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Zhu L, Wang L, Gao Z, Zeng Y, Tao K, Wang Q, Li X, Zhang H, Shen Z, Zhou J, Shen K, Ye Y, Wu A. Examined lymph node numbers influence prognosis in rectal cancer treated with neoadjuvant therapy. CANCER PATHOGENESIS AND THERAPY 2023; 1:168-176. [PMID: 38327833 PMCID: PMC10846314 DOI: 10.1016/j.cpt.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/25/2022] [Accepted: 01/02/2023] [Indexed: 02/09/2024]
Abstract
Background The number of lymph nodes examined (LNe) is often insufficient in patients with rectal cancer (RC) treated with neoadjuvant therapy; however, its prognostic value remains controversial. Thus, we retrospectively explored whether LNe had an influence on staging and prognosis and investigated whether there was a cut-off value for better prognosis in patients with RC treated with neoadjuvant therapy. Methods Data were collected from seven prospective hospital databases in China from July 2002 to May 2018. Binary logistic regression models were used to predict lymph node metastasis. The cut-off value for LNe was determined using X-tile 3.6.1. Survival outcomes and risk factors were analyzed using the log-rank test and Cox regression model. Results A total of 482 patients were included, of whom 459 had complete overall survival (OS) information. Using the percentile method, the total number of lymph nodes examined (TLNe) was 14-16 (40th-60th percentile), and the proportion of patients with lymph node metastasis reached a maximum of 48.1%. Cox multivariate analysis showed that the odds ratio (OR) remained the highest when TLNe was 14-16 (OR = 3.379, P = 0.003). The 3-year and 5-year OS were 85.4% and 77.8%, respectively. Negative lymph nodes examined (NLNe) of ≤6 was an independent risk factor for 3-year and 5-year OS (3-year OS 71.1% vs. 85.9%, P = 0.004; 5-year OS 66.3% vs. 74.3%, P = 0.035). Subgroup analysis for patients with ypN + showed that higher 3-year and 5-year OS were achieved when the TLNe was >10, 78.8% vs. 54.0% (P = 0.005), and 60.8% vs. 36.0% (P = 0.012), respectively. Patients with ypN0M0 had a higher 5-year OS when the TLNe was >19 (P = 0.055). Conclusion The TLNe and NLNe influenced the staging accuracy and demonstrated prognostic value in patients with RC treated with neoadjuvant therapy.
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Affiliation(s)
- Liyu Zhu
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, China
- Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing 100044, China
| | - Lin Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Zhidong Gao
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, China
- Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing 100044, China
| | - Yujian Zeng
- Yunnan Institute of Digestive Disease, Department of Gastrointestinal and Hernia Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650032, China
| | - Kaixiong Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Quan Wang
- Department of Gastrointestinal and Anal Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Xinming Li
- Department of Gastrointestinal and Anal Surgery, Huangshi Central Hospital, Huangshi, Hubei 435000, China
| | - Huanhu Zhang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Weihai, Shandong 264200, China
| | - Zhanlong Shen
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, China
- Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing 100044, China
| | - Jing Zhou
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, China
- Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing 100044, China
| | - Kai Shen
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, China
- Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing 100044, China
| | - Yingjiang Ye
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, China
| | - Aiwen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Beijing 100142, China
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Mroczkowski P, Dziki Ł, Vosikova T, Otto R, Merecz-Sadowska A, Zajdel R, Zajdel K, Lippert H, Jannasch O. Rectal Cancer: Are 12 Lymph Nodes the Limit? Cancers (Basel) 2023; 15:3447. [PMID: 37444557 DOI: 10.3390/cancers15133447] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/18/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
Lymph node dissection is a crucial element of oncologic rectal surgery. Many guidelines regard the removal of at least 12 lymph nodes as the quality criterion in rectal cancer. However, this recommendation remains controversial. This study examines the factors influencing the lymph node yield and the validity of the 12-lymph node limit. Patients with rectal cancer who underwent low anterior resection or abdominoperineal amputation between 2000 and 2010 were analyzed. In total, 20,966 patients from 381 hospitals were included. Less than 12 lymph nodes were found in 20.53% of men and 19.31% of women (p = 0.03). The number of lymph nodes yielded increased significantly from 2000, 2005 and 2010 within the quality assurance program for all procedures. The univariate analysis indicated a significant (p < 0.001) correlation between lymph node yield and gender, age, pre-therapeutic T-stage, risk factors and neoadjuvant therapy. The multivariate analyses found T3 stage, female sex, the presence of at least one risk factor and neoadjuvant therapy to have a significant influence on yield. The probability of finding a positive lymph node was proportional to the number of examined nodes with no plateau. There is a proportional relationship between the number of examined lymph nodes and the probability of finding an infiltrated node. Optimal surgical technique and pathological evaluation of the specimen cannot be replaced by a numeric cut-off value.
