1
|
Giani A, Bertoglio CL, Mazzola M, Giusti I, Achilli P, Carnevali P, Origi M, Magistro C, Ferrari G. Mid-term oncological outcomes after complete versus conventional mesocolic excision for right-sided colon cancer: a propensity score matching analysis. Surg Endosc 2022; 36:6489-6496. [PMID: 35028735 DOI: 10.1007/s00464-021-09001-z] [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: 09/28/2021] [Accepted: 12/31/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The correct extent of mesocolic dissection for right-sided colon cancer (RCC) is still under debate. Complete mesocolic excision (CME) has not gained wide diffusion, mainly due to its technical complexity and unclear oncological superiority. This study aims to evaluate oncological outcomes of CME compared with non-complete mesocolic excision (NCME) during resection for I-III stage RCC. METHOD Prospectively collected data of patients who underwent surgery between 2010 and 2018 were retrospectively analysed. 1:1 Propensity score matching (PSM) was used to balance baseline characteristics of CME and NCME patients. The primary endpoint of the study was local recurrence-free survival (LRFS). The two groups were also compared in terms of short-term outcomes, distant recurrence-free survival, disease-free survival, and overall survival. RESULTS Of the 444 patients included in the study, 292 were correctly matched after PSM, 146 in each group. The median follow-up was 45 months (IQR 33-63). Conversion rate, complications, and 90-day mortality were comparable in both groups. The median number of lymph nodes harvested was higher in CME patients (23 vs 19, p = 0.034). 3-year LRFS rates for CME patients was 100% and 95.6% for NCME (log-rank p = 0.028). At 3 years, there were no differences between the groups in terms of overall survival, distant recurrence-free survival, and disease-free survival. CONCLUSION Our PSM cohort study shows that CME is safe, provides a higher number of lymph nodes harvested, and is associated with better local recurrence-free survival.
Collapse
Affiliation(s)
- Alessandro Giani
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy.
| | - Camillo Leonardo Bertoglio
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Michele Mazzola
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Irene Giusti
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Pietro Achilli
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Pietro Carnevali
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Matteo Origi
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Carmelo Magistro
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Giovanni Ferrari
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| |
Collapse
|
2
|
Kang BM, Park JS, Kim HJ, Park SY, Yoon G, Choi GS. Prognostic Value of Mesorectal Lymph Node Micrometastases in ypN0 Rectal Cancer After Chemoradiation. J Surg Res 2022; 276:314-322. [DOI: 10.1016/j.jss.2022.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 02/11/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022]
|
3
|
Novel Diagnostic Biomarkers in Colorectal Cancer. Int J Mol Sci 2022; 23:ijms23020852. [PMID: 35055034 PMCID: PMC8776048 DOI: 10.3390/ijms23020852] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/27/2021] [Accepted: 01/03/2022] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is still a leading cause of cancer death worldwide. Less than half of cases are diagnosed when the cancer is locally advanced. CRC is a heterogenous disease associated with a number of genetic or somatic mutations. Diagnostic markers are used for risk stratification and early detection, which might prolong overall survival. Nowadays, the widespread use of semi-invasive endoscopic methods and feacal blood tests characterised by suboptimal accuracy of diagnostic results has led to the detection of cases at later stages. New molecular noninvasive tests based on the detection of CRC alterations seem to be more sensitive and specific then the current methods. Therefore, research aiming at identifying molecular markers, such as DNA, RNA and proteins, would improve survival rates and contribute to the development of personalized medicine. The identification of “ideal” diagnostic biomarkers, having high sensitivity and specificity, being safe, cheap and easy to measure, remains a challenge. The purpose of this review is to discuss recent advances in novel diagnostic biomarkers for tumor tissue, blood and stool samples in CRC patients.
Collapse
|
4
|
Ogawa S, Itabashi M, Bamba Y, Tani K, Yamaguchi S, Yamauchi S, Sugihara K. Stage II colon cancer staging using the number of retrieved lymph nodes may be superior to current TNM staging for prognosis stratification: the Japanese study group for postoperative follow-up of colorectal cancer. Int J Colorectal Dis 2021; 36:2205-2214. [PMID: 34302501 DOI: 10.1007/s00384-021-03990-y] [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] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of the study was to compare staging of stage II colon cancer using the number of retrieved lymph nodes (RN) to current TNM staging for stratification of prognosis. METHODS The subjects were 6307 patients with stage II colon cancer who underwent curative resection at 24 Japanese institutions. The cutoff for the number of RN was established using Akaike information criterion (AIC) values for relapse-free survival (RFS) and overall survival (OS). Comparison of survival using TNM and T + RN (TRN) staging was performed using a Cox proportional hazards regression model. RESULTS AIC was lowest for 14 retrieved lymph nodes for RFS and OS. This number was used as the cutoff. In multivariate analysis, age (≥ 69), male gender, V1, CEA (> 5), pT (T4a, T4b), and RN-L were independent factors associated with RFS and OS. Six combinations of pT and RN categories were used to establish three subgroups: TRN stages IIA, IIB, and IIC. The 5-year RFS was 83.9%, 72.3%, and 71.8% in TNM stages IIA, IIB, and IIC; and 86.0%, 76.9%, and 60.3% in TRN stages IIA, IIB, and IIC. The 5-year OS was 90.0%, 81.3%, and 82.6% for the TNM stages; and 91.6%, 85.0%, and 71.9% for the TRN stages. The AIC for RFS was lower for TRN (22,318.2) than for TNM (22,390.6), and that for OS was also lower for TRN (16,285.3) than for TNM (16,355.1). CONCLUSION Stage II colon cancer staging using the number of retrieved lymph nodes may be superior to current TNM staging for prognosis stratification.
Collapse
Affiliation(s)
- Shimpei Ogawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Michio Itabashi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yoshiko Bamba
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kimitaka Tani
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shigeki Yamaguchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shinichi Yamauchi
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kenichi Sugihara
- Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| |
Collapse
|
5
|
Ogawa S, Itabashi M, Bamba Y, Yamamoto M, Sugihara K. Superior prognosis stratification for stage III colon cancer using log odds of positive lymph nodes (LODDS) compared to TNM stage classification: the Japanese study group for postoperative follow-up of colorectal cancer. Oncotarget 2020; 11:3144-3152. [PMID: 32913558 PMCID: PMC7443365 DOI: 10.18632/oncotarget.27692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The aim of this study is to examine whether prognosis stratification in staging of Stage III colon cancer using T factor and log odds of positive lymph nodes (LODDS) categories is superior to that of the TNM staging system. MATERIALS AND METHODS The subjects were 5,919 patients with Stage III colon cancer who underwent curative resection at 24 Japanese institutions. Univariate analysis of LODDS categories and clinicopathologic factors was conducted using a Cox proportional hazards regression model for cancer-specific survival (CSS). Independent prognostic factors for CSS were extracted in multivariate analysis using factors with significance in univariate analysis. Effect sizes of risk factors for CSS were compared using the LogWorth statistic. Combinations of T factor and LODDS categories were used to create L-stage subgroups A, B and C. Stratification of prognosis with L-stage and TNM was compared using the Akaike information criterion (AIC). RESULTS In multivariate analysis, LODDS was identified as an independent prognostic factor, together with age, maximum tumor diameter, histopathological grade, L, V, pT, and pN. The LogWorth of LODDS was 17.149, which was the second highest after pT (31.562), and that of pN was 7.434. The 5-year CSS was 96.5%, 88.5%, and 66.6% in TNM stages IIIA, IIIB, and IIIC, respectively, and 96.0%, 87.6%, and 59.3% in L-stage A, B, and C, respectively (p < 0.0001). AICs for TNM and L-stage were 14,795.5 and 14,707.8, respectively. CONCLUSIONS Prognosis stratification of the stage classification for Stage III colon cancer was superior with L-stage compared to TNM stage classification.
Collapse
Affiliation(s)
- Shimpei Ogawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Michio Itabashi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yoshiko Bamba
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kenichi Sugihara
- Department of Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| |
Collapse
|
6
|
Efficacy and Safety of Complete Mesocolic Excision in Patients With Colon Cancer: Three-year Results From a Prospective, Nonrandomized, Double-blind, Controlled Trial. Ann Surg 2020; 271:519-526. [PMID: 30148752 DOI: 10.1097/sla.0000000000003012] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the oncological outcomes of complete mesocolic excision (CME) in colon cancer patients. SUMMARY BACKGROUND DATA CME is considered a standard procedure for colon cancer patients. However, previous evidence regarding the effect of CME on prognosis has fundamental limitations that prevent it from being fully accepted. METHODS Patients who underwent radical resection for colon cancer were enrolled between November 2012 and March 2016. According to the principles of CME, patients were stratified into 2 groups based on intraoperative surgical fields and specimen photographs. The primary outcome was local recurrence-free survival (LRFS). The clinicopathological data and follow-up information were collected and recorded. The final follow-up date was April 2016. The trial was registered in ClinicalTrials.gov (identifier: NCT01724775). RESULTS There were 220 patients in the CME group and 110 patients in the noncomplete mesocolic excision (NCME) group. Baseline characteristics were well balanced. Compared with NCME, CME was associated with a greater number of total lymph nodes (24 vs 20, P = 0.002). Postoperative complications did not differ between the 2 groups. CME had a positive effect on LRFS compared with NCME (100.0% vs 90.2%, log-rank P < 0.001). Mesocolic dissection (100.0% vs 87.9%, log-rank P < 0.001) and nontumor deposits (97.2% vs 91.6%, log-rank P < 0.022) were also associated with improved LRFS. CONCLUSIONS Our findings demonstrate that, compared with NCME, CME improves 3-year LRFS without increasing surgical risks.
Collapse
|
7
|
Al-Maghrabi J, Emam E, Gomaa W. Immunohistochemical staining of cytokeratin 20 and cytokeratin 7 in colorectal carcinomas: Four different immunostaining profiles. Saudi J Gastroenterol 2018; 24:129-134. [PMID: 29637921 PMCID: PMC5900473 DOI: 10.4103/sjg.sjg_465_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND/AIM Aberrant expression of CK20/CK7 is reported in a percentage of colorectal carcinomas (CRC); however, its relation to clinicopathological variables and survival data is still unclear. The objective of this study is to explore patterns of CK20/CK7 immunostaining in CRC and to analyse the diagnostic, prognostic, and predictive role of patterns of CK20/CK7 immunostaining. MATERIALS AND METHODS A total of 144 CRC cases were retrieved from the archives at the Department of Pathology, King Abdulaziz University, Jeddah, Saudi Arabia. Immunohistochemistry was performed using antibody to CK7 and CK20. Immunostaining was defined as low and high by using the extent of staining. The association of CK7 and CK20 with clinicopathological characteristics and survival. RESULTS CK20 was expressed in a higher percentage of CRC and nodal metastasis than CK7. No difference in CK7 and CK20 immunostaining in primary and metastasis carcinomas was found. Four patterns of CK20/CK7 were identified; CK20+/CK7- (60.4%), CK20+/CK7+ (2.1%), CK20-/CK7- (35.4%), and CK20-/CK7+ (2.1%). There was no statistically significant correlation between CK20/CK7 immunohistochemical profile and clinicopathological characteristics, prognosis, and survival was determined. CONCLUSIONS Our results may support the heterogeneity of CRC. CRC showed four different subclasses following patterns of relative CK20/CK7 immunostaining. A considerable number of CRC expressed aberrant immune profile of CK20/CK7, which should be considered during diagnosing CRC in metastatic regions. Further studies on larger cohorts correlating different immunohistochemical cytokeratin profiles to molecular subtypes of CRC are recommended for better understanding of pathogenesis and behaviour of CRC.
