Predictive model of outcome of targeted nodal assessment in colorectal cancer. Ann Surg. 2010;251:265-274. [PMID: 20054276 DOI: 10.1097/sla.0b013e3181bd5187]

Laparoscopic right hemicolectomy with complete mesocolic excision and D3 lymphadenectomy using the open book approach: a video vignette

According to the concept of total mesorectal excision for rectal cancer, Hohenberger translated this concept to colonic cancer by introducing complete mesocolic excision (CME). The concept of this surgical technique was further elucidated by Benz et al. in the form of an open book approach. This article presents and demonstrates in a video a case of laparoscopic right hemicolectomy with CME and D3 lymphadenectomy using open book approach in the treatment of a T3N1M0 distal ascending colonic adenocarcinoma. The final pathology report confirmed moderately differentiated adenocarcinoma with a maximum tumor size of 55 mm and 0/60 lymph nodes. The mesocolic fascia was intact and R0 was achieved. The final staging was pT3pN0pM0. However, D3 lymphadenectomy is not universally adopted due to concerns of higher morbidity we believe that with adequate training and supervision CME with D3 LDN is feasible and safe to be offered to all right-sided colorectal cancers with curative intent treatment.

Multidisciplinary Treatment Strategy for Early Colon Cancer: A Review-An English Version

Treatment for early colon cancer has progressed rapidly, with endoscopic resection and minimally invasive surgery. It is important to select patients without risk of lymph node metastasis before deciding on endoscopic resection for early colon cancer treatment. Pathological risk factors include histologic grade of cancer cell differentiation, lymphovascular invasion, perineural invasion, tumor budding, and deep submucosal invasion. These risk factors for predicting lymph node metastasis are crucial for determining the treatment strategy of endoscopic excision and radical resection for early colon cancer. A multidisciplinary approach is emphasized to establish a treatment strategy for early colon cancer to minimize the risk of complications and obtain excellent oncologic outcomes by selecting an appropriate treatment optimized for the patient's stage and condition. Therefore, we aimed to review the optimal multidisciplinary treatment strategies, including endoscopy and surgery, for early colon cancer.

Multidisciplinary treatment strategy for early colon cancer

Background: Treatment for early colon cancer has progressed rapidly with endoscopic resection and minimally invasive surgery. Selection of patients without risk of lymph node metastasis is necessary before deciding on endoscopic resection for early colon cancer treatment. We aimed to review the optimal multidisciplinary treatment strategies for early colon cancer, including endoscopy and surgery.Current Concepts: Pathological risk factors include histologic grade of cancer cell differentiation, lymphovascular invasion, perineural invasion, tumor budding, and deep submucosal invasion. These risk factors for predicting lymph node metastasis are crucial for determining the treatment strategy of endoscopic excision and radical resection for early colon cancer. Prediction of the depth of invasion in early colon cancer using endoscopic optical assessments is vital to determine the appropriate treatment method for endoscopic or surgical resection. Furthermore, optical assessment of pit and vascular patterns is useful for estimating the depth of submucosal invasion using magnifying chromoendoscopy and narrow-band imaging endoscopy. Performing an endoscopic and pathologic evaluation of the risk factors for lymph node metastasis is imperative when selecting endoscopic or surgical resection. Endoscopic treatments include cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection. In addition, appropriate surgical treatment should be recommended for patients with early colon cancer with a high risk of lymph node metastasis.Discussion and Conclusion: A multidisciplinary approach should be recommended to establish an optimized treatment strategy, minimize the risk of complications, and obtain excellent oncologic outcomes via patienttailored treatment in patients with early colon cancer.

Is Laparoscopic Complete Mesocolic Excision and Central Vascular Ligation Really Necessary for All Patients With Right-Sided Colon Cancer?

Colon cancer treatment is on the way to evolution over several decades. The minimally invasive surgery has improved postoperative short-term outcomes. Adjuvant chemotherapy has prolonged the survival of advanced colon cancer patients. Hohenberger proposed the noble concept of complete mesocolic excision (CME) which consists of 3 components: plane surgery, sufficient longitudinal bowel resection, and central vascular ligation (CVL). Mesocolic plane surgery shares the same surgical principle of total mesorectal excision, which is maintaining the intact mesothelial envelope. However, there remain debates about the extent of bowel resection and the level of CVL for maximizing lymph node dissection. There is no solid clinical evidence for the oncological necessity and benefit of extended radical dissection in right hemicolectomy. CME with CVL based on open surgery has been adopted in laparoscopic surgery. So, it is also necessary to look at how the CME could be transformed and successfully implanted in the laparoscopic era. Recent rapid advances in surgical technology and cancer biology are preparing for fundamental changes in cancer surgery. In this study, we reviewed the history, oncological necessity, and compatibility of CME for the right hemicolectomy in the laparoscopic era and outline the new perspectives on the evolution of cancer surgery.