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Affiliation(s)
- Paweł Mroczkowski
- Department for General and Colorectal Surgery, Medical University of Lodz, Pl. Hallera 1, 90-647 Lodz, Poland
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, D-39120 Magdeburg, Germany
- Department for Surgery, University Hospital Knappschaftskrankenhaus, Ruhr-University, In der Schornau 23-25, D-44892 Bochum, Germany
| | - Łukasz Dziki
- Department for General and Colorectal Surgery, Medical University of Lodz, Pl. Hallera 1, 90-647 Lodz, Poland
| | - Tereza Vosikova
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, D-39120 Magdeburg, Germany
| | - Ronny Otto
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, D-39120 Magdeburg, Germany
| | - Anna Merecz-Sadowska
- Department of Economic and Medical Informatics, University of Lodz, 90-214 Lodz, Poland
| | - Radosław Zajdel
- Department of Economic and Medical Informatics, University of Lodz, 90-214 Lodz, Poland
| | - Karolina Zajdel
- Department of Medical Informatics and Statistics, Medical University of Lodz, 90-645 Lodz, Poland
| | - Hans Lippert
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, D-39120 Magdeburg, Germany
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Leipziger Str. 44, D-39120 Magdeburg, Germany
| | - Olof Jannasch
- Institute for Quality Assurance in Operative Medicine Ltd., Otto-von-Guericke-University, Leipziger Str. 44, D-39120 Magdeburg, Germany
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Simões P, Fernandes G, Costeira B, Machete M, Baptista C, N Silva D, Leal-Costa L, Prazeres G, Correia J, Albuquerque J, Padrão T, Gomes C, Godinho J, Faria A, Casa-Nova M, Lopes F, Teixeira JA, F Pulido C, Oliveira H, Mascarenhas-Lemos L, Albergaria D, Maio R, Passos-Coelho JL. Lymph node yield in the pathological staging of resected nonmetastatic colon cancer: The more the better? Surg Oncol 2022; 43:101806. [PMID: 35841744 DOI: 10.1016/j.suronc.2022.101806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/31/2022] [Accepted: 07/03/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Guidelines recommend regional lymphadenectomy with a lymph node yield (LNY) of at least 12 lymph nodes (LN) for adequate colon cancer (CC) staging. LNY ≥22LN may improve survival, especially in right-sided CC [Lee et al., Surg Oncol, 27(3), 2018]. This multicentric retrospective cohort study evaluated the impact of LNY and tumor laterality on CC staging and survival. MATERIALS AND METHODS Patients with stage I-III CC that underwent surgery from 2012 to 2018 were grouped according to LNY: <22 and ≥ 22. Primary outcomes were LN positivity (N+ rate) and disease-free survival (DFS). Overall survival (OS) was the secondary outcome. Exploratory analyses were performed for laterality and stage. RESULTS We included 795 patients (417 < 22LN, 378 ≥ 22LN); 53% had left-sided CC and 29%/37%/38% had stage I/II/III tumors. There was no association between LNY ≥22LN and N+ rate after adjustment for grade, T stage, lymphovascular invasion (LVI) and perineural invasion; a trend for a higher N+ rate in left-sided CC was identified (interaction p = 0.033). With a median follow-up of 63.6 months for DFS and 73.2 months for OS, 254 patients (31.9%) relapsed and 207 (26.0%) died. In multivariate analysis adjusted for age, ASA score, laparoscopic approach, T/N stage, mucinous histology, LVI and adjuvant chemotherapy, LNY ≥22LN was significantly associated with both DFS (HR 0.75, p = 0.031) and OS (HR 0.71, p = 0.025). Restricted cubic spline analysis showed a more significant benefit for right-sided CC. CONCLUSION LNY ≥22LN was associated with longer DFS and OS in patients with operable CC, especially for right-sided CC.
