Apical Node Metastasis Research Articles

Level of Inferior Mesenteric Artery Ligation in Sigmoid Colon and Rectal Cancer Surgery: Analysis of Apical Lymph Node Metastasis and Recurrence

Introduction: Whether high or low ligation of the inferior mesenteric artery (IMA) is optimal for treating sigmoid colon and rectal cancers is controversial. The present study aimed to compare outcomes of high and low ligation of the IMA and determine the adequate extent of IMA lymph node dissection. Methods: Subjects were 455 consecutive stage I–III colorectal cancer patients who underwent curative surgery between 2011 and 2019. We assessed the association between the level of IMA ligation and overall survival and recurrence-free survival (RFS) by propensity score matching analysis. Clinicopathological features of IMA lymph node metastasis and recurrence patterns were analyzed. Results: After propensity score matching, the low ligation group had a significantly worse prognosis than that of the high ligation group for RFS (p = 0.039). Positive IMA lymph nodes were associated with pathological T3 or T4 stage and N2 stage. IMA lymph node recurrences in the high ligation group occurred at the superior left side of the IMA root. In contrast, all recurrences in the low ligation group occurred at the left colic artery bifurcation. Conclusion: High ligation of IMA is oncologically safe. However, even with high ligation, care must be taken to ensure adequate lymph node dissection.

What are the problems with the current staging of discontinuous tumour nodules (DTNs) in colorectal carcinoma? Is there a better way?

Discontinuous extramural tumour nodules (DTNs) are deposits of metastatic carcinoma in soft tissue not associated with lymph nodes. Although they are established as an adverse prognostic factor in colorectal carcinoma (CRC), under the AJCC eighth edition staging system their presence does not upstage patients who also have lymph node metastases. Counterintuitively, in some situations the presence of lymph node metastases may in effect downstage a patient with DTNs from pN1c to pN1a/b. Therefore, we sought to critically assess the significance of DTNs in a large unselected single institution cohort of patients undergoing surgical resection for CRC. Of 3822 CRC patients undergoing surgical resection from 2005 to 2021, DTNs were present in 686 (18.0%). In univariate (HR=2.687, 95CI 2.355-3.065; p<0.001) and multivariate analysis (HR=1.805, 95CI 1.529-2.132; p<0.001) in a model including age, gender, stage, grade, location, lymph node ratio and apical lymph node status, DTNs were associated with worse overall survival (OS). N1c patients (DTN present but no nodal metastasis) demonstrated worse OS compared to the current pN1a group (p<0.001) and were least different to the current pN2a group (p=0.571). Within the current N1a (p=0.013), N1b (p=0.004) and N2a (p=0.002) groups, patients who also had DTNs had worse OS. DTNs were associated with worse OS for all stage III CRCs combined (p<0.001), and for stage IIIB (p<0.001) and stage IIIC (p=0.007) individually. We conclude that DTNs are an independent adverse prognostic factor that should be considered in the staging system in a way that is additional to (rather than integrated with) the number of involved lymph nodes. We then assess a simple suggestion for how this could be achieved by increasing the overall stage by one group in the presence of DTNs (requiring the creation of a new stage IIID).

The Clinical Impact of Apical Lymph Node Metastasis of Colorectal Cancer After Curative Resection.

The present study aimed to investigate the clinical implications of apical lymph node metastasis (ALNM) after curative resection of stage III colorectal cancer. A retrospective study was conducted of 1403 consecutive colorectal cancer patients who underwent surgical resection at a single institution between April 2008 and January 2020. The characteristics of ALNM, the recurrence status and the relapse-free survival (RFS) were examined. The numbers of patients with stage ≤ I, II, III, and IV disease were 350, 437, 476, and 140 patients, respectively. Among these patients with stage III disease, ALNM was seen in 21 patients (4.4% of stage III patients). Among them, curative resection was performed in 19 patients. Recurrence was observed in 68% (13/19) of the patients with ALNM who received curative resection. The first sites of recurrence included the lymph nodes 53.8% (7/13), liver 30.8% (4/13), lung 15.4% (2/13), brain 7.7% (1/13), bone 7.7% (1/13), and peritoneum 7.7% (1/13). There was no significant difference in the RFS of patients with ALNM who were managed with or without adjuvant chemotherapy (P = 0.207). Furthermore, the RFS of the group managed without adjuvant chemotherapy and the group that received adjuvant chemotherapy with/without oxaliplatin did not differ to a statistically significant extent (P = 0.318). In stage III colorectal cancer patients with ALNM, recurrence was observed significantly more frequently in comparison tostage III colorectal cancer patients without ALNM (P = 0.007). The first site of recurrence in patientswith ALNM was most frequently seen inthe distant lymph nodes (P = 0.004). Our findings suggest that ALNM is strongly associated with recurrence in thedistant lymph nodes and that it may lead to the development of systemic disease. The current regimen for stage III colorectal cancer may therefore not be sufficient for patients with stage III ALNM.

