Lymph Node Recovery Research Articles

Contributing factors to lymph node recovery with esophagectomy by thoracic surgeons: an analysis of the Society of Thoracic Surgeons General Thoracic Surgery Database.

Given the association between lymphadenectomy and survival after esophagectomy, and the ongoing development of effective adjuvant protocols for identified residual disease, we determined factors contributing to lymph node yield and effects on postoperative morbidity following esophagectomy by thoracic surgeons. Using the Society of Thoracic Surgeons General Thoracic Surgery Database, all patients who underwent esophagectomy for primary esophageal cancer with gastric conduit reconstruction from 2012 to 2016 were identified. Patient demographics, technical factors, and tumor characteristics associated with lymph node yield were determined using a multivariable multilevel mixed-effects regression model. Associations between lymph node yield and perioperative morbidity and mortality were similarly assessed. A total of 8480 patients were included. The median number of nodes harvested was 16 [Interquartile Range 11-22]. Factors associated with fewer nodes included female gender (b=-0.53, P=0.032), body mass index <18.5 (b=-1.46, P=0.012), prior cardiothoracic surgery (b=-0.73, P=0.015), intraoperative blood transfusion (b=-1.43, P<0.001), squamous cell histology (b=-0.86, P=0.006), and neoadjuvant treatment (b=-1.41, P<0.001). Operative approach significantly affected lymph node yield, with minimally invasive approaches demonstrating higher lymph node counts, and open transhiatal esophagectomy recovering the fewest nodes. Findings were independent of clinical center. There was no association of higher lymph node yield with 30-day mortality, with only slightly increased risk for chyle leak (odds ratio [OR] 1.02, P=0.012). In conclusion, several patient and tumor factors affect lymph node recovery with esophagectomy, independent of hospital center. Technical aspects, specifically minimally invasive approach, play a significant role in quantified lymph node yield. Higher operative lymph node yield was associated with minimal increased morbidity.

Role of endoscopic tumor tattooing in improving lymph node retrieval of colorectal cancer

Background and study aims Adequate lymphadenectomy is crucial to ensure accuracy in staging and treatment of colorectal cancer. Endoscopic preoperative tattooing to mark the location of the tumor has recently been proposed to promote the recovery of lymph nodes in colorectal specimens. The purpose of the study was to evaluate the role of preoperative endoscopic tumor tattooing in improving the retrieval of lymph nodes in colorectal resections. Patients and methods The study was conducted on 100 candidates randomized into two groups. The first group included 50 patients who were injected with black eye dye by colonoscopy done 3–10 days before surgery (tattooed group), and the 50 other patients in the second group (control group) did not have preoperative tattooing. All patients underwent the standard resection under National Comprehensive Cancer Network Colorectal Cancers Guideline. Results The tattooed group showed higher number of lymph nodes retrieved compared with the control group in colon cases and rectum cases. In eight cases, among the patients included in our study, extra-anatomical lymph nodes (outside the standard resection margins) were detected stained. Of these eight cases, two showed malignant deposits. Conclusion Preoperative endoscopic tattooing of colorectal cancers is a safe and easy technique, which proved to have a benefit in improving lymph node retrieval for resected specimens of colorectal cancers either in obese or nonobese patients and also whether they had received or not a preoperative neoadjuvant therapy. There is a connection between lymphatics draining different parts of the colon, as proved by the presence of tattooed lymph nodes outside the standard resection margins. Its clinical significance needs more studies on a larger sample size.

Variability in multimodality treatment influences survival in non-metastatic gastric cancer patients.

