Lymph node status as a prognostic indicator after preoperative neoadjuvant chemoradiotherapy of rectal cancer

Prognostic value of nutrition and immune‑related biomarkers in patients with locally advanced rectal cancer treated with chemoradiotherapy

The ability of nutrition and immune-related biomarkers to predict outcomes in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant therapy followed by surgery remains controversial due to the lack of evidence regarding the accuracy and reliability of these biomarkers in predicting outcomes for such patients. Therefore, the present study aimed to investigate the prognostic potential of nutrition and immune-related biomarkers in patients with LARC who underwent chemoradiotherapy followed by curative surgery. The clinical data of patients with LARC treated with neoadjuvant therapy followed by surgery between January 2010 and December 2019 were analyzed. In total, 214 consecutive patients were enrolled into the present study, who were then categorized into low and high prognostic nutritional index (PNI) groups. The X-tile 3.6.1 program was used to calculate and then determine the optimal cut-off values for PNI. Disease-free survival (DFS) and overall survival (OS) were compared between the low and high PNI groups. Cox regression analysis demonstrated that low PNI and high post-chemoradiotherapy carcinoembryonic antigen levels were significantly associated with reduced disease-free survival and overall survival. Specifically, a low PNI was associated with inferior 5-year DFS (P=0.025) and OS (P=0.018). These findings suggest that amongst the nutritional and immune-related biomarkers, PNI is a significant predictive factor for disease recurrence and mortality in patients with LARC treated with neoadjuvant therapy followed by surgery.

Lymph node regression after neoadjuvant chemoradiotherapy in rectal cancer

AIMS

Lymph node metastases (LNM) are one of the most important prognostic indicators in solid tumours and a major component of cancer staging. Neoadjuvant therapy might influence nodal status by induction of regression. Our aim is to determine the prevalence and role of regression of LNM on outcomes in patients with rectal cancer.

METHODS AND RESULTS

Four independent study populations of rectal cancer patients treated with similar regimens of chemoradiotherapy were pooled together to obtain a total cohort of 469 patients. Post-treatment nodal status (ypN) and signs of tumour regression (Reg) were incorporated to form three-tiered (ypN- Reg+, ypN- Reg- and ypN+) and four-tiered (ypN- Reg+, ypN- Reg-, ypN+ Reg+ and ypN+ Reg-) classifications. In our cohort, 31% of patients presented with ypN+ rectal cancer. As expected, we found significantly worse overall survival (OS) in ypN+ patients compared to ypN- patients (P = 0.002). The percentage of ypN- patients with lymph nodes with complete regression was 20% in our cohort. While node-negative patients with and without regression had similar OS (P = 0.09), disease-free survival (DFS) was significantly better in node-negative patients with regression (P = 0.009).

CONCLUSIONS

Regression in lymph nodes is frequent, and node-negative patients with evidence of lymph node regression have better DFS compared to node-negative patients without such evidence.

Association between Dynamic Contrast-Enhanced MRI Parameters and Prognostic Factors in Patients with Primary Rectal Cancer

BACKGROUND

To evaluate the association between perfusion parameters derived from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with prognostic factors in primary rectal cancer patients.

METHODS

A sample of 51 patients with pathologically proven rectal adenocarcinoma through surgery were retrospectively enrolled. All the patients underwent preoperative DCE-MRI including 3D-spoiled gradient echo. Two radiologists determined the tumor border after radiologic-pathologic correlation and drew regions of interest. The perfusion parameters, including the volume transfer constant (K^trans), were calculated under the extended Toft model. The prognostic factors included TN stage, circumferential resection margin, extramural venous invasion, Kirsten-ras mutation, tumor size, carcinoembryonic antigen, and tumor differentiation. The association was assessed via correlation or t-test. For significant prognostic factors, receiver operating characteristic (ROC) curve analyses were performed to estimate the diagnostic predictive values.

RESULTS

K^trans only showed a significant difference according to tumor differentiation, between the well-differentiated (n = 6) and moderately differentiated (n = 45) groups (0.127 ± 0.032, 0.084 ± 0.036, p = 0.036). The AUC was 0.838 (95% CI, 0.702-0.929), and the estimated accuracy, sensitivity, and specificity were 87%, 90%, and 60%, respectively.

CONCLUSIONS

K^trans showed a significant difference based on tumor differentiation, which may be conducive to prediction of prognosis in primary rectal cancer.