Multifunctional Indocyanine Green Applications for Fluorescence-Guided Laparoscopic Colorectal Surgery

Indocyanine green (ICG) could be applied for multiple functions such as fluorescent tumor localization, fluorescence lymph node mapping (FLNM), and intraoperative angiography in colorectal cancer surgery. With the near-infrared (NIR) systems, colonoscopic ICG tattooing can be used to define the early colorectal cancer that cannot be easily distinguished through the serosal surface. The lymphatic pathways can be visualized under the NIR system when ICG is injected through the submucosal or subserosal layer around the tumor. Intraoperative ICG angiography can be applied to find a favorable perfusion segment before the colon transection. Although all fluorescence functions are considered essential steps in image-guided surgery, it is difficult to perform multifunctional ICG applications in a single surgical procedure at once because complex protocols could interfere with each other. Therefore, we review the multifunctional ICG applications for fluorescent tumor localization, FLNM, and ICG angiography. We also discuss the optimal protocol for fluorescence-guided colorectal surgery.

Prediction of Postoperative Clinical Recovery of Drop Foot Attributable to Lumbar Degenerative Diseases, via a Bayesian Network

BACKGROUND

Drop foot resulting from degenerative lumbar diseases can impair activities of daily living. Therefore, predictors of recovery of this symptom have been investigated using univariate or/and multivariate analyses. However, the conclusions have been somewhat controversial. Bayesian network models, which are graphic and intuitive to the clinician, may facilitate understanding of the prognosis of drop foot resulting from degenerative lumbar diseases.

QUESTIONS/PURPOSES

(1) To show a layered correlation among predictors of recovery from drop foot resulting from degenerative lumbar diseases; and (2) to develop support tools for clinical decisions to treat drop foot resulting from lumbar degenerative diseases.

METHODS

Between 1993 and 2013, we treated 141 patients with decompressive lumbar spine surgery who presented with drop foot attributable to degenerative diseases. Of those, 102 (72%) were included in this retrospective study because they had drop foot of recent development and had no diseases develop that affect evaluation of drop foot after surgery. Specifically, 28 (20%) patients could not be analyzed because their records were not available at a minimum of 2 years followup after surgery and 11 (8%) were lost owing to postoperative conditions that affect the muscle strength evaluation. Eight candidate variables were sex, age, herniated soft disc, duration of the neurologic injury (duration), preoperative tibialis anterior muscle strength (pretibialis anterior), leg pain, cauda equina syndrome, and number of involved levels. Manual muscle testing was used to assess the tibialis anterior muscle strength. Drop foot was defined as a tibialis anterior muscle strength score of less than 3 of 5 (5 = movement against gravity and full resistance, 4 = movement against gravity and moderate resistance, 3 = movement against gravity through full ROM, 3- = movement against gravity through partial ROM, 2 = movement with gravity eliminated through full ROM, 1 = slight contraction but no movement, and 0 = no contraction). The two outcomes of interest were postoperative tibialis anterior muscle strength (posttibialis anterior) of 3 or greater and posttibialis anterior strength of 4 or greater at 2 years after surgery. We developed two separate Bayesian network models with outcomes of interest for posttibialis anterior strength of 3 or greater and posttibialis anterior strength of 4 or greater. The two outcomes correspond to "good" and "excellent" results based on previous reports, respectively. Direct predictors are defined as variables that have the tail of the arrow connecting the outcome of interest, whereas indirect predictors are defined as variables that have the tail of the arrow connecting either direct predictors or other indirect predictors that have the tail of the arrow connecting direct predictors. Sevenfold cross validation and receiver-operating characteristic (ROC) curve analyses were performed to evaluate the accuracy and robustness of the Bayesian network models.

