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Hwang J, Lee D, Shin JK, Jang JH, Huh JW, Park YA, Cho YB, Kim HC, Yun SH, Lee WY, Chun HK. Is a cutoff value of 12 still useful in stage II right-sided colon cancer without risk factors? KOREAN JOURNAL OF CLINICAL ONCOLOGY 2022; 18:27-35. [PMID: 36945331 PMCID: PMC9942765 DOI: 10.14216/kjco.22004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/07/2022]
Abstract
Purpose Various clinical practice guidelines recommend at least 12 regional lymph nodes should be removed for resected colon cancer. According to a recent study, the lymph node yield (LNY) in colon cancer surgery in the last 20 years has tended to increase from 14.91 to 21.30. However, it is unclear whether these guidelines adequately reflect recent findings on the number of harvested lymph nodes in colon cancer surgery. The aim of this study is to assess the impact of an LNY of more than 25 on survival in right-sided colon cancer. Methods We included 285 patients who underwent a right hemicolectomy during the period from January 2010 through December 2015. Patients were divided into two groups (<25 nodes and ≥25 nodes). Primary endpoints included 5-year and 10-year survival including disease-free and overall. Results We found that survival outcomes of patients with a harvest of ≥25 nodes were not significantly different compared with a <25 group. Large tumor size (5 cm) is significantly associated with poor 5-year and 10-year overall survival. Conclusion Survival outcomes of patients with a harvest of ≥25 nodes were not significantly different compared with the <25 group in stage II colon cancer with no risk.
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Affiliation(s)
- Jinseok Hwang
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Donghyoun Lee
- Department of Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Jung Kyong Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hyuck Jang
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine Changwon, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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2
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Wang Y, Zhou M, Yang J, Sun X, Zou W, Zhang Z, Zhang J, Shen L, Yang L, Zhang Z. Increased lymph node yield indicates improved survival in locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. Cancer Med 2019; 8:4615-4625. [PMID: 31250569 PMCID: PMC6712464 DOI: 10.1002/cam4.2372] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/22/2019] [Accepted: 06/12/2019] [Indexed: 12/17/2022] Open
Abstract
PURPOSE It is recommended for colorectal cancer to harvest at least 12 lymph nodes (LNs) during surgery to avoid understaging of the disease. However, it is still controversial whether it is necessary to harvest from locally advanced rectal cancer (LARC) patients who underwent neoadjuvant chemoradiotherapy (neo-CRT). The impact of lymph node yield (LNY) on prognosis in LARC patients was analyzed. MATERIALS/METHODS In total, 495 LARC patients who underwent neo-CRT in 2006-2015 were analyzed. After examining clinicopathological distribution differences between the LNY subgroups (with the threshold of 12), univariate and multivariate Cox survival analyses were performed. Survival plots were obtained from Kaplan-Meier analyses. Similar subgroup analyses were performed according to the tumor regression grade (TRG) and metastatic status of post-operational LNs. RESULTS Of the 495 patients, 287 (57.98%) had an LNY of less than 12. Nearly no significant clinicopathological difference was found between the LNY subgroups, including the TRG scores. Multivariate survival analysis demonstrated that at least 12 LNs examined was an independent prognostic feature of good overall survival (OS), disease-free survival (DFS), and distant metastasis free survival (DMFS), but not local recurrence free survival (LRFS). However, in the subgroup analyses, no association was found between LNY and prognosis in patients with good TRG scores (0-1) or negative LNs. CONCLUSIONS For LARC patients treated with neo-CRT, an LNY of at least 12 indicated an improved survival. Decreased LNY was not related to better tumor regression. It suggests that a sufficiently high LNY is still required, especially in those with a potentially poor tumor response.
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Affiliation(s)
- Yaqi Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Menglong Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Jianing Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Xiaoyang Sun
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Wei Zou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Zhiyuan Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Jing Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Lijun Shen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Lifeng Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
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Lee CHA, Wilkins S, Oliva K, Staples MP, McMurrick PJ. Role of lymph node yield and lymph node ratio in predicting outcomes in non-metastatic colorectal cancer. BJS Open 2018; 3:95-105. [PMID: 30734020 PMCID: PMC6354193 DOI: 10.1002/bjs5.96] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/02/2018] [Indexed: 02/06/2023] Open
Abstract
Background Lymph node yield (LNY) of 12 or more in resection of colorectal cancer is recommended in current international guidelines. Although a low LNY (less than 12) is associated with poorer outcome in some studies, its prognostic value is unclear in patients with early‐stage colorectal or rectal cancer with a complete pathological response following neoadjuvant therapy. Lymph node ratio (LNR), which reflects the proportion of positive to total nodes obtained, may be more accurate in predicting outcome in stage III colorectal cancer. This study aimed to identify factors correlating with LNY and evaluate the prognostic role of LNY and LNR in colorectal cancer. Methods An observational study was performed on patients with colorectal cancer treated at three hospitals in Melbourne, Australia, from January 2010 to March 2016. Association of LNY and LNR with clinical variables was analysed using linear regression. Disease‐free (DFS) and overall (OS) survival were investigated with Cox regression and Kaplan–Meier survival analyses. Results Some 1585 resections were analysed. Median follow‐up was 27·1 (range 0·1–71) months. Median LNY was 16 (range 0–86), and was lower for rectal cancers, decreased with increasing age, and increased with increasing stage. High LNY (12 or more) was associated with better DFS in colorectal cancer. Subgroup analysis indicated that low LNY was associated with poorer DFS and OS in stage III colonic cancer, but had no effect on DFS and OS in rectal cancer (stages I–III). Higher LNR was predictive of poorer DFS and OS. Conclusion Low LNY (less than 12) was predictive of poor DFS in stage III colonic cancer, but was not a factor for stage I or II colonic disease or any rectal cancer. LNR was a predictive factor in DFS and OS in stage III colonic cancer, but influenced DFS only in rectal cancer.