While gastric cancer is a leading cause of cancer-related mortality in Eastern Europe and Asia, it is less common in the USA. Recommendations regarding optimal treatment of non-metastatic gastric cancer (nmGC) with regard to type and extent of surgery, choice and sequence of chemotherapeutic agents, and use of radiation therapy vary across geographic locations. To determine how variability in treatment practices affects patient outcomes, we conducted a retrospective study to evaluate clinical outcomes in nmGC patients treated at four high-volume academic institutions. California Cancer Registry data were collected for nmGC patients who underwent gastrectomy with curative intent from 2010 to 2018. We conducted chart reviews of the patients' electronic health records to validate clinical factors and outcomes. We performed multivariable Cox regressions to determine prognostic factors for outcomes. Demographics of study cohort (n=326): mean age 66 years; 64% male; 44% Caucasian, 35% Asian, 16% Latino. Tumor stage: 48% loco-regional (pT4 or pN1+) vs. 52% localized (pT1-3, pN0). Histology: 47% intestinal, 30% diffuse, 8% mixed, 15% unknown. Surgery: 34% open gastrectomy, 48% laparoscopic, 18% unknown; number of recovered lymph nodes varied from 0 to 60 in any tumor stage. Chemotherapy: 20% neoadjuvant alone, 25% adjuvant alone, 16% perioperative, 39% none. Multimodality therapy: 44% surgery only, 31% chemotherapy, 25% chemotherapy and radiation. With a median post-surgical follow-up of 6 years, 24% of patients developed recurrence and 40% had died. Compared to open surgery, laparoscopic surgeries were associated with fewer recovered lymph nodes (mean =18 vs. 25, P=0.0042). Fewer recovered lymph nodes were associated with a significant decrease in 5-year overall survival [hazard ratio (HR) =1.9, 95% confidence interval (CI): 1.3-2.8]. Timing of chemotherapy and addition of radiation therapy to chemotherapy did not confer further improvements in survival; in contrast, greater lymph node recovery plus chemotherapy were associated with a significant increase in survival (HR =0.3, 95% CI: 0.1-0.6). This study highlights major practice differences in the management of nmGC patients across providers and institutions. Further efforts should be made to standardize the use of chemotherapy and adequate recovery and assessment of lymph nodes in this patient population.

Variability in multimodality treatment influences survival in non-metastatic gastric cancer patients.

e16588 Background: While gastric cancer is a leading cause of cancer-related mortality in Eastern Europe and Asia, it is less common in the United States. Recommendations regarding optimal treatment of non-metastatic gastric cancer (nmGC) with regard to type and extent of surgery, choice and sequence of chemotherapeutic agents, and use of radiation therapy vary somewhat depending on geographic location. To determine how variability in treatment practices affects patient outcomes, we conducted a retrospective study to evaluate clinical outcomes in nmGC patients treated at four high-volume academic institutions. Methods: California Cancer Registry of demographic and clinical data were collected for nmGC patients who underwent surgery with curative intent from 2010-2018. We conducted chart reviews of the patients’ electronic health records to validate clinical factors and outcomes. We performed multivariable Cox regressions to determine prognostic factors for outcomes. Results: Demographics of study cohort (n = 326): mean age 66 years; 64% male; 44% Caucasian, 35% Asian, 16% Latino. Tumor stage: 48% loco-regional (pT4 or pN1+) versus 52% localized (pT1-3, pN0). Histology: 47% intestinal, 30% diffuse, 8% mixed, 15% unknown. Surgery: number of recovered lymph nodes varied from 0 to 60 in any tumor stage. Chemotherapy: 20% neoadjuvant, 25% adjuvant, 16% perioperative, 39% none. Multimodality therapy: 44% surgery only, 31% chemotherapy, 25% chemotherapy and radiation. With a median follow-up after surgery of 6 years, 24% of patients developed recurrence and 40% had died. Compared to open surgery, laparoscopic surgeries was associated with lower lymph node recovery (median = 15 vs 19, p = .0042), which in turn was associated with a significant decrease in overall 5-year survival after adjusted for tumor stage (hazard ratio HR = 1.9, p = .0012). Timing of chemotherapy and addition of radiation therapy to chemotherapy did not confer further improvements in survival. In contrast, greater lymph node recovery plus chemotherapy were associated with improved survival in patients with loco-regional tumors (HR = 0.3, p = .0020). Conclusions: This study highlights major practice differences in the management of nmGC across providers and institutions. Further efforts should be made to standardize the use of chemotherapy and adequate recovery and assessment of lymph nodes in this patient population.

