Effect of Lymph Node Count on Pathological Stage III Rectal Cancer with Preoperative Radiotherapy

Rectal Cancer: Are 12 Lymph Nodes the Limit?

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.

National multicentric evaluation of quality of pathology reports for rectal cancer in France in 2016

The quality of pathologic assessment of rectal cancer specimens is crucial for treatment efficiency and survival. The Royal College of Pathologists (RCP) recommends evaluating the quality of the pathology report in routine practice using three quality indicators (QIs): the number of lymph nodes (LNs) analyzed (≥ 12), the rate of venous invasion (VI ≥ 30%), and peritoneal involvement (pT4a ≥ 10%). In this study, we evaluated the three QIs of the French national pathology reports and compared them with British guidelines and assessed the influence of neoadjuvant radiochemotherapy on QIs. From January 1 to December 31, 2016, all pathology reports for rectal adenocarcinoma were collected from French departments. Neoadjuvant radiochemotherapy included long-course radiotherapy with concomitant 5-FU-based chemotherapy. A total of 983 rectal cancer pathology reports were evaluated. A median of 15 LNs were analyzed and 81% of centers had ≥ 12 LNs. The rate of VI was 30% and 41% of centers had ≥ 30% VI. The rate of pT4a was 4% and 18% of centers reported ≥ 10% pT4a. None of the centers reached the threshold for the three QIs. All three QIs were lower after radiochemotherapy compared to surgery alone. In conclusion, in French routine practice, the values of two of the three QIs (LNs analyzed and VI) were globally in line with RCP guidelines. However, the rate of pT4a was very low, particularly after radiochemotherapy, suggesting its low value in rectal cancer.

Prognostic accuracy of different lymph node staging systems in rectal adenocarcinoma with or without preoperative radiation therapy

Background and objective

A variety of different lymph node (LN) staging systems have been developed to describe the lymph node status accurately. We aim to compare the prognostic accuracy of American Joint Committee on Cancer seventh N stage relative to negative number of lymph node (nLN), lymph node ratio (LNR) and log odds of metastatic lymph nodes (LODDS) in rectal adenocarcinoma (RC).

Methods

A total of 19 167 Stage II-III rectal cancer patients who underwent surgical resection of rectal adenocarcinoma were identified from Surveillance, Epidemiology and End Results database. Akaike's Information Criterion (AIC) and the Harrell's concordance index (c statistic) were used to evaluate the relative discriminative power of the different LN staging systems.

Results

Of the 19 167 patients, 10 958 received preoperative radiotherapy (pre-RT cohort) and 8209 patients were treated with surgical resection directly (SURG cohort). When assessed using categorical cutoff values, LNR has a somewhat better prognostic accuracy both in pre-RT (c-index: 0.62; AIC: 2988.6) and SURG groups (c-index: 0.60; AIC: 3359.8). Further analysis based on different total number of lymph node (TNLN) suggested that when less than 10 lymph nodes were retrieved, LNR exhibited significant superiority (pre-RT: c-index: 0.597, AIC: 1006.8; SURG: c-index: 0.560, AIC: 810.5). When analyzed as a continuous variable, the LODDS system performed the best and was not impacted by TNLN.

Conclusion

When assessed as a categorical variable, LNR was the most powerful method to predict survival for Stage II-III RC patients with limited TNLN. Rather, LODDS was the most accurate staging system regardless of the TNLN when LN status was modeled as continuous variable.

Neoadjuvant Chemotherapy is Associated with Lower Lymph Node Counts in Colon Cancer

Adequate lymphadenectomy is associated with improved survival in patients who undergo oncologic resection of colorectal cancer and has been identified as a quality metric. Neoadjuvant chemotherapy has been found to be associated with collection of <12 lymph nodes in patients with rectal cancer. The purpose of this study was to evaluate patient and operative risk factors for inadequate lymph node retrieval during oncologic colectomy. The 2014 American College of Surgeons National Surgical Quality Improvement Program Participant Use File data set for oncologic colectomy (n = 9077) was analyzed. Patient- and operation-related factors were assessed by univariate and multivariate regression analyses to determine factors associated with the number of lymph nodes collected. Adequate lymphadenectomy was defined by collection of >12 lymph nodes. Of 9077 patients with a diagnosis of colon cancer who underwent colectomy, a minimum of 12 lymph nodes was harvested in 7897 (87%). Significant factors independently associated with inadequate lymphadenectomy included preoperative chemotherapy, emergent surgery, and T1 tumors (all P < 0.05). A large majority of patients who undergo colectomy for colon cancer have at least 12 lymph nodes collected. Preoperative chemotherapy is a major risk factor for inadequate lymph node retrieval. Recognition of factors associated with inadequate lymphadenectomy may improve colectomy lymph node yield and survival in patients with colon cancer.