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Affiliation(s)
- C H A Lee
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia
| | - S Wilkins
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
| | - K Oliva
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia
| | - M P Staples
- Cabrini Institute Cabrini Hospital Malvern Victoria Australia
| | - P J McMurrick
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia
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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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Unger LW, Muckenhuber M, Riss S, Argeny S, Stift J, Mesteri I, Stift A. Effect of pathologist's dedication on lymph node detection rate and postoperative survival in colorectal cancer. Colorectal Dis 2018; 20:O173-O180. [PMID: 29706021 DOI: 10.1111/codi.14241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 04/16/2018] [Indexed: 12/13/2022]
Abstract
AIM As adjuvant chemotherapy in colorectal cancer relies on the identification of lymph node metastases, the pathologist's dedication may have a considerable influence on postoperative survival. METHOD The aim of this retrospective study was to assess the impact of the pathologist's dedication on lymph node detection rate and postoperative survival in patients operated on by a single experienced colorectal surgeon within a 5-year period. We assessed 229 patients undergoing total mesorectal excision or complete mesocolic excision by the senior author between 1 January 2009 and 31 December 2013. Pathologists were grouped as 'general pathologist' or 'dedicated pathologist' depending on their dedication/specialization. RESULTS Dedicated pathologists found statistically significantly more lymph nodes in colorectal specimens than general pathologists [23 (interquartile range 24) vs 14 (interquartile range 11), respectively; P < 0.001]. The detection rate of ≥ 12 lymph nodes per specimen was significantly higher in the dedicated pathologist group [65/74 (87.8%) vs 105/155 (67.7%); P = 0.016]. However, postoperative survival did not differ in the respective subgroups. In the multivariable analysis by Cox proportional hazard model, International Union against Cancer Stage IV was the only factor associated with decreased disease-specific survival (hazard ratio 28.257; 95% CI 3.850-207.386; P = 0.001). CONCLUSION In our centre, the pathologist's dedication has an impact on lymph node detection rate but does not influence postoperative disease-specific survival.
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Affiliation(s)
- L W Unger
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - M Muckenhuber
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - S Riss
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - S Argeny
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - J Stift
- Department of Pathology, Clinical, Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - I Mesteri
- Department of Pathology, Clinical, Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - A Stift
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Kent I, Rudnicki Y, Abu-Ghanem Y, White I, Spitz B, Avital S. Mesenteric root dissection with individualized ileo-colic vessel ligation versus mesenteric pedicle stapling. Surg Endosc 2015; 30:3021-5. [PMID: 26487235 DOI: 10.1007/s00464-015-4593-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 09/21/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Numerous factors have been associated with the number of lymph nodes retrieved during laparoscopic colectomy. This study compared the impact of vascular pedicle ligation method on the number of retrieved lymph nodes in patients undergoing laparoscopic right hemicolectomy for cancer. Mesenteric root dissection with individualized vessel ligation was compared to en bloc vascular root stapling. METHODS Data were retrospectively collected from a database of patients' charts including operative and pathological reports. All patients that underwent laparoscopic colectomy in a single department were identified. Patients that underwent elective laparoscopic right hemicolectomy for cancer were further evaluated. The impact of the method used for ileo-colic vascular transection, age, gender, nodes status, T stage, BMI and the operating surgeon on the number of retrieved lymph nodes was studied. RESULTS Among 239 laparoscopic colectomies, 75 patients underwent elective laparoscopic right colectomy for cancer. Ileo-colic vascular transection was routinely performed at the level of the inferior border of the pancreas. In total, 34 patients underwent ileo-colic vascular root dissection with individualized vessel ligation and 41 underwent vascular root stapling. No difference was found in the mean number of retrieved lymph nodes between pedicle dissection and vascular root stapling (18.7 ± 5.9 vs. 19.6 ± 7.9, P = 0.396), and in the rate of patients who had 12 nodes or more (97.1 vs. 92.7 %, P = 0.401). BMI above 30 was associated with decreased number of retrieved nodes (P = 0.001). CONCLUSIONS No difference was found in the number of retrieved lymph nodes between ileo-colic vascular root dissection with individual vessel ligation and vascular root stapling in patients undergoing laparoscopic right hemicolectomy for cancer. High BMI was associated with decreased number of retrieved nodes in both groups. A standard approach regarding the level of mesenteric root transection, regardless of the ligation approach, leads to adequate lymph node harvesting by different surgeons.
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Affiliation(s)
- Ilan Kent
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.
| | - Yaron Rudnicki
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | | | - Ian White
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | - Baruch Spitz
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | - Shmuel Avital
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
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