Prognostic significance of extranodal microscopic foci discontinuous with primary lesion in rectal cancer

Tumour deposits are associated with worse survival than extranodal extension; a network meta-analysis on tumour nodules in colorectal cancer

Lymph node metastases (LNM) play a central role in the tumour-node-metastasis (TNM) classification for colorectal cancer (CRC), with extranodal extension (ENE) as an adverse feature. ENE has never been directly compared to tumour deposits (TD). The aim of this study was to perform an up-to-date systematic review, including a network meta-analysis to compare their prognostic value. A comprehensive search was conducted on PubMed, Embase, Web of Science and Cochrane databases to identify all prognostic studies on ENE and TD. A total of 20 studies were included, with 7719 cases. The primary outcome was 5-year disease-free survival (DFS); secondary outcomes were overall survival (OS) and disease-specific survival (DSS). Frequentist paired and network meta-analyses were performed using the netmeta package in R. For univariable DFS analysis, LNM + TD+ cases had a significantly worse outcome compared with LNM + ENE+ cases [hazard ratio (HR) = 1.27, 95% confidence interval (CI) = 1.06-1.53], which was no longer significant for multivariable DFS analysis (HR = 1.13, 95% CI = 0.87-1.46). All OS and multivariable DSS analyses showed a significantly worse outcome for LNM + TD+ cases compared with LNM + ENE cases. For all outcomes, both LNM + TD+ and LNM + ENE+ had a significantly increased hazard compared with LNM+ cases. This study shows that there is a trend towards worse outcome for LNM + TD+ than LNM + ENE+, not statistically significant in multivariable DFS analysis. Both groups perform significantly worse than cases with LNM only. To improve the accuracy of CRC staging, we recommend to put more emphasis on both ENE and TD in the TNM classification, with the most prominent role for TD.

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The purpose of this study was to evaluate the incidence and predictors of malignant soft tissue deposits (MSTDs) in advanced laryngeal carcinoma. MSTDs prognostic value on locoregional recurrence within 2 years after curative surgery was also studied. 40 patients with cT3/cT4 N0 laryngeal squamous cell carcinoma (SCC) were prospectively involved in the study. Soft tissue specimens were histopathologically examined for MSTDs. MSTDs were observed in 4 patients. Six patients had extranodal extension (ENE), four of whom showed MSTDs. All patients with MSTDs had associated comorbidities. cTNM staging, preoperative tracheostomy, tumor grade and surgical margins were not related to the incidence of MSTDs. The incidence of MSTDs in our report was less than that previously reported in the literature. MSTDs did not influence locoregional recurrence and did not influence the overall outcome. MSTDs were less significant as a prognostic factor in comparison to other factors such as ENE.

The past, present, and future of tumour deposits in colorectal cancer: Advancing staging for improved prognosis and treatment decision-making

Tumour deposits (TDs) significantly impact colorectal cancer (CRC) prognosis. Integrating TDs into the TNM staging system can enhance individualized disease management. Keeping abreast of evolving TDs research is pivotal for clinical advancement. We comprehensively reviewed both recent and popular literature to grasp the field's essence. Subsequently, a data retrieval sourced articles on TDs in CRC for bibliometric analysis, spanning from 1 January 1935 to 30 April 2023. Bibliometrix software facilitated paper analysis and visualization. Bibliometric indicators, the trends and hotspots were determined. A total of 2147 articles were successfully retrieved. Brown G emerged as the most productive author, and the USA as the most prolific country. Central South University and Memorial Sloan Kettering Cancer Center led productivity. Bradford's law categorized 48 journals into zone 1. Keywords co-occurrence analysis identified three main clusters: the application of TDs in TNM staging, the pathogenesis of TDs, and the assessment of TDs. The trend topic analysis highlighted research focused on refining TDs incorporation into tumour staging. TDs wield enduring medical significance, shaping ongoing research. Much literature focused on confirming TD's prognostic value and optimizing TNM integration. Additionally, it is worth highlighting that TD's enigmatic pathogenesis demands research priority, as it holds the potential to unveil concealed knowledge regarding their development.

MRI-detected tumor deposits in cT3 and cT4 rectal cancer following neoadjuvant chemoradiotherapy

OBJECTIVES

To evaluate the identification of tumor deposits (TDs) and the prognostic significance of an MRI tumor regression grade for TDs in patients with rectal cancer treated with neoadjuvant chemoradiotherapy (nCRT).

METHODS

Ninety-one patients with cT3 or cT4 rectal cancer who underwent surgery following nCRT between August 2014 and June 2020 were retrospectively analyzed. Changes in pre-nCRT MRI-detected TDs (mrTDs) were described as mrTD regression grade. The diagnostic performance of post-nCRT MRI-detected TDs (ymrTDs) was compared with histopathological reference standard. The correlation between ymrTDs, mrTD regression grade, and disease-free survival (DFS) was assessed.

RESULTS

The sensitivity and specificity of ymrTDs were 88.00% and 89.39%, respectively. The area under the receiver operating characteristic curve was 0.887 (95% confidence interval [CI]: 0.803-0.944). The 3-year DFS of patients with positive ymrTDs was significantly lower than of the negative group (44.83% vs 82.73%, p < 0.001). The 3-year DFS was 33.33% for patients with poor regression of mrTDs following nCRT and 55.56% for those with moderate regression, compared to 69.23% in good responders and 83.97% in patients without mrTDs (p < 0.001). On multivariable Cox regression, mrTD regression grade was the only independent MRI factor associated with DFS (p = 0.042).

CONCLUSIONS

Diagnostic performance of ymrTDs was moderate. The mrTD regression grade was independently correlated with DFS, which may have a prognostic implication for treatment and follow-up.

CLINICAL RELEVANCE STATEMENT

Patients with poor regression of MRI-detected tumor deposits may benefit from more aggressive treatments, such as chemoradiation therapy plus induction or consolidation chemotherapy.

KEY POINTS

• MRI provides a preoperative and noninvasive way to visualize tumor deposits (TDs) after neoadjuvant chemoradiotherapy (nCRT). • Post-nCRT MRI-detected TDs are a poor prognostic marker in cT3 and cT4 rectal cancer patients. • The regression of MRI-detected TDs after nCRT is associated with an improved disease-free survival.

The Relationship between Tumor Budding and Tumor Deposits in Patients with Stage III Colorectal Carcinoma

Background/Objectives: Recently, some new morphological features of colorectal cancer have been discovered as important prognostic factors; in this paper, we study the relationship between tumor budding (TB) and tumor deposits (TDs). Methods: The retrospective cohort study included 90 patients with pathohistologically confirmed stage III CRC who were treated with radical surgical resection. All hematoxylin and eosin (H and E)-stained slides from each patient were reviewed, and histological parameters were recorded. The samples were divided into two groups with similar sizes: a group without TDs (N = 51) and a control group with TDs (N = 39). The presence and TB grade were further analyzed in these groups and compared with other clinical and histological features. Results: The prevalence of TB in the investigated cohort was unexpectedly high (94.4%). Overall, there were 23 (25.6%) Bd1, 20 (22.2%) Bd2, and 47 (52.2%) Bd3 cases. The presence of TDs was significantly associated with a higher number of TB (p < 0.001, OR 16.3) and, consequently, with a higher TB grade (p = 0.004, OR 11.04). A higher TB grade (p = 0.001, HR 2.28; 95% CI 1.93-4.76) and a growing number of TDs (p = 0.014, HR 1.52; 95% CI 1.09-2.1) were statistically significantly associated with shorter survival. Conclusions: TDs appear more often in patients with higher TB grades in stage III CRC. A higher TB grade and a growing number of TDs were statistically significantly associated with shorter overall survival. These results could give additional emphasis to the importance of TB as an adverse prognostic factor since a strong relationship with TDs has been demonstrated.

Proposal for a Novel Histological Scoring System as a Potential Grading Approach for Muscle-invasive Urothelial Bladder Cancer Correlating with Disease Aggressiveness and Patient Outcomes

BACKGROUND

Grading of muscle-invasive bladder cancer (MIBC) according to the current World Health Organization (WHO) criteria is controversial due to its limited prognostic value. All MIBC cases except a tiny minority are of high grade.

OBJECTIVE

To develop a prognostic histological scoring system for MIBC integrating histomorphological phenotype, stromal tumor-infiltrating lymphocytes (sTILs), tumor budding, and growth and spreading patterns.