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Affiliation(s)
- Pedro Simões
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Gonçalo Fernandes
- Medical Oncology, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650, Lisbon, Portugal.
| | - Beatriz Costeira
- General Surgery, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Madalena Machete
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Carlota Baptista
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Diana N Silva
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Luísa Leal-Costa
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Gil Prazeres
- Medical Oncology, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650, Lisbon, Portugal.
| | - Jorge Correia
- Medical Oncology, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650, Lisbon, Portugal.
| | - Joana Albuquerque
- Medical Oncology, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650, Lisbon, Portugal.
| | - Teresa Padrão
- Medical Oncology, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650, Lisbon, Portugal.
| | - Catarina Gomes
- Gastroenterology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - João Godinho
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Ana Faria
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Mafalda Casa-Nova
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Fábio Lopes
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - José A Teixeira
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Catarina F Pulido
- Medical Oncology, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650, Lisbon, Portugal.
| | - Helena Oliveira
- Pathology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Luís Mascarenhas-Lemos
- Pathology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal; Pathology, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650, Lisbon, Portugal.
| | - Diogo Albergaria
- General Surgery, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal.
| | - Rui Maio
- General Surgery, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal; General Surgery, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650, Lisbon, Portugal.
| | - José L Passos-Coelho
- Medical Oncology, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514, Loures, Portugal; Medical Oncology, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650, Lisbon, Portugal.
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Analysis of the risk factor of insufficient examined lymph nodes in stage II colon cancer from the perspective of stage migration: A retrospective study combined with external validation. Int J Surg 2022; 101:106628. [PMID: 35447364 DOI: 10.1016/j.ijsu.2022.106628] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 04/01/2022] [Accepted: 04/08/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND An insufficient examined lymph node (ELN) count is a high risk factor for recurrence in patients with stage II colon cancer (CC). This study aimed to explore this risk factor in relation to stage migration. METHODS We screened 18,544 patients with stage II (pT3/4N0M0) and IIIB (pT3/4N1M0) CC diagnosed after radical resection from 2010 to 2015, using the National Cancer Institute Surveillance, Epidemiology, and End Results database. Propensity score matching was used to balance confounding factors for short-term and long-term survival, and survival analysis was carried out using the Kaplan-Meier method and log-rank test. The optimal cutoff for the number of ELNs in patients with stage II CC was determined using X-tile software. Independent prognostic factors were screened using Cox proportional hazards regression analysis. Finally, the results were externally validated in 318 patients with stage Ⅱ and ⅢB CC in our hospital from 2013 to 2015. RESULTS The best cutoff value for the number of ELNs in patients with stage II CC was 14. Multivariate analysis identified age, grade, histology, tumor size, T stage, N stage, ELN count, and chemotherapy as independent prognostic factors, and the Akaike and Bayesian information criteria values for the prognostic value of ELN count were relatively small. Patients with stage II CC with <15 ELNs had similar prognoses to patients with stage ⅢB CC (P = 0.939). Subgroup analysis and external validation yielded similar results. CONCLUSION Patients with stage II CC should be considered as stage ⅢB if the ELN count is insufficient.
