A lower cut-off for lymph node harvest predicts for poorer overall survival after rectal surgery post neoadjuvant chemoradiotherapy

Charleen Shanwen Yeo,Huimin Liu,Nicholas Syn,Sau Shung Fong

doi:10.1186/s12957-020-01833-8

Abstract

BackgroundA lymph node harvest (LNH) of < 12 is a predictor for poor prognosis in rectal cancer patients. However, neoadjuvant chemoradiotherapy (NACRT) is known to decrease LNH; hence, a cut-off of 12 is inappropriate in such patients. This paper aims to establish a LNH cut-off predictive for disease-free and overall survival in NACRT patients.MethodsA retrospective review of patients who underwent elective surgery for rectal cancer from 2006 to 2013 was performed. All patients with R1/2 resections and presence of metastases and those operated on for recurrence were excluded. Patient demographics, clinical features, operative details, LNH, 30-day mortality and disease-free and overall survival were recorded. P values of < 0.05 were considered significant.ResultsA total of 257 patients were studied, with 174 (68%) males and a median age of 66 years. Ninety-four (37%) patients received long-course NACRT, and 122 (48%) patients were stage 2 and below. Median LNH was 17, which was reduced in the NACRT group (14 versus 23, P < 0.01). Average length of stay was 9 ± 8 days, with a major post-operative complication rate of 4%. Using hazard ratio plots for the NACRT subgroup, LNH cut-offs of 16.5 and 8.5 were obtained for disease-free survival (DFS) and overall survival (OS) respectively. Survival analysis showed that a LNH cut-off of 8.5 was a significant predictor of OS (P < 0.001).ConclusionLNH is reduced in patients receiving NACRT before rectal cancer surgery. A LNH of 9 and above is associated with improved overall survival. We propose that this can be used as a tool for prognosis.

Highlights

The number of harvested lymph nodes (LN) is a wellestablished prognostic factor in patients with rectal cancer
Some studies show that lymph node harvest (LNH) has no significant correlation with recurrence or survival in neoadjuvant chemoradiotherapy (NACRT) patients [9, 12], some report that a suboptimal LNH of < 12 independently predicts
Optimal LNH cut-offs for the NACRT group As our data shows that NACRT significantly reduces LNH and that a cut-off of 12 was not applicable for this subgroup, we proceeded on to establish if there was a new optimal LNH cut-off for both disease-free survival (DFS) and overall survival (OS) in NACRT patients

Summary

Introduction

The number of harvested lymph nodes (LN) is a wellestablished prognostic factor in patients with rectal cancer. Neoadjuvant chemoradiotherapy (NACRT) is known to decrease the lymph node harvest (LNH) in the resected specimen [3,4,5]. While studies have shown that LNH is associated with recurrence and survival in rectal cancer patients who have undergone upfront surgery [6, 7], its prognostic value in patients who have received NACRT is debatable [8,9,10,11,12,13]. A lymph node harvest (LNH) of < 12 is a predictor for poor prognosis in rectal cancer patients. Neoadjuvant chemoradiotherapy (NACRT) is known to decrease LNH; a cut-off of 12 is inappropriate in such patients. This paper aims to establish a LNH cut-off predictive for disease-free and overall survival in NACRT patients

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Conclusion