DESIGN, SETTING, AND PARTICIPANTS

Tissue specimens and clinical data of 484 patients receiving cystectomy and lymphadenectomy with curative intent with or without adjuvant chemotherapy. Histomorphological phenotypes, sTILs, tumor budding, and growth and spreading patterns were evaluated and categorized into four grade groups (GGs). GGs were correlated with molecular subtypes, immune infiltration, immune checkpoint expression, extracellular matrix (ECM) remodeling, and epithelial-mesenchymal transition (EMT) activity.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

GGs were associated with overall (OS), disease-specific (DSS), and progression-free (PFS) survival in univariable and multivariable analyses. Association with biological features was analyzed with descriptive statistics.

RESULTS AND LIMITATIONS

Integration of two histomorphological tumor groups, three sTILs groups, three tumor budding groups, and four growth/spread patterns yielded four novel GGs that had high significance in the univariable survival analysis (OS, DSS, and PFS). GGs were confirmed as independent prognostic predictors with the greatest effect in the multivariable Cox regression analysis. Correlation with molecular data showed a gradual transition from basal to luminal subtypes from GG1 to GG4; a gradual decrease in survival, immune infiltration, and immune checkpoint activity; and a gradual increase in ECM remodeling and EMT activity.

CONCLUSIONS

We propose a novel, prognostically relevant, and biologically based scoring system for MIBC in cystectomies applicable to routine pathological sections.

PATIENT SUMMARY

We developed a novel approach to assess the aggressiveness of advanced bladder cancer, which allows improved risk stratification compared with the method currently proposed by the World Health Organization.

Prognostic value of tumor deposits in lymph node-negative gastric cancer: A propensity score matching study

BACKGROUND

The purpose of this study was to assess the prognostic value of TD in lymph node-negative GC.

METHODS

A retrospective study was conducted to collect the clinicopathological data from 1224 patients with lymph node-negative GC. According to their TD status, patients were categorized into TD-positive and TD-negative groups. Patients in both groups underwent a 1:1 propensity score matching analysis. Survival analysis was performed by the Kaplan-Meier method, and the differences between survival curves were measured by log-rank test. The cox proportional hazards model was used for univariate and multivariate analyses.

RESULTS

The TD-negative group had higher 5-year overall survival(OS) rate than TD-positive group(69.4%VS.36.4%,P < 0.05). Further subgroup analysis indicated that patients in the TD-negative group had higher 5-year OS rates than those in the TD-positive group in the T1-2, T3, and T4 subgroups(all with P < 0.05).The OS rates were decreased with the increase of the number of TD.The univariate Cox regression analysis demonstrated that tumor location in antrum, distal gastrectomy, perineural invasion, T4-stage,lymphovascular invasion and the number of TD were all associated with prognosis in patients undergoing curative gastric resection (P < 0.05).The multivariable analysis revealed that the number of TD, perineural invasion, lymphovascular invasion and T4 stage were independently associated with OS.

CONCLUSION

In lymph node-negative GC, TD is an independent risk factor for prognosis, regardless of T-stage, and patients with ≥3 TD have a worse prognosis.

Histopathological diagnosis of tumour deposits in colorectal cancer: a Delphi consensus study

AIMS

Tumour deposits (TDs) are an important prognostic marker in colorectal cancer. However, the classification, and inclusion in staging, of TDs has changed significantly in each tumour-node-metastasis (TNM) edition since their initial description in TNM-5, and terminology remains controversial. Expert consensus is needed to guide the future direction of precision staging.

METHODS AND RESULTS

A modified Delphi consensus process was used. Statements were formulated and sent to participants as an online survey. Participants were asked to rate their agreement with each statement on a five-point Likert scale and also to suggest additional statements for discussion. These responses were circulated together with anonymised comments, and statements were modified prior to carrying out a second online round. Consensus was set at 70%. Overall, 32 statements reached consensus. There were concerns that TDs were currently incorrectly placed in the TNM system and that their prognostic importance was being underestimated. There were concerns regarding interobserver variation and it was felt that a clearer, more reproducible definition of TDs was needed.

CONCLUSIONS

Our main recommendations are that the number of TDs should be recorded even if lymph node metastases (LNMs) are also present and that nodules with evidence of origin [extramural venous invasion (EMVI), perineural invasion (PNI), lymphatic invasion (LI)] should still be categorised as TDs and not excluded, as TNM-8 specifies. Whether TDs should continue to be included in the N category at all is controversial, and did not achieve consensus; however, participants agreed that TDs are prognostically worse than LNMs and the N1c category is suboptimal, as it does not reflect this.

Accuracy of MRI for nodal restaging in rectal cancer: a retrospective study of 166 cases

AIM

Assessing metastatic mesorectal nodal involvement is a challenge in rectal cancer, especially in the post chemoradiation setting. We aim to assess the accuracy of MRI for nodal restaging and the validity of SAR criteria (≥ 5 mm size being metastatic).

MATERIALS AND METHODS

This was an IRB-approved retrospective study of 166 patients with locally advanced rectal cancers, operated after neoadjuvant treatment. Two dedicated oncoradiologists reviewed the 166 post-chemoradiation presurgical MRIs in consensus. Nodal size and morphology (shape, margins, and signal intensity) were noted. The most accurate cut-off for size for predicting positive pN status was determined using the Youden index.

RESULTS

MRI understaged 30/166 (18%) and overstaged 40/166 (24%) patients using the SAR criteria. The most accurate cut-off for node size was 5.5 mm, with a sensitivity of 75%, specificity of 60.2%, PPV of 40.7%, NPV of 86.9% (95% CI:78-92.5%), accuracy of 64.2%, and area under the curve (AUC) 0.657 (95% CI-0.524-0.79). Morphological characteristics were not significant to determine involvement, with positive nodes including 42% of round and 31% of oval nodes, 40% of heterogeneous and 45% of homogeneous nodes, and 31% irregularly marginated and 46% nodes with regular margins being positive on pathology. MRI was accurate in predicting pathology for mucinous nodes in 9/29 (31%) cases. Seven cases which were yN2 on MRI and yN0 on pathology demonstrated mucinous changes on MRI and had acellular mucin on histopathology.

CONCLUSIONS

MRI has good negative predictive value, poor positive predictive value and moderate accuracy in nodal restaging. The cut-off of 5.5 mm demonstrated in our study is close to the SAR cut-off of 5 mm in the post-treatment setting. MRI accuracy is lower in patients with mucinous nodes.

Extranodal soft tissue metastasis as an independent prognostic factor in gastric cancer patients aged under 70 years after curative gastrectomy

BACKGROUND

Accumulating evidence confirms the potential prognostic value of extranodal soft tissue metastasis (ESTM) in patients with solid cancers. The aim of this study was to elucidate the potential relationship between ESTM and lymph node (LN) metastasis, demonstrate clinicopathological predictive prognostic factors for ESTM and LN metastasis, and identify the prognostic value of ESTM for gastric cancer (GC) patients aged under 70 years.

METHODS

A total of 580 GC patients who underwent the curative resection between 2003 and 2011 were included to identify if ESTM is essential to improve the accuracy of prognostic evaluation of the GC patients postoperatively. Overall survival rates were tested by Kaplan-Meier analysis. Univariate and multivariate analyses were applied to clarify the independent prognostic factors. Logistic regression analysis was adopted to clarify the risk factors for evaluating the presence of ESTM and LN metastasis. After cut-point survival analysis, the GC patients were divided into three subgroups based on the number of ESTM and then incorporated into the pTNM stage of gastric carcinoma to identify the possibility and necessity of incorporating ESTM into staging.

RESULTS

ESTM was associated with advanced pT, pN and pTNM categories, large tumour size and the presence of signet-ring cell (SRC) variants. Survival analyses revealed that ESTM was associated with the OS and was an independent prognostic predictor in this GC patient cohort. Logistic regression analysis proved that ESTM and pT stage are significantly correlated with LN metastasis. Additionally, the ESTM was incorporated into the eighth edition of the pTNM classification and the prognostic evaluation of pTNME classification were calculated directly, and the results indicated that ESTM can reduce the stage migration.

CONCLUSIONS

ESTM is a significant independent predictor of survival in GC patients. To achieve R0 surgery, lymph nodes, soft tissues, fascia and adipose tissue should be resected en bloc at the same time as lymph node dissection. ESTM should be incorporated into pTNM staging according to the number retrieved from postoperative samples.