RESULTS

Both of our Bayesian network models showed that weaker muscle power before surgery (pretibialis anterior ≤ 1) and longer duration of neurologic injury before treatment (> 30 days) were associated with a decreased likelihood of return of function by 2 years. The models for posttibialis anterior muscle strength of 3 or greater and posttibialis anterior muscle strength of 4 or greater were the same in terms of the graphs, showing that the two direct predictors were pretibialis anterior muscle strength (score ≤ 1 or ≥ 2) and duration (≤ 30 days or > 30 days). Age, herniated soft disc, and leg pain were identified as indirect predictors. We developed a decision-support tool in which the clinician can enter pretibialis anterior muscle strength and duration, and from this obtain the probability estimates of posttibialis anterior muscle strength. The probability estimates of posttibialis anterior muscle strength of 3 or greater and posttibialis anterior muscle strength of 4 or greater were 94% and 85%, respectively, in the most-favorable conditions (pretibialis anterior ≥ 2; duration ≤ 30 days) and 18% and 14%, respectively, in the least-favorable conditions (pretibialis anterior ≤ 1; duration > 30 days). On the sevenfold cross validation, the area under the ROC curve yielded means of 0.78 (95% CI, 0.68-0.87) and 0.74 (95% CI, 0.64-0.84) for posttibialis anterior muscle strength of 3 or greater and posttibialis anterior muscle strength of 4 or greater, respectively.

CONCLUSIONS

The results of this study suggest that the clinician can understand intuitively the layered correlation among predictors by Bayesian network models. Based on the models, the decision-support tool successfully provided the probability estimates of posttibialis anterior muscle strength to treat drop foot attributable to lumbar degenerative diseases. These models were shown to be robust on the internal validation but should be externally validated in other populations.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Colorectal cancer and lymph nodes: The obsession with the number 12

Lymphadenectomy of colorectal cancer is a decisive factor for the prognostic and therapeutic staging of the patient. For over 15 years, we have asked ourselves if the minimum number of 12 examined lymph nodes (LNs) was sufficient for the prevention of understaging. The debate is certainly still open if we consider that a limit of 12 LNs is still not the gold standard mainly because the research methodology of the first studies has been criticized. Moreover many authors report that to date both in the United States and Europe the number “12” target is uncommon, not adequate, or accessible only in highly specialised centres. It should however be noted that both the pressing nature of the debate and the dissemination of guidelines have been responsible for a trend that has allowed for a general increase in the number of LNs examined. There are different variables that can affect the retrieval of LNs. Some, like the surgeon, the surgery, and the pathology exam, are without question modifiable; however, other both patient and disease-related variables are non-modifiable and pose the question of whether the minimum number of examined LNs must be individually assigned. The lymph nodal ratio, the sentinel LNs and the study of the biological aspects of the tumor could find valid application in this field in the near future.

Factors influencing the success of in vivo sentinel lymph node procedure in colon cancer patients: Swiss prospective, multicenter study sentinel lymph node procedure in colon cancer

BACKGROUND

The sentinel lymph node (SLN) procedure has the potential to provide relevant improvement in nodal staging in colon cancer patients. However, there remains room for improvement for SLN identification and sensitivity. Therefore, the objective of the present investigation was to analyze factors influencing the success of the SLN procedure in colon cancer patients.

METHODS

One hundred seventy-four consecutive colon cancer patients were prospectively enrolled in this multicenter study and underwent in vivo SLN procedure with isosulfan blue 1 % followed by open standard oncologic colon resection. Several patient-, tumor-, and procedure-related factors possibly influencing the SLN identification and sensitivity were analyzed.

RESULTS

Sentinel lymph node identification rate and accuracy were 89.1 and 83.9 %, respectively. Successful identification of SLN was significantly associated with the intraoperative visualization of blue lymphatic vessels (p < 0.001) and with female gender (p = 0.024). True positive SLN results were significantly associated with higher numbers of SLN (p = 0.026) and with pN2 stage (p = 0.004). There was a trend toward better sensitivity in patients with lower body mass index (BMI) (p = 0.050).

CONCLUSIONS

The success of the SLN procedure in colon cancer patients depends on both procedure-related factors (intraoperative visualization of blue lymphatic vessels, high number of SLN identified) and patient factors (gender, BMI). While patient factors can not be influenced, intraoperative visualization of blue lymphatics and identification of high numbers of SLN are key for a successful SLN procedure.