The prognostic value of negative lymph node count for patients with gastric cancer who received preoperative radiotherapy

Negative lymph node (NLN) count provides accurate prognostic information in patients with gastric cancer. However, it is unclear whether NLN still has prognostic value for patients received preoperative radiotherapy. In this study, Surveillance, Epidemiology, and End Results Program (SEER)-registered gastric cancer patients were used for analysis. Clinicopathological characteristics and survival time were collected. Univariate and multivariate Cox proportional hazards models were used to assess the risk factors for survival. NLN count was validated as an independent prognostic factor in both univariate and mulivariate analysis (P < 0.001). X-tile plots identified 12 as the optimal cutoff value to divide the patients into high and low risk subsets in terms of survival rate. Nomogram based on cancer-specific survival was successfully established according to all significant factors. The C-index was 0.630 (95% CI: 0.605–0.655). Subgroup analysis showed that NLN count was a prognosis factor for patients with advanced gastric cancer (stage ypII and ypIII). In conclusion, our results firmly demonstrated that NLN count was an independent prognostic factor for patients with gastric cancer who received preoperative radiotherapy. It provides more accurate prognostic information especially for patients with advanced gastric cancer (stage ypII and ypIII). Nomograms based on cancer-specific survival could be recommended as practical models to evaluate prognosis.

The prognostic value of lymph nodes count on survival of patients with node-negative gastric cancer

The retrieved lymph node (LN) count has been validated as a prognostic factor in various cancers. However, the interaction between LN counts and patients' prognosis in gastric cancer with negative-LN metastasis is not fully studied. Surveillance, Epidemiology, and End Results Program (SEER)-registered gastric cancer patients were used for analysis in this study. Patients operated on for gastric cancer at N0 stage between 2004 and 2012 were identified from the SEER database. The association between the LN counts and survival was assessed using the Cox proportional hazards model. Patients were stratified into 1–4, 5−13, and > 13 subgroups according to LN count cut-off values determined by X-tile program, with the 5-year cause specific survival (CSS) rate of 64.8%, 72.5%, and 79.4%, respectively. LN count was also validated as an independently prognostic factor in multivariate Cox analysis (P < 0.001). In addition, nomograms including LN counts on CSS were established according to all significant factors, and the c-index was 0.703 (95% CI: 0.672−0.734). Further study indicated that patients with no LN metastasis had a decreased risk of death for each patient with LN examined up to approximately 14 LNs. Collectively, our study firmly demonstrated that the number of the retrieved LNs count was an independent prognostic factor for gastric cancer with no LN metastasis. The higher the LN count, the better the survival would be; the best CSS was observed on the LN count more than 14.

Lymph node status as a prognostic factor after palliative resection of primary tumor for patients with metastatic colorectal cancer

Lymph node (LN) status is one of the most important predictors for M0 colorectal cancer patients. However, its clinical impact on stage IV colorectal cancer remains unclear. The study aimed to explore the prognostic value of LN status after palliative resection of primary tumor for patients with metastatic colorectal cancer (mCRC). We combined analyses of mCRC patients in Surveillance, Epidemiology and End Results (SEER) database and Fudan University Shanghai Cancer Center (FUSCC).A total of 17,553 patients with mCRC were identified in SEER database. X-tile program was adopted to identify 2 and 10 as optimal cutoff values for negative lymph node (NLN) count to divide patients into 3 subgroups of high, middle and low risk of cancer related death. N stage and NLN count were verified as independent prognostic factors in multivariate analyses of patients in whole cohort and in subgroup analyses of each N stage (P<0.05). Validation of FUSCC cohort of patients demonstrated that metastatic tumor burden (P = 0.042), NLN count (P = 0.039) and sequential chemotherapy (P = 0.040) were significant predictors of poorer CSS. Specifically, the prognosis of patients at stage N0 was significantly more favorable than that of patients at stage N2 (P = 0.038). In conclusion, primary tumor LN status was a strong predictor of CSS after palliative resection of metastatic colorectal cancer. Advanced N stage and small number of NLN were correlated with high risk of cancer related death after palliative resection of primary tumor.

Negative lymph node count is a significant prognostic factor in patient with stage IV gastric cancer after palliative gastrectomy

Negative lymph node (NLN) count has been validated as a protective predictor in various cancers after radical resection. However, the prognostic value of NLN count in the setting of stage IV gastric cancer patients who have received palliative resection has not been investigated. Surveillance, Epidemiology, and End Results Program (SEER)-registered gastric cancer patients were used for analysis in this study. Kaplan-Meier survival curves and multivariate Cox proportional hazards model were used to assess the risk factors for patients’ survivals. The results showed that NLN count and N stage were independently prognostic factors in patients with stage IV gastric cancer after palliative surgery (P< 0.001). X-tile plots identified 2 and 11 as the optimal cutoff values to divide the patients into high, middle and low risk subsets in term of cause-specific survival (CSS). And NLN count was proved to be an independently prognostic factor in multivariate Cox analysis (P< 0.001). The risk score of NLN counts demonstrated that the plot of hazard ratios (HRs) for NLN counts sharply increased when the number of NLN counts decreased. Collectively, our present study revealed that NLN count was an independent prognostic predictor in stage IV gastric cancer after palliative resection. Standard lymph node dissection, such as D2 lymphadectomy maybe still necessary during palliative resection for patients with metastatic gastric cancer.