Collapse
Affiliation(s)
- Jaudah Al-Maghrabi
- Department of Pathology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,Address for correspondence: Dr. Jaudah Al-Maghrabi, Department of Pathology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia. E-mail:
| | - Eman Emam
- Department of Pathology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,Department of Pathology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Wafaey Gomaa
- Department of Pathology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,Department of Pathology, Faculty of Medicine, Minia University, Al-Minia, Egypt
| |
Collapse
|
8
|
Prognostic significance of Cytokeratin 20-positive lymph node vascular endothelial growth factor A mRNA and chromodomain helicase DNA binding protein 4 in pN0 colorectal cancer patients. Oncotarget 2017; 9:6737-6751. [PMID: 29467924 PMCID: PMC5805510 DOI: 10.18632/oncotarget.23424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 11/28/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Cytokeratin 20-positive cells in lymph nodes from pN0 colorectal cancer (CRC) patients were detected previously by us. The aims of this study were to investigate which tumor metastasis-related genes were involved and their potential clinical significance. RESULTS Fourteen of 84 (17%) genes were differentially expressed by at least 2-fold. Among them, 10 genes were up-regulated whereas 4 genes were down-regulated. Those differential expressed genes were validated in the second cohort of specimens. Follow-up analysis for 60 months showed that patients with lymph node vascular endothelial growth factor A (VEGF-A) mRNA and chromodomain helicase DNA binding protein 4 (CHD4) mRNA expression higher than the median copies had significantly shorter time to recurrence than those with lower than the median copies. Multivariate analysis showed that VEGF-A mRNA, CHD4 mRNA and lymphatic vessel involvement were independent prognostic factors for disease recurrence. CONCLUSIONS VEGF-A mRNA and CHD4 mRNA were up-regulated in CK20-positive pN0 lymph nodes and they may have prognostic significance in pN0 CRC patients. METHODS Two cohorts of lymph node specimens from pN0 CRC patients of each with and without CK20-positive cells were recruited. In the first cohort, tumor metastasis genes were profiled using gene expression arrays. Differential expressed genes were validated in the second cohort. Moreover, their prognostic significance was examined by following-up the second cohort of patients with CK20-positive cells for 60 months and all histopathological findings were correlated to recurrence.
Collapse
|
9
|
Wang C, Gao Z, Shen K, Shen Z, Jiang K, Liang B, Yin M, Yang X, Wang S, Ye Y. Safety, quality and effect of complete mesocolic excision vs non-complete mesocolic excision in patients with colon cancer: a systemic review and meta-analysis. Colorectal Dis 2017; 19:962-972. [PMID: 28949060 DOI: 10.1111/codi.13900] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/14/2017] [Indexed: 12/11/2022]
Abstract
AIM The application of complete mesocolic excision (CME) in colon cancer is controversial. We performed a meta-analysis to compare the safety, quality and effect of CME with non-complete mesocolic excision (NCME) in patients with colon cancer. METHOD We searched PubMed, ScienceDirect, the Cochrane Library and Scopus to identify studies comparing CME with NCME in colon cancer. We focused on three study outcome areas: safety (operation time, blood loss, complications, mortality); quality (large bowel length, distance from the tumour to the high vascular tie, area of mesentery, total lymph nodes); and effect (long-term survival). RESULTS A total of 8586 patients from 12 studies were included in the meta-analysis. CME was associated with greater intra-operative blood loss [weighted mean difference (WMD) 79.87, 95% CI: 65.88-93.86], more postoperative surgical complications (relative risk 1.23, 95% CI: 1.08-1.40), longer large bowel resection (WMD 47.06, 95% CI: 10.49-83.62), greater distance from the tumour to the high vascular tie (WMD 17.51, 95% CI: 15.16-19.87), larger area of mesentery (WMD 36.09, 95% CI: 18.06-54.13) and more lymph nodes (WMD 6.13, 95% CI: 1.97-10.28) than NCME. CME also had positive effects on 5-year survival [hazard ratio (HR) 0.33, 95% CI: 0.13-0.81], 3-year survival (HR 0.58, 95% CI: 0.39-0.86) and 3-year survival for Stage III disease (HR 0.69, 95% CI: 0.60-0.80) compared with NCME. CONCLUSION Limited evidence suggests that CME is a more effective strategy for improving specimen quality and survival but with a higher complication rate.
Collapse
Affiliation(s)
- C Wang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
- Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| | - Z Gao
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
- Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, China
| | - K Shen
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| | - Z Shen
- Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| | - K Jiang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| | - B Liang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| | - M Yin
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| | - X Yang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| | - S Wang
- Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| | - Y Ye
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Beijing, China
| |
Collapse
|
10
|
Choi J, Nahm JH, Kim SK. Prognostic clinicopathologic factors in carcinoma of unknown primary origin: a study of 106 consecutive cases. Oncotarget 2017; 8:62630-62640. [PMID: 28977975 PMCID: PMC5617535 DOI: 10.18632/oncotarget.16021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 02/20/2017] [Indexed: 12/22/2022] Open
Abstract
A heterogeneous group of cancers for which the site of origin remains occult after detailed investigations is defined as carcinomas of unknown primary origin (CUPs). Because patients with CUP have a dismal prognosis, we have analyzed CUPs to highlight the implication of clinicopathologic factors related with patient survival. A total of 106 consecutive cases of CUP were collected. A two-step strategy of immunohistochemistry to assess CUPs according NCCN Guidelines is used to separate carcinomatous tumors and subtype carcinomas. Median follow up of censored patients was 26 months. Median survival time of whole patients was 13 months (95% confidence interval [CI], 8.43 - 19.1 months), with one, two and five-year survival rate of 53.7%, 35.1%, and 30.5%, respectively. Factors related with shorter overall survival was adenocarcinoma histology (P=0.001), increased CA19-9 (P=0.003), increased CEA (P=0.047), increased LDH (P<0.001), CK20 positivity (P=0.002), presence of bone metastasis (P=0.017), metastasis not confined to the lymph nodes (P=0.015), unfavorable clinical group based predefined category (P=0.017), and patients with no treatment (P<0.001). Multivariable analysis with cox regression model revealed factors related with overall survival; cases belonged to Culine’s poor risk group (HR, 3.88; 95% CI, 1.75-8.64; P=0.001) and CK20 positivity (HR, 3.31; 95% CI, 1.42-7.70; P=0.005). In conclusion, the CK20 expression profile is a prognostic factor in patients with CUP and initial stratification of patient with Culine’s model may provide a prognostic information in these patients. Assessment of clinical implication of these factors in the context of site specific therapy needs to be evaluated.
Collapse
Affiliation(s)
- Junjeong Choi
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea
| | - Ji Hae Nahm
- Department of Pathology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Kyum Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
11
|
Aldecoa I, Atares B, Tarragona J, Bernet L, Sardon JD, Pereda T, Villar C, Mendez MC, Gonzalez-Obeso E, Elorriaga K, Alonso GL, Zamora J, Planell N, Palacios J, Castells A, Matias-Guiu X, Cuatrecasas M. Molecularly determined total tumour load in lymph nodes of stage I-II colon cancer patients correlates with high-risk factors. A multicentre prospective study. Virchows Arch 2016; 469:385-94. [PMID: 27447172 PMCID: PMC5033997 DOI: 10.1007/s00428-016-1990-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/17/2016] [Accepted: 07/07/2016] [Indexed: 01/11/2023]
Abstract
Stage I–II (pN0) colorectal cancer patients are surgically treated although up to 25 % will eventually die from disease recurrence. Lymph node (LN) status is an independent prognostic factor in colorectal cancer (CRC), and molecular tumour detection in LN of early-stage CRC patients is associated with an increased risk of disease recurrence and poor survival. This prospective multicentre study aimed to determine the relationship between LN molecular tumour burden and conventional high-risk factors in stage I–II colon cancer patients. A total of 1940 LN from 149 pathologically assessed pN0 colon cancer patients were analysed for the amount of tumour cytokeratin 19 (CK19) messenger RNA (mRNA) with the quantitative reverse transcription loop-mediated isothermal amplification molecular assay One-Step Nucleic Acid Amplification. Patient’s total tumour load (TTL) resulted from the sum of all CK19 mRNA tumour copies/μL of each positive LN from the colectomy specimen. A median of 15 LN were procured per case (IQR 12;20). Molecular positivity correlated with high-grade (p < 0.01), mucinous/signet ring type (p = 0.017), male gender (p = 0.02), number of collected LN (p = 0.012) and total LN weight per case (p < 0.01). The TTL was related to pT stage (p = 0.01) and tumour size (p < 0.01) in low-grade tumours. Multivariate logistic regression showed independent correlation of molecular positivity with gender, tumour grade and number of fresh LN [AUC = 0.71 (95 % CI = 0.62–0.79)]. Our results show that lymph node CK19 mRNA detection correlates with classical high-risk factors in stage I–II colon cancer patients. Total tumour load is a quantitative and objective measure that may help to better stage early colon cancer patients.
Collapse
Affiliation(s)
- Iban Aldecoa
- Pathology Department, Centre de Diagnòstic Biomèdic (CDB), Hospital Clínic, University of Barcelona, Escala 3, Planta 5. Villarroel 170, Barcelona, 08036, Spain
| | - Begoña Atares
- Pathology Department, Alava University Hospital, Vitoria-Gasteiz, Spain
| | - Jordi Tarragona
- Pathology Department, Hospital Arnau de Vilanova, Lleida, Spain
| | - Laia Bernet
- Pathology Department, Hospital L. Alcanyis, Xativa, Spain
| | | | - Teresa Pereda
- Pathology Department, Hospital Costa del Sol, Marbella, Spain
| | - Carlos Villar
- Pathology Department, Hospital Reina Sofia, Cordoba, Spain
| | - M Carmen Mendez
- Pathology Department, Hospital Severo Ochoa, Leganes, Madrid, Spain
| | | | - Kepa Elorriaga
- Pathology Department, Hospital Onkologikoa, San Sebastian, Spain
| | | | - Javier Zamora
- Biostatistic Unit, Hospital Ramon y Cajal, Madrid, Spain
| | - Nuria Planell
- Gastroenterology Department and Bioinformatics Unit, CIBERehd, IDIBAPS, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jose Palacios
- Pathology Department, Hospital Ramon y Cajal, Madrid, Spain
| | - Antoni Castells
- Gastroenterology Department, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | | | - Miriam Cuatrecasas
- Pathology Department, Centre de Diagnòstic Biomèdic (CDB), Hospital Clínic, University of Barcelona, Escala 3, Planta 5. Villarroel 170, Barcelona, 08036, Spain.