Tumor deposit indicates worse prognosis than metastatic lymph node in gastric cancer: a propensity score matching study

Background

The prognostic value of tumor deposit (TD) in gastric cancer is controversial. This study aims to investigate the prognostic value of TD.

Methods

The consecutive patients diagnosed with gastric cancer from October 2007 to October 2012 were selected. The patients were divided by whether they suffered TD into two groups. The basic data were comparable between the two groups after propensity score matching (PSM), then survival analysis [overall survival (OS) and cancer-specific survival (CSS)] was applied in two groups. After that, all the patients were divided by pN staging and survival analysis were applied in each subgroup. At last, all patients were divided into TD group, pN1 stage group, pN2 stage group, pN3a, and pN3b stage group, OS and CSS were compared between them. Multivariable competing risk analyses tested association of TD with OS and CSS, before and after PSM.

Results

Eight hundred and three patients were concluded. After PSM, 137 patients with TD and 274 patients without TD were selected, the 5-year OS and CSS rates of patients with TD were significantly worse than patients without TD (OS: 19.7% vs. 42.0%, P<0.001; CSS: 22.6% vs. 45.6%, P<0.001). In all patients' survival analysis, the 5-year OS and CSS rates of TD group were comparable with pN3a group (OS: 19.7% vs. 25.3%, P=0.221, CSS: 22.6% vs. 30.1%, P=0.092) and pN3b group (OS: 19.7% vs. 19.6% P=0.349, CSS: 22.6% vs. 23.5%, P=0.452). Meanwhile, on multivariable cox regression analyses, the presence of TD significantly reduces the OS and CSS of patients in gastric cancer.

Conclusions

TD has a marked impact on the prognosis of gastric cancer. Even patients with TD had the same prognosis with pN3 stage.

Clinical Implications of Lymph Node Metastasis in Colorectal Cancer: Current Status and Future Perspectives

Lymph node metastasis is regarded as an indubitable prognostic factor for predicting disease recurrence and survival in patients with colorectal cancer. Lymph node status based on examination of a resected specimen is a key element of the current staging system and is also a crucial factor to determine use of adjuvant chemotherapy after surgical resection. However, the current tumor-node-metastasis (TNM) staging system only incorporates the number of metastatic lymph nodes in the N category. Numerous attempts have been made to supplement this simplified N staging including lymph node ratio, distribution of metastatic lymph nodes, tumor deposits, or extracapsular invasion. In addition, several attempts have been made to identify more specific prognostic factors in resected colorectal specimens than lymph node status. In this review, we will discuss controversies in lymph node staging and factors that may influence survival beyond lymph node status.

Prognostic Impact of Extracapsular Lymph Node Invasion on Survival in Non-small-Cell Lung Cancer: A Systematic Review and Meta-analysis

The extracapsular tumor extension (ECE) of nodal metastasis is an important prognostic factor in different types of malignancies. However, there is a lack of recent data in patients with non-small-cell lung cancer (NSCLC). In addition, the TNM staging system does not include ECE status as a prognostic factor. This systematic review and meta-analysis has been conducted to summarize and pool existing data to determine the prognostic role of ECE in patients with lymph node-positive NSCLC. Two authors performed an independent search in PubMed using a predefined keyword list, without language restrictions with publication date since 1990. Prospective or retrospective studies reporting data on prognostic parameters in subjects with NSCLC with positive ECE or with only intracapsular lymph node metastasis were retrieved. Data were summarized using risk ratios (RR) for the survival with 95% confidence intervals (CI). The data was analyzed using Mix 2 (ref: Bax L: MIX 2.0 - Professional software for meta-analysis in Excel. Version 2.015. BiostatXL, 2016. https://www.meta-analysis-made-easy.com ). There 2,105 studies were reviewed. Five studies covering a total of 828 subjects met the inclusion criteria and were included in the meta-analysis. Two hundred and ninety-eight (35.9%) patients were categorized as ECE+, of whom 54 (18.1%) survived at the end of follow-up. In the ECE-negative group, 257 patients (48.4%) survived by the end of follow-up. Thus, ECE status is associated with a significantly decreased survival rate: pooled RR 0.45 (95% CI 0.35-0.59), Q ₍₄₎ = 4.06, P _value = 0.39, and I ² = 68.00% (95 CI 0.00-79.55%). In conclusion, ECE has a significant impact on survival in NSCLC patients and should be considered in diagnostic and therapeutic decisions in addition to the current TNM staging. Postoperative radiotherapy may be an option in ECE-positive pN1 NSCLC patients.

Tumor deposits: markers of poor prognosis in patients with locally advanced rectal cancer following neoadjuvant chemoradiotherapy

Background

Tumor deposits (TDs) were reported to be poor prognoses in colorectal carcinoma, but the significance in locally advanced rectal cancer (LARC) (T3-4/N+) following neoadjuvant chemoradiotherapy (neo-CRT) and surgery is unclear. Since adjuvant chemotherapy showed no benefit for LARC following neo-CRT, it is of great value to investigate whether TDs can identify the subgroup of patients who may benefit from adjuvant chemotherapy.

Methods

Between 2004 and 2012, 310 LARC patients following neo-CRT and surgery were retrospectively reviewed. Overall survival (OS), disease-free survival (DFS), distant metastasis free survival (DMFS) and local recurrence free survival (LRFS) were evaluated by Kaplan-Meier method, log-rank test and Cox models.

Results

TDs-positive patients showed adverse OS, DFS and DMFS (all P≤0.001), but not LRFS (P = 0.273). In multivariate analysis, TDs continued to be associated with poor OS (HR = 2.44, 95% CI 1.32-4.4, P = 0.004) and DFS (HR = 1.99, 95% CI 1.21-3.27, P = 0.007), but not DMFS (HR = 1.77, 95% CI 0.97-3.20, P = 0.061) or LRFS (HR = 1.85, 95% CI 0.58-5.85, P = 0.298). Among TDs-positive patients, adjuvant chemotherapy significantly improved OS (P = 0.045) and DMFS (P = 0.026), but not DFS (P = 0.127) or LRFS (P = 0.862).

Conclusions

TDs are predictive of poor survival in LARC after neo-CRT. Fortunately, TDs-positive patients appear to benefit from adjuvant chemotherapy.

Tumor deposits counted as positive lymph nodes in TNM staging for advanced colorectal cancer: a retrospective multicenter study

We investigated the possibility of counting tumor deposits (TDs) as positive lymph nodes (pLNs) in the pN category and evaluated its prognostic value for colorectal cancer (CRC) patients. A new pN category (npN category) was calculated using the numbers of pLNs plus TDs. The npN category included 4 tiers: npN1a (1 tumor node), npN1b (2-3 tumor nodes), npN2a (4-6 tumor nodes), and npN2b (≥7 tumor nodes). We identified 4,121 locally advanced CRC patients, including 717 (11.02%) cases with TDs. Univariate and multivariate analyses were performed to evaluate the disease-free and overall survival (DFS and OS) for npN and pN categories. Multivariate analysis showed that the npN and pN categories were both independent prognostic factors for DFS (HR 1.614, 95% CI 1.541 to 1.673; HR 1.604, 95% CI 1.533 to 1.679) and OS (HR 1.633, 95% CI 1.550 to 1.720; HR 1.470, 95% CI 1.410 to 1.532). However, the npN category was superior to the pN category by Harrell's C statistic. We conclude that it is thus feasible to consider TDs as positive lymph nodes in the pN category when evaluating the prognoses of CRC patients, and the npN category is potentially superior to the TNM (7th edition) pN category for predicting DFS and OS among advanced CRC patients.

Tumor Deposits in Colorectal Cancer: Improving the Value of Modern Staging-A Systematic Review and Meta-Analysis

Purpose Colorectal cancer (CRC) treatment is largely determined by tumor stage. Despite improvements made in the treatment of various types of metastatic disease, staging has not been refined. The role of tumor deposits (TDs) in staging remains debated. We have assessed the relation of TDs with metastatic pattern to evaluate whether TDs might add significant new information to staging. Methods We performed a systematic literature search that was focused on the role of TDs in CRC. Studies with neoadjuvant-treated patients were excluded. Data on stage, histologic factors, and outcome were extracted. Data from four large cohorts were analyzed for the relevance of the presence of TDs, lymph node metastases (LNMs), and extramural vascular invasion (EMVI) on the pattern of metastases and outcomes. Results Of 10,106 included patients with CRC, 22% presented with TDs. TDs are invariably associated with poor outcome. Presence of TDs was associated with presence of LNMs and EMVI. In a pairwise comparison, effects of TD were stronger than those of both LNMs and EMVI. In the logistic regression model, TDs in combination with LNMs is the strongest predictor for liver (odds ratio [OR], 5.5), lung (OR, 4.3) and peritoneal metastases (OR, 7.0). Presence of EMVI adds information for liver and lung metastases, but not for peritoneal metastases. Conclusion We have shown that TDs are not equal to LNMs or EMVI with respect to biology and outcome. We lose valuable prognostic information by allocating TDs into nodal category N1c and only considering TDs in the absence of LNMs. Therefore, we propose that the number of TDs should be added to the number of LNMs to derive a final N stage.