Long-term follow-up of HER2 overexpression in patients with rectal cancer after preoperative radiotherapy: A prospective cohort study

BACKGROUND

The role of HER2 overexpression in rectal cancer is controversial.

AIM

To assess the role of HER2 overexpression in the long-term prognosis of rectal cancer.

METHODS

Data from patients with locally advanced rectal cancer who underwent total mesorectal excision after short-course radiotherapy at Beijing Cancer Hospital between May 2002 and October 2005 were collected. A total of 151 tissue samples of rectal cancer were obtained using rigid proctoscopy before neoadjuvant radiotherapy, followed by immunohistochemistry and fluorescence in situ hybridisation to determine the patients’ HER2 expression status. Univariate and multivariate analyses of the associations between the clinicopathological factors and HER2 status were performed. Survival was estimated and compared using the Kaplan-Meier method based on HER2 expression status, and the differences between groups were verified using the log-rank test.

RESULTS

A total of 151 patients were enrolled in this study. A total of 27 (17.9%) patients were ultimately confirmed to be HER2-positive. The follow-up duration ranged from 9 mo to 210 mo, with a median of 134 mo. Distant metastasis and local recurrence occurred in 60 (39.7%) and 24 (15.9%) patients, respectively. HER2 positivity was significantly associated with the pre-treatment lymph node stage (pre-N) (P = 0.040), while there were no differences between HER2 status and age, sex, preoperative CEA levels (pre-CEA), T stage, and lympho-vascular invasion. In terms of prognosis, HER2 overexpression was correlated with distant metastasis (P = 0.002) rather than local recurrence (P > 0.05). The multivariate analysis demonstrated that elevated pre-CEA [P = 0.002, odds ratio (OR) = 3.277, 97.5% confidence interval (CI): 1.543-7.163], post N(+) (P = 0.022, OR = 2.437, 97.5%CI: 1.143-5.308) and HER2(+) (P = 0.003, OR = 4.222, 97.5%CI: 1.667-11.409) were risk factors for distant metastasis. The survival analysis showed that there were significant differences between rectal cancer patients in terms of disease-free survival (DFS) [hazard ratio: 1.69 (95%CI: 0.91-3.14); P = 0.048] and overall survival (OS) [1.95 (1.05-3.63); P = 0.0077].

CONCLUSION

HER2 overexpression is a potential biomarker for predicting lymph node metastasis and distant metastasis, which are associated with worse long-term DFS and OS in rectal cancer patients with locally advanced disease.

Lymph node regression grading of locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy

Neoadjuvant chemoradiotherapy (nCRT) and total rectal mesenteric excision are the main standards of treatment for locally advanced rectal cancer (LARC). Lymph node regression grade (LRG) is an indicator of prognosis and response to preoperative nCRT based on postsurgical metastatic lymph node pathology. Common histopathological findings in metastatic lymph nodes after nCRT include necrosis, hemorrhage, nodular fibrosis, foamy histiocytes, cystic cell reactions, areas of hyalinosis, residual cancer cells, and pools of mucin. A number of LRG systems designed to classify the amount of lymph node regression after nCRT is mainly concerned with the relationship between residual cancer cells and regressive fibrosis and with estimating the number of lymph nodes existing with residual cancer cells. LRG offers significant prognostic information, and in most cases, LRG after nCRT correlates with patient outcomes. In this review, we describe the systematic classification of LRG after nCRT, patient prognosis, the correlation with tumor regression grade, and the typical histopathological findings of lymph nodes. This work may serve as a reference to help predict the clinical complete response and determine lymph node regression in patients based on preservation strategies, allowing for the formulation of more accurate treatment strategies for LARC patients, which has important clinical significance and scientific value.

Role of MRI‑based radiomics in locally advanced rectal cancer (Review)

Colorectal cancer is the third most common type of cancer, with high morbidity and mortality rates. In particular, locally advanced rectal cancer (LARC) is difficult to treat and has a high recurrence rate. Neoadjuvant chemoradiotherapy (NCRT) is one of the standard treatment programs of LARC. If the response to treatment and prognosis in patients with LARC can be predicted, it will guide clinical decision‑making. Radiomics is characterized by the extraction of high‑dimensional quantitative features from medical imaging data, followed by data analysis and model construction, which can be used for tumor diagnosis, staging, prediction of treatment response and prognosis. In recent years, a number of studies have assessed the role of radiomics in NCRT for LARC. MRI‑based radiomics provides valuable data and is expected to become an imaging biomarker for predicting treatment response and prognosis. The potential of radiomics to guide personalized medicine is widely recognized; however, current limitations and challenges prevent its application to clinical decision‑making. The present review summarizes the applications, limitations and prospects of MRI‑based radiomics in LARC.