Reoperative central lymph node dissection for incidental papillary thyroid cancer can be performed safely: A retrospective review

BackgroundThis study compares the pathological outcomes and operative morbidity for papillary thyroid cancer (PTC) patients undergoing a primary total thyroidectomy (TT) with central lymph node dissection (CLND), to those undergoing an interval CLND following a previous thyroid operation, or for the unsuspected diagnosis of PTC. MethodsSingle-institution, retrospective review of PTC patients from 2000 to 2015 was performed. Three treatment groups were identified: primary TT/CLND, interval prophylactic CLND, and interval therapeutic CLND. Primary outcome measures were number of lymph nodes removed, hypoparathyroidism and recurrent laryngeal nerve (RLN) injury. ResultsResults for 30 prophylactic and 35 therapeutic interval CLND were compared with 218 patients undergoing primary TT/CLND. Interval CLND was associated with similar rates of cervical metastases, complications, and a trend towards decreased lymph node recovery. ConclusionReoperative CLND for incidental PTC frequently identifies cervical lymph node metastases, potentially reduces recurrence, and can be performed with similar morbidity to a primary lymphadenectomy.

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

Increased lymph node count (LNC) has been associated with prolonged survival in colorectal cancer (CRC), but the underlying mechanisms are still poorly understood. The study aims to identify new predictors and develop a preoperative nomogram for predicting the probability of adequate LNC (≥ 12). 501 eligible patients were retrospectively selected to identify clinical-pathological factors associated with LNC ≥ 12 through univariate and multivariate logistic regression analyses. The nomogram was built according to multivariate analyses of preoperative factors. Model performance was assessed with concordance index (c-index) and area under the receiver operating characteristic curve (AUC), followed by internal validation and calibration using 1000-resample bootstrapping. Clinical validity of the nomogram and LNC impact on stage migration were also evaluated. Multivariate analyses showed patient age, CA19-9, circulating lymphocytes, neutrophils, platelets, tumor diameter, histology and deposit significantly correlated with LNC (P < 0.05). The effects were marginal for CEA, anemia and CRC location (0.05 < P < 0.1). The multivariate analyses of preoperative factors suggested decreased age, CEA, CA19-9, neutrophils, proximal location, and increased platelets and diameter were significantly associated with increased probability of LNC ≥ 12 (P < 0.05). The nomogram achieved c-indexes of 0.75 and 0.73 before and after correction for overfitting. The AUC was 0.75 (95% CI, 0.70–0.79) and the clinically valid threshold probabilities were between 10% and 60% for the nomogram to predict LNC < 12. Additionally, increased probability of adequate LNC before surgery was associated with increased LNC and negative lymph nodes rather than increased positive lymph nodes, lymph node ratio, pN stages or AJCC stages. Collectively, the results indicate the LNC is multifactorial and irrelevant to stage migration. The significant correlations with preoperative circulating markers may provide new explanations for LNC-related survival advantage which is reflected by the implication of regional and systemic antitumor immune responses.

Assessment of lymph node involvement in colorectal cancer.

Lymph node metastasis informs prognosis and is a key factor in deciding further management, particularly adjuvant chemotherapy. It is core to all contemporary staging systems, including the widely used tumor node metastasis staging system. Patients with node-negative disease have 5-year survival rates of 70%-80%, implying a significant minority of patients with occult lymph node metastases will succumb to disease recurrence. Enhanced staging techniques may help to identify this subset of patients, who might benefit from further treatment. Obtaining adequate numbers of lymph nodes is essential for accurate staging. Lymph node yields are affected by numerous factors, many inherent to the patient and the tumour, but others related to surgical and histopathological practice. Good lymph node recovery relies on close collaboration between surgeon and pathologist. The optimal extent of surgical resection remains a subject of debate. Extended lymphadenectomy, extra-mesenteric lymph node dissection, high arterial ligation and complete mesocolic excision are amongst the surgical techniques with plausible oncological bases, but which are not supported by the highest levels of evidence. With further development and refinement, intra-operative lymphatic mapping and sentinel lymph node biopsy may provide a guide to the optimum extent of lymphadenectomy, but in its present form, it is beset by false negatives, skip lesions and failures to identify a sentinel node. Once resected, histopathological assessment of the surgical specimen can be improved by thorough dissection techniques, step-sectioning of tissue blocks and immunohistochemistry. More recently, molecular methods have been employed. In this review, we consider the numerous factors that affect lymph node yields, including the impact of the surgical and histopathological techniques. Potential future strategies, including the use of evolving technologies, are also discussed.