Laparoscopic segmental colectomy with extensive D3 lymph node dissection: a good choice for right transverse colon cancer

BackgroundPrevious research was yet to establish a definite operation for transverse colon cancer (TCC); surgical procedure was often dictated by the surgeon’s preference in clinical practice. The main surgical methods could be summarized in two main points: segmental colectomy (transverse colectomy) and right hemicolectomy.MethodThe first patient was a 78-year-old woman, who was diagnosed with right TCC. Computed tomography revealed a right TCC and a very long transverse colon; laparoscopic exploration revealed an enlarged apical lymph node surrounding the ileocolic vessels. We performed a segmental colectomy with extensive apical lymph node dissection along the superior mesenteric vessels and its main branches for her. To distinguish it from the previous radical operations for TCC, we called this operation a segmental colectomy with extensive D3 lymph node dissection. Then, this surgical intervention was performed on 8 other TCC patients.ResultsThe total operating time was 158 min. Pathological examination confirmed 2 apical lymph node metastases; among them, one apical lymph node metastasis was in group No.203. For all 9 patients, the median operative time was 160 min (range, 140–185 min), the average number of lymph node retrieval was 30 (range, 25–39), and the average number of apical lymph node (No.203, No.213, and No.223) retrieval was 5.9 (range, 0–11). Because of the preservation of the ileocecal junction and part of the ascending colon, all patients recovered uneventfully after surgery, and long-term diarrhea, water-electrolyte imbalance, and other Clavien–Dindo grade III or greater postoperative complications did not occur.ConclusionsOur procedure combined the advantages of segmental colectomy and right hemicolectomy and gave consideration to oncological and functional outcomes. It may be an optimal choice for TCC patients with a very long transverse colon and preoperative diagnosis of lymph node metastasis.

The prognostic significance of apical lymph node metastasis in patients with high-risk stage III colon cancer

The effect of apical lymph node (APN) metastasis on the prognosis of colon cancer is unknown. The present study investigated the impact of APN metastasis on the prognosis of the patients with high-risk stage III colon cancer. This retrospective multi-institutional study included patients with pathological high-risk stage III colon cancer who underwent surgery between April 2009 and December 2014. Clinicopathological factors were examined by univariate and multivariate analyses to clarify independent risk factors for overall survival (OS) and relapse-free survival (RFS). A total of 185 patients were collected. The 5-year OS rates of patients with and without APN metastasis were 35.0% and 72.1%, respectively (p = 0.0014). The 5-year RFS rates of patients with and without APN metastasis was 16.2% and 57.2%, respectively (p = 0.0002). The rate of distant metastasis in patients with APN metastasis was significantly higher than that in patients without APN metastasis (68.8% vs. 36.7%, p = 0.012). The univariate analysis revealed that the differentiation, lymph node ratio, and APN metastasis were significantly associated with 5-year OS, and the preoperative CEA and CA19-9 levels and APN metastasis were significantly associated with 5-year RFS. The multivariate analysis showed that APN metastasis was an independent risk factor for 5-year OS and RFS. APN metastasis may be independently associated with the prognosis of patients with high-risk Stage III colon cancer.

Chylous ascites after complete mesocolic excision for right-sided colon cancer with D3 lymphadenectomy: Aretrospective cohort-study.

