1
|
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.
Collapse
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
| |
Collapse
|
2
|
Bustamante-Lopez LA, Nahas CSR, Nahas SC, Marques CFS, Pinto RA, Cotti GC, Imperiale AR, de Mello ES, Ribeiro U, Cecconello I. Pathologic complete response implies a fewer number of lymph nodes in specimen of rectal cancer patients treated by neoadjuvant therapy and total mesorectal excision. Int J Surg 2018; 56:283-287. [PMID: 29981939 DOI: 10.1016/j.ijsu.2018.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/30/2018] [Accepted: 07/02/2018] [Indexed: 12/26/2022]
Abstract
Studies have suggested that the use of neoadjuvant chemoradiation results in a lower lymph nodes yield in rectal cancer patients. OBJECTIVE To evaluate factors associated with less than 12 lymph nodes harvested on patients with rectal cancer treated with preoperative chemoradiotherapy followed by total mesorectal excision. PATIENTS This was a cohort/retrospective single cancer center study. Low and mid locally advanced rectal cancer or T2N0 under risk of sphincter resection underwent chemoradiotherapy followed by total mesorectal excision with curative intent. Chemotherapy consisted of 5-FU and leucovorin IV. Total dose of pelvic radiation was 5040 Gys. All patients were staged and restaged by digital rectal examination, proctoscopy, colonoscopy, CT of abdomen and chest, and MRI of the pelvis. Patients were stratified in two groups: ≥12 and < 12 L N retrieved. The possible factors affecting number of LN were analyzed. RESULTS 95 patients met the inclusion criteria. Mean LN harvest was 23.2 (3-67). 81 patients (85%) had ≥12 L N. Gender, age, tumor size, tumor stage, tumor location, length of specimen, presence of LN involvement, type of surgery, and surgical access showed no association with number of LN retrieved. Only pathological complete response showed a statistically significant association with <12 L N on univariate (p = 0.004) and multivariate analyses (p = 0.002). LIMITATIONS Data were collected retrospectively. The number of patients disparity between the two groups. CONCLUSIONS Complete pathologic response is associated with <12 L N harvested. Thus, the number of lymph nodes should not be used as a surrogate for oncologic adequacy of resection in patients with pathologic complete response.
Collapse
Affiliation(s)
| | - Caio Sergio Rizkallah Nahas
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Rodrigo Ambar Pinto
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Guilherme Cutait Cotti
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Antonio Rocco Imperiale
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Evandro Sobroza de Mello
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| |
Collapse
|
3
|
Kang S, Na Y, Joung SY, Lee SI, Oh SC, Min BW. The significance of microsatellite instability in colorectal cancer after controlling for clinicopathological factors. Medicine (Baltimore) 2018; 97:e0019. [PMID: 29489646 PMCID: PMC5851768 DOI: 10.1097/md.0000000000010019] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The colorectal cancer (CRC) patients with microsatellite instability (MSI) have distinct clinicopathological characteristics consisting of factors predicting positive and negative outcomes, such as a high lymph node harvest and poor differentiation. In this study, we measured the value of MSI as a prognostic factor after controlling for these discrepant factors. A total of 603 patients who underwent curative surgery for stages I to III colorectal cancer were enrolled. The patients were divided into microsatellite instability high (MSI-H) and microsatellite stable/microsatellite instability low (MSS/MSI-L) groups. Propensity score matching was used to match clinicopathological factors between the 2 groups. MSI-H patients had a high lymph node harvest (median: 31.0 vs 23.0, P < .001), earlier-stage tumors (P < .001), advanced T stage (89.3% vs 74.0%, P = .018), and poor differentiation (19.6% vs 2.0%, P < .001). Survival analysis showed better survival in the MSI-H group, but the difference was not statistically significant (P = .126). Propensity score matching was performed for significant prognostic factors identified by Cox hazard regression. After the matching, the survival difference by MSI status was estimated to be larger than before, and reached statistical significance (P = .045). In conclusion, after controlling for pathological characteristics, MSI-H could be a potent prognostic factor regarding patient survival.