Lymph node dissection in resectable perihilar cholangiocarcinoma: a systematic review

BackgroundPerihilar cholangiocarcinoma is usually unresectable at the time of diagnosis. Only few patients are candidates for a potential curative treatment. For those patients, prognosis is strongly related to negative resection margin and lymph node status. Thus, a certain benchmark of lymph node count is necessary to secure relevant lymph node recovery and to avoid understaging. However, the required minimum number of retrieved lymph nodes remains unclear for perihilar cholangiocarcinoma. The 7th American Joint Committee on Cancer tumor, nodes, metastases edition increased the requirement for the histologic examination of lymph nodes in perihilar cholangiocarcinoma patients from 3 to 15. The applicability of such recommendation appears difficult and questionable. Therefore, the purpose of this systematic review is to evaluate the number of retrieved lymph nodes for staging of patients undergoing surgery for perihilar cholangiocarcinoma. MethodsThe MEDLINE, EMBASE, and The Cochrane Library databases were systematically screened up to December 2014. All studies reporting the number of lymph node count in perihilar cholangiocarcinoma were included and assessed for eligibility. ResultsA total of 725 abstracts were screened and 20 studies were included for analysis, comprising almost 4,000 patients. The cumulative median lymph node count was 7 (2 to 24). A median lymph node count greater than or equal to 15 was reported in 9% of perihilar cholangiocarcinoma patients and could only be achieved in extended lymphadenectomy. Subgroup analysis revealed a median lymph node count of 7 (range 7 to 9), which was associated with the detection of most lymph node positive patients and showed the lowest risk for understaging patients. Lymph node count greater than or equal to 15 did not increase detection rate of lymph node positive patients. ConclusionsThis systematic analysis suggests that lymph node count greater than or equal to 7 is adequate for prognostic staging, while lymph node count greater than or equal to 15 does not improve detection of patients with positive lymph nodes.

PEGylated polylysine dendrimers increase lymphatic exposure to doxorubicin when compared to PEGylated liposomal and solution formulations of doxorubicin

Improved delivery of chemotherapeutic drugs to the lymphatic system has the potential to augment outcomes for cancer therapy by enhancing activity against lymph node metastases. Uptake of small molecule chemotherapeutics into the lymphatic system, however, is limited. Nano-sized drug carriers have the potential to promote access to the lymphatics, but to this point, this has not been examined in detail. The current study therefore evaluated the lymphatic exposure of doxorubicin after subcutaneous and intravenous administration as a simple solution formulation or when formulated as a doxorubicin loaded PEGylated poly-lysine dendrimer (hydrodynamic diameter 12nm), a PEGylated liposome (100nm) and various pluronic micellar formulations (~5nm) to thoracic lymph duct cannulated rats. Plasma and lymph pharmacokinetics were analysed by compartmental pharmacokinetic modelling in S-ADAPT, and Berkeley Madonna software was used to predict the lymphatic exposure of doxorubicin over an extended period of time. The micelle formulations displayed poor in vivo stability, resulting in doxorubicin profiles that were similar to that observed after administration of the doxorubicin solution formulation. In contrast, the dendrimer formulation significantly increased the recovery of doxorubicin in the thoracic lymph after both intravenous and subcutaneous dosing when compared to the solution or micellar formulation. Dendrimer-doxorubicin also resulted in increases in lymphatic doxorubicin concentrations when compared to the liposome formulation, although liposomal doxorubicin did increase lymphatic transport when compared to the solution formulation. Specifically, the dendrimer formulation increased the recovery of doxorubicin in the lymph up to 30h post dose by up to 685 fold and 3.7 fold when compared to the solution and liposomal formulations respectively. Using the compartmental model to predict lymphatic exposure to longer time periods suggested that doxorubicin exposure to the lymphatic system would ultimately be 9796 times and 6.1 times greater after administration of dendrimer doxorubicin when compared to the solution and liposome formulations respectively. The recovery of doxorubicin in the sentinel lymph nodes draining the subcutaneous injection site was also quantified directly, and consistent with the lymph pharmacokinetic data, lymph node recovery was greatest for the dendrimer formulation (12% of dosed doxorubicin/g node) when compared to the liposome (1.4%/g node) and solution (<1%/g node) formulations. The data suggest that dendrimer-based drug delivery systems have the potential to enhance drug exposure to lymph-based drug targets such as lymphatic metastases.