This retrospective study was designed to evaluate risk factors of the occurrence and severity of chylous ascites after complete mesocolic excision (CME) and D3lymphadenectomy in patients with right-sided colon cancer. Consecutive patients receiving CME and D3lymphadenectomy for right-sided colon cancer were included. Risk factors of the occurrence and severity of chylous ascites by using logistic analysis were assessed. A nomogram predicting chylous ascites was constructed. Among 661 patients included in the study, postoperative chylous ascites occurred in 48 (7.3%) patients. Logistic regression analysis demonstrated that prognostic nutritional index (PNI≤47, OR=2.172, p=0.016), laparoscopic surgery (OR=2.798, p=0.034), operating time (>225min, OR=2.645, p=0.002), and apical lymph node (APN) metastasis (OR=3.698, p=0.034) were correlated with the occurrence of postoperative chylous ascites. A nomogram predicting postoperative chylous ascites was constructed (C-index 0.701). 31.2% (15/48) of patients with chylous ascites were resolved in more than 7days. The number of retrieved lymph nodes (OR=1.074, 95% CI: 1.002-1.152, p=0.044) and PNI≤47 (OR=7.890, 95% CI: 1.224-50.869, p=0.030) were independently predictive of prolonged chylous ascites resolution (≥7days). In our series, 7.3% of patients developed chylous ascites after right hemicolectomy with CME and D3 lymphadenectomy. Laparoscopic surgery, PNI, operation time, and APN metastasis were independently predictive of postoperative chylous ascites. Lower PNI and more retrieved lymph nodes were correlated with prolonged resolution of chylous ascites.

Prognostic value of apical lymph node metastasis at the inferior mesenteric artery in sigmoid and rectal cancer patients who undergo laparoscopic surgery.

Evidence supporting the importance of apical lymph nodes (LNs) and the potential long-term impact of LN metastases at the inferior mesenteric artery (IMA) lymphectomy remains limited. This study aimed to evaluate the prognostic value of LNs at the IMA (IMA-LN) in sigmoid and rectal cancer patients undergoing laparoscopic surgery. We retrospectively evaluated 265 consecutive patients who underwent laparoscopic sigmoid or rectal cancer surgery between August 2016 and May 2020. They were divided into two groups according to the pathological results of the IMA LNs: IMA-LN negative (n = 248) and IMA-LN positive (n = 17). The IMA-LN negative group had significantly better overall survival (OS) (p = .020) and disease-free survival (DFS) (p = .000) than did the IMA-LN positive group. IMA-LN metastasis was associated with worse OS and DFS regardless of the pN stage. Patients with IMA-LN metastasis had a higher risk of postoperative recurrence, especially liver (p = .000) and lung (p = .025) metastasis, than did those without metastasis. However, there was no significant difference in the local recurrence rate between the two groups. IMA-LN metastasis is an independent risk factor for poor prognosis in sigmoid and rectal cancer. Dissecting and evaluating IMA-LN separately is a more accurate and practical method for predicting prognosis.

The role of apical lymph node metastasis in right colon cancer.

The role of apical lymph node (APN) metastasis in colorectal cancer remains controversial. The main purpose of this study is to explore the prognostic value of APN metastasis in patients with right colon cancer. This is a retrospective study of patients with stage III right colon cancer between April 2007 and December 2016. Patients who underwent resection of right colon cancers with D3 lymph node dissection were divided into APN-positive (APN+) and APN-negative (APN-) groups according to the postoperative pathological presence or absence of APN metastasis. Relapse-free survival (RFS) and overall survival (OS) between groups were compared after Cox regression analysis and 1:1 propensity score matching (PSM). A total of 254 patients were included in this study: 28 (11.0%) were APN+ and 226 (89.0%) were APN-. Before matching, the rates of elevated carcinoembryonic antigen (CEA), T3-4 tumor invasion, and N2 lymph node metastasis were significantly higher in the APN+ group (CEA ≥ 5ng/mL, 53.6% vs. 37.6%, p < 0.001; T3-4, 92.9% vs. 85.4%, p < 0.001; N2 metastasis, 57.1% vs. 20.4%, p < 0.001), and APN+ tumors were associated with significantly higher postoperative relapse rates (39.3% vs. 21.2%; p = 0.03), especially with lung metastases (14.3% vs. 4.0%; p = 0.019), which conferred worse RFS (p = 0.013), although OS was similar (p = 0.078). However, after PSM, there were no apparent between-group differences in RFS (p = 0.29) or overall survival rate (p = 0.637). The Cox regression analysis indicated that lymphatic vessel infiltration and depth of invasion were independent risk factors for OS, while APN+ status was not a significant predictor for RFS or OS. APN metastasis was not a prognostic indicator for RFS or OS in right colon cancer. However, APN+ patients with elevated CEA levels and deeper tumor invasion should be closely monitored for lung metastasis during postoperative follow-up.

Prognostic Utility of Apical Lymph Node Metastasis in Patients With Left-sided Colorectal Cancer.