Prognostic impact and implications of extracapsular lymph node involvement in colorectal cancer: a systematic review with meta-analysis

BACKGROUND

The extranodal extension (ENE) of nodal metastasis (i.e. the extension of tumor cells through the nodal capsule into the perinodal adipose tissue) has recently emerged as an important prognostic factor in different types of malignancies. However, the tumor-node-metastasis (TNM) staging system for colorectal cancer does not consider it as a prognostic parameter. Therefore, we conducted a systematic review and meta-analysis to determine the prognostic role of ENE in patients with lymph node-positive colorectal cancer.

MATERIALS AND METHODS

Two independent authors searched PubMed and SCOPUS until 7 January 2015 without language restrictions. Prospective studies reporting data on prognostic parameters in subjects with colorectal cancer, comparing participants with the presence of ENE (ENE+) versus only intranodal extension (ENE-) were eligible. Data were summarized using risk ratios (RRs) for the number of deaths/recurrences and hazard ratios (HRs) together with 95% confidence intervals (CIs) for time-dependent risk related to ENE+, adjusted for potential confounders.

RESULTS

Thirteen studies including 1336 patients were identified with a median follow-up of 4.7 years. ENE was associated with a higher T stage and tumor grading. In addition, ENE was associated with a significantly increased risk of all-cause mortality (RR = 1.75; 95% CI 1.42-2.16, P < 0.0001, I(2) = 60%; HR = 1.69, 95% CI 1.32-2.17, P < 0.0001, I(2) = 46%) and of recurrence of disease (RR = 2.07, 95% CI 1.65-2.61, P < 0.0001, I(2) = 47%; HR = 2.31, 95% CI 1.54-3.44, P < 0.0001, I(2) = 48%).

CONCLUSIONS

Based of these results, in colorectal cancer, ENE should be considered from the gross sampling to the pathology report, as well as in future oncologic staging systems.

Detection and Characterization of Metastatic Cancer Cells in the Mesogastrium of Gastric Cancer Patients

Gastric cancer is the second leading cause of cancer death worldwide. Here, we propose a novel type of tumor metastasis designated as Metastasis V in gastric cancer. Metastasis V is defined as the appearance of cancer cells in the mesogastrium with perigastric adipose tissue. To detect its incidence and characterize its clinic pathological features, large cross sectional tissue analysis of mesogastrium from 74 patients were used. Metastasis V was detected in 1 of 40 (2.5%) patients with early gastric cancer, 8 of 34 (24%) patients with advanced gastric cancer. The mean distance of Metastasis V from gastric wall was approximately 2.6 cm. Metastasis V was closely associated with tumor invasion depth, along with a number of positive lymph node metastasis. The prognosis of patients with Metastasis V was significantly (P<0.05) worse than those with tumor cell-free mesogastrium. These findings indicate that by using whole-sectional analysis, Metastasis V can be detected in the mesogastrium of gastric cancer patients, and also suggests that it may be a risk factor for patient survival after radical surgery.

Prognostic value of tumor shrinkage versus fragmentation following radiochemotherapy and surgery for rectal cancer

Most patients with rectal cancer receive neoadjuvant radiochemotherapy (RCT), causing a variable decrease in tumor mass. We evaluated the prognostic impact of pathologic parameters reflecting tumor response to RCT, either directly or indirectly. Seventy-six rectal cancer patients receiving neoadjuvant RCT between 2006 and 2009 were included. We studied the association between disease-free survival (DFS) and the "classical" clinicopathologic features as well as tumor deposits, circumferential resection margin (CRM), Dworak regression grade, and tumor and nodal downstaging. Patients with tumor downstaging had a longer DFS (p = 0.05), indicating a more favorable prognosis when regression was accompanied by a decrease in tumor infiltrative depth, referred to as tumor shrinkage. Moreover, tumor downstaging was significantly associated with larger CRM and nodal downstaging (p = 0.02), suggesting that shrinkage of the primary tumor was associated with a decreased nodal tumor load. Higher Dworak grade did not correlate with tumor downstaging, nor with higher CRM or prolonged DFS. This implies that tumor mass decrease was sometimes due to fragmentation rather than shrinkage of the primary tumor. Lastly, the presence of tumor deposits was clearly associated with reduced DFS (p = 0.01). Assessment of tumor shrinkage after RCT via tumor downstaging and CRM is a good way of predicting DFS in rectal cancer, and shrinkage of the primary tumor is associated with a decreased nodal tumor load. Assessing regression based on the amount of tumor in relation to stromal fibrosis does not accurately discern tumor fragmentation from tumor shrinkage, which is most likely the reason why Dworak grade had less prognostic relevance.

Tumor deposits in rectal adenocarcinoma after neoadjuvant chemoradiation are associated with poor prognosis

Although tumor deposits have been associated with poor prognosis in colorectal carcinoma, the prevalence and clinical significance of tumor deposits in rectal adenocarcinoma following neoadjuvant chemoradiation are relatively unexplored. The aims of this study are to assess the clinical significance of tumor deposits in rectal adenocarcinoma patients, including those receiving neoadjuvant therapy. Pathology slides and medical records from 205 consecutive patients who underwent resection for rectal adenocarcinoma between 1990 and 2010 at a single tertiary care center were reviewed. Patients with tumor deposits had higher tumor grade (P=0.006) and worse tumor stage (P<0.001) at presentation than patients without tumor deposits. Among 110 patients who underwent neoadjuvant chemoradiation, tumor deposits were associated with higher rates of lymph node involvement (P=0.035) and distant metastases (P=0.006), and decreased survival (P=0.027). These patients had a trend toward lower treatment response scores (P=0.285) and higher local recurrence (P=0.092). Of 52 patients with tumor deposits, those who underwent neoadjuvant chemoradiation had significantly worse pretreatment stage by endoscopic ultrasound (P<0.001) but interestingly had significantly lower rates of lymphovascular invasion on resection (P<0.001) compared with those who had not received neoadjuvant chemoradiation. Despite treatment with neoadjuvant chemoradiation, tumor deposits were present in over one-fifth of rectal adenocarcinoma patients. Overall, the outcome of patients with tumor deposits in treated and untreated patients were similar, however the association of tumor deposits with deeply invasive tumors and less tumor regression when comparing with treated patients without tumor deposits raises the possibility that these tumors could have a more aggressive biology, possibly explaining the association of tumor deposits with higher rates of recurrence and lower survival after neoadjuvant chemoradiation. Overall, tumor deposits appear to be a poor prognostic marker among rectal adenocarcinoma patients following neoadjuvant chemoradiation and may identify a subset of patients who require aggressive adjuvant therapy to prevent recurrence.

Tumor deposits in gastric carcinomas

We performed this study to examine the prevalence of tumor deposits (TD) in gastric adenocarcinomas (GACa), and the relevance of their presence, size and type to clinical outcome. Ninety-six patients, histopathologically diagnosed as GACa following a total/subtotal gastrectomy were included, and clinicopathologic data were recorded. Due to the statistical analysis, the majority of TD(+) cases were of intestinal type and showed vascular invasion. In these cases, the incidence of local recurrence was significantly higher. The majority of GACa of intestinal type with TD were of high grade and showed vascular invasion. Recurrence and death were more commonly encountered among them. The recurrence-free survival (RFS) was significantly shorter in patients with TDs, which was also confirmed by multivariate analysis, and there was a significant difference between both RFS and overall survival of TD(+) and TD(-) cases of intestinal type GACa. In conclusion, in this study, we demonstrate that TDs are not infrequently observed in GACa, they are more commonly associated with the intestinal type and vascular invasive gastric cancers. Our study shows the prognostic impact of TDs, especially regarding the RFS. Therefore, the documentation of TDs might be considered for prospective studies, especially for the intestinal type GACa, a shortcoming of this study.