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Shannon AB, Straker RJ, Keele L, Fraker DL, Roses RE, Miura JT, Karakousis GC. Lymph Node Evaluation after Neoadjuvant Chemotherapy for Patients with Gastric Cancer. Ann Surg Oncol 2021; 29:1242-1253. [PMID: 34601642 DOI: 10.1245/s10434-021-10803-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/31/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Adequate lymphadenectomy with at least 16 nodes retrieved at the time of gastrectomy is a quality measure recommended to ensure adequate staging. The minimum nodal retrieval recommended after receipt of neoadjuvant chemotherapy (NACT) is less defined. METHODS Patients with clinical stages 1 to 3 gastric adenocarcinoma who received NACT and surgical resection were identified from the 2004-2015 National Cancer Database. The optimal nodal harvest number was calculated with Cox spline regression modeling. Cohorts with a nodal harvest higher or lower than this number were 1:1 propensity score-matched. Overall survival (OS) was analyzed using Kaplan-Meier survival estimates. RESULTS Among 4337 patients receiving NACT, the optimal minimal nodal harvest at gastrectomy was 23 nodes. Compared with the patients who had fewer than 23 nodes retrieved, the patients with at least 23 nodes examined (n = 1073, 24.7%) were more likely to be female (26.1% vs 22%; p = 0.006) and non-white (29.3% vs 18.5%; p < 0.0001), to have a Charlson-Deyo score of 0 (71.5% vs 66.8%; p = 0.005), and to have undergone resection at an academic facility (67.9% vs 51.5%; p < 0.0001). The patients with at least 23 nodes examined had higher proportions of high-grade tumor (62% vs 57.4%; p = 0.030), pT3 or pT4 tumor (56.3% vs 48.7%; p < 0.0001), body tumor (21.3% vs 12.5%; p < 0.0001), or antrum/pylorus tumor (15.3% vs 11.4%; p < 0.0001). The patients with at least 23 nodes were more likely to have lymph node metastases identified (61% vs 51%; p < 0.0001). After matching, the patients with at least 23 nodes (n = 990) demonstrated an improved 5-year OS (57.9% vs 49%; p = 0.001). CONCLUSIONS The extent of lymphadenectomy during gastrectomy for gastric adenocarcinoma should not be reduced after NACT because adequate lymph node retrieval remains important for prognostication.
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Affiliation(s)
- Adrienne B Shannon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Richard J Straker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Luke Keele
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Fraker
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Roses
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - John T Miura
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Comment on: Significance of Lymph Node Resection After Neoadjuvant Therapy in Pancreatic, Gastric, and Rectal Cancers. Ann Surg 2020; 274:e858-e859. [PMID: 33630466 DOI: 10.1097/sla.0000000000004734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Song J, Chen Z, Huang D, Wu Y, Lin Z, Chi P, Xu B. Nomogram Predicting Overall Survival of Resected Locally Advanced Rectal Cancer Patients with Neoadjuvant Chemoradiotherapy. Cancer Manag Res 2020; 12:7375-7382. [PMID: 32884350 PMCID: PMC7443447 DOI: 10.2147/cmar.s255981] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/10/2020] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The overall survival (OS) of resected locally advanced rectal cancer patients who underwent neoadjuvant chemoradiotherapy (nCRT) was significantly different, even among patients with the same tumor stage. The nomogram was designed to predict OS of rectal cancer with nCRT and divide the patients into different risk groups. MATERIALS AND METHODS Based on materials from 911 rectal cancer patients with nCRT, the multivariable Cox regression model was carried out to select the significant prognostic factors for overall survival. And then, the nomogram was formulated using these independent prognostic factors. The discrimination of the nomogram was assessed by concordance index (C-index), calibration curves and time-dependent area under curve (AUC). The patients respective risk scores were calculated through the nomogram. The best cut-off risk score was calculated to stratify the patients. The survival curves of the two different risk cohorts were performed, which assessed the predictive ability of the nomogram. RESULTS Age, cT stage, pretreatment CEA, pretreatment CA19-9, surgery, posttreatment CEA, posttreatment CA19-9, pT stage, pN stage and adjuvant chemotherapy were selected for the construction of the nomogram. And then the nomogram was constructed with independent prognostic factors. The C-index of the nomogram was 0.724, which showed the nomogram provided good discernment. The acceptable agreement between the predictions of nomogram and actual observations was illustrated by calibration plots for 3-, 5- and 10-year OS in the cohort. Time-dependent AUC with 6-fold cross-validation also showed consistent results of the nomogram. Risk group stratification confirmed that the nomogram had great capacity for distinguishing the prognosis. CONCLUSION The nomogram was developed and validated to predict overall survival of resected locally advanced rectal cancer patients with nCRT. The proposed nomogram might help clinicians to develop individualized treatment strategies. However, further studies are warranted to optimize the nomogram by finding out other unknown prognostic factors, and more external validation is still required.
