A Nomogram to Predict Adequate Lymph Node Recovery before Resection of Colorectal Cancer

Association between the number of retrieved lymph nodes and demographic/tumour-related characteristics in colorectal cancer: a systematic review and meta-analysis

OBJECTIVE

Clinical practice guidelines recommend retrieving at least 12 lymph nodes for correct staging in colorectal cancer. However, it is difficult to retrieve adequate lymph nodes because of various factors. We aimed to evaluate the association between the number of retrieved lymph nodes and demographic/tumour-related characteristics in colorectal cancer.

DESIGN

Systematic review and meta-analysis of primary studies.

DATA SOURCES

PubMed, Embase, Cochrane and Web of Science were searched from January 2016 to June 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies that evaluated the association between retrieved lymph nodes and demographic/tumour-related characteristics in colorectal cancer were included.

DATA EXTRACTION AND SYNTHESIS

OR with 95% conference intervals was extracted and pooled.

RESULTS

A total of 54 studies containing 2 05 821 patients were included in this meta-analysis. The results showed that fewer nodes were retrieved from elderly patients (OR=0.70, 95% CI (0.54 to 0.90), p=0.005), and from tumours located in the left colon than in the right colon (OR=0.43, 95% CI (0.33 to 0.56), p<0.001). More lymph nodes were obtained from females than males (OR=1.15, 95% CI (1.04 to 1.28), p=0.006), from the advanced T stage (T3+T4) than T1+T2 stage (OR=1.57, 95% CI (1.25 to 1.97), p<0.001) and from the N2 stage than N0 stage (OR=1.32, 95% CI (1.15 to 1.51), p<0.001). Body mass index, ethnicity, N1 stage, M stage, tumour differentiation and lymph-vascular invasion were not significantly associated with the lymph node yield.

CONCLUSIONS

The study results suggest that clinicians have an increased opportunity to retrieve sufficient lymph nodes for accurate pathological staging to guide treatment decisions in patients with colorectal cancer who are young, female, with tumours located in the right colon, advanced T stage and N2 stage.

A nomogram for predicting feasibility of laparoscopic anterior resection with trans-rectal specimen extraction (NOSES) in patients with upper rectal cancer

Background

Laparoscopic anterior resection with trans-rectal specimen extraction (NOSES) has been demonstrated as a safe and effective technique in appropriate patients with upper rectal cancer (RC). However, improper selection of RC candidates for NOSES may lead to potential surgical and oncological unsafety as well as complications such as bacteria contamination and anastomotic leak. Unfortunately, no tools are available for evaluating the risk and excluding improper cases before surgery. This study aims to estimate its clinical relevancy and to investigate independent clinical-pathological predictors for identifying candidates for NOSES in patients with upper RC and to develop a validated scoring nomogram to facilitate clinical decision making.

Methods

The study was performed at Shanghai East hospital, a tertiary medical center and teaching hospital. 111 eligible patients with upper RC who underwent elective laparoscopic anterior resection between February and October of 2017 were included in the final analysis. Univariate and multivariate analyses were performed to compare characteristics between the two surgical techniques. Odds ratios (OR) were determined by logistic regression analyses to identify and quantify the clinical relevancy and ability of predictors for identifying NOSES candidate. The nomogram was constructed and characterized by c-index, calibration, bootstrapping validation, ROC curve analysis, and decision curve analysis.

Results

Upper RC patients with successful NOSES tended to be featured with female gender, negative preoperative CEA/CA19-9, decreased mesorectum length (MRL), ratio of diameter (ROD) and ratio of area (ROA) values, while no significant statistical correlations were observed with age, body mass index (BMI), tumor location, and tumor-related biological characteristics (ie., vascular invasion, lymph node count, TNM stages). Furthermore, the two techniques exhibited comparably low incidence of perioperative complications and achieved similar functional results under the standard procedures. The nomogram incorporating three independent preoperative predictors including gender, CEA status and ROD showed a high c-index of 0.814 and considerable reliability, accuracy and clinical net benefit.

Conclusions

NOSES for patients with upper RC is multifactorial; while it is a safe and efficient technique if used properly. The nomogram is useful for patient evaluation in the future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01290-4.

Determinants of lymph node count and positivity in patients undergoing surgery for colon cancer

Prognosis in colon cancer is based on pathological criteria including TNM staging. However, there are deficiencies in this approach, and the lymph node ratio (LNR) has been proposed to improve the prediction of outcomes. LNR is dependent on optimal retrieval of lymph nodes-lymph node count (LNC). Recent studies have suggested that an elevated preoperative systemic inflammatory response (SIR) was associated with a lower LNC and a higher LNR. However, there are a number of potential confounding factors. The aim of the present study was to examine, in detail, these relationships in a large cohort of patients.A prospectively maintained database of all patients undergoing colon cancer resection in our institution was examined. The SIR was measured by a number of inflammatory markers and their scores: modified Glasgow Prognostic Score (mGPS) (C-reactive protein/albumin), neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), and lymphocyte monocyte ratio (LMR) using standard thresholds. The relationships between LNC and LNR, and clinicopathological characteristics (including the mGPS, NLR, PLR, and LMR) were examined using chi-square test for trend and binary logistic regression analysis, where appropriate.Of the 896 patients included in the study, 418 (47%) were male, the median LNC was 17 (1-71), and the median LNR in node positive disease was 0.16 (0.03-1). On multivariate analysis, there was a significant independent relationship between an elevated LNC (≥12) and laparoscopic surgery (P < .001), right-sided tumors (P < .001), later date of resection (2007-2016) (P < .001), T stage (P < .001), and venous invasion (P < .001). In those patients with a LNC ≥12 and node-positive disease (n = 272), on multivariate analysis, there was a significant relationship between an elevated LNR (≥0.25), and T stage (P < .01) and differentiation (P < .05). Finally, in patients with node-positive disease who had surgery later (2007-2016), LNR was directly superior to N stage for both cancer-specific survival (LNR: hazard ratio [HR] 2.62, 95% confidence interval [CI] 1.25-5.52, P = .011) and overall survival (LNR: HR 2.02, 95% CI 1.12-3.68, P = .022).Neither LNC nor LNR was associated with markers of the SIR; however, LNC and LNR were directly associated. In high-quality surgical and pathological practice, LNR had superior prognostic value compared with N stage in patients undergoing surgery for colon cancer.