Extranodal metastasis is a powerful prognostic factor in patients with adenocarcinoma of the esophagogastric junction

BACKGROUND AND OBJECTIVES

The purpose of this study is to estimate the effect of extranodal metastasis (EM) on recurrence and survival in patients with adenocarcinoma of the esophagogastric junction (AEG) after curative resection.

METHODS

Clinical data from 284 node-positive AEG patients who underwent curative resection were reviewed. Univariate and multivariate analyses were conducted to elucidate the effect of EM on recurrence-free survival (RFS) and overall survival (OS).

RESULTS

EM was detected in 70 (24.6%) of the 284 cases. It had a significant correlation with tumor size, Lauren type, histopathological grading, depth of tumor invasion, number of metastatic nodes, lymph node ratio, and TNM stage. The 5-year RFS and OS rates were 22.2% and 24.3%, respectively. Patients with EM had a significantly decreased RFS (16 vs. 36 months, P < 0.001) and OS (23 vs. 41 months, P < 0.001) compared with those without EM. Multivariate analyses identified EM as an independent prognostic factor (P = 0.003 and 0.001, respectively).

CONCLUSION

The presence of EM increases recurrence probability and reduces OS probability of AEG patients with lymph node metastasis. EM is a powerful prognostic factor reflecting a particularly aggressive biological behavior. Better understanding of EM status can help clinicians with regard to treatment decision and prognosis evaluation.

Debating deposits: an interobserver variability study of lymph nodes and pericolonic tumor deposits in colonic adenocarcinoma

CONTEXT

The American Joint Committee on Cancer's Cancer Staging Manual 7th edition defines pericolonic tumor deposits (TDs) as discrete tumor foci in pericolic fat showing no evidence of residual lymph node (LN). This definition relies on subjective features rather than size (5th edition) or shape (6th edition) and introduced the category N1c. Although typically straightforward, metastases are encountered for which the distinction between LNs and TDs is unclear. For data to be meaningful, agreement on distinguishing features between positive LNs and TDs is needed.

OBJECTIVES

To assess agreement among gastrointestinal pathologists evaluating difficult metastases and to report the distinguishing features they found helpful.

DESIGN

Twenty-five tumor metastases from right-sided colonic adenocarcinomas were selected in which the distinction between positive LNs and TDs was challenging. Virtual slides were reviewed by 7 gastrointestinal pathologists. A list of features potentially helpful in differentiating positive LNs and TDs was ranked for usefulness by each pathologist. Every metastasis was diagnosed as positive LN or TD. For each case diagnosed as positive LN, reviewers were asked to list every feature used in diagnosis.

RESULTS

Complete agreement was found for 11 of 25 metastases, 5 positive LNs and 6 TDs (κ statistic, 0.48; 95% confidence interval, 0.28-0.67). Top-ranked features included round shape, peripheral lymphocyte rim, peripheral lymphoid follicles, possible subcapsular sinus, residual LN in surrounding fibroadipose tissue, and thick capsule. The top used features were similar among reviewers.

CONCLUSIONS

Significant agreement on positive LNs and TDs in difficult colonic adenocarcinoma metastases was found among evaluators, but inconsistency remains. Round shape, peripheral lymphocyte rim, peripheral lymphoid follicles, possible subcapsular sinus, residual LN in surrounding fibroadipose tissue, and thick capsule were most often used to aid in diagnosis.

Rectal cancer staging: focus on the prognostic significance of the findings described by high-resolution magnetic resonance imaging

High-resolution (HR) magnetic resonance imaging (MRI) has become an indispensable tool for multidisciplinary teams (MDTs) addressing rectal cancer. It provides anatomic information for surgical planning and allows patients to be stratified into different groups according to the risk of local and distant recurrence. One of the objectives of the MDT is the preoperative identification of high-risk patients who will benefit from neoadjuvant treatment. For this reason, the correct evaluation of the circumferential resection margin (CRM), the depth of tumor spread beyond the muscularis propria, extramural vascular invasion and nodal status is of the utmost importance. Low rectal tumors represent a special challenge for the MDT, because decisions seek a balance between oncologic safety, in the pursuit of free resection margins, and the patient's quality of life, in order to preserve sphincter function. At present, the exchange of information between the different specialties involved in dealing with patients with rectal cancer can rank the contribution of colleagues, auditing their work and incorporating knowledge that will lead to a better understanding of the pathology. Thus, beyond the anatomic description of the images, the radiologist's role in the MDT makes it necessary to know the prognostic value of the findings that we describe, in terms of recurrence and survival, because these findings affect decision making and, therefore, the patients' life. In this review, the usefulness of HR MRI in the initial staging of rectal cancer and in the evaluation of neoadjuvant treatment, with a focus on the prognostic value of the findings, is described as well as the contribution of HR MRI in assessing patients with suspected or confirmed recurrence of rectal cancer.

Perigastric tumor deposits in primary gastric cancer: implications for patient prognosis and staging

BACKGROUND

Metastatic nodules in perigastric adipose tissue without evidence of lymph node tissue have been reported in gastric cancers. However, the morphological features and clinical significance of perigastric tumor deposits (TD) have not been clarified in gastric cancers.

METHODS

To demonstrate the clinical implication of perigastric TD, 653 consecutive gastric cancer patients were enrolled and all of their slides were reviewed. Separate tumor nodules in the perigastric fat were classified as perigastric TD and correlated with clinicopathologic features and patient survival.

RESULTS

Perigastric TD were observed in 156 (23.9 %) of 653 patients. Perigastric TD were associated with synchronous distant metastasis (p < 0.001), independently of depth and venous invasion. There was a significant difference between the overall survival of those with and without TD by univariate (p < 0.001) and multivariate (p = 0.001) survival analyses. However, distant metastasis or patient prognosis could not be predicted by the morphologic patterns of the TD (p > 0.05). When TD without lymph node tissue and lymph node metastasis were recorded separately, TD were observed in 13 node-negative patients. The overall survival of node-negative patients with TD was significantly worse than that of node-negative patients without TD (p < 0.001).

CONCLUSIONS

Perigastric TD significantly correlated with distant metastasis and satisfactorily predicted patient outcomes independently of invasion depth, lymph node metastasis, and other clinicopathologic factors. Our findings suggest that perigastric TD should be included in the staging of patients with gastric cancer.

The prognostic impact of extracapsular lymph node involvement in rectal cancer patients: Implications for staging and adjuvant treatment strategies

Limited data suggest that extracapsular lymph node involvement (LNI) has a negative prognostic impact in gastrointestinal malignancies. The aim of this study was to assess the prevalence and prognostic impact of LNI in patients with primary resected rectal cancer. Between 1997 and 2007, 243 rectal cancer patients underwent surgical therapy without neoadjuvant treatment at our Department. Of these, 12 (5%) patients received transanal endoscopic microsurgery and were not included for further analyses. In the remaining patients, a (low) anterior resection was performed in 79% and an abdominoperineal rectal amputation in 21%. The total number of analyzed lymph nodes and the number of metastatic lymph nodes with/without extracapsular LNI were determined and the prognostic impact of LNI was assessed. The median number of analyzed lymph nodes was 14. In total, 59% of patients were node-negative, 18% of patients were node-positive without extracapsular LNI and 23% of patients were node-positive with extracapsular LNI. A positive lymph node status with extracapsular LNI was significantly correlated with a poorer T-, N- and M-category, grading and more frequent lymphatic vessel infiltration compared with node-negative or node-positive without extracapsular LNI patients (p<0.001). The overall 5-year survival rate of node-negative patients was 75%, for node-positive without extracapsular LNI patients 69% and for node-positive with extracapsular LNI patients 36% (p<0.001). By multivariate analysis, the N-category with extracapsular LNI was characterized as an independent prognostic factor. Extracapsular lymph node involvement reveals an independent negative prognostic impact in patients with rectal cancer undergoing surgical therapy. Staging systems for rectal cancer should include the implementation of extracapsular lymph node involvement.

Actual Status of Distribution and Prognostic Impact of Extramural Discontinuous Cancer Spread in Colorectal Cancer

Purpose

To clarify the prognostic impact of tumor nodules without residual lymph node (LN) structure (ND) in colorectal cancer and to determine optimal categorization of ND in tumor staging.

