide survival benefits for locoregional colon cancer. A proper reduction in the scope of lymph node dissection may be reasonable in radical surgery for colon cancer.

Examining More Lymph Nodes May Improve the Prognosis of Patients With Right Colon Cancer: Determining the Optimal Minimum Lymph Node Count

OBJECTIVES

The objective is to determine the optimal minimum lymph node examination number for right colon cancer (RCC) patients.

METHODS

We comprehensively analysed the Surveillance, Epidemiology and End Results database data from 2004 to 2016 to determine the 13-year trend in the number of lymph nodes examined among 108,703 left colon cancer and 165,937 RCC patients. 133,137 RCC patients eligible for inclusion were used to determine the optimal minimum for lymph node examination. We used restricted cubic splines to analyse the dose-response relationship between the number of lymph nodes examined and prognosis. X-tiles and decision trees were used to determine the optimal cutoff for the number of lymph nodes based on the survival outcomes of patients with RCC. The Kaplan-Meier method and COX model were used to estimate the overall survival and independent prognostic factors, and a prediction model was constructed. The C-index, calibration curve, net reclassification improvement and integrated discrimination improvement were used to determine the predictive performance of the model, and decision curve analysis was used to evaluate the benefits.

RESULTS

Lymph node examinations were common among colon cancer patients over the 13-year study period. It is generally agreed that at least 12 lymph nodes must be examined to ensure proper dissection and accurate staging of RCC; however, the optimal number of lymph nodes to be examined is controversial. The dose-response relationship indicated that 12 was not the optimal minimum number of lymph nodes for RCC patients. X-tile and survival decision-tree analysis indicated that 20 nodes was the optimal number. Survival analysis indicated that <20 nodes examined was a risk factor for poor prognosis, and the classification performance was superior for 20 nodes compared to 12 nodes.

CONCLUSION

Lymph node examination in RCC patients should be altered. Our research suggests that a 20-node measure may be more suitable for RCC patients.

Laparoscopic colectomies associated with decreased retrieval of 12 or more lymph nodes compared to open in elective colon cancer surgery

Background

Colorectal cancer is the third most commonly diagnosed cancer worldwide. Lymph node (LN) retrieval is a key factor for pathologic staging and prognosis of colorectal cancer. Increase in number of LNs removal suggests improvement in tumour clearance and decrease in metastatic spread. Studies have suggested that excising 12 or more LNs during colectomy in patients with colon cancer is associated with improved survival. To date, there have been no studies to determine whether minimally invasive surgery affects the ability to retrieve 12+ LNs in elective colon cancer surgery. Therefore, we elected to determine whether a difference exists on the ability to retrieve 12+ nodes in elective colon cancer colectomies performed open versus laparoscopic.

Methods

The National Surgical Quality Improvement Program (NSQIP) Procedure Specific Colectomy database was analysed for the year 2014–2015. Inclusion criteria were colon cancer (ICD-9 Code 153.9), age greater than 18 years. Exclusion criteria were missing data. Data abstracted included patient demographics, type of operation performed and number of LNs retrieved. The patients were categorised based on their elective colon cancer colectomies such as laparoscopic or open. Binary logistic regression was used to identify confounding variables in the retrieval of 12+ LNs.

Results

After accounting for missing cases, a total of 18,792 patients with a diagnosis of colon cancer were analysed. Twelve or more LNs were retrieved in 88% (16,538) of patients, Among them, 2,516 patients underwent laparoscopic colectomy and 5,284 patients underwent open colectomy. The difference was not statistically significant for the average number of LNs retrieved among both the groups. Open operative approach compared to the laparoscopic approach was associated with 15% greater odds of retrieval of >12 LNs (OR 1.148; 95% CI (1.035–1.272); p = 0.008).

Conclusion

The majority of colectomies such as open or laparoscopic are able to retrieve 12 or more LNs. However, there are greater odds of retrieving more than 12 LNs with the open approach compared to the laparoscopic approach. By allowing for more LN retrieval, open colectomies suggest improvement in tumour clearance and decrease metastatic spread. Additional research is needed to further investigate the specific factors influencing the ability to retrieve an adequate number of LNs, such as viewing angles provided with an open approach versus laparoscopic approach.

Factors affecting retrieval of 12 or more lymph nodes in pT1 colorectal cancers

Objective

The aim of this study was to identify clinicopathological factors that affect the number of lymph nodes (LNs) (12 or more) retrieved from patients with colorectal cancer (CRC), particularly those with pathologic T1 (pT1) disease.

Methods

From 429 CRC patients, 75 pT1 cancers were identified and digitally scanned. Binary logistic regression analysis was performed to identify the clinicopathological factors affecting the number of LNs retrieved from all 429 patients and from the subset of patients with pT1 CRC.

Results

For the 429 patients, the mean number of harvested LNs per specimen was 20 (median, 19). The number of retrieved LNs was independently associated with maximum tumor diameter > 2.3 cm and right-sided tumor location. The mean number of LNs retrieved from the 75 patients with pT1 CRC was 14 (median, 15); retrieval of 12 or more LNs from this group was independently associated with maximum tumor diameter > 14.1 mm.