Unlike the tumor nodes metastasis (TNM) lymph node classification, based solely on counts of nodal metastases, the Japanese system of classifying colorectal carcinoma (CRC) focuses on regional lymph node spread. In this study, we explored the prognostic utility of inferior mesenteric artery (IMA) apical lymph node (APN) metastasis. This was a retrospective study of patients with stage III left-sided CRC. All enrollees were subjected to D3 resection between April 2007 and December 2016 at the International Medical Center of Saitama Medical University and then stratified by histologic presence (APN+ group) or absence (APN- group) of tumor in APNs examined postoperatively. Ultimately, propensity score matching was invoked (1:2) and COX regression analysis was conducted, determining group rates of relapse-free survival (RFS) and cancer-specific survival (CSS). A total of 498 patients were studied, grouped as APN+ (19/498, 3.8%) or APN- (479/498, 96.2%). Prior to matching, the APN+ (vs. APN-) group showed significantly more lymphatic involvement (73.7% vs. 47.8%; p=0.023), deep (T3/T4) tumor infiltration (100% vs. 78.9%; p=0.024), and nodal metastasis (N2: 84.2% vs. 27.6%; p<0.001). In addition, para-aortic nodal recurrences were significantly increased (15.7% vs. 2.0%; p<0.001), conferring worse RFS (p<0.001) and CSS (p=0.014) rates. Once baseline factors were matched, the two groups appeared similar in RFS (p=0.415) and CSS (p=0.649). Multivariate regression analysis indicated that elevated carcinoembryonic antigen (CEA) level and deep tumor infiltration were independent risk factors for RFS, whereas postoperative complications and tumor-positive node counts were independent risk factors for CSS. APN+ status was not a significant risk factor for RFS or CSS. APN positivity may thus constitute a regional rather than systemic manifestation. The TNM staging based on the number of metastatic lymph nodes seems to be more reasonable than the regional lymph node classification method.

16. Apical lymph node metastasis and survival in resected colorectal cancer

The prognostic significance of apical lymph node metastasis in colorectal cancer has been widely debated in the past. Current AJCC staging guidelines do not explicitly take this pathological variable into account but most structured reporting schemes recommend that the apical lymph node status be determined and recorded. We sought to investigate the prognostic significance of apical lymph node metastasis in colorectal carcinomas undergoing surgery with curative intent. The data from 1,374 patients used in this analysis was collected during a period of six years (2004–2009) at a large Australian tertiary hospital. For each patient where survival data was available, histopathology reports relevant to the patient's curative resection were obtained and reviewed for apical node status information. Survival analysis was performed using Kaplan-Meier method and the relationship between apical node status and total nodal involvement examined using the Mann-Whitney U test. On univariate analysis, overall survival was significantly lower in patients with apical node metastasis (mean survival: 2.4 years) compared with patients without apical node involvement (median survival: 8.3 years). After controlling for pathological stage, significantly lower survival was only observed in selected apical node positive patient groups with higher stage disease – stages 3C and 4B. A positive relationship was also observed between the total number of involved nodes and the likelihood of apical node metastasis.

Factors influencing apical node metastasis in colorectal cancer patients treated with laparoscopic radical resection with D3 lymphadenectomy: results from two centers in China.

To identify the risk factors for apical node metastasis in colorectal cancer (CRC) patients who underwent laparoscopic radical resection with D3 lymphadenectomy. The subjects were 578 consecutive patients who underwent laparoscopic radical resection with D3 lymphadenectomy for CRC between February, 2003 and December, 2009. The Cox proportional regression model was used to evaluate the association between apical node metastasis and survival and the logistic regression model was used to identify the risk factors for apical node metastasis. Thirty patients (5.2 %) had apical node metastasis, which was an independent risk factor for poor disease-free survival [hazard ratio (HR) = 3.02, P = 0.019]. Multivariate logistic regression analysis revealed that poor differentiation [odds ratio (OR) = 4.58, P < 0.001] and ulcerative/infiltrative morphology (OR = 5.57, P = 0.023) were independent risk factors for apical node metastasis. In the subgroup analysis based on pT3-4 tumors, multivariate logistic regression analysis also suggested that these factors were significantly associated with apical node metastasis. Apical node metastasis is an independent risk factor for poor oncologic outcome. T3-4 stage, poor differentiation, and ulcerative/infiltrative morphology are significantly associated with apical node metastasis. Notably, in this study, T1-2 stage tumors had no apical node metastasis, suggesting that D3 lymphadenectomy may be over-performed without considering the T stage of tumors.