Patients and Methods

A multicenter, retrospective pathologic review was performed for 1,716 patients with stages I to III curatively resected colorectal cancer treated at 11 institutions between 1994 and 1998. An additional 2,242 patients from nine institutions were enrolled between 1999 and 2003 as a second cohort to validate the results.

Results

LN metastasis (LNM) and ND were observed in 33.7% and 16.0% (smooth-contour nodule [S-ND], 8.2%; irregular-contour nodule [I-ND], 10.7%) of patients in the first cohort. S-ND and I-ND were similarly distributed in the regional area. There was no considerable difference in the impact on survival between S-ND (hazard ratio [HR], 2.7; 95% CI, 1.9 to 3.8) and I-ND (HR, 4.3; 95% CI, 3.3 to 5.8) or between LNM (HR, 4.5; 95% CI, 3.4 to 6.0) and ND (HR, 4.0; 95% CI, 3.1 to 5.3). LNM and ND were similarly associated with the mode of recurrence. Tumor nodules ≥ 5 mm growing with venous/perineural invasion (ND [v/pni+]), judged with 0.61 κ value among 11 observers, had an independent prognostic value for 5-year survival of 42%; similar results were observed in the second cohort.

Conclusion

These results do not support the TNM system in which S-ND is treated differently from I-ND in tumor staging; LNM and ND should be considered together in the same category. The presence of ND (v/pni+) has a considerable adverse prognostic effect.

Lymph node negative colorectal cancers with isolated tumor deposits should be classified and treated as stage III

Background

The prognostic role of pericolic or perirectal isolated tumor deposits (ITDs) in node-negative colorectal cancer (CRC) patients is unclear. Rules to define ITDs as regional lymph node metastases changed in subsequent editions of the TNM staging without substantial evidence. Aim of this study was to investigate the correlation between ITDs and disease recurrence in stage II and III CRC patients.

Materials and Methods

The medical files of 870 CRC patients were reviewed. Number, size, shape, and location pattern of all ITDs in node-negative patients were examined in relation to involvement of vascular structures and nerves. The correlation between ITDs and the development of recurrent disease was investigated.

Results

Disease recurrence was observed in 50.0% of stage II patients with ITDs (13 of 26), compared with 24.4% of stage II patients without ITDs (66 of 270) (P < .01). Disease-free survival of ITD-positive stage II patients was comparable with that of stage III patients. Also within stage III, more recurrences were observed in ITD-positive patients compared with ITD-negative patients (65.1 vs. 39.1%, respectively). No correlation was found between size of ITDs and disease recurrence. More recurrences were seen in patients with irregularly shaped ITDs compared with patients with 1 or more smooth ITDs present.

Conclusions

Because of the high risk of disease recurrence, all node-negative stage II patients with ITDs, regardless of size and shape, should be classified as stage III, for whom adjuvant chemotherapy should be considered.

Impact of difference in the definition of extranodal spread on the outcome of node-positive patients with gastric cancer

PURPOSE

Previous studies have reported that extranodal spread is a prognostic factor in patients with several solid cancers. However, the definition of extranodal spread varies with the reporting investigator and has not been standardized yet. Therefore, we selected several widely used definitions from previous reports and comparatively assessed the clinicopathologic significance of these definitions.

METHODS

Extranodal spread in the 103 node-positive patients who had received curative resections for gastric cancer was classified into two groups, viz., (a) capsule rupture, where cancer cells infiltrated into the perinodal fatty tissue beyond the capsule of the involved lymph node, and (b) no capsule rupture, where nests of cancer cells were detected demonstrable in adjacent tissues around the metastatic lymph node without rupture of the capsule.

RESULTS

Sixty-five (63.1%) of the 103 patients showed extranodal spread. Of the 65 patients, 50 patients showed the capsule rupture type and 15 showed the no capsule rupture type of extranodal spread. The 5-year survival rate was significantly poorer in the capsule rupture group as compared with that in the no capsule rupture group and extranodal spread-negative group (P < 0.05 and P < 0.01, respectively). In regard to the mode of recurrence, the rate of peritoneal recurrence was significantly higher in the capsule rupture group (P < 0.01).

CONCLUSIONS

In the assessment of patients with extranodal spread, it is considered important to classify the patients based on the status of extranodal spread into the capsule rupture group and no capsule rupture group.

Preoperative staging of rectal cancer

Detailed preoperative staging using high resolution magnetic resonance imaging (MRI) enables the selection of patients that require preoperative therapy for tumour regression. This information can be used to instigate neoadjuvant therapy in those patients with poor prognostic features prior to disturbing the tumour bed and potentially disseminating disease. The design of trials incorporating MR assessment of prognostic factors prior to therapy has been found to be of value in assessing treatment modalities and outcomes that are targeted to these preoperative prognostic subgroups and in providing a quantifiable assessment of the efficacy of particular chemoradiation treatment protocols by comparing pre-treatment MR staging with post therapy histology assessment. At present, we are focused on achieving clear surgical margins of excision (CRM) to avoid local recurrence. We recommend that all patients with rectal cancer should undergo pre-operative MRI staging. Of these, about half will have good prognosis features (T1-T3b, N0, EMVI negative, CRM clear) and may safely undergo primary total mesorectal excision. Of the remainder, those with threatened or involved margins will certainly benefit from pre-operative chemoradiotherapy with the aim of downstaging to permit safe surgical excision. In the future, our ability to recognise features predicting distant failure, such as extramural vascular invasion (EMVI) may be used to stratify patients for neo-adjuvant systemic chemotherapy in an effort to prevent distant relapse. The optimal pre-operative treatment regimes for these patients (radiotherapy alone, systemic chemotherapy alone or combination chemo-radiotherapy) is the subject of current and future trials.

[Clinico-pathological characteristics of colonic carcinoma in relation to localization and histologic type]

BACKGROUND/AIM

A significant increase in colonic carcinoma has been analyzed in numerous clinico-pathological studies and genetics models. The aim of this study was to determinate the differences in clinico-pathological parameters of colonic carcinoma regarding localization and histological type.

METHODS

The study enrolled 124 patients who had undergone surgery for colorectal carcinoma at the Clinic of Surgery in the town of Nis within 2005. Paraffin sections were stained with Hematoxilin-eosin (H&E), High iron diamine-Alcian blue (HID-AB) (pH-2.5) and Alcian blue-Preiodic arid Shiff (AB-PAS) (pH-2.5) methods. From pathological report we used data regarding: localization (right or left colon), histological type, histological grade, and parameters which determinate the tumor stage.

RESULTS

The total number of patients with right-sided colonic carcinoma was 40 (32.36%) and 84 (67.74%) with left-sided colonic carcinoma. Histopathologically, 96 (77.42%) adenocarcinomas and 28 (22.58%) mucinous adenocarcinomas were verified. There were no statistically significant differences between the right-sided and left-sided colonic carcinoma regarding sex, age, histological grade and tumor stage (p > 0.05). Mucinous adenocarcinomas was statistically significantly more frequent in right-sided colon (35.00%) than in left-sided colon (16.67%) (p < 0.05). There were no statistically significant differences between adenocarcinomas and mucinous adenocarcinomas regarding sex and disease stage. In younger patients the percentage of mucinous adenocarcinomas (28.57%) compared to non-mucinous ones (11.46%) was significantlly higher (p < 0.05) than in older patients. Mucinous adenocarcinomas had statistically significantly more frequently poor differentiation in comparision to adenocarcinomas (46.43% versus 9.37%, p < 0.001).

CONCLUSION

According to the presented results it can be concluded that the lower grade of differentiation of the colon adenocarcinoma and mucinous secretion are significantly often present in younger patients.

Predictive clinicopathologic factors for limited response of T3 rectal cancer to combined modality therapy

PURPOSE

The response of T3 rectal cancer to combined modality therapy (CMT) is highly predictive of long-term outcome following surgery. The aim of this study was to identify pretreatment factors associated with poor tumor response to neoadjuvant chemoradiation.

METHODS

A prospective institutional database at Memorial Sloan-Kettering Cancer Center was queried for endorectal ultrasound (ERUS) stage T3N0-2 rectal cancer patients, treated with CMT followed by surgical resection, between 1998 and 2003. Preoperative clinicopathologic factors determined by biopsy, ERUS, proctoscopy, and digital rectal examination were correlated with the degree of downstaging of the primary mural lesion (tumor downstaging) in response to neoadjuvant therapy. Associations were analyzed by chi-square, Kaplan-Meier, and logistic regression.