Impact of neoadjuvant chemoradiotherapy on the local recurrence and distant metastasis pattern of locally advanced rectal cancer: a propensity score-matched analysis

BACKGROUND

Previous studies have demonstrated different predominant sites of distant metastasis between patients with and without neoadjuvant chemoradiotherapy (NCRT). This study aimed to explore whether NCRT could influence the metastasis pattern of rectal cancer through a propensity score-matched analysis.

METHODS

In total, 1296 patients with NCRT or post-operative chemoradiotherapy (PCRT) were enrolled in this study between January 2008 and December 2015. Propensity score matching was used to correct for differences in baseline characteristics between the two groups. After propensity score matching, the metastasis pattern, including metastasis sites and timing, was compared and analyzed.

RESULTS

After propensity score matching, there were 408 patients in the PCRT group and 245 patients in the NCRT group. NCRT significantly reduced local recurrence (4.1% vs. 10.3%, P = 0.004), but not distant metastases (28.2% vs. 27.9%, P = 0.924) compared with PCRT. In both the NCRT and PCRT groups, the most common metastasis site was the lung, followed by the liver. The NCRT group developed local recurrence and distant metastases later than the PCRT group (median time: 29.2 [18.8, 52.0] months vs. 18.7 [13.3, 30.0] months, Z = -2.342, P = 0.019; and 21.2 [12.2, 33.8] vs. 16.4 [9.3, 27.9] months, Z = -1.765, P = 0.035, respectively). The distant metastases occurred mainly in the 2nd year after surgery in both the PCRT group (39/114, 34.2%) and NCRT group (21/69, 30.4%). However, 20.3% (14/69) of the distant metastases appeared in the 3rd year in the NCRT group, while this number was only 13.2% (15/114) in the PCRT group.

CONCLUSIONS

The predominant site of distant metastases was the lung, followed by the liver, for both the NCRT group and PCRT group. NCRT did not influence the predominant site of distant metastases, but the NCRT group developed local recurrence and distant metastases later than the PCRT group. The follow-up strategy for patients with NCRT should be adjusted and a longer intensive follow-up is needed.

Lymph Node Regression to Neoadjuvant Chemoradiotherapy in Patients with Locally Advanced Rectal Cancer: Prognostic Implication and a Predictive Model

AIM

Currently, few studies have focused on the prognostic impact of lymph node regression to neoadjuvant chemoradiotherapy (NCRT) in rectal cancer. This study aimed to explore the prognostic impact of lymph node regression grade (LRG) in patients with locally advanced rectal cancer (LARC) following NCRT and radical surgery and develop a predictive nomogram for disease-free survival (DFS).

METHODS

LARC patients undergoing NCRT and radical surgery between 2013 and 2014 were enrolled and divided into LRG low (≤ 2), middle (3-9), and high (≥ 10) groups. Clinicopathological characteristics and survival outcomes were compared. Predictors for DFS were identified by Cox regression analysis, and a nomogram was constructed.

RESULTS

A total of 257 LARC patients were eligible, including LRG low (n = 149), middle (n = 59), and high (n = 49) groups. Higher LRG score was associated with higher TRG, more advanced ypT and ypN stages, and poorer OS and DFS (all P < 0.001). Cox regression analysis demonstrated that tumor differentiation (poor and anaplastic, HR = 2.048, P = 0.048), ypTNM stage (HR = 2.389, P = 0.015), and LRG-sum (HR = 1.020, P = 0.029) were independent prognostic determinants for DFS after NCRT. A nomogram for DFS was developed with a C-index of 0.68 (95%CI 0.64-0.72).

CONCLUSION

LRG is an important prognostic indicator for DFS in LARC patients after NCRT. A predictive nomogram based on LRG was developed to guide more tailored adjuvant treatment and surveillance.