Incorporation of apical lymph node status into the seventh edition of the TNM classification improves prediction of prognosis in stage III colonic cancer.

The node classification outlined in the seventh edition of the TNM classification is based solely on the number of metastasized lymph nodes. This study examined the prognostic value of apical lymph node (ALN) metastasis and the additional value of incorporating ALN status into a risk model based on the seventh edition. This was a cohort study of patients with stage III colonic cancer who underwent tumour resection with dissection of regional (including apical) lymph nodes at 71 hospitals across Japan between 2000 and 2002. The main exposure was pathologically confirmed ALN metastasis, and the primary endpoint was cancer-specific death. ALN metastasis was present in 113 (8·3 per cent) of 1355 patients. During 5356 patient-years of follow-up (median 5·0 years), 221 instances (16·3 per cent) of cancer-specific death were observed. After adjustment for tumour and node classification (as described in the seventh edition of the TNM classification) and other prognostic factors, ALN metastasis was found to be independently associated with cancer-specific death (hazard ratio 2·29, 95 per cent confidence interval (c.i.) 1·49 to 3·52). Incorporation of ALN metastasis into the prognostic model based on the seventh edition of the TNM classification significantly improved discriminative performance for cancer-specific death (difference in concordance index 0·0146, 95 per cent c.i. 0·0030 to 0·0262) and risk reclassification for cancer-specific death at 5 years (category-free net reclassification improvement 19·4 (95 per cent c.i. 5·0 to 33·4) per cent). Assessment of ALN metastasis provided independent prognostic information beyond that achievable with the seventh edition of the TNM classification in patients with stage III colonic cancer.

Significance of lymph node metastatic level in surgery for stage III colon cancer

Purpose: Lymph node metastasis is a stage-determining factor and the most important prognostic factor for colon cancer patients. We aimed to verify the influence of the aspects of lymph node metastatic level on the prognosis of the stage III colon cancer patients. Methods: We studied the survival rate of ninety-eight patients with stage III colon cancer who underwent an open and laparoscopic surgery at Eulji University Hospital from November 1998 to December 2009. We evaluated the survival rate and prognostic factors including the level of positive lymph node and additional factors. The level of positive lymph node was classified as either level I (pericolic and intermediate lymph node metastasis) or level II (apical lymph node metastasis). Results: The average age of the patients was 62.7 years (range, 30 to 89 years) old and the mean follow-up period was 45.9 months (range, 2 to 129 months). The comparison of the survival rates based on the level of lymph nodes shows that level I was 89.5% while level II was 41.7% (P=0.002). Multivariate analysis showed that level of positive lymph node was a significant prognostic factor. Conclusion: In this study, the level of lymph node metastasis in stage III colon cancer was significant prognostic factor. Therefore, exact evaluation and further treatment plans should be determined based on clear analysis of various aspects of the lymph nodes acquired by accurate and meticulous surgery. Keywords: Colon cancer, Lymph node, Survival rate, Prognosis

Prognostic significance of apical lymph node metastasis in patients with node‐positive rectal cancer

The aim of this study was to assess the effect of apical lymph node (APN) metastasis in predicting prognosis in curatively treated node-positive rectal cancer. We also investigated the relationship between APN metastasis and the total number of metastatic lymph nodes. A retrospective study was performed of 510 curatively treated patients with node-positive rectal cancer. Clinicopathological variables, including APN status, were assessed in univariate and multivariate analyses. The prognostic significance of APN status in predicting patient outcomes and the relationship between APN status and American Joint Committee on Cancer (AJCC) N stage were analysed. At a median follow up of 47 months, the 5-year local recurrence (LR) rate, the disease-free survival (DFS) rate and the overall survival (OS) rate were 18.3%, 55.5% and 58.8%, respectively. The 5-year OS rate was 69.6% for patients with no metastasis in APNs (APN(-)) and 40.8% for patients with metastasis in APNs (APN(+)). DFS and OS for patients with undetermined APN status were between those for APN(-) and APN(+). Subgroup analysis gave a 5-year OS rate of 48.7% in Stage N1 patients with APN(+) and 58.8% for Stage N2 patients with APN(-) (P = 0.0004). APN metastasis is an important prognostic factor in node-positive rectal cancer, which provides additional survival-related prognostic classification irrespective of N stage. As the APN is usually outside the radiation field, in the era of multidisciplinary treatment its assessment should be incorporated into prognostic evaluation of rectal cancer.