Collapse
Affiliation(s)
- Sanghee Kang
- Department of Surgery, Korea University Guro Hospital, Gurodong-gil, Guro-gu, Seoul, Korea
| | - Younghyun Na
- Department of Surgery, Korea University Guro Hospital, Gurodong-gil, Guro-gu, Seoul, Korea
| | - Sung Yup Joung
- Department of Surgery, Korea University Guro Hospital, Gurodong-gil, Guro-gu, Seoul, Korea
| | - Sun Il Lee
- Department of Surgery, Korea University Guro Hospital, Gurodong-gil, Guro-gu, Seoul, Korea
| | - Sang Cheul Oh
- Division of Oncology/Hematology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Wook Min
- Department of Surgery, Korea University Guro Hospital, Gurodong-gil, Guro-gu, Seoul, Korea
| |
Collapse
|
4
|
Rogers AC, Handelman GS, Solon JG, McNamara DA, Deasy J, Burke JP. Meta-analysis of the clinicopathological characteristics and peri-operative outcomes of colorectal cancer in obese patients. Cancer Epidemiol 2017; 51:23-29. [PMID: 28987964 DOI: 10.1016/j.canep.2017.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/18/2017] [Accepted: 09/24/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND The effect of obesity on the clinicopathological characteristics of colorectal cancer (CRC) has not been clearly characterized. This meta-analysis assesses the pathological and perioperative outcomes of obese patients undergoing surgical resection for CRC. METHODS Meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases were searched for studies reporting outcomes for obese and non-obese patients undergoing primary CRC resection, based on body-mass index measurement. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS A total of 2183 citations were reviewed; 29 studies comprising 56,293 patients were ultimately included in the analysis, with an obesity rate of 19.3%. Obese patients with colorectal cancer were more often female (OR 1.2, 95% CI 1.1-1.2, p<0.001) but there was no difference in the proportion of rectal cancers, T4 tumours, tumour differentiation or margin positivity. Obese patients were significantly more likely to have lymph node metastases (OR 1.2, 95% CI 1.1-1.2, p<0.001), have a lower nodal yield, were associated with a longer duration of surgery, more blood loss and conversions to open surgery (OR 2.6, 95% CI 1.6-4.0, p<0.001) but with no difference in length of stay or post-operative mortality. CONCLUSION This meta-analysis demonstrates that obese patients undergoing resection for CRC are more likely to have node positive disease, longer surgery and higher failure rates of minimally invasive approaches. The challenges of colorectal cancer resection in obese patients are emphasized.
Collapse
Affiliation(s)
- Ailin C Rogers
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - Guy S Handelman
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - J Gemma Solon
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | | | - Joseph Deasy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - John P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland; Royal College of Surgeons in Ireland, Dublin 2, Ireland.
| |
Collapse
|
5
|
Bustamante-Lopez L, Nahas CS, Nahas SC, Ribeiro U, Marques CF, Cotti G, Rocco A, Cecconello I. Understanding the factors associated with reduction in the number of lymph nodes in rectal cancer patients treated by neoadjuvant treatment. Int J Colorectal Dis 2017; 32:925-927. [PMID: 28035459 DOI: 10.1007/s00384-016-2747-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Rectal cancer patients frequently present with locally advanced disease for which the standard of care includes neoadjuvant chemoradiotherapy followed by total mesorectal excision. Positive lymph nodes are one of the most powerful risk factors for recurrence and survival in colorectal cancer. In the absence of specific rectal guidelines, the literature recommends to the pathologist to optimize the number of rectal lymph nodes (LN) retrieved. We made a literature review in order to identify factors that could potentially affect the number of LN retrieved in specimens of patients with rectal cancer treated by chemoradiotherapy (CRT) followed by total mesorectal excision (TME). RESULTS Age did not have a significant effect on LN yield. The effect of sex on LN number is not consistent in the literature. Most of the papers did not find a relationship between lower LN obtained and gender. Laparoscopy for primary rectal cancer is associated with a greater number of LN as well as short-term benefits. Tumors in the upper rectum are associated with a higher number of LN than those in the mid and lower rectum. The type of surgery had no effect on lymph node yield either. Tumors with complete or almost complete pathologic regression were exactly the ones with lower number of lymph nodes detected. Approximately one-third of patients with neoadjuvant treatment had less than 12 LN yield. CONCLUSION The tumor regression grade is the most important factor for the decrease in the number of lymph nodes.
Collapse
Affiliation(s)
- L Bustamante-Lopez
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil.
| | - C S Nahas
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - S C Nahas
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - U Ribeiro
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - C F Marques
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - G Cotti
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - A Rocco
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - I Cecconello
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| |
Collapse
|
6
|
Lykke J, Jess P, Roikjær O. A high lymph node yield in colon cancer is associated with age, tumour stage, tumour sub-site and priority of surgery. Results from a prospective national cohort study. Int J Colorectal Dis 2016; 31:1299-305. [PMID: 27220610 DOI: 10.1007/s00384-016-2599-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2016] [Indexed: 02/04/2023]
Abstract
AIM To determine the relation between patient-related and histopathological factors, as well as the influence of national programs for diagnosing and treatment of colon cancer and a lymph node yield (LNY) ≥ 12. METHOD An analysis was carried out of the LNY in a nationwide Danish cohort treated by curative resection of stage I-III colon cancer in the period 2003-2011. The association between a LNY ≥ 12 and age, sex, body mass index, open vs. laparoscopic surgery, acute vs. elective surgery, pT stage, tumour sub-site and year of diagnosis was analysed. RESULTS A total of 13,766 patients were eligible for the analysis. In total, 71.4 % of the patients had a LNY ≥ 12. In multivariate analysis, age, pT stage, tumour sub-site and priority of surgery were independently associated with the probability of a LNY ≥ 12. Odds ratios (ORs) were as follows: age <65 1, 65-75 0.685 (confidence interval (CI) 0.586-0.800), >75 0.517 (CI 0.439-0.609); T1 1, T2 2.750 (CI 2.168-3.487), T3 6.016 (CI 4.879-7.418), T4 6.317 (CI 4.950-8.063); right colon 1, left colon 0.568 (0.511-0.633); elective surgery 1, acute surgery 0.748 (CI 0.625-0.894). Moreover, year of diagnosis was associated with the probability of a LNY ≥ 12: OR 1.480 (CI 1.445-1.516) for each increasing year in the study period. CONCLUSION A LNY ≥ 12 is significantly associated with age, pT stage, tumour sub-site and priority of surgery. A significant increase in the LNY over the period of the study was observed, probably reflecting the effect of national programmes initiated by the Danish Colorectal Cancer Group.