The effect of colonoscopic tattooing on lymph node retrieval and sentinel lymph node mapping

BACKGROUND

In colorectal cancer (CRC), colonoscopic tattooing is performed to mark the tumor site before laparoscopic surgery.

OBJECTIVE

To determine whether colonoscopic tattooing can be used to refine staging accuracy by increasing the lymph node (LN) yield per specimen and to determine its accuracy as a sentinel LN procedure.

DESIGN

Retrospective, case-control study. All LNs were microscopically examined for the presence of carbon particles.

SETTING

A university hospital and a teaching hospital.

PATIENTS

A consecutive series of 95 tattooed patients who had surgery for CRC between 2005 and 2009. A series of 210 non-tattooed patients who had surgery in the same time period served as controls.

MAIN OUTCOME MEASUREMENTS

Total number of LNs retrieved, detection rate, and sensitivity of tattooing as a sentinel node procedure.

RESULTS

A higher LN yield was observed in patients with preoperative tattooing, median (interquartile range) 15 (10-20) versus 12 (9-16), (P = .014). In multivariable analysis, the presence of carbon-containing LNs was an independent predictive factor for a higher LN yield (P = .002). The detection rate was 71%, with a median of 5 carbon-containing LNs per specimen. If preoperative tattooing was used for sentinel node mapping, the overall accuracy of predicting LN status was 94%. In the 24 N1 cases, there were 4 false-negative procedures (sensitivity 83%).

LIMITATIONS

Retrospective series.

CONCLUSION

After tattooing of CRC, the LN yield was higher than in a control group, and it could be used as a sentinel node procedure with acceptable accuracy rates. Because LN yield and sentinel node mapping are associated with improved diagnostic accuracy of LN involvement, preoperative tattooing can refine staging.

Implications of sentinel lymph node mapping on nodal staging and prognosis in colorectal cancer

AIM

Sentinel lymph node (SN) mapping for staging in colorectal cancer remains controversial and needs to be validated before it can be implemented in daily practice. We prospectively assessed the effect of SN mapping on nodal staging and its implication on survival in patients with colorectal cancer.

METHOD

Between November 2005 and July 2009, 331 patients underwent a resection for colorectal cancer. In 189 patients (group A) an ex-vivo SN procedure was performed with immunohistochemical analysis of the SN. Tumour cell deposits between 0.2 mm and 2.0 mm were referred to as micrometastases (pN1mi+). The remaining patients (n = 142, group B) had standard nodal staging. Multivariate Cox regression analysis was performed to identify prognostic factors for disease recurrence.

RESULTS

The average number of harvested lymph nodes was higher in group A than in group B (15.5 ± 7.3 vs 12.1 ± 5.2, P < 0.0001). After conventional staging, 81 (43%) patients of group A were judged to have nodal metastasis. This increased to 89 (47%) patients when immunohistochemically detected micrometastases were included. In group B, 50 (35%) patients had nodal metastasis. During follow up, a lower recurrence rate was seen in N0 patients after SN mapping compared with the conventional staging group (4%vs 15.2%, P = 0.04). The SN procedure (hazard ratio = 4.1) was an independent predictor of disease recurrence.

CONCLUSION

The SN procedure results in a more accurate staging of patients with colorectal cancer. This is reflected by a better prognosis of N0 patients after SN mapping.

Systematic review of sentinel lymph node mapping procedure in colorectal cancer

BACKGROUND

The clinical impact of sentinel lymph node (SN) biopsy in colorectal cancer is still controversial. The aim of our study was to determine the accuracy of this procedure from published data and to identify factors that contribute to the conflicting reports.

METHODS

A systematic search of the Medline, Embase, and Cochrane databases up to July 2011 revealed 98 potentially eligible studies, of which 57 were analyzed including 3,934 patients (3,944 specimens).

RESULTS

The pooled SN identification rate was 90.7% (95% CI 88.2-93.3), with a significant higher identification rate in studies including more than 100 patients or studies using the ex vivo SN technique. The pooled sensitivity of the SN procedure was 69.6% (95% CI 64.7-74.6). Including the immunohistochemical findings increased the pooled sensitivity of SN procedure to 80.2% (95% CI 4.7-10.7). Subgroups with significantly higher sensitivity could be identified: ≥4 SNs versus <4 SNs (85.2 vs. 66.3%, p = 0.003), colon versus rectal cancer (77.6 vs. 65.7%, p = 0.04), early T1 or T2 versus advanced T3 or T4 carcinomas (93.4 vs. 58.8%, p = 0.01). Serial sectioning and immunohistochemistry resulted in a mean upstaging of 18.9% (range 0-50%). True upstaging defined as micrometastases (pN1mi+) rather than isolated tumor cells (pN0itc+) was 7.7%.