- CIBERehd, and Banc de Tumors-Biobanc Clinic-IDIBAPS-XBTC, Hospital Clinic, Barcelona, Spain.
| |
Collapse
|
12
|
Yamamoto H, Murata K, Fukunaga M, Ohnishi T, Noura S, Miyake Y, Kato T, Ohtsuka M, Nakamura Y, Takemasa I, Mizushima T, Ikeda M, Ohue M, Sekimoto M, Nezu R, Matsuura N, Monden M, Doki Y, Mori M. Micrometastasis Volume in Lymph Nodes Determines Disease Recurrence Rate of Stage II Colorectal Cancer: A Prospective Multicenter Trial. Clin Cancer Res 2016; 22:3201-8. [DOI: 10.1158/1078-0432.ccr-15-2199] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 01/10/2016] [Indexed: 01/11/2023]
|
13
|
Expression of AKR1C3 and CNN3 as markers for detection of lymph node metastases in colorectal cancer. Clin Exp Med 2014; 15:333-41. [PMID: 24934327 PMCID: PMC4522272 DOI: 10.1007/s10238-014-0298-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 05/10/2014] [Indexed: 12/21/2022]
Abstract
The aim of the study was to identify a set of discriminating genes that could be used for the prediction of Lymph node (LN) metastasis in human colorectal cancer (CRC), and for this, we compared the whole genome profiles of two CRC cell lines (the primary cell line SW480 and its LN metastatic variant, SW620) and identified eight genes [S100 calcium-binding protein P; aldo–keto reductase family 1(AKR1), member B1 (aldose reductase; AKR1B1); AKR1, member C3 (AKR1C3); calponin 3, acidic; metastasis associated in colon cancer 1; hemoglobin, epsilon 1; trefoil factor 3; and FGGY carbohydrate kinase domain containing]. These genes were examined by quantitative RT-PCR in tissues and LNs in 14 CRC patients and 11 control patients. The level of AKR1C3 mRNA expression was significantly different between the Dukes’ stage A, B, and C groups and the control group (p < 0.05, p < 0.001, and p < 0.001) and was also significantly different between Dukes’ stage C and A or B groups (p < 0.05 and p < 0.001, respectively). The expression of CNN3 was significantly different between the Dukes’ stage C and B or control groups (p < 0.001 and p < 0.01, respectively). There were significant correlations between the expression levels of AKR1C3 and CNN3. AKR1C3 and CNN3 expressions are more accurate and suitable markers for the diagnosis of LN metastasis than the other six genes examined in this study.
Collapse
|
14
|
Molecular staging of lymph node-negative colon carcinomas by one-step nucleic acid amplification (OSNA) results in upstaging of a quarter of patients in a prospective, European, multicentre study. Br J Cancer 2014; 110:2544-50. [PMID: 24722182 PMCID: PMC4021519 DOI: 10.1038/bjc.2014.170] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/19/2014] [Accepted: 03/04/2014] [Indexed: 02/06/2023] Open
Abstract
Background: Current histopathological staging procedures in colon carcinomas depend on midline division of the lymph nodes with one section of haematoxylin & eosin (H&E) staining only. By this method, tumour deposits outside this transection line may be missed and could lead to understaging of a high-risk group of stage UICC II cases, which recurs in ∼20% of cases. A new diagnostic semiautomated system, one-step nucleic acid amplification (OSNA), detects cytokeratin (CK) 19 mRNA in lymph node metastases and enables the investigation of the whole lymph node. The objective of this study was to assess whether histopathological pN0 patients can be upstaged to stage UICC III by OSNA. Methods: Lymph nodes from patients who were classified as lymph node negative after standard histopathology (single (H&E) slice) were subjected to OSNA. A result revealing a CK19 mRNA copy number >250, which makes sure to detect mainly macrometastases and not isolated tumour cells (ITC) or micrometastases only, was regarded as positive for lymph node metastases based on previous threshold investigations. Results: In total, 1594 pN0 lymph nodes from 103 colon carcinomas (median number of lymph nodes per patient: 14, range: 1–46) were analysed with OSNA. Out of 103 pN0 patients, 26 had OSNA-positive lymph nodes, resulting in an upstaging rate of 25.2%. Among these were 6/37 (16.2%) stage UICC I and 20/66 (30.3%) stage UICC II patients. Overall, 38 lymph nodes were OSNA positive: 19 patients had one, 3 had two, 3 had three, and 1 patient had four OSNA-positive lymph nodes. Conclusions: OSNA resulted in an upstaging of over 25% of initially histopathologically lymph node-negative patients. OSNA is a standardised, observer-independent technique, allowing the analysis of the whole lymph node. Therefore, sampling bias due to missing investigation of certain lymph node tissue can be avoided, which may lead to a more accurate staging.
Collapse
|
15
|
Yamamoto M, Yoshinaga K, Matsuyama A, Tsutsui S, Ishida T. CEA/CA72-4 levels in peritoneal lavage fluid are predictive factors in patients with gastric carcinoma. J Cancer Res Clin Oncol 2014; 140:607-12. [PMID: 24509654 DOI: 10.1007/s00432-014-1601-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 01/30/2014] [Indexed: 12/27/2022]
Abstract
PURPOSE Increased levels of tumor marker in intra-operative peritoneal lavage are associated with an earlier detection of recurrent peritoneal dissemination. METHOD Intra-operative peritoneal lavage samples from 193 patients with gastric cancer were obtained to determine the levels of the tumor markers, carcinoembryonic antigen (CEA) and cancer-related antigen 72-4 (CA72-4) using a chemiluminescent enzyme immunoassay. RESULTS The peritoneal lavage CEA (CY-CEA), CA72-4 (CY-CA72-4) and serosal invasion were independent factors predicting the peritoneal dissemination including CY(+). The patients were divided into four groups on the basis of peritoneal lavage tumor marker status; group A: CY-CEA (-), CY-CA72-4 (-) group (CEA < 0.5 ng/ml, CA72-4 < 1.3 U/ml); group B: CY-CEA (-), CY-CA72-4 (+) group (CEA < 0.5 ng/ml, CA72-4 ≥ 1.3 U/ml); group C: CY-CEA (+), CY-CA72-4 (-) group (CEA ≥ 0.5 ng/ml, CA72-4 < 1.3 U/ml); and group D: CY-CEA (+), CY-CA72-4 (+) group (CEA ≥ 0.5 ng/ml, CA72-4 ≥ 1.3 U/ml). The 5-year survival among the patients in groups A, B, C and D was 87, 68, 38 and 20 %, respectively (p < 0.0001). CONCLUSION Combined analysis of these markers is therefore considered to be helpful for accurately determining sites of recurrence and the prognosis in advanced gastric cancer patients.
Collapse
Affiliation(s)
- Manabu Yamamoto
- Department of Surgery, Hiroshima Atomic Bomb Survivors Hospital, 1-9-6 Senda-machi, Naka-ku, Hiroshima, 730-8619, Japan,
| | | | | | | | | |
Collapse
|
16
|
Lymph node micrometastasis in gastrointestinal tract cancer--a clinical aspect. Int J Clin Oncol 2013; 18:752-61. [PMID: 23775112 DOI: 10.1007/s10147-013-0577-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Indexed: 12/11/2022]
Abstract
Lymph node micrometastasis (LNM) can now be detected thanks to the development of various biological methods such as immunohistochemistry (IHC) and reverse transcription-polymerase chain reaction (RT-PCR). Although several reports have examined LNM in various carcinomas, including gastrointestinal (GI) cancer, the clinical significance of LNM remains controversial. Clinically, the presence of LNM is particularly important in patients without nodal metastasis on routine histological examination (pN0), because patients with pN0 but with LNM already in fact have metastatic potential. However, at present, several technical obstacles are impeding the detection of LNM using methods such as IHC or RT-PCR. Accurate evaluation should be carried out using the same antibody or primer and the same technique in a large number of patients. The clinical importance of the difference between LNM and isolated tumor cells (≤0.2 mm in diameter) will also be gradually clarified. It is important that the results of basic studies on LNM are prospectively introduced into the clinical field. Rapid diagnosis of LNM using IHC and RT-PCR during surgery would be clinically useful. Currently, minimally invasive treatments such as endoscopic submucosal dissection and laparoscopic surgery with individualized lymphadenectomy are increasingly being performed. Accurate diagnosis of LNM would clarify issues of curability and safety when performing such treatments. In the near future, individualized lymphadenectomy will develop based on the establishment of rapid, accurate diagnosis of LNM.
Collapse
|
17
|
Akagi Y, Kinugasa T, Adachi Y, Shirouzu K. Prognostic significance of isolated tumor cells in patients with colorectal cancer in recent 10-year studies. Mol Clin Oncol 2013; 1:582-592. [PMID: 24649214 DOI: 10.3892/mco.2013.116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 04/18/2013] [Indexed: 12/14/2022] Open
Abstract
Circulating tumor cells (CTCs) that detach from the primary tumor and move into the circulation are detected in patients with metastatic cancer. The discovery of such cancer cells has been used as a predictor of recurrence and prognosis, although a consensus regarding such applications has not been reached. Peritoneal cytology may be used for identifying high risk of recurrence or mortality, whereas the intraoperative presence of tumor cells in drainage veins, bone marrow, or the liver is not always useful for evaluating the prognosis. The reported positive rate for tumor cells in the peripheral blood of patients with colorectal cancer, including metastasis, has varied from 10 to 80%; however, numerous studies have demonstrated significant differences in the recurrence and mortality rates between patients with and without isolated tumor cells (ITCs) in the peripheral blood. However, the clinical significance of CTCs as an absolute prognostic factor has not been elucidated, since the measurement methodologies and/or the number of cases differed between the studies. Future prospective studies including larger patient populations may elucidate the utility of routine detection of ITCs in daily practice.
Collapse
Affiliation(s)
- Yoshito Akagi
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Tetsushi Kinugasa
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Yosuke Adachi
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Kazuo Shirouzu
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| |
Collapse
|
18
|
Abstract
BACKGROUND Myofibroblasts have an important role in regulating the normal colorectal stem cell niche. While the activation of myofibroblasts in primary colorectal cancers has been previously described, myofibroblast activation in lymph node metastases has not been described before. METHODS Paraffin-embedded lymph node sections from patients with macrometastases, micrometastases and isolated tumour cells were stained to identify myofibroblasts and to characterise the distribution of different cell types in tumour-containing lymph nodes. The extent of myofibroblast presence was quantified and compared with the size of the metastasis and degree of proliferation and differentiation of the cancer cells. RESULTS We show substantial activation of myofibroblasts in the presence of colorectal metastases in lymph nodes, which is intimately associated with glandular structures, both in micro- and macrometastases. The degree of activation is positively associated with the size of the metastases and the proportion of Ki67+ve cancer cells, and negatively associated with the degree of enterocyte differentiation as measured by CK20 expression. CONCLUSION The substantial activation of myofibroblasts in tumour-containing lymph nodes strongly suggests that these metastatic cancer cells are still significantly dependent on their microenvironment. Further understanding of these epithelial-mesenchymal interactions could lead to the development of new therapies in metastatic disease.