Variables Impacting Lymph Node Recovery in Colectomy Resection Specimens Removed for Colorectal Adenocarcinoma

Background: Recent data suggest that a higher number of nodes evaluated in colectomy specimens for colorectal adenocarcinoma is associated with increased survival. Recommendations mandate the harvesting of at least 12 nodes in colectomy specimens for adequate assessment. Recent studies argue that the above association is complex and is uncontrolled for a variety of variables. Objective: The study's objective is to evaluate several factors that impact the harvesting of lymph nodes in colectomy

Adequate lymph node recovery improves survival in colorectal cancer patients

Current recommendations suggest recovery of 12 lymph nodes during surgical resection for colorectal cancer (CRC) for proper staging and prognostication. Adequate lymph node recovery has been associated with improved patient survival, with results inconsistent. We examined factors for association with adequate lymph node recovery and used findings to adjust survival analyses to clarify whether adequate lymph node examination is associated with CRC survival or associated with a subset of characteristics that biases lymph node recovery. In 74% of subjects (1,036/1,397) an adequate number of lymph nodes was examined. A stepwise multivariate regression analysis showed procedure year, cancer stage, tumor size, and age at diagnosis were significantly associated with lymph node recovery. These and other factors associated with survival status were adjusted for in further analyses, revealing no difference in unadjusted overall survival by adequacy of lymph node recovery (HR = 0.90, 95% CI: 0.75-1.08, P = 0.239). However, in adjusted Cox proportional hazards analysis, adequate lymph node recovery was associated with reduced risk for death (HR = 0.71, 95% CI: 0.57-0.89, P = 0.002). The current recommendation for retrieval and examination of at least 12 lymph nodes is appropriate for proper treatment and prognostication in patients undergoing surgical resection for CRC.

Does body mass index impact the number of LNs harvested and influence long-term survival rate in patients with stage III colon cancer?

The aim of this study is to evaluate whether different body mass index (BMI) values affect lymph node (LN) retrieval and whether such variations influence long-term survival in Asian patients. From January 1995 to July 2003, 645 stage III colon cancer patients were enrolled in our study. Patients were stratified into four groups: Obese (BMI ≧ 27 kg/m(2)), overweight (24 ≤ BMI < 27 kg/m(2)), normal (18.5 ≤ BMI < 24 kg/m(2)), and underweight (BMI < 18.5 kg/m(2)). Mean BMI in the cohort was 23.3kg/m(2). Mean number of LNs harvested was 23.1, 19.5, 19.8 and 28.1 in the normal, overweight, obese and underweight groups, respectively. There was a significant difference in the mean number of LNs harvested when comparing the overweight and underweight groups to the normal group (p = 0.013 and p = 0.04, respectively). Females were overrepresented in the underweight group (p = 0.011), and patients who had proximal colon cancers were more frequently underweight (p = 0.018). The mean number of LNs harvested varied by cases of right hemicolectomy (p = 0.009) and proximal cancer location (p = 0.009) for different BMI groups. Multivariate analysis showed that underweight, proximal colon cancer, well- or moderately differentiated adenocarcinoma and stage IIIC cancer were significant variables for adequate LN recovery. BMI was not significantly associated with relapse-free survival (p = 0.523) or overall survival (p = 0.127). BMI is associated with LN harvest but is not an independent variable in stage III colon cancer survival.