CONCLUSIONS

The SN procedure in colorectal cancer has an overall sensitivity of 70%, with increased sensitivity and refined staging in early-stage colon cancer. Because the ex vivo SN mapping is an easy technique it should be considered in addition to conventional resection in colon cancer.

Near-infrared (NIR) laparoscopy for intraoperative lymphatic road-mapping and sentinel node identification during definitive surgical resection of early-stage colorectal neoplasia

BACKGROUND

Appropriate lymphatic assessment is a cornerstone of definitive surgical resection for colorectal cancer. Near-infrared (NIR) laparoscopy may allow real-time intraoperative identification of territorial lymphatic drainage and sentinel nodes in patients with early-stage disease prior to radical basin resection.

METHODS

With IRB approval and individual consent, consecutive patients with radiologically localized neoplasia underwent peritumoral submucosal injection of indocyanine green (ICG, a fluorophore capable of injection site tattooing and efferent lymphatic migration) prior to standard laparoscopic oncological resection. Intraoperatively, a prototype NIR laparoscope provided both white light and, by switch activation, NIR irradiation with or without discrete spectral back-filtration. Fluorescence identification of sentinel nodes prior to formal specimen dissection allowed their identification for separate histopathological analysis by in situ clipping when found within the specimen or selective lymphadenectomy by "berry-picking" when such nodes lay outside of the standard resection field. Concordance with nonsentinel nodes was then analysed.

RESULTS

Eighteen patients (mean age = 66.4 years [range = 47.9-80.1], mean BMI = 29.1 [range = 20.0-39.9]) were studied. Fourteen had biopsy-proven carcinoma and four had endoscopically unresectable dysplasia. Mesocolic sentinel nodes (mean = 4.1/patient) were rendered obvious by fluorescence either solely within the standard resection field (n = 14) or both within and without the planned field (n = 4) within minutes of dye injection in every case. Laparoscopic ultrasound (n = 5) as well as histopathological analysis demonstrated oncologic correlation of mesocolic sentinel with corresponding territory nonsentinel nodes, correctly confirming the presence of mesocolic disease in 3 patients and the absence of such lymphatic spread in the remaining 15 patients.

CONCLUSIONS

In this study, NIR laparoscopy with ICG mapping allowed ready and rapid confirmation of mesocolic lymphatic drainage patterns and sentinel node identification. With further validation, this technology and technique promises precise, tailored resection surgery by indicating basin pattern and status in advance of radical lymphadenectomy.

Development of a prognostic naive bayesian classifier for successful treatment of nonunions

BACKGROUND

predictive models permitting individualized prognostication for patients with fracture nonunion are lacking. The objective of this study was to train, test, and cross-validate a Bayesian classifier for predicting fracture-nonunion healing in a population treated with extracorporeal shock wave therapy.

METHODS

prospectively collected data from 349 patients with delayed fracture union or a nonunion were utilized to develop a naïve Bayesian belief network model to estimate site-specific fracture-nonunion healing in patients treated with extracorporeal shock wave therapy. Receiver operating characteristic curve analysis and tenfold cross-validation of the model were used to determine the clinical utility of the approach.

RESULTS

predictors of fracture-healing at six months following shock wave treatment were the time between the fracture and the first shock wave treatment, the time between the fracture and the surgery, intramedullary stabilization, the number of bone-grafting procedures, the number of extracorporeal shock wave therapy treatments, work-related injury, and the bone involved (p < 0.05 for all comparisons). These variables were all included in the naïve Bayesian belief network model.

CONCLUSIONS

a clinically relevant Bayesian classifier was developed to predict the outcome after extracorporeal shock wave therapy for fracture nonunions. The time to treatment and the anatomic site of the fracture nonunion significantly impacted healing outcomes. Although this study population was restricted to patients treated with shock wave therapy, Bayesian-derived predictive models may be developed for application to other fracture populations at risk for nonunion.

