Prognostic impact of at least 12 lymph nodes after neoadjuvant therapy in rectal cancer: A meta-analysis

Feasibility of indocyanine green (ICG) fluorescence in ex vivo pathological dissection of colorectal lymph nodes-a pilot study

Accurate lymph node (LN) retrieval during colorectal carcinoma resection is pivotal for precise N-staging and the determination of adjuvant therapy. Current guidelines recommend the examination of at least 12 mesocolic or mesorectal lymph nodes for accurate staging. Traditional histological processing techniques, reliant on visual inspection and palpation, are time-consuming and heavily dependent on the examiner's expertise and availability. Various methods have been documented to enhance LN retrieval from colorectal specimens, including intra-arterial ex vivo methylene blue injection. Recent studies have explored the utility of indocyanine green (ICG) fluorescence imaging for visualizing pericolic lymph nodes and identifying sentinel lymph nodes in colorectal malignancies. This study included 10 patients who underwent colon resection for malignant tumors. During surgery, intravenous ICG dye and an endoscopic camera were employed to assess intestinal perfusion. Post-resection, ex vivo intra-arterial administration of ICG dye was performed on the specimens, followed by routine histological processing and an ICG-assisted lymph node dissection. The objective was to evaluate whether ICG imaging could identify additional lymph nodes compared to routine manual dissection and to assess the clinical relevance of these findings. For each patient, a minimum of 12 lymph nodes (median = 25.5, interquartile range = 12.25, maximum = 33) were examined. ICG imaging facilitated the detection of a median of three additional lymph nodes not identified during routine processing. Metastatic lymph nodes were found in four patients however no additional metastatic nodes were detected with ICG assistance. Our findings suggest that ex vivo intra-arterial administration of indocyanine green dye can augment lymph node dissection, particularly in cases where the number of lymph nodes retrieved is below the recommended threshold of 12.

Prognostic significance of lymph node yield on oncologic outcomes according to tumor response after preoperative chemoradiotherapy in rectal cancer patients

PURPOSE

This study aimed to evaluate the predictive value of lymph node yield (LNY) for survival outcomes according to tumor response after preoperative chemoradiotherapy (PCRT) in patients with rectal cancer.

METHODS

This study was a retrospective study conducted in a tertiary center. A total of 1,240 patients with clinical stage II or III rectal cancer who underwent curative resection after PCRT between 2007 and 2016 were included. Patients were categorized into the good response group (tumor regression grade [TRG], 0-1) or poor response group (TRG, 2-3). Propensity score matching was performed for age, sex, and pathologic stage between LNY of ≥12 and LNY of <12 within tumor response group. The primary outcome was 5-year disease-free survival (DFS) and overall survival (OS).

RESULTS

LNY and positive lymph nodes were inversely correlated with TRG. In good responders, 5-year DFS and 5-year OS of patients with LNY of <12 were better than those with LNY of ≥12, but there was no statistical significance. In poor responders, the LNY of <12 group had worse survival outcomes than the LNY of ≥12 group, but there was also no statistical significance. LNY of ≥12 was not associated with DFS and OS in multivariate analysis.

CONCLUSION

LNY of <12 showed contrasting outcomes between the good and poor responders in 5-year DFS and OS. LNY of 12 may not imply adequate oncologic surgery or proper staging in rectal cancer patients treated by PCRT. Furthermore, a decrease in LNY should be comprehended differently according to tumor response.

Predictors and survival outcomes of having less than 12 harvested lymph nodes in proctectomy for rectal cancer

BACKGROUND

Current recommendations suggest that a minimum of 12 lymph nodes (LNs) should be harvested during curative rectal cancer resection. We aimed to assess predictors and survival outcomes of harvesting < 12 lymph nodes in rectal cancer surgery.

METHODS

A retrospective case-control analysis of factors associated with harvesting < 12 LNs in rectal cancer surgery was conducted. Data were derived from the National Cancer Database 2010-2019. Univariate and multivariate binary logistic regression analyses were performed to determine predictors of harvesting < 12 LNs. Association between harvesting < 12 LNs and 5-year overall survival (OS) was assessed using Cox regression and Kaplan Meier statistics.