RESULTS

Of 274 patients, 51% obtained tumor downstaging in response to preoperative treatment, i.e., lower pathologic T-stage compared with pretreatment ERUS. Five-year recurrence-free survival was 89% in the cohort that obtained tumor downstaging compared with only 45% in the cohort that obtained no tumor downstaging. Factors significantly associated with limited or lack of tumor downstaging after CMT included: fixed tumor on digital rectal examination (p < 0.021), near-circumferential tumor (p < 0.011), tumor stenosis (p < 0.025), metastatic disease (p < 0.012), biopsy-proven poorly differentiated pathology (p < 0.002), and radial extension >2.5 mm on ERUS (p < 0.031). On multivariate analysis, deep radial extension on ERUS, metastatic disease, and poorly differentiated pathology were in each, independently associated with limited or lack of tumor downstaging.

CONCLUSIONS

Pretreatment evaluation with biopsy, proctoscopy, and ERUS can identify T3 rectal cancer patients unlikely to respond well to CMT. These patients may be considered for alternative protocols and their tumors studied to ascertain the molecular events responsible for resistance to chemoradiation.

Pathological assessment of pericolonic tumor deposits in advanced colonic carcinoma: relevance to prognosis and tumor staging

The current TNM classification considers a tumor nodule in the pericolic/perirectal adipose tissue as venous invasion if the nodule has an irregular contour and as regional lymph node metastasis if the nodule has the form and smooth contour of a lymph node. However, detailed studies on the clinico-pathological implications of pericolonic tumor deposits and of extranodal extension are still lacking. We investigated the impact of these metastatic deposits in the pericolic fat in a series of 228 patients with advanced colon cancer. The pericolonic tumor deposits were characterized by their appearance, size, distance from the primary tumor and by their relation with the lymphatic tissue not organized in lymph nodes. These features were then compared with the clinico-pathological characteristics of the tumors and with the patients' survival. All these lesions were associated with reduced disease-free and overall survivals in a univariate analysis, but only pericolonic tumor deposits retained an independent prognostic role in the multivariate analysis. Our findings suggest that pericolonic tumor deposits are a destructive type of venous invasion different from other types of vessel involvement, and that these lesions may rather be included in the M category for staging purposes.

Prognostic significance of perinodal extension in gastric cancer

BACKGROUND

The grouping of patients who have a poor prognosis is important in determining a treatment strategy. The aim of this study was to investigate the clinicopathologic features and prognosis in patients with perinodal extension, with a focus on the difference of survival between homogenous groups.

METHODS

This study included a total of 1,092 patients who underwent curative gastrectomy for gastric adenocarcinoma from 1997 to 2004 at the Department of Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine.

RESULTS

One hundred sixty-one patients had perinodal extension. The incidence of perinodal extension was positively correlated for T and N stages. Perinodal extension was identified as an independent prognostic factor and had more influence on survival than T and N stages. Patients who had nodal metastasis without serosal exposure and who had serosal exposure without nodal metastasis were selected as homogenous groups, and there was no difference of survival between these groups. However, when the nodal metastasis group was subdivided according to the perinodal extension, perinodal extension subgroup had significant poorer prognosis than no perinodal extension subgroup.

CONCLUSIONS

The perinodal extension was the most important independent prognostic factor in gastric cancer, and should be included in the TNM gastric cancer staging system.

Colorectal tumour deposits in the mesorectum and pericolon; a critical review

Although tumour deposits (TD) in the pericolic and mesorectal fat have been recognized since 1935, incorporation in the Tumour Node Metastasis (TNM)/American Joint Committee on Cancer (AJCC) system took place in 1997. The 3-mm rule classified TD as lymph node metastases. This rule was changed in 2002, when the contour of the deposit became the diagnostic feature. This review has evaluated the 3714 patients described in the literature. The incidence of TD varies from 5 to 45%. Their origin has been shown to be heterogeneous; however, their presence indicates a poorer survival. The hazard ratio for death due to disease is 1.96. Various studies have tried to determine the importance of types of TD, based on contour, size and origin, but all fail to provide an evidence base to substantiate its use in the TNM system. To classify TD as positive lymph nodes after neoadjuvant therapy is a misconception, since the presence of tumour microfoci after therapy can be a sign of good response to treatment and indicative of a good prognosis. In conclusion, we did not find adequate evidence for the inclusion of TD in TNM/AJCC staging systems. Moreover, the current directives are confusing, and the definitions should not be used after neoadjuvant therapy.

Oncologic results of laparoscopic D3 lymphadenectomy for male sigmoid and upper rectal cancer with clinically positive lymph nodes

BACKGROUND

Many Japanese surgeons routinely perform extended D3 lymph node dissection for the treatment of advanced rectosigmoid cancer with a view to achieving better tumor control. However, the application of a laparoscopic approach to perform D3 lymphadenectomy has been challenging. This phase 2 prospective study aimed to explore the oncologic results of this surgical approach.

METHODS

The study was conducted during a 6-year period, in consideration of median follow-up time being >3 years. The study subjects were tumor, node, metastasis system stage III rectosigmoid cancer staged by clinical images. The extent of D3 dissection and the postoperative lymph node mapping were according to the guidelines of the Japanese Society for Cancer of the Colon and Rectum. Patients were stratified according to the histopathologically proved highest level of involved lymph nodes and placed into N0, N1, N2, and N3 groups. The primary end points of the study were the estimated time to recurrence and 5-year recurrence rate of cancer after laparoscopic D3 dissection.

RESULTS

The estimated 5-year recurrence rate (20% in the N0 group [n = 10]; 25% in N1 [n = 44]; 33.3% in N2 [n = 30]; and 42.8% in N3 [n = 14]), time to recurrence (mean [95% confidence interval] 59.8 [42.6-76.9] months in the N0 group; 56.8 [48.3-65.2] months in N1; 46.8 [37.5-56.1] months in N2; and 43.9 [28.3-59.4] months in N3), and recurrence patterns were without significant difference (all P values >.05) among N0, N1, N2, and N3 groups. Therefore, by laparoscopic wide anatomic dissection, patients with lymph node involvement could be treated as well as those without lymph node metastasis. Laparoscopic D3 dissection facilitated the collection of more lymph nodes (mean +/- standard deviation, 27.4 +/- 4.2) for histopathologic examination. Mapping of dissected lymph nodes showed that 18.2% (16 of 88) patients had skip lymph node metastasis. D3 dissection facilitated upstaging of cancer (from N0 to N3) in five patients (5.1%). However, this procedure resulted in transient voiding dysfunction in 77.5% patients and loss of ejaculatory function in 91.7%. By laparoscopic approach, the D3 lymph node dissection was safely performed through small wounds, resulting in quick functional recovery and only moderate blood loss (324.8 +/- 44.5 mL), but at the expense of a long operation time (294.4 +/- 34.8 minutes).

CONCLUSIONS

The good short-term oncologic results and quick convalescence mean that the laparoscopic D3 dissection may be recommended for patients with stage III rectosigmoid cancer who could accept the genitourinary dysfunction.

A systematic review on the significance of extracapsular lymph node involvement in gastrointestinal malignancies

AIMS

The impact of extracapsular lymph node involvement (LNI) has been studied for several malignancies, including gastrointestinal malignancies. Aim of this study was to assess the current evidence on extracapsular LNI as a prognostic factor for recurrence in gastrointestinal malignancies.

METHODS

The Cochrane Database of systematic reviews, the Cochrane central register of controlled trials, and MEDLINE databases were searched using a combination of keywords relating to extracapsular LNI in gastrointestinal malignancies. Primary outcome parameters were incidence of extracapsular LNI and overall five-year survival rates.

FINDINGS

Fourteen manuscripts were included, concerning seven oesophageal, three gastric, one colorectal, and three rectal cancer series with a total of 1528 node positive patients. The pooled incidence of extracapsular LNI was 57% (95% CI: 53-61%) for oesophageal cancer, 41% (95% CI: 36-47%) for gastric cancer, and 35% (95% CI: 31-40%) for rectal cancer. In nine of the 14 studies a multivariate analysis was performed. In eight of these nine studies extracapsular LNI was identified as an independent risk factor for recurrence.

CONCLUSION

Extracapsular LNI is a common phenomenon in patients with gastrointestinal malignancies. It identifies a subgroup of patients with a significantly worse long-term survival. This systematic review highlights the importance of assessing extracapsular LNI as a valuable prognostic factor. Pathologists and clinicians should be aware of this important feature.