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Affiliation(s)
- Jianyuan Song
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
- Department of Oncology, Fujian Medical University Union Clinical Medicine College, Fuzhou, Fujian Province, People's Republic of China
- Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
| | - Zhuhong Chen
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
| | - Daxin Huang
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
| | - Yimin Wu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
| | - Zhuangbin Lin
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
- Department of Oncology, Fujian Medical University Union Clinical Medicine College, Fuzhou, Fujian Province, People's Republic of China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
| | - Benhua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, People's Republic of China
- Department of Oncology, Fujian Medical University Union Clinical Medicine College, Fuzhou, Fujian Province, People's Republic of China
- Department of Medical Imaging Technology, College of Medical Technology and Engineering, Fujian Medical University, Fuzhou, Fujian Province, People's Republic of China
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Can Ex Vivo Magnetic Resonance Imaging of Rectal Cancer Specimens Improve the Mesorectal Lymph Node Yield for Pathological Examination? Invest Radiol 2020; 54:645-652. [PMID: 31219996 PMCID: PMC6738635 DOI: 10.1097/rli.0000000000000581] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Supplemental digital content is available in the text. The aim of this study was to use 7 T ex vivo magnetic resonance imaging (MRI) scans to determine the size of lymph nodes (LNs) in total mesorectal excision (TME) specimens and to increase the pathological yield of LNs with MR-guided pathology.
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Koëter T, van Elderen SGC, van Tilborg GFAJB, de Wilt JHW, Wasowicz DK, Rozema T, Zimmerman DDE. MRI response rate after short-course radiotherapy on rectal cancer in the elderly comorbid patient: results from a retrospective cohort study. Radiat Oncol 2020; 15:53. [PMID: 32122381 PMCID: PMC7053128 DOI: 10.1186/s13014-020-01500-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/18/2020] [Indexed: 02/07/2023] Open
Abstract
Background The aim of the present study was to evaluate MRI response rate and clinical outcome of short-course radiotherapy (SCRT) on rectal cancer as an alternative to chemoradiotherapy in patients where downstaging is indicated. Methods A retrospective analysis was performed of a patient cohort with rectal carcinoma (cT1-4cN0-2 cM0–1) from a large teaching hospital receiving restaging MRI, deferred surgery or no surgery after SCRT between 2011 and 2017. Patients who received chemotherapy during the interval between SCRT and restaging MRI were excluded. The primary outcome measure was the magnetic resonance tumor regression grade (mrTRG) at restaging MRI after SCRT followed by a long interval. Secondary, pathological tumor stage, complete resection rate and 1-year overall survival were assessed. Results A total of 47 patients (M:F = 27:20, median age 80 (range 53–88) years), were included. In 33 patients MRI was performed for response assessment 10 weeks after SCRT. A moderate or good response (mrTRG≤3) was observed in 24 of 33 patients (73%). While most patients (85%; n = 28) showed cT3 or cT4 stage on baseline MRI, a ypT3 or ypT4 stage was found in only 20 patients (61%) after SCRT (p < 0.01). A complete radiologic response (mrTRG 1) was seen in 4 patients (12%). Clinical N+ stage was diagnosed in n = 23 (70%) before SCRT compared to n = 8 (30%) post-treatment (p = 0.03). After SCRT, 39 patients underwent deferred surgery (after a median of 14 weeks after start of SCRT) and a resection with complete margins was achieved in 35 (90%) patients. One-year overall survival after surgery was 82%. Complete pathological response was found in 2 patients (5%). Conclusions The use of SCRT followed by a long interval to restaging showed a moderate to good response in 73% and therefore can be considered as an alternative to chemoradiotherapy in elderly comorbid patients.