Postoperative intra‐arterial methylene blue injection of colorectal cancer specimens increases the number of lymph nodes recovered

To determine the possible advantage of intra-arterial injection of methylene blue with a view to improving lymph node recovery in postoperative examination of colorectal cancer specimens. Thirty-two colorectal cancer specimens were assigned randomly to either dissection with intra-arterial methylene blue injection or to routine dissection (without methylene blue injection). Immediately postoperatively, the specimens in the staining group were injected intra-arterially with methylene blue dye. The two procedures were compared with respect to the number of lymph nodes recovered. The number of recovered lymph nodes was significantly higher in the intra-arterial methylene blue injection group than in the group investigated with routine procedures (P<0.0001). The intra-arterial methylene blue injection method is fairly easy to use postoperatively and increases significantly the number of lymph nodes recovered in colorectal cancer specimens.

Lymph Node Harvesting in Colorectal Carcinoma Specimens

Adequate lymph node evaluation is an important determinant of prognosis in patients with colorectal cancer. Current guidelines recommend evaluation of at least 12 lymph nodes; however, a significant number of patients fail to meet these criteria. To investigate the factors that influence adequate recovery and evaluation of lymph nodes in colorectal cancer. We retrospectively analyzed 454 consecutive cases of colorectal cancer surgically treated from September 2000 to September 2006. Univariate and multivariate linear and logistic regression analysis was used to study the effect of various factors in lymph node recovery. The number of lymph nodes retrieved ranged from 0 to 62 with a median of 13 nodes. Overall, 189 (41.6%) patients had fewer than 12 nodes removed. Patient age, tumor stage, location and size were associated with lymph node retrieval. Multivariable regression revealed that the aforementioned variables, including gender and hospital type, explained 17% of the observed variance of the lymph node number. Patient and tumor characteristics, although important, are only partly responsible for the variation of lymph node yield. Quality of surgical resection and/or the thoroughness of examination of the tissue by the pathologist might explain the wider proportion of this variance. Training in colorectal node evaluation could help to improve the quality of cancer care.

Does obesity impact lymph node retrieval in colon cancer surgery?

Background Evaluation of lymph nodes is important for the optimal treatment of colon adenocarcinoma. Few studies have assessed whether lymph node harvest is compromised by obesity. We hypothesized that lymph node retrieval in colon cancer resection would be reduced in obese patients. Methods Patients undergoing resection for colon adenocarcinoma diagnosed from 2000 to 2007 were reviewed retrospectively and stratified by body mass index (BMI). Lymph node harvest was evaluated. Results A total of 401 patients were included. Their mean age was 72.8 years, and 44% were men. Their mean BMI was 28.2 kg/m 2. Mean lymph node recovery among BMI groups was as follows: BMI less than 18.5 was 20.6; BMI of 18.5 to 24.9 was 25.1; BMI of 25 to 29.9 was 23.1; BMI of 30 to 34.9 was 22.4; BMI of 35 to 39.9 was 19.0; and BMI of 40 or greater was 21.1 nodes ( P = .321). Surgical time increased with increasing BMI ( P = .005). Adequacy of node harvest differed by stage ( P = .007), left-sided versus right-sided resections ( P = .001), and pathology technician ( P = .001). Conclusions Lymph node retrieval was not affected by BMI.

Multimodal salvage therapy for locally recurrent and re-recurrent rectal cancer.