Collapse
Affiliation(s)
- Jakob Lykke
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark.
| | - Per Jess
- Department of Surgery, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark
| | - Ole Roikjær
- Department of Surgery, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark
| |
Collapse
|
7
|
Lykke J, Jess P, Roikjaer O. The prognostic value of lymph node ratio in a national cohort of rectal cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:504-12. [PMID: 26856955 DOI: 10.1016/j.ejso.2016.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/13/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To analyze the prognostic implications of the lymph node ratio (LNR) in curative resected rectal cancer. SUMMARY BACKGROUND DATA It has been proposed that the LNR has a high prognostic impact in colorectal cancer, but the lymph node ratio has not been evaluated exclusively for rectal cancer in a large national cohort study. METHODS All 6793 patients in Denmark diagnosed with stage I to III adenocarcinoma of the rectum, and so treated in the period from 2003 to 2011, were included in the analysis. The cohort was divided into two groups according to whether or not neo-adjuvant treatment had been given. RESULTS In a multivariate analysis the pN status, ypN status and lymph node yield were found to be independent prognostic factors for overall survival, irrespective of neo-adjuvant therapy. The LNR was also found to be a significant prognostic factor with a Hazard Ratio ranging from 1.154 (95% CI: 0.930-1.432) (LNR: 0.01-0.08) to 2.974 (95% CI: 2.452-3.606) (LNR > 0.5) in the group of patients who had surgery to begin with and from 1.381 (95% CI: 0.891-2.139) (LNR: 0.01-0.08) to 2.915 (95% CI: 2.244-3.787) (LNR > 0.5) in the group of patients who had neo-adjuvant treatment. CONCLUSIONS The LNR reflects the influence on survival from N-status and the lymph node yield and since LNR was shown to be a significant prognostic predictor for overall survival in patients with curatively resected stage III rectal cancer irrespective of neo-adjuvant therapy we recommend that the introduction of LNR should be considered for rectal cancer in a revised TNM classification.
Collapse
Affiliation(s)
- J Lykke
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark.
| | - P Jess
- Department of Surgery, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark
| | - O Roikjaer
- Department of Surgery, Roskilde Hospital, University of Copenhagen, Roskilde, Denmark
| | | |
Collapse
|
8
|
Lykke J, Roikjaer O, Jess P. Tumour stage and preoperative chemoradiotherapy influence the lymph node yield in stages I-III rectal cancer: results from a prospective nationwide cohort study. Colorectal Dis 2014; 16:O144-9. [PMID: 24329928 DOI: 10.1111/codi.12521] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Accepted: 10/02/2013] [Indexed: 02/08/2023]
Abstract
AIM The study aimed to determine whether the lymph node yield (LNY) in rectal cancer is influenced by patient-related and histopathological factors and the use of preoperative chemoradiotherapy (CRT). METHOD An analysis was carried out of the LNY in a nationwide Danish cohort of 7950 patients, treated by curative resection of Stage I-III rectal cancer during the period 2001-2011. The impact of year of diagnosis, age, gender, pathological stage of the tumour (pT-stage) and preoperative CRT on LNY was analysed. RESULTS Twenty-nine per cent of the patients received preoperative CRT. The median LNY was 13 [interquartile range (IQR): 8-19]. A total of 43.4% of the patients had an LNY of < 12. The median LNY increased from 8 (IQR: 5-12) to 20 (IQR: 13-28) LNs over the years of the study period (P < 0.0001). Gender and body mass index (BMI) had no impact on the median LNY. Age had a minor impact, with a range of 12 (IQR: 8-18) to 13 (IQR: 9-20) (P < 0.0001). The LNY ranged from 9 (IQR: 6-14) to 16 (IQR: 10-26), according to pT-stage (pT0-pT4) (P < 0.0001). Median LNY, according to preoperative CRT or no preoperative CRT, was 10 (IQR: 6-16) and 14 (IQR: 8-18), respectively (P < 0.0001). The percentages of patients with an LNY of < 12, according to preoperative CRT or no preoperative CRT, were 58.7% and 37.1%, respectively (P < 0.0001). CONCLUSION An increase in the LNY over the period of the study was observed, probably reflecting improved quality of surgery and histopathology. A minor significant reduction of LNY was found with increasing age of the patient. LNY was significantly related to pT-stage and to the use of preoperative chemoradiotherapy. For these reasons the minimum harvest of 12 LNs as a surrogate marker for the oncological quality of surgery should be questioned.
Collapse
Affiliation(s)
- J Lykke
- Department of Surgery, Slagelse Hospital, University of Copenhagen, Slagelse, Denmark
| | | | | | | |
Collapse
|