Collapse
|
19
|
Prognostic significance of EpCAM-positive disseminated tumor cells in rectal cancer patients with stage I disease. Am J Surg Pathol 2013; 36:1809-16. [PMID: 23060348 DOI: 10.1097/pas.0b013e318265288c] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Here we evaluated the prevalence and prognostic impact of epithelial cell adhesion molecule (EpCAM)-positive disseminated tumor cells (DTCs) in stage I rectal cancer. Further we tested the association of these single tumor cells or small tumor cell groups with the extent of peritumoral lymphangiogenesis. A total of 845 regional lymph nodes (LN) of 44 patients classified as negative on conventional histopathology were retrospectively reanalyzed with immunohistochemistry (IHC) using the monoclonal antibody Ber-Ep4 directed against EpCAM for the detection of DTCs. The degree of lymphangiogenesis in the primary tumors was assessed by IHC of the primary tumor tissue using the monoclonal antibody D2-40, which reacts with the lymphatic endothelium. The IHC results were correlated with clinico-pathologic parameters and clinical follow-up data. EpCAM-positive DTCs in LNs were detected in 8 (18.2%) of the 44 patients. During a median follow-up of 59 months, 3 (37.5%) of the 8 patients with EpCAM-positive DTCs relapsed, whereas none of the DTC-negative patients developed tumor recurrence (P=0.004). Survival analysis revealed a significant effect of the prevalence of DTCs on overall survival (P=0.0009) and on recurrence-free survival (P=0.0001). Finally, the prevalence of EpCAM-positive DTCs in perirectal LNs was significantly correlated with a high density of peritumoral lymphatic vessels (P=0.015). Our results show that DTCs may occur in stage I of rectal cancer and are associated with poor prognosis. Their occurrence seems to be linked to a high density of newly formed lymphatic vessel at the primary tumor site. According to our data, patients with DTCs in their LN might benefit from adjuvant therapy.
Collapse
|
20
|
Recent approaches to identifying biomarkers for high-risk stage II colon cancer. Surg Today 2012; 42:1037-45. [PMID: 22961195 DOI: 10.1007/s00595-012-0324-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 08/12/2011] [Indexed: 01/04/2023]
Abstract
The use of adjuvant chemotherapy for stage II colon cancer remains controversial. The accurate assessment of the risk factors associated with recurrence in patients with stage II disease is the key to identifying the patients that are most likely to benefit from adjuvant chemotherapy. Recent guidelines advocate that adjuvant chemotherapy for high-risk stage II colon cancer should take into account factors such as the T stage, number of lymph nodes examined, tumor differentiation, and tumor perforation. In addition to these clinicopathological factors, there has also been intense interest in the identification of new prognostic or predictive biomarkers that can improve outcomes through better patient classification and selection for adjuvant chemotherapy. Recent advances in the field of molecular genetics have led to the identification of specific biomarkers involved in colorectal cancer progression, whereas gene expression microarray technology has led to the identification of molecular profiles able to predict recurrence or benefit from adjuvant chemotherapy. However, none of these has yet been validated in large prospective clinical trials. In this article, we review the current status of prognostic and predictive biomarkers for stage II colon cancer and provide an update on the most recent developments.
Collapse
|
21
|
Persiani R, Cananzi FCM, Biondi A, Paliani G, Tufo A, Ferrara F, Vigorita V, D'Ugo D. Log odds of positive lymph nodes in colon cancer: a meaningful ratio-based lymph node classification system. World J Surg 2012; 36:667-74. [PMID: 22270984 DOI: 10.1007/s00268-011-1415-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The log odds of positive lymph nodes (LODDS), defined as the log of the ratio between the numbers of positive and negative lymph nodes, has recently been proposed as a new prognostic index in surgical oncology. The aim of the present study was to investigate whether the LODDS system of lymph node classification was a more accurate prognostic tool than the tumor node metastasis (TNM) and lymph node ratio (LNR) classifications in colon cancer patients. MATERIALS AND METHODS Clinicopathologic data from 258 colon cancer patients who had undergone surgical resection were reviewed. Lymph node parameters were categorized according to the Internation Union Against Cancer/American Joint Cancer Commission (UICC/AJCC) TNM staging system, the LNR (LNR0 with ratio ≤ 0.05, LNR1 with 0.05 < ratio ≤ 0.20, LNR2 with ratio > 0.20), and the log odds ratio (LODDS0 ≤ -1.36, -1.36 < LODDS1 ≤ -0.53, and LODDS2 > -0.53). RESULTS The LODDS was able to identify patients who would have been included in different prognostic categories, according to both the TNM and LNR. In addition, LODDS was significantly related to the number of positive and negative lymph nodes, as well as the number of examined lymph nodes. In multivariate analysis, LODDS classification (LODDS0: HR 1; LODDS1: HR 3.687, p = 0.003; LODDS2: HR 9.440, p < 0.001) was identified as an independent prognostic factor. DISCUSSION The LODDS system is a highly reliable staging system with strong predictive ability for patient outcome. Compared with other nodal staging systems, the prognostic power of LODDS is less influenced by the number of lymph nodes dissected and examined.
Collapse
Affiliation(s)
- Roberto Persiani
- General Surgery Unit, Department of Surgery, Catholic University, Rome, Italy
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Barresi V, Reggiani Bonetti L, Vitarelli E, Di Gregorio C, Ponz de Leon M, Barresi G. Immunohistochemical assessment of lymphovascular invasion in stage I colorectal carcinoma: prognostic relevance and correlation with nodal micrometastases. Am J Surg Pathol 2012; 36:66-72. [PMID: 21989343 DOI: 10.1097/pas.0b013e31822d3008] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Several studies have suggested that the presence of occult nodal metastases (micrometastases) is related to adverse clinical course in stage I colorectal carcinoma. Herein we analyzed the correlation between nodal micrometastases and lymphovascular invasion (LVI) or lymphatic vessel density (LVD) in a series of stage I colorectal carcinomas; the cohort included cases characterized or not characterized by disease progression during the follow-up. In these cases, LVI and LVD were evidenced through the immunohistochemical detection of the specific marker for lymphatic vessels, D2-40. LVI was significantly more frequent in colorectal carcinomas characterized by the presence of micrometastases (P<0.0001), high peritumoral LVD (P<0.0001), and disease progression (P<0.0001). The analysis for progression risk indicated that nodal micrometastases and LVI were significant, negative, independent prognostic parameters associated with shorter disease-free survival of stage I colorectal cancer (P=0.0001; P=0.0242). In conclusion, in this study we demonstrated for the first time that LVI is significantly associated with nodal occult metastases in stage I colorectal carcinoma. In the light of its significant, independent, prognostic value in this neoplasia, the detection of LVI may represent a faster and cheaper tool compared with the time-consuming evaluation of micrometastases to select high-risk patients who may benefit from adjuvant systemic treatment. Furthermore, the assessment of LVI may be applied to establish the likelihood of nodal involvement from carcinomas treated with conservative local excision techniques, which provide no regional nodes for histologic examination.
Collapse
Affiliation(s)
- Valeria Barresi
- Department of Human Pathology, University of Messina, Messina, Italy.
| | | | | | | | | | | |
Collapse
|
23
|
Prediction of prognosis is not improved by the seventh and latest edition of the TNM classification for colorectal cancer in a single-center collective. Ann Surg 2012; 254:793-800; discussion 800-1. [PMID: 22042471 DOI: 10.1097/sla.0b013e3182369101] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To compare the prognostic value of the sixth and seventh editions of the TNM classification, and of additional prognostic factors, in colorectal cancer. BACKGROUND The seventh TNM edition was released in 2009 with the aim of providing a more precise prediction of prognosis. METHODS Clinical and histopathological data of 2229 patients with colorectal cancer who underwent tumor resection between 1990 and 2006 were analyzed and compared by using the sixth and seventh editions of the TNM classification and a statistically calculated model of prognostic factors. RESULTS With the sixth edition, 5-year survival was 96% for stage I, 90% for IIA, 86% for IIB, 90% for IIIA, 72% for IIIB, 48% for IIIC, and 13% for IV. With the seventh edition, 5-year survival was 96% for stage I, 90% for IIA, 84% for IIB, 87% for IIC, 89% for IIIA, 72% for IIIB, 36% for IIIC, 15% for IVA, and 10% for IVB. The stage shifted for only 155 (7%) patients: from IIB to IIC (2%), from IIIB to IIIC (1%), and from IIIC to IIIA/B (4%). The performance of the seventh edition [concordance index (c-index) 0.83; 95% confidence interval (CI), 0.82-0.85] revealed no relevant improvement compared with the sixth edition (c-index 0.83; 95% CI, 0.82-0.84), or compared to a model based on independent prognostic factors (c-index 0.84; 95% CI, 0.83-0.86). CONCLUSIONS The seventh TNM edition did not provide greater accuracy in predicting colorectal cancer patients' prognosis but resulted in a more complex classification for daily clinical use.
Collapse
|
24
|
Rahbari NN, Bork U, Motschall E, Thorlund K, Büchler MW, Koch M, Weitz J. Molecular detection of tumor cells in regional lymph nodes is associated with disease recurrence and poor survival in node-negative colorectal cancer: a systematic review and meta-analysis. J Clin Oncol 2011; 30:60-70. [PMID: 22124103 DOI: 10.1200/jco.2011.36.9504] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Up to 25% of patients with node-negative colorectal cancer (CRC) on conventional histopathologic analysis ultimately die of recurrent disease. We performed a systematic review with meta-analyses to clarify whether molecular detection of isolated tumor cells or micrometastases in regional lymph nodes indicates high risk of disease recurrence and poor survival in node-negative CRC. METHODS The following databases were searched in August 2011 to identify studies on the prognostic significance of molecular tumor-cell detection in regional lymph nodes of node-negative CRC: MEDLINE, BIOSIS, Science Citation Index, EMBASE, CCMed, and publisher databases. We extracted hazard ratios (HRs) and associated 95% CIs from the identified studies and performed random-effects model meta-analyses on overall survival, disease-specific survival, and disease-free survival. RESULTS A total of 39 studies with a cumulative sample size of 4,087 patients were included. Immunohistochemistry, reverse transcriptase polymerase chain reaction, and both techniques were applied in 30, seven, and two studies, respectively. Thirteen studies were graded with low risk of bias. Meta-analyses revealed that molecular tumor-cell detection in regional lymph nodes was associated with poor overall survival (HR, 2.20; 95% CI, 1.43 to 3.40), disease-specific survival (HR, 3.37; 95% CI, 2.31 to 4.93), and disease-free survival (HR, 2.24; 95% CI, 1.57-3.20). Subgroup analyses showed the prognostic significance of molecular tumor-cell detection of being independent of the applied detection method, molecular target, and number of retrieved lymph nodes. CONCLUSION Molecular detection of occult disease in regional lymph nodes is associated with an increased risk of disease recurrence and poor survival in patients with node-negative CRC.