RESULTS

67,529 patients (60.8% male; mean age: 61.2 ± 12.5 years) were included. Median number of harvested LNs was 15 (IQR: 11-20); 27.1% of patients had < 12 harvested LNs. Independent predictors of harvesting < 12 LNs were older age (OR: 1.016;p < 0.001), neoadjuvant systemic treatment (OR: 1.522;p < 0.001), neoadjuvant radiation treatment (OR: 1.367;p < 0.001), longer duration of radiation therapy (OR: 1.003;p < 0.001) and abdominoperineal resection (OR: 1.071;p = 0.017). Higher clinical TNM stage and tumor grade, pull-through coloanal anastomosis, and minimally invasive surgery were independently associated with ≥ 12 harvested LNs. < 12 harvested LNs was independently associated with lower 5-year OS (HR: 1.24;p < 0.001) and shorter mean OS (96.7 vs 102.8 months;p < 0.001) than ≥ 12 harvested LNs.

CONCLUSIONS

Older age, open resection, and neoadjuvant therapy were independent predictors of < 12 harvested LNs. Conversely, higher clinical TNM stage and tumor grade, coloanal anastomosis, and minimally invasive surgery were predictive of ≥ 12 harvested LNs. < 12 LNs harvested was associated with lower OS.

Lymph node harvest as a predictor of survival for colon cancer: A systematic review and meta-analysis

Background and Objectives

The number of lymph nodes found harboring metastasis can be impacted by the extent of harvest. Guidelines recommend 12 lymph nodes for adequate lymphadenectomy to predict long-term oncologic outcomes, yet different cut-offs remain unevaluated. The aim of this review was to determine cut-offs that may predict survival outcomes.

Methods

Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared overall survival (OS) or disease-free survival (DFS) above and below a lymph node harvest cut-off. Studies solely examining rectal cancer or stage-IV disease were excluded. Pairwise meta-analyses using inverse variance random effects were performed.

Results

From 2587 citations, 20 studies with 854,359 patients (51.9% female, mean age: 68.9) were included, with 19 studies included in quantitative synthesis. A lymph node harvest cut-off of 12 predicted improved five-year OS (7 studies; OR 1.11, 95% CI 1.08-1.14, p<0.00001). A cut-off as low as 7 was associated with improved five-year OS (2 studies; OR 1.16, 95% CI 1.08-1.25, p<0.0001) and DFS (3 studies; OR 1.66, 95% CI 1.32-2.10, p<0.00001). All cut-offs greater than 12 demonstrated improved survival.

Conclusions

A lymph node cut-off of 12 distinguishes differences in five-year oncologic outcomes. Contrarily, lymph node harvests other than 12 have not been rigorously studied and thus lack the statistical power to derive meaningful conclusions compared to the 12-lymph node cut-off. Nonetheless, it is possible that a lymph node harvest cut-offs less than 12 may be adequate in predicting long-term survival. Further prospective study evaluating cut-offs below 12 are warranted.

A systematic review and meta-analysis of the use of methylene blue to improve the lymph node harvest in rectal cancer surgery

BACKGROUND

Methylene blue staining of the resected specimen has been described as an alternative to the conventional palpation and visual inspection method to improve lymph node harvest. This meta-analysis evaluates the usefulness of this technique in surgery for rectal cancer, particularly after neoadjuvant therapy.

METHODS

Randomized controlled trials (RCTs) comparing lymph node harvest in methylene blue-stained rectal specimens to those of unstained specimens were identified from the Medline, Embase, and Cochrane databases. Non-randomized studies and those with only colonic resections were excluded. The quality of RCTs was assessed using Cochrane's risk of bias tool. A weighted mean difference (WMD) was calculated for overall harvest, harvest after neoadjuvant therapy, and metastatic nodal yield. In contrast, the risk difference (RD) was calculated to compare yields of less than 12 lymph nodes between the stained and unstained specimens.