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Affiliation(s)
- T Koëter
- Department of Surgery, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands. .,Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
| | - S G C van Elderen
- Department of Radiology, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands
| | - G F A J B van Tilborg
- Department of Radiology, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - D K Wasowicz
- Department of Surgery, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands
| | - T Rozema
- Department of Radiotherapy, Verbeeten Instituut Tilburg, Tilburg, The Netherlands
| | - D D E Zimmerman
- Department of Surgery, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands
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Brady AC, Rao KA, Lane R, Garvin L, Sola JE, Perez EA. Increased lymph node ratio predicts poor survival in pediatric rhabdomyosarcoma. J Pediatr Surg 2020; 55:369-375. [PMID: 31706606 DOI: 10.1016/j.jpedsurg.2019.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 08/16/2019] [Accepted: 09/01/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Lymph Node Ratio (LNR) is defined as the number of positive lymph nodes (pLN) divided by total lymph nodes (LN) examined. LNR correlates with recurrence and/or overall survival in many adult cancers but has not previously been described in pediatric oncologic disease. We hypothesized that LNR correlates with worse disease specific survival (DSS) in pediatric rhabdomyosarcoma (RMS). METHODS Patients <20 years who underwent surgery for RMS between 1988 and 2013 in the SEER database were analyzed. RESULTS 188 patients with a mean age at diagnosis of 8.8 ± 6 years and a mean LNR of 0.13 ± 0.27 were identified. Univariate analysis found that alveolar type, positive lymph node (pLN), stage, site, LNR, and age had significantly worse survival. Cox regression analysis identified LNR > 0.75 (HR 4.32, P = 0.015), alveolar histology (HR 4.797, P < 0.003), age < 1 year (HR 4.402, P = 0.004), and distant disease (HR 5.738, P < 0.001), as independent determinants of worse DSS. pLN and site were not statistically significant determinant of DSS on multivariate analysis. DSS for the entire cohort was 83% at 5 and 78% at 10 and 15 years. DSS at 5, 10, and 15 year for LNR ≤ 0.75 was 79% while patients with LNR > 0.75 had a 22% 5 year and 0% 10 year survival (P <0.001). CONCLUSIONS LNR is superior to pLN status as an independent prognostic indicator of DSS in pediatric RMS. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ann-Christina Brady
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, SUITE 450, Miami, Florida, 33136, USA
| | - Krishnamurti A Rao
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, SUITE 450, Miami, Florida, 33136, USA
| | - Rebecca Lane
- Leonard M. Miller School of Medicine, University of Miami, 1600 NW 10th Ave #1140, Miami, Florida, 33136, USA
| | - Lillian Garvin
- Department of Biology, Florida Atlantic University, 777 Glades Rd, Boca Raton, Florida, 33431, USA
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, SUITE 450, Miami, Florida, 33136, USA
| | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, SUITE 450, Miami, Florida, 33136, USA.