Collapse
Affiliation(s)
- Nuh N Rahbari
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
| | | | | | | | | | | | | |
Collapse
|
25
|
Sirop S, Kanaan M, Korant A, Wiese D, Eilender D, Nagpal S, Arora M, Singh T, Saha S. Detection and prognostic impact of micrometastasis in colorectal cancer. J Surg Oncol 2011; 103:534-7. [PMID: 21480246 DOI: 10.1002/jso.21793] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Review of literature was performed on studies with prognostic impact of micrometastasis in colorectal cancer. Among 16 studies included, micrometastasis was detected in 26.5% of patients. Most analysis revealed that micrometastasis carries a poorer prognosis compared to node negative disease (NND). The results of those studies were compared with our pilot study of 109 patients with colon cancer, showing improved prognosis of micrometastasis after being upstaged and treated with chemotherapy when compared with NND.
Collapse
Affiliation(s)
- Saad Sirop
- Department of Surgical Oncology, McLaren Regional Medical Center, Michigan State University, Flint, Michigan, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Shanmugam C, Hines RB, Jhala NC, Katkoori VR, Zhang B, Posey JA, Bumpers HL, Grizzle WE, Eltoum IE, Siegal GP, Manne U. Evaluation of lymph node numbers for adequate staging of Stage II and III colon cancer. J Hematol Oncol 2011; 4:25. [PMID: 21619690 PMCID: PMC3124418 DOI: 10.1186/1756-8722-4-25] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 05/28/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although evaluation of at least 12 lymph nodes (LNs) is recommended as the minimum number of nodes required for accurate staging of colon cancer patients, there is disagreement on what constitutes an adequate identification of such LNs. METHODS To evaluate the minimum number of LNs for adequate staging of Stage II and III colon cancer, 490 patients were categorized into groups based on 1-6, 7-11, 12-19, and ≥ 20 LNs collected. RESULTS For patients with Stage II or III disease, examination of 12 LNs was not significantly associated with recurrence or mortality. For Stage II (HR = 0.33; 95% CI, 0.12-0.91), but not for Stage III patients (HR = 1.59; 95% CI, 0.54-4.64), examination of ≥20 LNs was associated with a reduced risk of recurrence within 2 years. However, examination of ≥20 LNs had a 55% (Stage II, HR = 0.45; 95% CI, 0.23-0.87) and a 31% (Stage III, HR = 0.69; 95% CI, 0.38-1.26) decreased risk of mortality, respectively. For each six additional LNs examined from Stage III patients, there was a 19% increased probability of finding a positive LN (parameter estimate = 0.18510, p < 0.0001). For Stage II and III colon cancers, there was improved survival and a decreased risk of recurrence with an increased number of LNs examined, regardless of the cutoff-points. Examination of ≥7 or ≥12 LNs had similar outcomes, but there were significant outcome benefits at the ≥20 cutoff-point only for Stage II patients. For Stage III patients, examination of 6 additional LNs detected one additional positive LN. CONCLUSIONS Thus, the 12 LN cut-off point cannot be supported as requisite in determining adequate staging of colon cancer based on current data. However, a minimum of 6 LNs should be examined for adequate staging of Stage II and III colon cancer patients.
Collapse
|
27
|
Su H, Hu N, Yang HH, Wang C, Takikita M, Wang QH, Giffen C, Clifford R, Hewitt SM, Shou JZ, Goldstein AM, Lee MP, Taylor PR, Kaempgen E, Van Gool SW, Helms W, Keegan P, Pazdur R. Global gene expression profiling and validation in esophageal squamous cell carcinoma and its association with clinical phenotypes. Clin Cancer Res 2011. [PMID: 16061868 DOI: 10.1158/1078-0432] [Citation(s) in RCA: 402] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Esophageal squamous cell carcinoma (ESCC) is an aggressive tumor with poor prognosis. Understanding molecular changes in ESCC will enable identification of molecular subtypes and provide potential targets for early detection and therapy. EXPERIMENTAL DESIGN We followed up a previous array study with additional discovery and confirmatory studies in new ESCC cases by using alternative methods. We profiled global gene expression for discovery and confirmation, and validated selected dysregulated genes with additional RNA and protein studies. RESULTS A total of 159 genes showed differences with extreme statistical significance (P < E-15) and 2-fold differences or more in magnitude (tumor/normal RNA expression ratio, N = 53 cases), including 116 upregulated and 43 downregulated genes. Of 41 genes dysregulated in our prior array study, all but one showed the same fold change directional pattern in new array studies, including 29 with 2-fold changes or more. Alternative RNA expression methods validated array results: more than two thirds of 51 new cases examined by real-time PCR (RT-PCR) showed 2-fold differences or more for all seven genes assessed. Immunohistochemical protein expression results in 275 cases which were concordant with RNA for five of six genes. CONCLUSION We identified an expanded panel of genes dysregulated in ESCC and confirmed previously identified differentially expressed genes. Microarray-based gene expression results were confirmed by RT-PCR and protein expression studies. These dysregulated genes will facilitate molecular categorization of tumor subtypes and identification of their risk factors, and serve as potential targets for early detection, outcome prediction, and therapy.
Collapse
Affiliation(s)
- Hua Su
- Genetic Epidemiology Branch, DCEG, National Cancer Institute, NIH, Bethesda, MD 20892, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Whitney Helms
- Office of Hematology and Oncology Products, Office of New Drugs, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Patricia Keegan
- Office of Hematology and Oncology Products, Office of New Drugs, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Richard Pazdur
- Office of Biostatistics, Office of Translational Sciences, U.S. Food and Drug Administration, Silver Spring, Maryland
| |
Collapse
|
28
|
Zöller M, Jung T. The Colorectal Cancer Initiating Cell: Markers and Their Role in Liver Metastasis. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/978-94-007-0292-9_4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
29
|
Faerden AE, Sjo OH, Bukholm IRK, Andersen SN, Svindland A, Nesbakken A, Bakka A. Lymph node micrometastases and isolated tumor cells influence survival in stage I and II colon cancer. Dis Colon Rectum 2011; 54:200-6. [PMID: 21228669 DOI: 10.1007/dcr.0b013e3181fd4c7c] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Lymph-node status is considered the most important prognostic factor in colorectal cancer. The aim of the present prospective study was to evaluate the influence of micrometastases and isolated tumor cells on recurrence and disease-free survival in colon cancer. METHODS A total of 193 patients with colon cancer, operated on between 2000 and 2005, were enrolled in the study. All lymph nodes were examined by routine microscopy in hematoxylin and eosin-stained sections. If no metastases were identified in any node, all nodes were examined immunohistochemically with monoclonal antibody CAM 5.2. RESULTS Ordinary metastases were found in 67 patients, leaving 126 patients in stage I/II. Immunohistochemistry showed that 5% (6/126) of these had micrometastases and 26% (33/126) had isolated tumor cells. A median of 5 years of follow-up revealed local or distant recurrence in 23% (9/39) of stage I/II patients with micrometastases or isolated tumor cells, compared with 7% (6/87) without micrometastases or isolated tumor cells (P = .010). Five-year disease-free survival for patients with and without micrometastases or isolated tumor cells was 75% and 93%, respectively (P = .012). When analyzed separately, patients with isolated tumor cells (excluding micrometastases) had also lower survival than node-negative patients (P = .012). CONCLUSION The presence of micrometastases and isolated tumor cells was found to be a prognostic factor for recurrence and disease-free survival. This may have implications for future treatment of stage I/II colon cancer.
Collapse
Affiliation(s)
- Arne E Faerden
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Oslo, Norway.
| | | | | | | | | | | | | |
Collapse
|
30
|
The prognostic value of lymph node ratio in a population-based collective of colorectal cancer patients. Ann Surg 2010; 251:1070-8. [PMID: 20485149 DOI: 10.1097/sla.0b013e3181d7789d] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We analyzed 3 previously identified cut-off values of lymph node ratios (0.17, 0.41, and 0.69) in a large population-based collective of patients with colorectal cancer for their prognostic value. SUMMARY BACKGROUND DATA The lymph node ratio (LNR) (relation of tumor-infiltrated to total examined lymph nodes) has a high prognostic impact, but the relevant cut-off values are not determined. METHODS Patients (N = 27,803) with a primary colorectal cancer diagnosed and operated in the Munich region between 1991 and 2006 were registered in the Munich Cancer Registry. Lymph node numbers and survival data were available for 17,309 patients with a mean follow-up of 5.9 years. RESULTS The mean number (+/-SD) of resected lymph nodes was 16.8 +/- 8.4. Twelve or more lymph nodes were resected in 76.8%. Estimated 5-year overall survival decreased significantly with increasing LNR: LNR = 0 in 71.4%, LNR 0.01 to 0.17 in 52.4%, LNR 0.18 to 0.41 in 33.3%, LNR 0.42 to 0.69 in 19.8%, and LNR > or = 0.70 in 8.3% (P < 0.001). Multivariable survival analyses identified separately both LNR and pN- category, as well as number of resected lymph nodes, patient's age, tumor location, pT-category, pM-status, R-status, tumor grade, and year of operation as independent prognostic factors. CONCLUSION : The 3 cut-off values of LNRs had strong independent prognostic value in a population-based collective of patients with colorectal cancer. The LNR should be routinely reported and included in the American Joint Committee on Cancer staging system. Nevertheless, the benefit of lymphadenectomy on survival is still unclear.
Collapse
|
31
|
Chen CH, Hsieh MC, Lai CC, Yeh CY, Chen JS, Hsieh PS, Chiang JM, Tsai WS, Tang R, Changchien CR, Wang JY. Lead time of carcinoembryonic antigen elevation in the postoperative follow-up of colorectal cancer did not affect the survival rate after recurrence. Int J Colorectal Dis 2010; 25:567-71. [PMID: 20162425 DOI: 10.1007/s00384-010-0889-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The role of carcinoembryonic antigen (CEA) in the early detection of recurrence during the postoperative follow-up of colorectal cancer remains unclear. We hypothesize that the tumor with longer lead time of CEA elevation to the definite recurrence may have a better prognosis because of its slower growth rate and closer observation. MATERIALS AND METHODS From 1995 to 2003, 4,841 consecutive patients who received curative resection of localized colorectal adenocarcinoma were enrolled from a prospective database. The patients with persisting CEA elevation after operation had been already excluded. Postoperative follow-up, including physical examination, imaging, and CEA test, were performed according to a surveillance program. A CEA >/=5 ng/mL was defined as elevated. The definition of the CEA lead time was the period between CEA elevation and detection of recurrence. All statistical analyses were performed by SPSS package for Windows (Microsoft, Redmond, WA, USA). RESULTS The postoperative median follow-up time for the 4,841 patients was 68 months. A total of 999 patients (20.6%) had CEA elevation and recurrence. Among these patients, recurrence was confirmed in 727 patients (72.8%)before, at the same time, or within 3 months of CEA elevation and thus had a short lead time of CEA elevation (SLT group). In 272 patients (27.2%), recurrence was confirmed after more than 3 months of CEA elevation and thus had a longer lead time of CEA elevation (LLT group). The recurrence pattern showed similarities in these two groups. A total of 193 patients (193/999, 19.3%) received a second radical operation, and 806 patients (80.7%) were inoperable. The re-resection rate between the SLT group (146 patients, 20.1%) and the LLT group (47 patients, 17.3%) was not significantly different. The overall survival rate after recurrence showed no difference between these two groups (P = 0.123). CONCLUSION Most cases of recurrence were detected at nearly the same time when the CEA level was elevated. Therefore, a more sensitive test is needed for early detection. The relationship between the lead time of CEA and the clinical outcome was not statistically significant. A more aggressive approach to the patient who has CEA elevation and is highly suspect of recurrence may be needed.