3647 Background: Radical salvage surgery offers the only chance of potential cure for locally recurrent rectal cancer (LRRC). We examined predictors of outcome after multimodality salvage for LRRC and determined outcomes after secondary failure. Methods: A retrospective consecutive cohort study of patients (pts) undergoing surgical salvage for LRRC between 1988 and 2008 was conducted. Only pts who underwent radical resection for their primary rectal tumors were included. Cox regression analysis was performed to evaluate survival outcomes. Results: A total of 171 pts were identified. Median age was 59 years (interquartile range [IQR] 47-67); 97 pts (57%) were male. Salvage for LRRC required repeat rectal resection in 80 (47%), exenteration in 63 (37%), and radical pelvic tumor excision in 28 (16%) pts. Bone resection was needed in 50 (29%). The rate of R0 resection was 79%. Radiation was used in 109 (67%) prior to salvage, including 43 (47%) who had received prior pelvic radiation. Intraoperative radiotherapy was given to 57 (33%) and postoperative chemotherapy, to 48 (28%). At 5 years, overall survival (OS) was 42% and recurrence-free survival was 30%. Secondary failure occurred in 94 (55%) after a median interval of 11 months from salvage operation. The site of first failure was local only in 44 (25%), distant only in 33 (19%), both in 5 (3%). Second operative salvage was undertaken in 26 (28%) pts, including repeat pelvic resection in 21 (81%). Other treatments included chemotherapy, reirradiation, and brachytherapy. The 5-year OS with secondary failure was 37% (vs. 50% without failure; p = 0.036), but pts who underwent repeat salvage operation had significantly higher OS than those who did not: 46 vs. 33% (p = 0.049). In multivariate analysis, independent predictors of improved OS included: R0 resection margin status (p = 0.01) and recovery of lymph nodes during salvage surgery (p = 0.027). Conclusions: Prolonged survival and local control can be achieved by multimodality salvage therapy for LRRC. Repeat salvage after secondary failure is appropriate in select patients. Finding residual lymph nodes at salvage operation may suggest incomplete mesorectal resection at primary rectal cancer resection which correlated with improved salvageability. No significant financial relationships to disclose.

Small Bowel Adenocarcinoma: Understaged and Undertreated?

Primary small bowel adenocarcinoma (SBA) is a rare, chemoresistant tumor with an aggressive clinical nature. Surgery is the mainstay of therapy, but the extent of lymph node (LN) recovery necessary for optimal care of jejunoileal SBA is unknown. The SEER database was queried to identify patients whose primary jejunoileal SBA was diagnosed between 1995 and 2005. Patients were grouped by AJCC stage and number of LNs recovered from the surgical specimen. Of 1444 patients with primary SBA, 93 (6.4%), 529 (36.6%), 356 (24.7%), and 466 (32.3%) were initially diagnosed with stage I, II, III, and IV disease, respectively. Five-year overall survival (OS) rate was 59.8%, 39.5%, 27.0%, and 3.2% for patients with stage I, II, III, and IV SBA, respectively. When≥10 nodes were recovered, OS rate increased nonsignificantly in stage I (73.2% vs. 55.6%) and significantly in stage II (61.8% vs. 32.9%, P<.001) but was unchanged in stage III (27.4% vs. 27.3%, P=.13). Recovery of≥10 nodes occurred in 26.9%, 23.6%, and 42.1% of patients with stage I, II, and III SBA, respectively. Multivariate analysis identified age, AJCC stage, site of primary tumor, recovery of≥10 LNs, and number of positive nodes as significant for OS. We have found SBA staging is largely inadequate. Our results suggest recovery of≥10 LNs ensures accurate staging. Improvement in stage II SBA OS after adequate LN may reflect a high degree of understaging in this dataset rather than a therapeutic effect of LAD.

Introduction of laparoscopic low anterior resection for rectal cancer early during residency: a single institutional study on short-term outcomes