Apical-node metastasis in sigmoid colon or rectal cancer: is it a factor that indicates a poor prognosis after high ligation?

The prognostic significance of apical-node metastasis around the inferior mesenteric artery (IMA) remains unclear. We investigated the oncological relevance of apical-node metastasis detected after high ligation of the IMA in stage III sigmoid colon or rectal cancer. Between May 2003 and December 2007, 229 consecutive patients with stage III sigmoid colon or rectal cancer, who had undergone curative resection with high ligation, were analyzed. Cox proportional regression model was used to identify the prognostic factors for disease-free survival. Thirty-one patients (13.5%) had apical-node metastases: 0% with T0-1, 3.8% with T2, 11.5% with T3, and 29.3% with T4 disease (p = 0.017). Additionally, the factors related to apical-node metastasis were tumor size, number of metastatic lymph nodes, lymph-node ratio, and N-stage. Multivariate analysis showed that the lymph-node ratio (odds ratio (OR) = 40.53, 95% confidence interval (CI) = 8.41-195.22, p < 0.001) was an independent prognostic factor for disease-free survival but that apical-node metastasis was not a factor that predicted a poor outcome (OR = 1.53, 95% CI = 0.81-2.91, p = 0.192). Apical-node metastasis was not a prognostic factor for disease-free survival on multivariate analysis of the subgroups based on tumor location (sigmoid colon cancer: OR = 1.42, 95% CI = 0.42-1.82, p = 0.577; rectal cancer: OR = 1.82, 95% CI = 0.82-4.06, p = 0.141). This study suggests that apical-node metastasis is not a poor prognostic factor for stage III sigmoid colon or rectal cancer after high ligation.

Apical node metastasis independently predicts poor survival in Dukes C colorectal cancer

The prognostic significance of apical node metastasis in node-positive colorectal cancer (CRC) is disregarded by the Fourth American Joint Committee on Cancer and the International Union Against Cancer (AJCC/UICC) TNM classification system. The influence of apical node metastases on overall 5-year survival among patients with Dukes stage C CRC was examined. Patients who underwent operative resection for CRC between 1999 and 2003 were reviewed. Two-hundred and ninety patients were included in the study, including 203 with Dukes C apical node-negative cancers, 39 with Dukes C apical node-positive cancers and 48 with Dukes D cancers. The respective prevalence of extramural vascular invasion was 35%vs 64%vs 56% (P = 0.0005), T4-stage 24%vs 38%vs 48% (P = 0.013), positive resection margin 16%vs 41%vs 23% (P = 0.001), more than three positive nodes harvested 28%vs 85%vs 52% (P < 0.0001) and poorer tumour differentiation grade 9%vs 21%vs 23% (P = 0.009). Multivariate analyses of all Dukes C cancer patients (n = 242) showed a positive apical node to be a highly significant independent predictor of mortality (hazard ratio 2.281, 95% confidence interval 1.421-3.662, P = 0.0006). Extramural vascular invasion and a positive resection margin were also independent predictors of poor survival. Patients with Dukes C apical node-positive cancers had a significantly poorer overall 5-year survival compared to patients with Dukes C apical node-negative cancers (P < 0.0001) but survival was not significantly different compared to patients with distant metastases at initial presentation (P = 0.504). Apical node metastasis appears to be a strong independent, negative prognostic factor of poor survival in Dukes C CRC.

Adjuvant chemotherapy for stage C colonic cancer in a multidisciplinary setting

In this study of patients undergoing adjuvant chemotherapy for clinicopathological stage C colonic cancer after optimal surgery, the aims were: to describe their immediate experience of chemotherapy, to assess disease-free survival, to compare overall survival with that of a matched untreated historical control group, and to evaluate the associations between previously identified adverse risk factors and survival. Data were drawn from a comprehensive, prospective hospital registry of resections for colorectal cancer between 1971 and 2004, with retrospective data on adjuvant chemotherapy. The main end point was overall survival. Statistical analysis employed the chi-squared test, Kaplan-Meier estimation and proportional hazards regression. From May 1992 to December 2004, there were 104 patients who received adjuvant chemotherapy. Duration of treatment, withdrawal from treatment, toxicity and other immediate treatment outcomes were similar to those in other equivalent studies. There were no toxicity-associated deaths. Overall survival was significantly longer in the treated patients than in the control group (3-year rates 81% and 66%, respectively, P = 0.009). A significant protective effect of adjuvant therapy was found (hazard ratio 0.5, 95% confidence interval 0.3-0.8, P = 0.001) after adjustment for histopathology features previously shown to be negatively associated with survival (high grade, venous invasion, apical node metastasis, free serosal surface involvement). For patients who have had a curative resection for lymph node positive colonic cancer in a specialist colorectal surgical unit and been managed by a multidisciplinary team, post-operative adjuvant chemotherapy is safe and provides the same survival advantage as seen in randomized trials.