Collapse
Affiliation(s)
- Chin-Hsin Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, 199, Tung Hwa North Road, Taipei, Taiwan, Republic of China
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Doekhie FS, Mesker WE, Kuppen PJ, van Leeuwen GA, Morreau H, de Bock GH, Putter H, Tanke HJ, van de Velde CJ, Tollenaar RA. Detailed examination of lymph nodes improves prognostication in colorectal cancer. Int J Cancer 2010; 126:2644-52. [PMID: 19676050 DOI: 10.1002/ijc.24817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Up to 30% of stage II patients with curatively resected colorectal cancer (CRC) will develop disease recurrence. We evaluated whether examination of lymph nodes by multilevel sectioning and immunohistochemical staining can improve prognostication. Lymph nodes (n = 780) from 36 CRC patients who had developed disease recurrence (cases) and 72 patients who showed no recurrence of disease for at least 5 years (controls) were analyzed. Sections of 4 levels at 200-microm interval were immunohistochemically stained for cytokeratin expression. The first level was analyzed by conventional and automated microscopy, and the 3 following levels were analyzed by automated microscopy for the presence of tumor cells. Overall, cases showed more micrometastases (3 patients) than controls (1 patient). Analysis of a second level led to the additional detection of 1 patient with micrometastases (case) and 1 patient with macrometastasis (case). Examining more levels only led to additional isolated tumor cells, which were equally divided between cases and controls. Likewise, automated microscopy resulted only in detection of additional isolated tumor cells when compared with conventional microscopy. In multivariate analysis, micrometastases [odds ratio (OR) 26.3, 95% confidence interval (CI) 1.9-364.8, p = 0.015], T4 stage (OR 4.8, 95% CI 1.4-16.7, p = 0.013) and number of lymph nodes (OR 0.9, 95% CI 0.8-1.0, p = 0.028) were independent predictors for disease recurrence. Lymph node analysis of 2 levels and immunohistochemical staining add to the detection of macrometastases and micrometastases in CRC. Micrometastases were found to be an independent predictor of disease recurrence. Isolated tumor cells were of no prognostic significance.
Collapse
Affiliation(s)
- Fania S Doekhie
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Pantalone D, Monici M, Romano G, Cialdai F, Santi R, Fusi F, Comin C, Bechi P. Colonic and gastric cancer metastatic lymph nodes: applications of autofluorescence-based techniques. Oncol Rev 2010. [DOI: 10.1007/s12156-009-0032-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
|
34
|
Quantitative RT-PCR detection of tumor cells in sentinel lymph nodes isolated from colon cancer patients with an ex vivo approach. Ann Surg 2009; 249:602-7. [PMID: 19300229 DOI: 10.1097/sla.0b013e31819ec923] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To investigate quantitative RT-PCR-based detection of tumor cells in lymph nodes (LNs) isolated from colon cancer patients by ex vivo sentinel lymph node (SLN) mapping. SUMMARY BACKGROUND DATA Although lymph node status is among the strongest prognostic factors in colon cancer patients, 20% to 30% of node negative patients experience disease recurrence. These patients may have LN metastases that are not detected by routine examination. METHODS Ex vivo SLN mapping was applied to 131 prospectively recruited patients undergoing curative surgery for primary colon cancer. The SLNs were analyzed for the presence of tumor cells by routine histology and real-time RT-PCR quantitation of cytokeratin 20 (CK20) and mucin 2(MUC2) mRNA. RESULTS SLNs were identified in 125 (95%) of the 131 patients included.Routine histologic analysis of SLNs and other regional lymph nodes revealed LN metastases in 42 patients (N+), of which 29 (69%) had metastases detected in 1 or more SLNs (sensitivity, 69%; false negative rate, 31%).When analyzing the SLNs by quantitative RT-PCR, the sensitivity, compared with routine LN examination, was 37/42 (88%) for both the CK20 and the MUC2 mRNA markers. In addition, 46% and 27% of the patients' node negative by routine LN examination (N0) were positive for the CK20 and MUC2 mRNA markers, respectively, possibly reflecting the presence of occult tumor cells in their SLNs. CONCLUSIONS Quantitative RT-PCR analysis of SLNs identified N+ patients with high sensitivity and revealed a subgroup of N0 patients with potential occult LN disease.
Collapse
|
35
|
Wiese D, Saha S, Yestrepsky B, Korant A, Sirop S. A Prospective Study of False-Positive Diagnosis of Micrometastatic Cells in the Sentinel Lymph Nodes in Colorectal Cancer. Ann Surg Oncol 2009; 16:2166-9. [PMID: 19412630 DOI: 10.1245/s10434-009-0497-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Revised: 04/11/2009] [Accepted: 04/12/2009] [Indexed: 11/18/2022]
Affiliation(s)
- D Wiese
- Department of Pathology, Michigan State University, McLaren Regional Medical Center, Flint, MI, USA.
| | | | | | | | | |
Collapse
|
36
|
The potential of cytokeratin 20 and mucin 2 mRNA as metastasis markers in regional lymph nodes of colon cancer patients investigated by quantitative RT-PCR. Int J Colorectal Dis 2009; 24:261-8. [PMID: 19119477 DOI: 10.1007/s00384-008-0613-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2008] [Indexed: 02/04/2023]
Abstract
PURPOSE The presence of regional lymph node metastases is one of the most important prognostic factors in colon cancer. Nevertheless, up to 30% of the lymph node negative patients experience disease recurrence. Possibly, this patient group may be identified by more sensitive techniques than routine histopathological examination of the lymph nodes. METHODS In the present study, we have evaluated the detection of colon cancer lymph node metastases by real-time RT-PCR quantitation of the epithelial-specific cytokeratin 20 (CK20) and mucin 2 (MUC2) mRNAs. RESULTS Both assays were able to detect dilutions of tumor cells down to one tumor cell in 10(6) normal lymphocytes. CK20 and MUC2 mRNA were quantitated in 52 normal lymph nodes from 12 patients undergoing surgery for benign bowel diseases and in 144 primary colon tumors. The median tumor level of both markers were more than 10(4)-fold higher than the highest level in normal lymph nodes, indicating that the markers had a potential for metastasis detection in a clinical context. We applied the assays to 61 lymph nodes with known metastases detected by routine staining. Elevated CK20 or MUC2 mRNA levels were detected in 57 (95%) of the 61 LNs. CONCLUSIONS Thus, CK20 and MUC2 quantitation by real-time RT-PCR seems to be a promising, sensitive tool to detect metastases in regional lymph nodes from colon cancer patients.
Collapse
|
37
|
Mejia A, Waldmana SA. Previstage GCC test for staging patients with colorectal cancer. Expert Rev Mol Diagn 2009; 8:571-8. [PMID: 18785805 DOI: 10.1586/14737159.8.5.571] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The presence of tumor cells in regional lymph nodes is the most important prognostic and predictive marker in staging patients with colorectal cancer. Cancer cells in lymph nodes are associated with a poorer prognosis and an increased risk of recurrent disease. Additionally, nodal metastases identify patients who derive maximum benefit from adjuvant therapy. However, traditional paradigms for staging patients with colorectal cancer underestimate the extent of metastases and patients whose lymph nodes are ostensibly free of tumor cells by histopathology (pN0) have a 25-30% risk of developing recurrent disease, reflected by the presence of occult nodal metastases. These observations underscore the unmet clinical need for molecular approaches to accurately detect metastatic disease and identify patients at risk for disease relapse that could benefit from adjuvant chemotherapy. Detection of disease-specific mRNA targets as prognostic and predictive markers employing quantitative reverse transcription (qRT)-PCR is an emerging technology that has become a benchmark for individualization of patient management. However, to date, applications of qRT-PCR to detecting occult nodal metastases in colorectal cancer have been equivocal, reflecting markers with suboptimal sensitivity and specificity; limitations of utilizing qualitative, rather than quantitative, RT-PCR; and underpowered study designs based on inadequate patient populations. In that context, guanylyl cyclase C (GCC) is the most sensitive and specific biomarker for metastatic colorectal cancer in extra-intestinal tissues. GCC qRT-PCR detects occult metastases in lymph nodes, providing the most powerful independent prognostic information for predicting disease recurrence in pN0 patients in prospective multicenter clinical trials. This technology forms the basis for the Previstagetrade mark GCC Colorectal Cancer Staging Test encompassing a proprietary multiplex qRT-PCR assay compatible with formalin-fixed, paraffin-embedded lymph nodes for detecting occult metastases. Previstage GCC is a new diagnostic tool that may improve the accuracy of staging, prognosis of clinical outcomes and prediction of therapeutic responses to adjuvant therapy, representing a key advance in the management of patients with colorectal cancer.
Collapse
Affiliation(s)
- Alex Mejia
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 132 South 10th Street, 1170 Main, Philadelphia, PA 19107, USA.
| | | |
Collapse
|
38
|
CpG-island methylation of the ER promoter in colorectal cancer: analysis of micrometastases in lymph nodes from UICC stage I and II patients. Br J Cancer 2009; 100:360-5. [PMID: 19142184 PMCID: PMC2634714 DOI: 10.1038/sj.bjc.6604859] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Patients with UICC stage II colorectal cancer (CRC) have a risk of approximately 20% to develop disease recurrence after tumour resection. The presence and significance of micrometastases for locoregional recurrence in these patients lacking histopathological lymph node involvement on routine stained HE sections is undefined. Oestrogen receptor (ER) promoter methylation has earlier been identified in CRC. Therefore, we evaluated the methylation status of the ER promoter in lymph nodes from 49 patients with CRC UICC stage I and II as a molecular marker of micrometastases and predictor of local recurrence. DNA from 574 paraffin-embedded lymph nodes was isolated and treated with bisulphite. For the detection of methylated ER promoter sequences, quantitative real-time methylation-specific PCR was used. Of the 49 patients tested, 15 (31%) had ER methylation-positive lymph nodes. Thirteen of those (86%) remained disease free and two (14%) developed local recurrence. In the resected lymph nodes of 34 of the 49 patients (69%), no ER promoter methylation could be detected and none of these patients experienced a local relapse. The methylation status of the ER promoter in lymph nodes of UICC stage I and II CRC patients may be a useful marker for the identification of patients at a high risk for local recurrence.