Histologic Lymph Nodes Regression after Preoperative Chemotherapy as Prognostic Factor in Non-metastatic Advanced Gastric Adenocarcinoma

Background: The study aims to evaluate the lymph node (LN) response to preoperative chemotherapy and its impact on long-term outcomes in advanced gastric cancer (AGC). Methods: Histological specimens retrieved at gastrectomy from patients who received preoperative chemotherapy were evaluated. LN regression was graded by the adapted tumor regression grading system proposed by Becker. Patients were classified as node-negative (lnNEG) in the case of all negative LN without evidence of previous tumor involvement. Patients with LN metastasis were classified as nodal responders (lnR) in case of a regression score 1a-2 was detected in the LN. Nodal non-responders (lnNR) had a regression score of 3 in all of the metastatic nodes. Survival was compared using Kaplan-Meier and Cox regression analysis. Results: Among 87 patients included in the final analysis 29.9 % were lnNEG, 21.8 % were lnR and 48.3 % were lnNR. Kaplan-Meier curves showed a survival benefit for lnR over lnNR (p=0.03), while the survival of lnR and lnNEG patients was similar. Cox regression confirmed nodal response to be associated with decreased odds for death in univariate (HR: 0.33; 95 % CI 0.11-0.96, p=0.04) and multivariable (HR 0.37; 95 CI% 0.14-0.99, p=0.04) analysis. Conclusions: Histologic regression of LN metastasis after preoperative chemotherapy predicts the increased survival of patients with non-metastatic resectable AGC.

The prognostic significance of the treatment response of regional lymph nodes and the refinement of the current TNM staging system in locally advanced rectal cancer after neoadjuvant chemoradiotherapy

The current TNM staging system uses the same category definitions for both rectal cancer patients with and without neoadjuvant chemoradiotherapy (NCRT). However, ypTNM stage, especially ypN stage does not predict patient survival after NCRT well. Whether tumor regression in lymph nodes (LRG) may improve the prediction has not been well studied. In total, 358 patients with rectal cancer who received NCRT followed by radical resection were recruited from 2004 to 2015, and the median follow‐up time was 57.5 months. The main outcome measure was disease‐free survival (DFS). In univariate analysis, factors associated with DFS were ypT stage, ypN stage, number of negative lymph nodes (NLN), lymph node ratio (LNR), tumor regression grade (TRG), M‐TTRG (modified ypT stage by combining ypT stage and TRG), maximum LRG (LRGmax), sum score of LRG (LRGsum), LRG ratio (average value of LRGsum), and M‐NLRG (modified ypN stage by combining LRGmax and LNR). In the multivariate Cox regression analysis, M‐TTRG and M‐NLRG (p < 0.001 and p = 0.030, respectively) were significantly associated with DFS. The estimated 5‐year DFS rates were 86.6%, 60.3%, and 36.4% for patients with M‐NLRG‐0, M‐NLRG‐1, and M‐NLRG‐2, respectively (p < 0.001). A significant difference in survival was observed among patients with NCRT after incorporating TRG and LRG simultaneously into the current ypTNM staging system (p < 0.001). LRG was an important prognostic factor in rectal cancer patients treated with NCRT and could refine the ypTNM staging system. The modified ypTNM staging system in combination with LRGmax, LNR, and TRG could improve the DFS prediction in each subset of patients.

"Watch and wait" approach in rectal cancer patients following complete clinical response to neoadjuvant chemoradiotherapy does not compromise oncologic outcomes

BACKGROUND/AIMS

Although standart treatment for non-metastatic locally advanced rectal cancer includes neoadjuvant chemoradiation followed by surgical resection, patients who have achieved complete clinical response can be followed up without surgery.

MATERIALS AND METHODS

Between 2010 and 2016, 61 patients received neoadjuvant chemoradiotherapy for low rectal cancer. Those patients who achieved clinical complete response were included in the "watch and wait" protocol and did not receive surgery. The remaining patients underwent radical surgery and some of these were diagnosed as having complete response pathologically. This study compared the oncological results of clinically complete responders with those patients defined as pathologically tumor-free.

RESULTS

Seven patients who received neoadjuvant chemoradiotherapy were re-staged as having complete clinical response and included in the "watch and wait" approach protocol. The 5-year disease free survival was 100%. Mean follow-up was 63 months and the mean age was 57.3. Fifty-four patients underwent radical surgery and 7 of them were diagnosed as having pathological complete response. The 5-year survival was 100%. Mean follow-up was 56 months and the mean age was 50.6. All patients except one are alive without tumor recurrence in the surgery group. However, those who received surgery experienced significant morbidities due to their surgery.

CONCLUSION

The oncological results of the "watch and wait" approach patients were no different from the patients who received radical surgery and were diagnosed as having pathological complete response. Those patients in particular who required abdomino-perineal resection before chemoradiation should be informed about this approach if they have achieved complete response clinically.