Conclusion

The number of LNs retrieved from patients with CRC was associated with maximum tumor diameter and right-sided tumor location. For patients with pT1 CRC, maximum tumor diameter was independently associated with the harvesting of 12 or more LNs.

Prognostic Significance of Tumor Deposits in Patients With Stage III Colon Cancer: A Nomogram Study

BACKGROUND

The clinical characteristics of stage III colon cancer and the prognostic significance of tumor deposits were investigated, to construct a prognostic nomogram.

METHODS

The data of patients were retrieved from the Surveillance, Epidemiology, and End Results database. Patients were randomized to a training or validation cohort. The Kaplan-Meier method was used to analyze survival rates. In the training cohort, a prognostic nomogram was established via Cox regression and then tested in the validation cohort. The accuracy and discrimination of the nomogram were assessed using concordance indices (C-indices) and calibration curves.

RESULTS

Of the 9246 patients meeting the inclusion criteria, 1788 (19.3%) had tumor deposits. Patients with tumor deposits only showed similar survival rates to those with lymph node metastases only (P = 0.83). Compared with these, patients with both tumor deposits and lymph node metastases exhibited significantly worse survival (P < 0.01). In the multivariate Cox regression analyses, the following were identified as independent prognostic indicators and adopted to formulate the nomogram: tumor deposits, age, ethnicity, T stage, the number of positive regional lymph nodes, grade, and carcinoembryonic antigen. In the training cohort, the calibration curve showed good consistency, and the concordance index of the nomogram for predicting overall survival reaches 0.727 (95% CI: 0.71524-0.73876), superior to the concordance index of the American Joint Committee on Cancer staging system (0.594, 95% CI: 0.58224-0.60576). These results are supported in the validation cohort.

CONCLUSIONS

Tumor deposits may be an independent prognostic factor for patients with stage III colon cancer after colectomy. The nomogram constructed herein accurately predicted overall survival.

Usefulness of the endoscopic surgical skill qualification system in laparoscopic colorectal surgery: short-term outcomes: a single-center and retrospective analysis

BACKGROUND

The use of laparoscopic surgery has become widespread, and many surgeons are striving to acquire the necessary techniques for it. The Endoscopic Surgical Skill Qualification System (ESSQS), established by the Japan Society for Endoscopic Surgery, serves to maintain and improve the quality of laparoscopic surgery in Japan. In this study, we aimed to determine whether ESSQS certification is useful in maintaining and improving the quality of surgical techniques and in standardization of laparoscopic surgery in Japan.

METHODS

This retrospective study used data from the Institute for Integrated Medical Sciences, Tokyo Women's Medical University, Japan. From January 2016 to October 2017, 241 patients with colorectal cancer underwent laparoscopic surgery. Of them, 220 patients were selected and divided into two groups on the basis of surgery performed by an ESSQS-qualified surgeon (QS group) (n = 170) and a non-ESSQS-QS (NQS) (n = 50). We compared the short-term results in the two groups and examined those before and after propensity score matching (PSM).

RESULTS

Mean operation time was longer in the NQS group than in the QS group. Furthermore, mean blood loss was significantly less in the QS group. These were similar before and after PSM. The rate of conversion to open surgery was significantly higher in the NQS group before PSM. However, the rate of postoperative complications was not different between the two groups.

CONCLUSIONS

A laparoscopic procedure performed by ESSQS-QS often leads to good short-term outcomes. Thus, the ESSQS system works and is potentially useful in maintaining and improving the quality of surgical techniques and in standardization of laparoscopic surgery in Japan.

Marked impact of tumor location on the appropriate cutoff values and the prognostic significance of the lymph node ratio in stage III colon cancer: a multi-institutional retrospective analysis

BACKGROUND

The prognostic significance of lymph node ratio (LNR) is not constant among studies. Exploration of appropriate location-specific cutoffs might be necessary because the number of lymph nodes harvested is generally higher in right than in left colon cancer. We aimed to determine appropriate cutoff values of LNR in right and left colon cancer and to clarify its clinical significance.

METHODS

The clinicopathologic data of 5463 patients with stage III colon cancer were collected. The best cutoff for LNR as a prognostic indicator for patients with right and left colon cancer was studied separately. We compared the prognostic impact between LNR and the number of lymph node metastasis using the Akaike information criterion (AIC), and evaluated the prognostic significance of LNR in each stage III subcategory.

RESULTS

The best performance was noted when LNR was categorized by cutoffs of 0.16 and 0.22 for right and left colon cancer, respectively. AIC scores were better with these categorizations than with subgrouping by number of positive nodes. LNR-low right colon cancer patients showed better cancer-specific survival than LNR-high in stage IIIA (95.7% vs. 89.3%), IIIB (86.7% vs. 77.2%), and IIIC (71.2% vs. 58.7%). The same results were obtained in left colon cancer patients with stage IIIB (88.3% vs. 80.7%) and IIIC (79.8% vs. 68.4%).

CONCLUSIONS

We demonstrated the difference in the appropriate cutoffs of LNR between right and left colon cancer. Categorization by location-specific cutoff of LNR may be useful for risk stratification of patients with stage III cancer.