Negative lymph node count is an independent prognostic factor for patients with rectal cancer who received preoperative radiotherapy

Background

Negative lymph node (NLN) count has been reported to provide more accurate prognostic information than the N stage alone in patients with rectal cancer (RC). Since preoperative radiotherapy (Pre-RT) can significantly affect the LN status, it is unclear whether NLN count still has prognostic value count on survival of patients with RC who received Pre-RT.

Methods

In this study, clinicopathological characteristics, number of positive LNs and survival time were collected from Surveillance, Epidemiology, and End Results Program (SEER)-registered RC patients. Univariate and multivariate Cox proportional hazards models were used to assess the risk factors for survival.

Results

X-tile plots identified 9 (P < 0.001) as the optimal cutoff NLN value to divide the patients into high and low risk subsets in terms of cause specific survival (CSS). NLN count was validated as independently prognostic factor in univariate and multivariate analysis (P < 0.001). Subgroup analysis showed that NLN count was an independently prognostic factor for patients with stage ypII (P = 0.002) and ypIII (P < 0.001).

Conclusions

Our results firmly demonstrated that NLN count provides accurate prognostic information for RC patients with Pre-RT.

Adjuvant radiotherapy improves cause specific survival in stage II, not stage III mucinous carcinoma of the rectum

Background

The effect of adjuvant radiotherapy on the survival outcomes of patients with mucinous rectal cancer remains unclear. This study evaluated the 5-year cause specific survival (CSS) of patients with mucinous rectal cancer after surgery to determine whether adjuvant radiotherapy conferred a survival benefit.

Methods

An analysis of the Surveillance, Epidemiology, and End Results (SEER)-registered database was conducted of patients presenting with mucinous rectal cancer between 2004 and 2011. The primary endpoint was 5-year CSS; univariate and multivariate analyses were performed using Cox proportional hazards regression models.

Results

A total of 574 patients were included for analysis with 248 patients in postoperative radiotherapy group and 326 patients in surgery alone group. Preliminary analysis demonstrated that adjuvant radiotherapy was not associated with CSS (χ² = 0.560, P = 0.454). Subgroup analysis indicated that postoperative radiotherapy group had survival advantage in stage II rectal cancer (93.3% vs. 76.6%, χ² = 4.654, P = 0.031), but not in stage III rectal cancer (67.5% vs. 64.7%, χ² = 0.186, P = 0.666). Multivariate analysis demonstrated that postoperative radiotherapy group had a reduced risk of death on survival (HR 0.346; 95%CI 0.129-0.927, P = 0.035)

Conclusion

Postoperative radiotherapy is an independent factor for improvement in CSS in patients with stage II rectal mucinous adenocarcinoma, and it should be routinely recommended in these patients. But for stage III patients, considering the losing of CSS advantage and potential radiotherapy toxicity, postoperative radiotherapy should be recommended with great caution.

Nomograms incorporated serum direct bilirubin level for predicting prognosis in stages II and III colorectal cancer after radical resection

An elevated serum bilirubin has been reported to be associated with a reduced risk of some cancer; however, the prognostic significance of serum bilirubin in colorectal cancer wasn’t fully understood. The purpose of this study was to evaluate whether serum bilirubin could predict the prognosis of patients in stages II and III colorectal cancer. A retrospective cohort of 986 patients with colorectal cancer who received surgical resection between January 2005 and December 2010 was included in the study. Levels for serum bilirubin were obtained from medical records. Survival analysis was used to evaluate the predictive value of bilirubin. Serum direct bilirubin (DBIL) was validated as a significant prognostic factor by univariate cox regression test for both overall survival (OS) and disease free survival (DFS) (P < 0.05). X-tile program identified 3.6 as optimal cutoff values for DBIL in terms of OS and DFS. Patients were then divided into DBIL high (DBIL ≥ 3.60 μmol/l) and low group (DBIL < 3.60 μmol/l) according to the optimal cutoff. High DBIL had higher percentage of lymph node metastasis and lymphovascular invasion as compared with low DBIL levels (P < 0.05). Multivariate cox regression analyses confirmed that high DBIL level was an independently prognostic factor for both OS (HR: 1.337, 95% CI: 1.022–1.748, P = 0.034) and DFS (HR: 1.312, 95% CI: 1.049–1.643, P = 0.018). In addition, nomograms on OS and DFS were established according to all significant factors, and c-indexes were 0.715 (95% CI: 0.683–0.748) and 0.704 (95% CI: 0.678–0.730), respectively. Nomograms based on OS and DFS can be recommended as practical models to evaluate prognosis for CRC patients.