Effect of Responsiveness of Lymph Nodes to Preoperative Chemoradiotherapy in Patients With Rectal Cancer on Prognosis After Radical Resection

BACKGROUND

The influence of lymph node (LN) response to preoperative chemoradiotherapy (PCRT) has not been well evaluated for prognosis and additional use of adjuvant treatment after PCRT in rectal cancer patients. The aim of this study was to evaluate the prognostic effect of LN regression grade (LRG) in rectal cancer after PCRT and radical resection.

PATIENTS AND METHODS

From 2008 to 2011, 389 patients with rectal cancer treated with PCRT followed by radical resection were identified. The pathologic LRG (pLRG) score was determined on the basis of the proportion of tumor cells and fibrosis. The sum of the pLRG of each evaluated LN was used as the final LRG score, LRG-sum. Cox regression analysis was used to evaluate the association of LRG-sum and recurrence-free survival (RFS).

RESULTS

The distribution of LRG-sum was significantly associated with tumor regression grade of the primary tumor (P < .001). LRG-sum showed different values even in patients with the same number of metastatic LNs. LRG-sum was confirmed as the most relevant associated factor among LN-related variables with RFS along with ypT stage in multivariate analysis. Patients were categorized according to the cutoff points of LRG-sum distribution: LRG1 (LRG-sum 0 to ≤3), LRG2 (LRG-sum 3 to ≤21), and LRG3 (LRG-sum >21). RFS showed a significant difference according to LRG group (P < .001) and showed more effective difference in RFS in the same ypN stage subgroup on the basis of the number of metastatic LNs.

CONCLUSION

LRG was a prognostic factor of oncologic outcomes of rectal cancer. LN response to PCRT might help in prognostication and determination of treatments after PCRT.

Prognostic significance of neoadjuvant rectal score in locally advanced rectal cancer after neoadjuvant chemoradiotherapy and construction of a prediction model

AIM

To evaluate the prognostic significance of neoadjuvant rectal (NAR) score after neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer (LARC), and to develop a nomogram predicting disease-free survival (DFS).

METHOD

A total of 522 LARC patients undergoing nCRT and surgery were included. NAR scores were calculated using the equation [5pN-3(cT-pT) + 12]^2/9.61, and classified as low (<8), intermediate (8-16), and high (>16). Clinicopathological and survival outcomes were compared. Cox regression analysis was performed to identify risk factors of DFS. A predicting nomogram was developed and validated internally.

RESULTS

For NAR score classification, 193 (37.0%) were low, 183 (35.0%) were intermediate, and 146 (28.0%) were high. Higher NAR score was associated with fewer pCR, lower tumor regression grade (TRG), and higher ypTNM stage. A total of 5-year DFS for low, intermediate, and high NAR groups was 85.6%, 71.9%, and 47.2%, respectively (P < 0.001). NAR score (HR = 2.488, P = 0.002), TRG (HR = 2.811, P = 0.047), CRM involvement (HR = 2.703, P = 0.002), and IMA nodal metastasis (HR = 2.441, P = 0.001) were independent prognostic factors of DFS. A predicting nomogram was developed with C-index of 0.701.

CONCLUSION

NAR score could help in predicting DFS after nCRT. A nomogram was developed to identify subpopulations with aggressive tumors during clinical decision-making.

Effects of local multivisceral resection for clinically locally advanced rectal cancer on long-term outcomes

INTRODUCTION

Multivisceral resection is occasionally needed to obtain clear margins in patients with transmural rectal cancer. Most series demonstrate equivalent outcomes between those patients who undergo multivisceral resections and those who do not, provided an R0-resection is achieved. This study focuses solely on patients who received neoadjuvant treatment for clinically transmural rectal cancers and underwent a local multivisceral R0-resection.

METHODS

A retrospective, single center analysis of consecutive series of patients who received a surgical R0-resection after neoadjuvant treatment for a clinically transmural, non-metastatic, primary rectal cancer. All patients were operated on between 2004 and 2015.

RESULTS

A total of 279 patients was included, of whom 29 patients underwent a local multivisceral R0-resection (LMVR). These patients were more often female and less often diagnosed through screening. Pathologic AJCC-staging was significantly lower for non-LMVR patients, with more favorable tumor characteristics. LMVR patients demonstrated higher rates of distant disease recurrence, and impaired survival, even after adjusting for disease stage.