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Sun Y, Zhang Y, Huang Z, Chi P. Prognostic Implication of Negative Lymph Node Count in ypN+ Rectal Cancer after Neoadjuvant Chemoradiotherapy and Construction of a Prediction Nomogram. J Gastrointest Surg 2019; 23:1006-1014. [PMID: 30187336 DOI: 10.1007/s11605-018-3942-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE This study aimed to investigate the prognostic significance of negative lymph nodes (NLNs) for ypN+ rectal cancer after neoadjuvant chemoradiotherapy (nCRT) and radical surgery and to construct a nomogram predicting disease-free survival (DFS). METHOD One hundred fifty-eight eligible patients were included. X-tile analysis was performed to determine cutoff values of NLNs. Clinicopathological and survival outcomes were compared. A Cox regression analysis was performed to identify prognostic factors of DFS. A nomogram was constructed and validated internally. RESULTS X-tile analysis identified cutoff values of 4 and 16 in terms of DFS (χ2 = 8.129, p = 0.017). The 3-year DFS rates for low (≤ 4), middle (5-16), and high (≥ 17) NLNs group was 15.2, 55.5, and 73.1%, respectively (P = 0.017). NLN count (NLNs ≥ 17, HR = 0.400, P = 0.022), IMA nodal metastasis (HR = 1.944, P = 0.025), tumor differentiation (poor/anaplastic, HR = 1.805, P = 0.021), and ypT4 stage (HR = 7.787, P = 0.047) were independent prognostic factors of DFS. A predicting nomogram incorporating the four significant predictors was developed with a C-index of 0.64. CONCLUSION NLN count was an independent prognostic factor of DFS in patients with ypN+ rectal cancer following nCRT. A nomogram incorporating NLN count, IMA nodal metastasis, tumor differentiation, and ypT stage could stratify rectal cancer patients with different DFS and might be helpful during clinical decision-making.
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Affiliation(s)
- Yanwu Sun
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Yiyi Zhang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Zhekun Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China.
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Lymph Node Yield After Neoadjuvant Chemoradiotherapy in Rectal Cancer Specimens: A Randomized Trial Comparing Two Fixatives. Dis Colon Rectum 2018; 61:888-896. [PMID: 29944580 DOI: 10.1097/dcr.0000000000001097] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND It is widely reported that neoadjuvant chemoradiation reduces lymph node yield in rectal cancer specimens. Some have questioned the adequacy of finding ≥12 lymph nodes for accurate staging, and fewer nodes were correlated with good response. Others reported that low lymph node count raises the chance for understaging and correlates with worse survival. In addition, a few studies demonstrated that diligent specimen analysis increases lymph node count. OBJECTIVE The aim of this study was to compare Carnoy's solution and formalin concerning lymph node yield in specimens of patients with rectal cancer after neoadjuvant chemoradiation. DESIGN This is a prospective randomized trial that was conducted from 2012 to 2015. SETTINGS This study was performed in a reference cancer center in Brazil. PATIENTS Patients who underwent low anterior resection with total mesorectal excision after neoadjuvant chemoradiation for rectal adenocarcinoma were included. INTERVENTION Rectosigmoid specimens were randomized for fixation with Carnoy's solution or formalin. MAIN OUTCOME MEASURES A total of 130 specimens were randomized. After dissection, the residual fat from the formalin group was immersed in Carnoy's solution in search for missed lymph nodes (Revision). RESULTS The Carnoy's solution group had superior lymph node count (24.0 vs 16.3, p < 0.01) and fewer cases with <12 lymph nodes (6 vs 22, p = 0.001). The Revision group found lymph nodes in all cases (mean, 11.1), retrieving metastatic lymph nodes in 6 patients. It reduced the formalin cases with <12 lymph nodes from 33.8% to 4.6% and upstaged 2 patients. Tumor response to neoadjuvant chemoradiotherapy was not associated with lymph node count. LIMITATIONS This was a unicentric study. CONCLUSIONS Compared with formalin, the Carnoy's solution increases lymph node count and reduces the cases with <12 lymph nodes. Harvested lymph nodes are missed following routine analysis and this is clinically relevant. Finding <12 lymph nodes is not a sign of good response to neoadjuvant chemoradiation (www.clinicaltrials.gov. Unique identifier: NCT02629315). See Video Abstract at http://links.lww.com/DCR/A694.