Tumor invasion of lymph node capsules in patients with Dukes C colorectal adenocarcinoma

PURPOSE

The objective of this study was to investigate the correlation between the microscopic findings of positive lymph nodes, especially focusing on capsular invasion, and the outcome after curative surgical resection of colorectal cancer.

METHODS

We analyzed 480 positive lymph nodes from 155 consecutive patients with Stage III colorectal cancer to determine the frequency and significance of lymph node capsular invasion. Recurrence-free and cancer-specific survival rates were assessed in the patients with and without lymph node capsular invasion.

RESULTS

Between April 1995 and December 2000, 406 consecutive patients with primary colorectal cancer underwent curative resection. Regional lymph node metastases were present in 155 cases (38.2 percent). During the median follow-up period of 4.8 years, 41 patients (26.5 percent) developed recurrent disease and 28 patients died of cancer. Lymph node capsular invasion was detected in one or more lymph nodes from 75 cases (48.3 percent). The five-year recurrence-free rate was 56.1 percent in this group, whereas in the 80 patients without lymph node capsular invasion the rate was 88 percent (P<0.01). Features that were associated with recurrent disease were greater number of positive lymph nodes, venous invasion in primary tumor, infiltrative growth pattern of intranodal tumor, and presence of lymph node capsular invasion. Multivariate analysis identified lymph node capsular invasion as the only significant prognostic factor for recurrence. In multivariate analysis with regard to survival, lymph node capsular invasion, venous invasion, and number of positive nodes remained as significant prognostic factors.

CONCLUSIONS

Lymph node capsular invasion, determined by routine hematoxylin-eosin staining, is a potent prognostic factor in Stage III colorectal cancer.

Regional micrometastasis of low rectal cancer in mesorectum: a study utilizing HE stain on whole-mount section and ISH analyses on tissue microarray

AIM

To investigate the regional spread of microscopic tumor nodules in the mesorectum of patients with low rectal cancer, and to provide further pathological evidence for optimal procedure selection of radical resection for rectal cancer.

METHODS

Sixty-two patients with low rectal cancer underwent low anterior resection and total mesorectal excision (TME). Surgical specimens were sliced transversely on serial embedded blocks at 2.5-mm intervals, and stained with hematoxylin and eosin (HE). On whole-mount sections the mesorectum was divided into 3 regions: the outer region of the mesorectum (ORM), the middle region of the mesorectum (MRM), and the inner region of the mesorectum (IRM). Microscopic metastatic foci were investigated for metastatic mesorectal region, frequency, types, involvement of the lymphatic system, and correlation with the primary tumor. Tumor-suspect nodules previously considered disease free by HE stain on whole-mount section were examined by in situ hybridization (ISH) on tissue microarray (TMA) through detecting mRNAs of CEA and CK20 with non radioactive biotin-tagged oligonucleotide probes.

RESULTS

Microscopic spread of the tumor was observed in 50.0 percent of patients (31 out of 62, 24 by HE stain on whole-mount section and 7 by ISH on TMA) and that in the ORM was observed in 38.7 percent of the patients (24 out of 62, 16 observed by HE stain on whole-mount section and 8 by ISH on TMA). Microscopic tumor foci spread in the circumferential resection margin (CRM) occurred in 8.1 percent of the patients (5 out of 62, 4 observed by HE stain on whole-mount section and one by ISH on TMA), and distal mesorectum (DMR) involvement was detected in 6.5 percent (4 out of 62, all observed by HE stain on whole-mount section), with the spread extending to within 3 cm from the lower margin of the tumor. Most (26 of 31) of the patients with microscopic spread in mesorectum had TNM Stage III diseases.

CONCLUSIONS

The results of the present study support the theory that complete excision of the mesorectum without destruction of the ORM is essential for surgical management of low rectal cancer, and an optimal DMR clearance resection margin of no less than 4 cm was referenced. Five patients with microscopic tumor nodule spread in the CRM observed in the study suggested that microscopic metastases exist in pelvic lateral areas and in the mesorectum simultaneously, indicating the significance of preoperative and/or postoperative radiochemotherapy.

Extranodal metastasis is an indicator of poor prognosis in patients with gastric carcinoma

BACKGROUND

The aim of this study was to determine the clinical significance and prognostic impact of extranodal metastasis (EM) in gastric carcinoma.

METHODS

The study included 1023 patients who underwent gastrectomy with lymphadenectomy for primary gastric carcinoma between January 1993 and December 1996. EM was defined as the presence of tumour cells in extramural soft tissue that was discontinuous with either the primary lesion or locoregional lymph nodes.

RESULTS

EM was detected in 146 (14.3 per cent) of the 1023 patients and in 1060 (3.0 per cent) of the 35 811 nodules that were retrieved as 'lymph nodes' from adipose connective tissues. The incidence of EM was significantly higher in patients with tumours that were large (diameter 10 cm or more), infiltrative, deeply invading or undifferentiated and in those with lymph node, peritoneal or liver metastases, or lymphatic or vascular involvement. After curative operation overall survival was significantly worse for patients with EM than those without (P < 0.001). Multivariate analysis identified EM as an independent prognostic factor (hazard ratio 1.82 (95 per cent confidence interval 1.23 to 2.71); P = 0.003).

CONCLUSION

EM is an independent prognostic factor and should therefore be included in the tumour node metastasis (TNM) staging system.

Evaluation of prognostic significance in extracapsular spread of lymph node metastasis in patients with gastric cancer

BACKGROUND

Extracapsular spread of lymph node metastasis has been shown as a negative prognostic factor in cancers of several other organs. This study was performed to clarify the prognostic significance of extracapsular spread in patients receiving curative resection for gastric cancer.

METHODS

Extracapsular spread was defined as infiltration of cancer cells beyond the capsule of the metastatic lymph node. Four hundred and two patients who underwent curative gastrectomy were evaluated. Eight potential prognostic factors, including the International Union Against Cancer (Union International Contra la Cancrum; [UICC]) N stage and nodal status classified by the presence of lymph node metastasis or extracapsular spread, were examined.

RESULTS

Three survival curves grouped by nodal status differed significantly, and prognosis of patients with extracapsular spread was significantly worse than for the other groups. Both UICC N stage ( P < .001) and nodal status ( P < .001) were significant prognostic factors by multivariate analysis. UICC N stages were subcategorized by nodal status, and survival was shown to be significantly worse in patients with extracapsular spread in the UICC N1 group ( P = .04).

CONCLUSIONS

Extracapsular spread was a significant negative prognostic indicator on multivariate analysis, and may be useful in combination with UICC N stage. Extracapsular spread was regarded as an important indicator to refine the nodal staging system in gastric cancer.

Microscopic spread of low rectal cancer in regions of the mesorectum: detailed pathological assessment with whole-mount sections

BACKGROUND AND AIMS

The aim was to investigate the regional spread of microscopic tumor nodules in the mesorectum of patients with low rectal cancer, and to provide further pathological evidence for optimal procedure selection of radical resection for rectal cancer.

PATIENTS AND METHODS

Sixty-two patients with low rectal cancer underwent low anterior resection and total mesorectal excision (TME). Surgical specimens were sliced transversely on serial embedded blocks at 2.5-mm intervals, and stained with hematoxylin and eosin. On whole-mount sections the mesorectum was divided into three regions: the outer region of the mesorectum (ORM), the middle region of the mesorectum (MRM), and the inner region of the mesorectum (IRM). Microscopic metastatic foci were investigated for metastatic mesorectal region, frequency, types, involvement of the lymphatic system, and correlation with the primary tumor.

RESULTS

Microscopic spread of the tumor was observed in 38.7% of patients (24 out of 62) and that in the ORM was observed in 25.8% of the patients (16 out of 62). Microscopic tumor foci spread in the circumferential resection margin (CRM) occurred in 6.5% of the patients (4 out of 62), and distal mesorectum (DMR) involvement was detected in 6.5% (4 out of 62), with the spread extending to within 3 cm from the lower margin of the tumor.

CONCLUSIONS

The results of the present study support the theory that complete excision of the mesorectum without destruction of the ORM is essential for surgical management of low rectal cancer, and an optimal DMR clearance resection margin should be no less than 4 cm. Four patients with microscopic tumor nodule spread in the ORM observed in the study suggested that microscopic metastases exist in pelvic lateral areas and in the mesorectum simultaneously, indicating the significance of preoperative and/or postoperative radiochemotherapy.