Collapse
|
39
|
|
40
|
Koyanagi K, Bilchik AJ, Saha S, Turner RR, Wiese D, McCarter M, Shen P, Deacon L, Elashoff D, Hoon DSB. Prognostic relevance of occult nodal micrometastases and circulating tumor cells in colorectal cancer in a prospective multicenter trial. Clin Cancer Res 2008; 14:7391-6. [PMID: 19010855 PMCID: PMC2586882 DOI: 10.1158/1078-0432.ccr-08-0290] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Nodal micrometastasis and circulating tumor cells detected by multimarker quantitative real-time reverse transcription-PCR (qRT-PCR) may have prognostic importance in patients with colorectal cancer. EXPERIMENTAL DESIGN Paraffin-embedded sentinel lymph nodes from 67 patients and blood from 34 of these patients were evaluated in a prospective multicenter trial of sentinel lymph node mapping in colorectal cancer. Sentinel lymph nodes were examined by H&E staining and cytokeratin immunohistochemistry. Sentinel lymph nodes and blood were examined by a four-marker qRT-PCR assay (c-MET, melanoma antigen gene-A3 family, beta1-->4-N-acetylgalactosaminyltransferase, and cytokeratin-20); qRT-PCR results were correlated with disease stage and outcome. RESULTS In H&E-negative sentinel lymph node patients that recurred, cytokeratin immunohistochemistry and qRT-PCR detected metastasis in 30% and 60% of patients, respectively. Disease-free survival differed significantly by multimarker qRT-PCR upstaged sentinel lymph node (P = 0.014). qRT-PCR analysis of blood for circulating tumor cells correlated with overall survival (P = 0.040). CONCLUSION Molecular assessment for micrometastasis in sentinel lymph node and blood specimens may help identify patients at high risk for recurrent colorectal cancer, who could benefit from adjuvant therapy.
Collapse
Affiliation(s)
- Kazuo Koyanagi
- Department of Molecular Oncology, John Wayne Cancer Institute, Santa Monica, California 90404, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Park SJ, Lee KY, Kim SY. Clinical significance of lymph node micrometastasis in stage I and II colon cancer. Cancer Res Treat 2008; 40:75-80. [PMID: 19688052 DOI: 10.4143/crt.2008.40.2.75] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 06/14/2008] [Indexed: 02/08/2023] Open
Abstract
PURPOSE A 25% rate of recurrence after performing complete resection in node-negative colon cancer patients suggests that their nodal staging is frequently suboptimal. Moreover, the value of occult cancer cells in tumor-free lymph nodes still remains uncertain. The authors evaluated the prognostic significance of the pathologic parameters, including the lymph node occult disease (micrometastases) detected by immunohistochemistry, in patients with node-negative colon cancer. MATERIALS AND METHODS The study included 160 patients with curatively resected stage I or II colon cancer and they were without rectal cancer. 2852 lymph nodes were re-examined by re-do hematoxylin and eosin (H-E) staining and immunohistochemical staining. The detection rates were compared with the clinicopathologic characteristics and with the cancer-specific survival. RESULTS Occult metastases were detected in 8 patients (5%). However, no clinicopathologic parameter was found to be correlated with the presence of micrometastasis. Twenty patients developed recurrence at a median follow-up of 45.7 months: 14 died of colon cancer and 9 died from noncancer-related causes. Univariate analysis showed that lymphatic invasion and the number of retrieved lymph nodes significantly influenced survival, and multivariate analysis revealed that the stage, the number of retrieved lymph nodes and lymphatic invasion were independently related to the prognosis. CONCLUSIONS Inadequate lymph node retrieval and lymphatic invasion were found to be associated with a poorer outcome for node-negative colon cancer patients. The presence of immunostained tumors cells in pN0 lymph nodes was found to have no significant effect on survival, but these tumor were identified by re-do H-E staining. Maximal attention should be paid to the total number of lymph nodes that are retrieved during surgery for colon cancer patients.
Collapse
Affiliation(s)
- Sun Jin Park
- Department of Surgery, Kyung Hee University College of Medicine, Seoul, Korea
| | | | | |
Collapse
|
42
|
Friederichs J, Gertler R, Rosenberg R, Dahm M, Nekarda H, Holzmann B, Siewert JR. Correlation of CK-20-positive cells in peripheral venous blood with serum CEA levels in patients with colorectal carcinoma. World J Surg 2008; 31:2329-34. [PMID: 17914651 DOI: 10.1007/s00268-007-9149-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Tumor cell dissemination appears to be an early event in tumor progression, and tumor cells can be detected in peripheral venous blood at the time of the operation. Although cytokeratin 20 (CK-20) is not specifically expressed by colorectal carcinomas, it represents a widely used marker for the detection of colorectal tumor cells. We used the combination of density centrifugation and CK-20 real-time reverse transcription polymerase chain reaction to detect CK-20-positive cells in the peripheral venous blood of 37 patients with colorectal carcinoma. Detection rates were compared to serum levels of the tumor markers carcinoembryonic antigen (CEA), carbohydrate antigen CA 19-9, and cancer antigen CA 125. The prognostic impact was assessed by the overall survival and by univariate and multivariate analysis. Overall, CK-20-positive cells in peripheral venous blood were detected in 11 of 37 (29.7%) patients. CK-20-positive patients showed a significantly higher mean serum CEA level (90.3 ng/ml) than the 4.1 ng/ml found in the CK-20-negative group (p = 0.03). CEA levels also correlated with CK-20 copy numbers. No significant correlation was observed for CA 19-9 or CA 125. CK-20-negative patients showed a trend toward better survival (p = 0.08). In the univariate analysis, CA 19-9, CEA, tumor size, lymph node status, grading, the presence of distant metastases, and resection status reached significant prognostic levels, whereas the detection of CK-20-positive cells showed only a prognostic trend (p = 0.06). Multivariate analysis failed to identify independent prognostic parameters. Here we report the correlation of CK-20-positive cells in peripheral venous blood with the serum CEA level of patients with colorectal cancer, which may represent a potential marker of the tumor load.
Collapse
Affiliation(s)
- Jan Friederichs
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, 81675, Munich, Germany.
| | | | | | | | | | | | | |
Collapse
|
43
|
Iddings D, Bilchik A. The biologic significance of micrometastatic disease and sentinel lymph node technology on colorectal cancer. J Surg Oncol 2008; 96:671-7. [PMID: 18081169 DOI: 10.1002/jso.20918] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The sentinel lymph node (SLN) technique has practical applications in multiple solid tumors including colorectal carcinoma. Identifying the SLN(s) provides better staging of the regional lymphatics beyond standard H&E analysis. This additional information assists in predicting biology and may be useful in guiding adjuvant therapy. We postulate the era of sentinel node has ushered in a new generation of node-negative patients; patients that have an exceptionally favorable outcome when compared to historic controls.
Collapse
Affiliation(s)
- Douglas Iddings
- Department of Surgical Oncology, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA
| | | |
Collapse
|
44
|
Sandrucci S, Mussa B, Goss M, Mistrangelo M, Satolli MA, Sapino A, Bellò M, Bisi G, Mussa A. Lymphoscintigraphic localization of sentinel node in early colorectal cancer: results of a monocentric study. J Surg Oncol 2007; 96:464-9. [PMID: 17929257 DOI: 10.1002/jso.20848] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Evaluation of the feasibility of the sentinel node technique in early colorectal neoplasms and its overall accuracy in predicting nodal metastases. METHODS Thirty-five patients with colon or rectal lesions or degenerate polyps not radically excised by endoscopy were included. Lymphatic mapping was performed with 99mTc labeled albumin colloid injected submucosally by an endoscopic route the afternoon before the surgical procedure. The day of the intervention, 2.5% patent blue V dye (S.A.L.F: Italy) was injected circumferentially around the tumor. A hand held gamma detecting probe (Scintiprobe m100, Pol-Hi-Tech, Italy) was employed to detect "hot" nodes, in vivo and ex vivo. All sentinel nodes were embedded separately for haematoxylin and eosin staining. No IHC or PCR techniques were employed. RESULTS Sentinel lymph nodes (SLN) were successfully identified in 35 out of 35 patients. Concordance between SLN and nodal status was observed in 32 out of 35 cases (91.4%); four patients (11.4%) were upstaged. Three skip nodal metastases were observed (false-negative rate: 8.5%). CONCLUSIONS The sentinel node technique with blue dye and radiotracer seems valuable in early colorectal cancers detected by screening programs: a good organization and a learning curve are needed, as further multicentric studies.
Collapse
Affiliation(s)
- Sergio Sandrucci
- Oncologic Surgery, S. Giovanni Battista Hospital, University of Turin, Turin, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Bianchi P, Andreoni B, Rottoli M, Celotti S, Chiappa A, Montorsi M. Technique of sentinel lymph node biopsy and lymphatic mapping during laparoscopic colon resection for cancer. Ecancermedicalscience 2007; 1:60. [PMID: 22275957 PMCID: PMC3223971 DOI: 10.3332/ecancer.2008.60] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Indexed: 12/11/2022] Open
Abstract
Background: The utility of lymph node mapping to improve staging in colon cancer is still under evaluation. Laparoscopic colectomy for colon cancer has been validated in multi-centric trials. This study assessed the feasibility and technical aspects of lymph node mapping in laparoscopic colectomy for colon cancer. Methods: A total of 42 patients with histologically proven colon cancer were studied from January 2006 to September 2007. Exclusion criteria were: advanced disease (clinical stage III), rectal cancer, previous colon resection and contraindication to laparoscopy. Lymph-nodal status was assessed preoperatively by computed tomography (CT) scan and intra-operatively with the aid of laparoscopic ultrasound. Before resection, 2–3 ml of Patent Blue V dye was injected sub-serosally around the tumour. Coloured lymph nodes were marked as sentinel (SN) with metal clips or suture and laparoscopic colectomy with lymphadenectomy completed as normal. In case of failure of the intra-operative procedure, an ex vivo SN biopsy was performed on the colectomy specimen after resection. Results: A total number of 904 lymph nodes were examined, with a median number of 22 lymph nodes harvested per patient. The SN detection rate was 100%, an ex vivo lymph node mapping was necessary in four patients. Eleven (26.2%) patients had lymph-nodal metastases and in five (45.5%) of these patients, SN was the only positive lymph node. There were two (18.2%) false-negative SN. In three cases (7.1%) with aberrant lymphatic drainage, lymphadenectomy was extended. The accuracy of SN mapping was 95.2% and negative predictive value was 93.9%. Conclusions: Laparoscopic lymphatic mapping and SN removal is feasible in laparoscopic colectomy for colon cancer. The ex vivo technique is useful as a salvage technique in case of failure of the intra-operative procedure. Prospective studies are justified to determine the real accuracy and false-negative rate of the technique.