LEVEL OF EVIDENCE

prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

IgG responses to tissue-associated antigens as biomarkers of immunological treatment efficacy

We previously demonstrated that IgG responses to a panel of 126 prostate tissue-associated antigens are common in patients with prostate cancer. In the current report we questioned whether changes in IgG responses to this panel might be used as a measure of immune response, and potentially antigen spread, following prostate cancer-directed immune-active therapies. Sera were obtained from prostate cancer patients prior to and three months following treatment with androgen deprivation therapy (n = 34), a poxviral vaccine (n = 31), and a DNA vaccine (n = 21). Changes in IgG responses to individual antigens were identified by phage immunoblot. Patterns of IgG recognition following three months of treatment were evaluated using a machine-learned Bayesian Belief Network (ML-BBN). We found that different antigens were recognized following androgen deprivation compared with vaccine therapies. While the number of clinical responders was low in the vaccine-treated populations, we demonstrate that ML-BBN can be used to develop potentially predictive models.

Application of Bayesian classifier for the diagnosis of dental pain

Toothache is the most common symptom encountered in dental practice. It is subjective and hence, there is a possibility of under or over diagnosis of oral pathologies where patients present with only toothache. Addressing the issue, the paper proposes a methodology to develop a Bayesian classifier for diagnosing some common dental diseases (D = 10) using a set of 14 pain parameters (P = 14). A questionnaire is developed using these variables and filled up by ten dentists (n = 10) with various levels of expertise. Each questionnaire is consisted of 40 real-world cases. Total 14*10*10 combinations of data are hence collected. The reliability of the data (P and D sets) has been tested by measuring (Cronbach's alpha). One-way ANOVA has been used to note the intra and intergroup mean differences. Multiple linear regressions are used for extracting the significant predictors among P and D sets as well as finding the goodness of the model fit. A naïve Bayesian classifier (NBC) is then designed initially that predicts either presence/absence of diseases given a set of pain parameters. The most informative and highest quality datasheet is used for training of NBC and the remaining sheets are used for testing the performance of the classifier. Hill climbing algorithm is used to design a Learned Bayes' classifier (LBC), which learns the conditional probability table (CPT) entries optimally. The developed LBC showed an average accuracy of 72%, which is clinically encouraging to the dentists.

Surgical quality and nodal ultrastaging is associated with long-term disease-free survival in early colorectal cancer: an analysis of 2 international multicenter prospective trials

BACKGROUND

The National Quality Forum has endorsed a minimum of 12 lymph node (LN) as a surrogate measure of quality in colorectal cancer (CRC). The prognostic value of ultrastaging hematoxylin and eosin (H&E) negative LNs (N0) using pan-cytokeratin immunohistochemistry (pan-CK-IHC) is unknown.

PURPOSE

To assess the effect on survival of surgical quality and focused pathologic analysis.

PATIENTS AND METHODS

Between 2001 and 2007, 253 evaluable patients with resectable CRC were enrolled. Multiple sectioning and pan-CK-IHC were performed on N0 LNs (American Joint Commission on Cancer Stage II). Follow-up was performed at 6-month intervals with a 4-year disease-free survival (DFS) primary end-point.

RESULTS

There were 253 patients, 177 N0 and 76 N1/N2 patients, staged conventionally. Thirty-six (20%) N0 patients were upstaged using ultrastaging (N0-->N0i+ [n = 27] and N0-->N1mi [n = 9]). At a mean follow-up of 3.4 +/- 1.6 years, 38 (15%) have recurred. Only 3% (3/108) of patients with > or =12 LNs, negative by H&E and pan-CK-IHC (N0i-), compared with 18% (6/33) with <12 LNs/N0i- (6/33; P = 0.0015) have recurred. Four-year DFS differed significantly according to surgical quality (<12 vs. > or =12 LNs) among Stage II patients only (DFS, <12 vs. > or =12 LNs: Stage I, 90.5% vs. 97.7%, P = 0.22; Stage II, 67.5% vs. 94.7%, P = 0.0036; Stage III, 61% vs. 61%, P = 0.61).

CONCLUSION

This represents the first prospective report demonstrating that both surgical quality and nodal ultrastaging impacts survival in Stage II CRC. Patients with Stage II CRC having > or =12 LNs negative for micrometastases (N0i-) are likely cured by surgery alone. Both surgical and pathologic quality measures are imperative in early CRC to improve patient selection for adjuvant chemotherapy.