CONCLUSION

An R0-resection after neoadjuvant therapy led to comparative local control of disease; however, patients with multivisceral resection had more distant recurrence and impaired survival, compared to those did not undergo a multivisceral resection. Further research should determine optimal postoperative care.

Is the pathological regression level of metastatic lymph nodes associated with oncologic outcomes following preoperative chemoradiotherapy in rectal cancer?

PURPOSE

The oncologic impact of the lymph node (LN) regression level after preoperative chemoradiotherapy (PCRT) has not been thoroughly evaluated. Hence, this study aimed to examine whether the regression level of metastatic LNs following PCRT is associated with oncologic outcomes in rectal cancer.

RESULTS

The optimal number of cut points for LRG sum was determined to be three. The three LRG groups demonstrated different distributions according to the ypT and ypN stages (p < 0.001 for both). However, the distribution of the LRG groups was not associated with the TRG of the primary tumor (p = 0.527). The RFS significantly differed according to the LRG groups (p = 0.001). Moreover, the differences in RFS remained when the LRG groups were analyzed within each separate ypN stage. The LRG group was confirmed as a factor associated with RFS in the multivariate analysis (p=0.018), while the ypN stage was not (p=0.4).

PATIENTS AND METHODS

We analyzed the outcomes of 142 rectal cancer patients diagnosed with ypN1 disease after PCRT followed by radical resection. The pathological responses of the primary tumor and LNs to PCRT were evaluated using the tumor regression grade (TRG) and LN regression grade (LRG), respectively. The impact of LRG on recurrence-free survival (RFS) was analyzed. The K-adaptive partitioning for survival data method was applied to determine the optimal number of cut points for the LRG-sum and the optimal number of subgroups.

CONCLUSION

The LRG as an indicator of response to PCRT should be considered as a prognostic determinant in rectal cancer patients. Future large-scale prospective studies are needed to confirm this finding.

Prognostic Relevance of Lymph Node Regression After Neoadjuvant Chemoradiation for Esophageal Cancer

Prognostic factors after preoperative chemoradiation for patients with advanced esophageal cancer are under discussion. Treatment response measured in the primary tumor is a well-defined prognostic marker. The prognostic relevance of tumor regression in lymph nodes (LNs), eg, histomorphologic characteristics must be evaluated in a larger series of patients. From 1997-2010, 403 patients with cT3N×M0 esophageal cancer underwent preoperative chemoradiation followed by transthoracic esophagectomy. Histopathologic response of the primary tumor was graded in resected specimens as "minor" (≥10% vital residual tumor cells) or "major." The LNs of all patients without LN metastases (ypN0 n = 222, adenocarcinoma n = 129, squamous cell carcinoma n = 93) were reevaluated for central fibrosis. Univariate and multivariate analyses were performed on histomorphologic criteria of examined LNs and used to correlate these with tumor response and prognosis. The 5-year survival rate (5YSR) for all patients was 30%. Overall, 5480 LNs were reevaluated for the existence of central fibrosis in ypN0 cases. The prognostic relevance of the LN regression (LNR) grading system was confirmed for all patients with univariate (P < 0.001) and multivariate (P = 0.02) analyses. In results, the 5YSR for ypN0 patients overall was 37%, for patients with major response by the primary tumor was 42%, and for minor responders was 19% (P < 0.001). Analyzing LNR in major responders, the group with less than 3 LNs with central fibrosis (n = 52) showed significantly better prognosis (5YSR = 63%) compared to those with more (5YSR = 34%), (P = 0.016). Conclusion includes morphologic signs of metastatic LNR after chemoradiation, such as central fibrosis, are of prognostic relevance for patients with advanced esophageal cancer, especially for those with major response of the primary tumor.

Pathology reporting of pancreatic cancer following neoadjuvant therapy: challenges and uncertainties

An increasing number of studies investigate the use of neoadjuvant treatment for ductal adenocarcinoma of the pancreas. While a strong rationale supports this approach, study results are difficult to interpret and compare due to marked variance in multiple aspects of study design and performance. Divergence in pathology examination and reporting as a cause for heterogeneity and incomparability of study results has not been brought into this discussion yet, despite the fact that several key outcome measures for neoadjuvant treatment are pathology-based. This article discusses areas of controversy and difficulty regarding the evaluation of the extent of residual tumour tissue, grading of tumour regression and assessment of the margins, and explains the important clinical implications of the present uncertainty and divergence in pathology practice.