Collapse
Affiliation(s)
- Pp Bianchi
- Department of General and Laparoscopic Surgery, European Institute of Oncology IRCCS
| | | | | | | | | | | |
Collapse
|
46
|
Bilchik AJ, Hoon DSB, Saha S, Turner RR, Wiese D, DiNome M, Koyanagi K, McCarter M, Shen P, Iddings D, Chen SL, Gonzalez M, Elashoff D, Morton DL. Prognostic impact of micrometastases in colon cancer: interim results of a prospective multicenter trial. Ann Surg 2007; 246:568-75; discussion 575-7. [PMID: 17893493 DOI: 10.1097/sla.0b013e318155a9c7] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The 25% rate of recurrence after complete resection of stage II colon cancer (CC) suggests the presence of occult nodal metastases not identified by hematoxylin and eosin staining (H&E). Interim data from our ongoing prospective multicenter trial of sentinel node (SN) biopsy indicate a 29.6% rate of micrometastases (MM) identified by immunohistochemical staining (IHC) of H&E-negative SNs in CC. We hypothesized that these MM have prognostic importance. METHODS Between March 2001 and August 2006, 152 patients with resectable colorectal cancer were enrolled in the trial. IHC and quantitative RT-PCR (qRT) assay were performed on H&E-negative SNs. Results were correlated with disease-free survival. RESULTS The sensitivity of lymphatic mapping was significantly better in CC (75%) than rectal cancer (36%), P<0.05. Of 92 node-negative CC patients 7 (8%) were upstaged to N1 and 18 (22%) had IHC MM. Four patients negative by H&E and IHC were positive by qRT. At a mean follow-up of 25 months, 15 patients had died from noncancer-related causes, 12 had developed recurrence, 5 had died of CC (2 with macrometastases, 3 with MM), and 7 were alive with disease. The 12 recurrences included 4 patients with SN macrometastases and 6 with SN MM (2 by IHC, 4 by qRT). One of the 2 SN-negative recurrences had other positive lymph nodes by H&E. All patients with CC recurrences had a positive SN by either H&E/IHC or qRT. No CC patient with a negative SN by H&E and qRT has recurred (P=0.002). CONCLUSION This is the first prospective evaluation of the prognostic impact of MM in colorectal cancer. These results indicate that the detection of MM may be clinically relevant in CC and may improve the selection of patients for adjuvant systemic chemotherapy. Patients with CC who are node negative by cumulative detection methods (H&E/IHC and qRT) are likely to be cured by surgery alone.
Collapse
Affiliation(s)
- Anton J Bilchik
- Department of Gastrointestinal Oncology, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA 90404, and Michigan State University McLaren Regional Medical Center, Flint, MI, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Nicastri DG, Doucette JT, Godfrey TE, Hughes SJ. Is occult lymph node disease in colorectal cancer patients clinically significant? A review of the relevant literature. J Mol Diagn 2007; 9:563-71. [PMID: 17916603 DOI: 10.2353/jmoldx.2007.070032] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The clinical significance of micrometastasis of colorectal cancer (CRC) to regional lymph nodes remains controversial. In this review, we analyze publications that have evaluated the clinical significance of occult lymph node metastasis in CRC. An extensive literature search identified 19 publications that evaluated the clinical significance of micrometastatic CRC by various methods, including immunohistochemistry (IHC; n = 13) and reverse transcription-polymerase chain reaction (RT-PCR, n = 6). These studies were reviewed for methodology and findings. Significant limitations in methodology were identified, including inconsistent histological definitions of micrometastatic disease, poor sampling because of an inadequate number of lymph nodes or number of sections per lymph node analyzed, lack of conformity with respect to IHC antibody or RT-PCR marker, and inadequate power because of small sample size. Micrometastatic lymph node metastasis identified by RT-PCR was consistently found to be prognostically significant, but this was not true of micrometastatic disease identified by IHC. RT-PCR analysis of lymph nodes with specific markers can help identify pN0 (pathological-negative lymph node) CRC patients at increased risk for recurrence. The identification of occult disease by IHC techniques may also ultimately prove to be associated with worse outcome, but a number of inadequately powered studies have concluded conversely.
Collapse
Affiliation(s)
- Daniel G Nicastri
- University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | | | | | | |
Collapse
|
48
|
Bori R, Vinh-Hung V, Vajda K, Svébis M, Cserni G. The impact of the largest metastasis size on nodal tumor burden in colorectal carcinomas: implications for the sentinel lymph node theory in cancers of the large intestine. J Surg Oncol 2007; 95:629-34. [PMID: 17492634 DOI: 10.1002/jso.20725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Successful sentinel lymph node (SLN) biopsy has been reported in colorectal cancer (CRC), but its results are still controversial. The SLN theory suggests that there is an orderly spread from the primary tumor to the SLNs first, and from the SLNs to further nodes later. This study examines the influence of nodal metastasis size on further nodal involvement. METHODS CRC resection specimens with nodal metastasis have been evaluated for the maximum nodal metastasis size for a period of 5 years. All lymph nodes (LNs) were submitted to standard histological examination. RESULTS Two hundred thirty-five CRC specimens with a single invasive tumor were assessed. The mean numbers of LNs examined and involved were 18 and 4, respectively. The largest metastasis size ranged from 0.14 to 22.1 mm. There was a significant correlation between this parameter and the number or the ratio of LNs involved (Spearman's Rho: 0.517, and 0.382, respectively; P < 0.0001). A cluster analysis identified three relatively distinct groups of low, intermediate, and extensive nodal involvement. CONCLUSIONS The correlation of the largest metastasis size with the number and the ratio of involved nodes may be an indirect proof of the sequential spread from first echelon LNs to further nodes. However, the data suggest a more complex process: with increasing metastasis size, the number of involved nodes and its variability increase more than might be expected. This suggests a recruitment or cascade process, which becomes more unpredictable as nodal tumor burden increases.
Collapse
Affiliation(s)
- Rita Bori
- Department of Pathology, Bács-Kiskun County Teaching Hospital, Kecskemét, Hungary
| | | | | | | | | |
Collapse
|
49
|
Stojadinovic A, Nissan A, Protic M, Adair CF, Prus D, Usaj S, Howard RS, Radovanovic D, Breberina M, Shriver CD, Grinbaum R, Nelson JM, Brown TA, Freund HR, Potter JF, Peretz T, Peoples GE. Prospective randomized study comparing sentinel lymph node evaluation with standard pathologic evaluation for the staging of colon carcinoma: results from the United States Military Cancer Institute Clinical Trials Group Study GI-01. Ann Surg 2007; 245:846-57. [PMID: 17522508 PMCID: PMC1876962 DOI: 10.1097/01.sla.0000256390.13550.26] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The principal role of sentinel lymph node (SLN) sampling and ultrastaging in colon cancer is enhanced staging accuracy. The utility of this technique for patients with colon cancer remains controversial. PURPOSE This multicenter randomized trial was conducted to determine if focused assessment of the SLN with step sectioning and immunohistochemistry (IHC) enhances the ability to stage the regional nodal basin over conventional histopathology in patients with resectable colon cancer. PATIENTS AND METHODS Between August 2002 and April 2006 we randomly assigned 161 patients with stage I-III colon cancer to standard histopathologic evaluation or SLN mapping (ex vivo, subserosal, peritumoral, 1% isosulfan blue dye) and ultrastaging with pan-cytokeratin IHC in conjunction with standard histopathology. SLN-positive disease was defined as individual tumor cells or cell aggregates identified by hematoxylin and eosin (H&E) and/or IHC. Primary end point was the rate of nodal upstaging. RESULTS Significant nodal upstaging was identified with SLN ultrastaging (Control vs. SLN: 38.7% vs. 57.3%, P = 0.019). When SLNs with cell aggregates < or =0.2 mm in size were excluded, no statistically significant difference in node-positive rate was apparent between the control and SLN arms (38.7% vs. 39.0%, P = 0.97). However, a 10.7% (6/56) nodal upstaging was identified by evaluation of H&E stained step sections of SLNs among study arm patients who would have otherwise been staged node-negative (N0) by conventional pathologic assessment alone. CONCLUSION SLN mapping, step sectioning, and immunohistochemistry (IHC) identifies small volume nodal disease and improves staging in patients with resectable colon cancer. A prospective trial is ongoing to determine the clinical significance of colon cancer micrometastasis in sentinel lymph nodes.
Collapse
Affiliation(s)
- Alexander Stojadinovic
- Department of Surgery, Division of Surgical Oncology, and United States Military Cancer Institute, Walter Reed Army Medical Center, 6900 Georgia Avenue N.W., Washington, D.C. 20307, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Tangoku A, Seike J, Nakano K, Nagao T, Honda J, Yoshida T, Yamai H, Matsuoka H, Uyama K, Goto M, Miyoshi T, Morimoto T. Current status of sentinel lymph node navigation surgery in breast and gastrointestinal tract. THE JOURNAL OF MEDICAL INVESTIGATION 2007; 54:1-18. [PMID: 17380009 DOI: 10.2152/jmi.54.1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Sentinel lymph node biopsy (SLNB) has been developed as a new diagnostic and therapeutic modality in melanoma and breast cancer surgery. The purpose of the SLNB include preventing the operative morbidity and improving the pathologic stage by focusing on fewer lymph nodes using immunocytochemic and molecular technology has almost achieved in breast cancer surgery. The prognostic meaning of immunocytochemically detected micrometastases is also evaluating in the SLN and bone marrow aspirates of women with early-stage breast cancer. SLNB using available techniques have suggested that the lymphatic drainage of the gastrointestinal tract is much more complicated than other sites, skip metastasis being rather frequent because of an aberrant lymphatic drainage outside of the basin exist. At the moment, the available data does not justify reduced extent of lymphadenectomy, but provides strong evidence for an improvement in tumor staging on the basis of SLNB. Two large scale prospective multi-center trials concerning feasibility of gamma-probe and dye detection for gastric cancer are ongoing in Japan. Recent studies have shown favorable results for identification of SLN in esophageal cancer. CT lymphography with endoscopic mucosal injection of iopamidol was applicable for SLN navigation of superficial esophageal cancer. The aim of surgical treatment is complete resection of the tumor-infiltrated organ including the regional lymph nodes. Accurate detection of SLN can achieve a selection of a more sophisticated tailor made approach. The patient can make a individualized choice from a broader spectrum of therapeutic options including endoscopic, laparoscopic or laparoscopy-assisted surgery, modified radical surgery, and typical radical surgery with lymph node dissection. Ultrastaging by detecting micrometastasis at the molecular level and the choice of an adequate treatment improve the postoperative quality of life and survival. However these issues require further investigation.
Collapse
Affiliation(s)
- Akira Tangoku
- Department of Oncological and Regenerative Surgery, Institute of Health Bioscience, The University of Tokushima Graduate School, Tokushima, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|