What pathologic features influence survival in patients with local residual tumor after resection of colorectal cancer?

Local residual tumor predicts poor patient survival after resection for colorectal cancer. The aim of this study was to determine the prevalence of residual tumor in a line of resection in a large prospective series and to identify other pathology variables that may influence survival in the absence of distant metastases in such patients. This study was based on all patients who had a resection for colorectal cancer at Concord Hospital between 1971 and 2001. Patients were followed up annually until death or December 2002. Survival analysis used the Kaplan-Meier method and log rank test. Proportional hazards regression was used in multivariate modeling. The overall prevalence of residual tumor in a line of resection was 5.9%. Of 12 pathology variables examined, only high grade and apical node metastasis were independently associated with survival in the subset of 120 patients with residual tumor in a line of resection but without distant metastases. The 2-year survival rate for patients with neither of these adverse features was 46.4% (95% CI, 31.7% to 59.9%) as compared with only 7.7% (CI, 0.5% to 29.2%) in those who had both. These results show that presence of local residual tumor after colorectal cancer resection does not carry a universally poor prognosis. Two specific histopathologic features independently associated with diminished survival were identified.

Anastomotic Leakage Is Predictive of Diminished Survival After Potentially Curative Resection for Colorectal Cancer

The aim of this study was to determine whether anastomotic leakage has an independent association with overall survival and cancer-specific survival. There are many known prognostic indicators following surgery for colorectal cancer (CRC). However, the impact of anastomotic leakage has not been adequately assessed. Consecutive patients undergoing resection between 1971 and 1999 were recorded prospectively in the Concord Hospital CRC database. Total anastomotic leakage was defined as any leak, whether local, general, or radiologically diagnosed. Patients were followed until death or to December 31, 2002. The association between anastomotic leakage and both overall survival and cancer-specific survival was examined by proportional hazards regression with adjustment for other patient and tumor characteristics influencing survival. Confidence intervals (CI) were set at the 95% level. From an initial 2980 patients, 1722 remained after exclusions. The total leak rate was 5.1% (CI 4.1-6.2%). In patients with a leak, the 5-year overall survival rate was 44.3% (CI 33.5-54.6%) compared to 64.0% (CI 61.5-66.3%) in those without leak. In proportional hazards regression-after adjustment for age, gender, urgent resection, site, size, stage, grade, venous invasion, apical node metastasis and serosal surface involvement-anastomotic leakage had an independent negative association with overall survival (hazard ratio [HR] 1.6, CI 1.2-2.0) and cancer-specific survival (HR 1.8, CI 1.2-2.6). Apart from its immediate clinical consequences, anastomotic leakage also has an independent negative association with survival.

Adverse histopathological findings as a guide to patient management after curative resection of node-positive colonic cancer.

The aim of this study was to identify patient and tumour characteristics that might assist in developing an improved approach to patient selection for chemotherapy after resection of clinicopathological stage C colonic cancer. Clinical, pathological and follow-up data have been collected prospectively for all patients undergoing resection for colorectal cancer at Concord Hospital since 1971. From an initial 2980 patients, after exclusions 378 remained who had a potentially curative operation for colonic cancer with nodal metastases and did not receive adjuvant chemotherapy. Associations between several pathological features and survival were examined by proportional hazards regression. In a multivariate model, both overall and colonic cancer-specific survival rates were negatively associated with serosal surface involvement, apical node metastasis, high histological grade and venous invasion. The survival of patients with stage C disease who had none of these adverse features was not significantly different from that of patients with stage B lesions. However, survival diminished significantly when one or more of the adverse features were present. Patients with a stage C tumour but with none of the identified adverse features experience relatively good survival and are unlikely to benefit from adjuvant chemotherapy. In this series such patients accounted for 40.5 per cent of patients with stage C disease.