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13
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What Is the Minimum Number of Examined Lymph Nodes After Neoadjuvant Therapy in Rectal Cancer? J Gastrointest Surg 2018; 22:1068-1076. [PMID: 29468556 DOI: 10.1007/s11605-018-3717-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/08/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND To date, no guidelines have standardized the number of examined lymph nodes (eLNs) after neoadjuvant treatment. This study investigated the minimum number of eLNs required for patients with rectal cancer (RC) who received neoadjuvant treatment. MATERIAL AND METHODS This study was based on data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. We included 2173 patients with RC who received neoadjuvant therapy. Restricted cubic spline was used to analyze the association between eLNs and lymph node metastasis (LNM). RESULTS The number of eLNs was an independent predictive factor for the presence of LNM (odds ratio 1.033; 95% confidence interval 1.020-1.046; P < 0.001). When the number of eLN ≤ 16, 10 and 11 eLNs had the highest rates of positive LNM. Analysis of the restricted cubic spline method found that when number of eLNs was < 10, the LNM rate increased rapidly, but this increase was not so obviously when there were > 10 eLNs. CONCLUSIONS Among RC patients who receive neoadjuvant therapy, the minimum number of eLNs may be 10 to ensure pathological quality.
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Ceelen W, Willaert W, Varewyck M, Libbrecht S, Goetghebeur E, Pattyn P. Effect of Neoadjuvant Radiation Dose and Schedule on Nodal Count and Its Prognostic Impact in Stage II-III Rectal Cancer. Ann Surg Oncol 2016; 23:3899-3906. [PMID: 27380639 DOI: 10.1245/s10434-016-5363-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND It is unknown how neoadjuvant treatment schedule affects lymph node count (LNC) and lymph node ratio (LNR) and how these correlate with overall survival (OS) in rectal cancer (RC). METHODS Data were used from the Belgian PROCARE rectal cancer registry on RC patients treated with surgery alone, short-term radiotherapy with immediate surgery (SRT), or chemoradiation with deferred surgery (CRT). The effect of neoadjuvant therapy on LNC was examined using Poisson log-linear analysis. The association of LNC and LNR with overall survival (OS) was studied using Cox proportional hazards models. RESULTS Data from 4037 patients were available. Compared with surgery alone, LNC was reduced by 12.3 % after SRT and by 31.3 % after CRT (p < 0.001). In patients with surgery alone, the probability of finding node-positive disease increased with LNC, while after SRT and CRT no increase was noted for more than 12 and 18 examined nodes, respectively. Per node examined, we found a decrease in hazard of death of 2.7 % after surgery alone and 1.5 % after SRT, but no effect after CRT. In stage III patients, the LNR but not (y)pN stage was significantly correlated with OS regardless of neoadjuvant therapy. Specifically, a LNR > 0.4 was associated with a significantly worse outcome. CONCLUSIONS Nodal counts are reduced in a schedule-dependent manner by neoadjuvant treatment in RC. After chemoradiation, the LNC does not confer any prognostic information. A LNR of >0.4 is associated with a significantly worse outcome in stage III disease, regardless of neoadjuvant therapy type.
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Affiliation(s)
- Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium.
| | - Wouter Willaert
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Machteld Varewyck
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - Sasha Libbrecht
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - Els Goetghebeur
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
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Abstract
One of the most important factors influencing cancer-specific survival in the field GI oncology is the presence of positive lymph nodes. Although it remains controversial, adequate lymph node examination is required for accurate staging such that patients can receive correct adjuvant treatments and for stratification in clinical trials. Nevertheless, wide variation in the quality of lymph node examination exists in the US and many centers are not meeting guideline treatment recommendations.
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