RESULTS

Study selection comprised seven RCTs with 343 patients in the unstained group and 337 in the stained group. Overall lymph node harvest and harvest after neoadjuvant therapy were significantly higher in stained specimens with a WMD of 13.4 and 10.6 and a 95% confidence interval (CI) of 9.5-17.2 and 4.8-16.3, respectively. Harvest of metastatic lymph nodes was significantly higher in the stained group (WMD 1.0, 95% CI 0.6-1.4). The yield of less than 12 lymph nodes was significantly higher in the unstained group with RD of 0.292 and 95% CI of 0.182-0.403.

CONCLUSION

Despite a small number of patients, this meta-analysis confirms improved lymph node harvest in surgical specimens stained with methylene blue compared with unstained specimens.

A prognostic nomogram for stage II/III rectal cancer patients treated with neoadjuvant chemoradiotherapy followed by surgical resection

Background

The purpose of this study was to develop a large population-based nomogram incorporating the log odds of positive nodes (LODDS) for predicting the overall survival (OS) of stage II/III rectal cancer patients treated with neoadjuvant chemoradiotherapy (NCRT) followed by surgical resection.

Methods

The Surveillance, Epidemiology, and End Results database was used to collect information on patients diagnosed with stage II/III rectal cancer between 2010 and 2015 and treated with NCRT followed by surgical resection. The Cox regression analyses were performed to determine the independent prognostic factors. In this study, LODDS was employed instead of American Joint Committee on Cancer (AJCC) 7th N stage to determine lymph node status. Then a nomogram integrating independent prognostic factors was developed to predict the 24-, 36-, and 60-month overall survival. The receiver operating characteristic (ROC) curves and calibration curves were used to validate the nomogram. Furthermore, patients were stratified into three risk groups (high-, middle-, and low-risk) based on the total points obtained from the nomogram. And Kaplan–Meier curves were plotted to compare the OS of the three groups.

Results

A total of 3829 patients were included in the study. Race, sex, age, marital status, T stage, tumor grade, tumor size, LODDS, CEA level, and postoperative chemotherapy were identified as independent prognostic factors, based on which the prognostic nomogram was developed. The area under curve values of the nomogram for the 24-, 36-, and 60-month OS in the training cohort were 0.736, 0.720, and 0.688, respectively; and 0.691, 0.696, and 0.694 in the validation cohort, respectively. In both the validation and training cohorts, the calibration curves showed a high degree of consistency between actual and nomogram-predicted survival rates. The Kaplan–Meier curves showed that the three risk groups had significant differences in overall survival (P < 0.001).

Conclusion

A large population-based nomogram incorporating LODDS was developed to assist in evaluating the prognosis of stage II/III rectal cancer patients treated with NCRT followed by surgical resection. The nomogram showed a satisfactorily discriminative and stable ability to predict the OS for those patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01710-z.

Prognostic value of lymph node ratio in resectable rectal cancer after preoperative short-course radiotherapy-results from randomized clinical trial

PURPOSE

The value of the lymph node ratio (LNR) in patients with rectal cancer has not yet been unequivocally established. This study aims to assess the effect of the lymph node ratio on the prognosis of rectal cancer in patients operated after short-course preoperative 25 Gy radiotherapy, at 10-year follow-up.

METHODS

This is a substudy based on data from a prospective randomized clinical trial. A total of 141 patients with resectable rectal cancer were included. Lymph node yield was compared in patients with short and long time intervals between radiotherapy and surgery. Survival curves were compared between patients with different ypN and LNR categories. Univariate and multivariate analyses were performed to identify independent prognostic factors for overall survival and disease-free survival.

RESULTS

Survival and recurrence data were available for a median follow-up of 11.6 years. The lymph node yield did not differ significantly between the patients in the short- and long-interval groups. A greater difference in 10-year survival was observed in patients with LNR ≤ 0.41 and > 0.41 when compared to the ypN categories. Separate prognostic factor analyses were performed for the entire population and for subgroups that had < 12 and 12 lymph nodes resected. LNR was identified as an independent prognostic factor for overall survival, in multivariate analyses, for all patients and those with less than 12 retrieved lymph nodes.

CONCLUSION

The lymph node yield is comparable in patients with different time intervals between radiation therapy and surgery. LNR better discriminates patients in terms of overall survival than ypN categories.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01444495, date of registration: September 30, 2011.