Prognostic value of total number of lymph nodes retrieved differs between left-sided colon cancer and right-sided colon cancer in stage III patients with colon cancer

Background

The consensus is that a minimum of 12 lymph nodes should be analyzed at colectomy for colon cancer. However, right colon cancer and left colon cancer have different characteristics, and this threshold value for total number of lymph nodes retrieved may not be universally applicable.

Methods

The data of 63,243 patients with colon cancer treated between 2004 and 2012 were retrieved from the National Cancer Institute’s Surveillance, Epidemiology, and End Results database. Multivariate Cox regression analysis was used to determine the predictive value of total number of lymph nodes for survival after adjusting for lymph nodes ratio. The predictive value in left-sided colon cancer and right-sided colon cancer was compared. The optimal total number of lymph nodes cutoff value for prediction of overall survival was identified using the online tool Cutoff Finder. Survival of patients with high total number of lymph nodes (≥12) and low total number of lymph nodes (< 12) was compared by Kaplan–Meier analysis.

Results

After stratifying by lymph nodes ratio status, total number of lymph nodes≥12 remained an independent predictor of survival in the whole cohort and in right-sided colon cancer, but not in left-sided colon cancer. The optimal cutoff value for total number of lymph nodes was determined to be 11. Low total number of lymph nodes (< 11) was associated with significantly poorer survival after adjusting for lymph nodes ratio in all subgroups except in the subgroup with high lymph nodes ratio (0.5–1.0).

Conclusions

Previous reports of the prognostic significance of total number of lymph nodes on node-positive colon cancer were confounded by lymph nodes ratio. The 12-node standard for total number of lymph nodes may not be equally applicable in right-sided colon cancer and left-sided colon cancer.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4431-5) contains supplementary material, which is available to authorized users.

Rectal cancer and the pathologist

Examination of the rectum by pathologists is instrumental in the management of patients affected by rectal carcinoma. That role includes evaluation of multiple gross and microscopic features that convey prognostic implications. The analysis is based on the authors' experience handling rectal specimens along with review of the pertinent literature in these areas: margins of excision, quality of the mesorectum, diligence and techniques to sample lymph nodes, tumor budding, grading of residual amount of carcinoma after preoperative therapy, vascular/perineural invasion, and staging the tumor. Pathologists must communicate the findings in a clear manner. Evaluation of margins and completeness of mesorectum are markers of the quality of surgical excision. The number of lymph nodes obtained and examined is dependent in great part on the diligence of the pathologist finding them in the mesenteric adipose tissue. There are grades for budding and response to prior chemoradiation therapy. The location of vascular invasion (extramural vs. intramural) may predict aggressive behavior. Pathologists proactively are to choose sections of tumor for molecular testing. Meticulous macro- and microscopic evaluation of specimens for rectal carcinoma by pathologist is needed to determine an accurate assessment of staging and other prognostic factors. The modern pathologists play a pivotal part in the care and management of patients suffering from rectal adenocarcinoma. That role goes from the initial histological diagnosis to the gross and microscopic examination of the excised specimens. Based on that examination pathologists issue statements that not only evaluate the quality of the surgical procedure, but also through the application of molecular tests they give light on prognostic factors and information for therapeutic purposes.

Supervision by a technically qualified surgeon affects the proficiency and safety of laparoscopic colectomy performed by novice surgeons

BACKGROUND

The use of laparoscopic colectomy is becoming widespread and acquisition of its technique is challenging. In this study, we investigated whether supervision by a technically qualified surgeon affects the proficiency and safety of laparoscopic colectomy performed by novice surgeons.

METHODS

The outcomes of 23 right colectomies and 19 high anterior resections for colon cancers performed by five novice surgeons (experience level of <10 cases) between 2014 and 2016 were assessed. A laparoscopic surgeon qualified by the Endoscopic Surgical Skill Qualification System (Japan Society for Endoscopic Surgery) participated in surgeries as the teaching assistant.

RESULTS

In the right colectomy group, one patient (4.3%) required conversion to open surgery and postoperative morbidities occurred in two cases (8.6%). The operative time moving average gradually decreased from 216 to 150 min, and the blood loss decreased from 128 to 28 mL. In the CUSUM charts, the values for operative time decreased continuously after the 18th case, as compared to the Japanese standard. The values for blood loss also plateaued after the 18th case. In the high anterior resection group, one patient (5.2%) required conversion to open surgery and no postoperative complication occurred in any patient. The operative time moving average gradually decreased from 258 to 228 min, and the blood loss decreased from 33 to 18 mL. The CUSUM charts showed that the values of operative time plateaued after the 18th case, as compared to the Japanese standard. In the CUSUM chart for blood loss, no distinguishing peak or trend was noted.

CONCLUSIONS

Supervision by a technically qualified surgeon affects the proficiency and safety of laparoscopic colectomy performed by novice surgeons. The trainee's learning curve in this study represents successful mentoring by the laparoscopic surgeon qualified by the Endoscopic Surgical Skill Qualification System.