Laparoscopic surgery for rectal cancer is unpopular because it is technically challenging. Suitable training systems have not been widely studied or established despite the steep learning curve for this procedure. We developed a systematic training program that enables resident surgeons to perform laparoscopic low anterior resection (LLAR) for rectal cancer and evaluated the safety and feasibility of this training program. We analyzed prospectively gathered data on all LLARs for rectal cancer performed at a single center over a 7-year period. Patients were assessed for demographic characteristics, tumor characteristics, operative procedure, operative time, blood loss, conversion to open surgery, complications, time to bowel recovery, distal margin, and number of lymph nodes harvested. We compared the early surgical, oncological, and functional outcomes of LLARs performed by expert surgeons with those of LLARs performed by resident surgeons for both intraperitoneal and extraperitoneal rectal cancer. All analyses were performed on an intention-to-treat basis. A total of 137 patients met the inclusion criteria for this study. Of the 75 LLARs for intraperitoneal rectal cancer, 40 were performed by expert surgeons (I-E group) and 35 by resident surgeons (I-R group). Of the 62 LLARs for extraperitoneal rectal cancer, 51 were performed by expert surgeons (E-E group) and 11 by resident surgeons (E-R group). The operative time was longer in the E-R group than in the E-E group. The time to resumption of diet was longer in the I-E group than in the I-R group. The other early outcomes, including blood loss, anastomotic leakage, conversion to open surgery, and number of lymph nodes harvested, were similar in the I-E and I-R groups and in the E-E and E-R groups. Our systematic training program on LLAR for rectal cancer enables resident surgeons to perform this procedure safely early during residency, with acceptable short-term outcomes.

Preoperative Chemoradiotherapy Does Not Necessarily Reduce Lymph Node Retrieval in Rectal Cancer Specimens—Results from a Prospective Evaluation with Extensive Pathological Work-up

PurposePreoperative chemoradiotherapy (CRT) is supposed not only to reduce lymph node metastases but also lymph node recovery in rectal cancer specimens. The objective of this prospective study was to determine the effects of chemoradiation on mesorectal lymph node retrieval under terms of a meticulous histopathological evaluation. MethodsSpecimens from 64 consecutive patients with stage II/III rectal cancer receiving preoperative 5-FU-based CRT were investigated. All patients were treated within the German Rectal Cancer Trial CAO/ARO/AIO-04. After surgery (including quality assessed total mesorectal excision), extensive pathological diagnostics was performed with embedding and microscopic evaluation of the whole mesorectal soft tissue compartment. ResultsA total number of 2,021 lymph nodes were recovered (31.6 per specimen) within pathological work-up. There was no significant correlation between the number of retrieved nodes and patient- as well as tumor-dependent parameters. Lymph node size constantly amounted for less than 0.5 cm. Twenty patients (31.3%) had persistent nodal metastases. A considerable incidence of residual micrometastatic involvement in lymph nodes <0.3 cm (in 9.4% of all patients) was detected by extensive pathologic work-up. ConclusionReliable nodal staging with high numbers of detected nodes was feasible after neoadjuvant CRT. Micrometastases frequently occur in small lymph nodes detected by microscopic evaluation.

Does Specialized Surgical Training Increase Lymph Node Yield in Colon Cancer?

Most colon cancer resections do not meet the 12-lymph node minimum recommended in 2001 National Cancer Institute (NCI) panel guidelines. Previous reports suggest surgical training influences lymph node recovery. We hypothesized that recent trends show improved results for lymphadenectomy regardless of specialty. The cancer registry database at a large community hospital with an academic surgical oncology training program was queried to identify resections performed for colon cancer before (1995 to 2000) and after (2001 to 2006) NCI guideline publication. There were no changes in pathology procedures between 374 early and 411 later procedures. The later period brought increases in mean total lymph nodes (15.4 vs 10.4, P < 0.0001), total positive nodes (1.8 vs 1.2, P = 0.005), and the percentage of procedures yielding 12 or more nodes (overall: 65.9 vs 36.0%, P < 0.0001; Stage II and III disease: 73.0 vs 41.4%, P < 0.003). In addition, mean nodal yield increased (P < 0.0001) for fellowship-trained surgeons (16.7 vs 11.2) and nonfellowship-trained surgeons (14.9 vs 10.2). Single-registry data show that since 2001, most colon resections exceed minimum recommendations for lymph node recovery regardless of surgical training. The increased rate of adequate lymphadenectomy for Stage II and III disease is encouraging because this patient population will benefit most by accurate staging of colon cancer.