Lymph Node Cluster Dissection After Carbon Nanoparticles Injection Enhances the Retrieval Number in Colorectal Cancer

For colorectal cancer patients, NCCN recommended that at least 12 lymph nodes should be detected since the number and metastases status of lymph nodes played an important role in the treatment and prognostic. Carbon nanoparticles have been proved to be an efficient lymph node tracer. Faced with the clinical problem of insufficient lymph nodes in colorectal cancer, we proposed a lymph node cluster (D3, D2 and D1) dissection method combined with carbon nanoparticle injection. In our study, patients were divided into 2 groups (CNP and control). All lymph nodes of each patient were collected and made into hematoxylin-eosin sections to observe their size, staining appearance and metastasis status under the microscope. As a result, the total lymph nodes in CNP group were greatly higher than control group (51.45 vs. 29.62, P = 0.000), especially micro LNs and positive micro LNs. Compared with D2 and D1 stations, fewer lymph nodes were found in D3, and it was the same for cancer metastasis status. In CNP group, most lymph nodes got black for quick visualization. In conclusion, lymph node cluster dissection combined with carbon nanoparticles could enhance the number of lymph node retrieval.

Development and validation of a nomogram to predict overall survival in young non-metastatic rectal cancer patients after curative resection: a population-based analysis

PURPOSE

This study aimed to establish and validate a nomogram for predicting overall survival (OS) in young non-metastatic rectal cancer (RC) patients after curative resection.

METHODS

Young RC patients (under 50 years of age) from 2010 to 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Those patients randomly assigned to a training cohort and a validation cohort at a ratio of 7:3. The independent prognostic factors for OS were identified by univariate and multivariate Cox regression analysis. A nomogram model was built based on the independent prognostic variables and was evaluated by concordance index (C-index), receiver operating characteristics (ROC) curves, calibration plot, and decision curve analysis (DCA).

RESULTS

A total number of 3026 young RC patients were extracted from SEER database. OS nomogram was constructed based on race, histological type, tumor grade, T stage, N stage, carcinoembryonic antigen (CEA) level, and number of lymph nodes (LN) examined. C-index, ROC curves, calibration plot, and DCA curves presented satisfactory performance of the above nomogram in predicting the prognosis of young non-metastatic RC patients after curative resection. The nomogram can identify three subgroups of patients at different risks, which showed different prognostic outcomes both in the training cohort and validation cohort.

CONCLUSION

We successfully established a reliable and insightful nomogram to predict OS for young non-metastatic RC patients after curative resection. The nomogram may provide accurate prognosis prediction to guide individualized follow-up and treatment plans.

Carbon nanoparticle suspension could help get a more accurate nodal staging for patient with rectal cancer

This study aimed to evaluate whether carbon nanoparticles could improve the accuracy of nodal staging in colorectal cancer (CRC). We performed a randomized controlled trial with CRC at the department of general surgery, the affiliated hospital of Nanjing University Medical School. A total of 160 patients were recruited in this research and 132 patients were included in the safety analyses. Among these patients, 72 cases were classified into control group and 60 cases into study group. The mean number of lymph nodes harvested from patients in study group was 19.3 ± 6.7 (range from 4 to 38), which was higher than that in control group (15.1 ± 5.7 (range from 3 to 29)) (p < 0.001). The mean number of positive lymph nodes got from patients in study group was 1.7 ± 3.5 (range from 0 to 22), which was also higher than that in control group (0.7 ± 1.4 (range from 0 to 7)) (p = 0.045). In study group, there were 30 patients (50%) proved to be N0, and remaining 30 patients (50%) were N1 or N2. However, 50 patients (69.4%) were N0 and 22 patients (30.6%) were N1 or N2 in control group. The rate of N0 in control group was significantly higher than that in study group (p = 0.023). Injecting carbon nanoparticle suspension could get a more accurate nodal staging to receive enough chemoradiotherapy, improving prognosis. Besides, injecting carbon nanoparticles suspension at four points 5 cm, 10 cm, 15 cm and 20 cm away from the anus by “sandwich” method was a new try.

Trial registration: This study was registered with ClinicalTrials.gov, number ChiCTR1900025127 on 12/8/2019.