Less Than 12 Nodes in the Surgical Specimen After Total Mesorectal Excision Following Neoadjuvant Chemoradiation: It means more than you think!

Campos-Lobato, Luiz Felipe de; Stocchi, Luca; Sousa, João Batista de; Buta, Martin; Lavery, Ian C.; Fazio, Victor W.; Dietz, David W.; Kalady, Matthew F.

doi:10.1245/s10434-013-3010-x

Cited by 64 publications

(47 citation statements)

References 32 publications

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“…The location of the tumor in relation to the number of lymph nodes retrieved is also controversial as some authors have a notion that distal rectum has tendency to have higher lymph node retrieval and <12 lymph nodes reflects suboptimal radicality of the surgery (29). In contrast, other authors have observed that in the group of fewer lymph nodes tumor located at the lower level with similar results in our study (30,31).…”

Section: Discussionsupporting

confidence: 82%

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Less than 12 lymph nodes in the surgical specimen after neoadjuvant chemo-radiotherapy: an indicator of tumor regression in locally advanced rectal cancer?

Gurawalia¹,

Dev²,

Nayak³

et al. 2016

J. Gastrointest. Oncol.

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Background: The number of lymph node retrieved in the surgical specimen is important for tumor staging and has paramount impact on prognosis in colorectal cancer and imitates the adequacy of lymph node surgical clearance. The paucity of lymph node yields in patients undergoing resection after preoperative chemo radiotherapy (CRT) in rectal cancer has seen. Lower total number of lymph nodes in the total mesoractal excision (TME) specimen after CRT, could a marker of better tumor response. Methods: We retrospectively reviewed the prospectively managed data of patients underwent excision for rectal cancer, who treated by neoadjuvant radiotherapy with or without chemotherapy in locally advanced rectal cancer. From 2010 to 2014, 364 patients underwent rectal cancer surgery, of which ninety-one treated with neoadjuvant treatment. Standard surgical and pathological protocols were followed. Patients were categorized into two groups based on the number of total harvested lymph nodes with group 1, having 12 or more nodes harvested, and group 2 including patients who had <12 lymph nodes harvested. The total number of lymph nodes retrieved from the surgical specimen was correlated with grade of tumor regression with neoadjuvant treatment. Results: Out of 91 patients, 38 patients (42%) had less than 12 lymph nodes examined in specimen. The difference in median number of lymph nodes was observed significantly as 9 (range, 2-11) versus 16 (range, 12-32), in group 2 and 1, respectively (P<0.01). Patients with fewer lymph node group were comparable with respect to age, BMI, pre-operative staging, neoadjuvant treatment. Pathological complete response in tumor pCR was seen with significantly higher rate (40% vs. 26%, P<0.05) in group 2. As per Mandard criteria, there was significant difference in tumor regression grade (TRG) between both the groups (P<0.05). Among patients with metastatic lymph nodes, median LNR was lower in <12 lymph nodes group at 0.167 (range, 0.09-0.45) versus 0.187 (range, 0.05-0.54), difference was not statistically significant (P=0.81).Conclusions: Retrieval of fewer than 12 lymph nodes in surgical specimen of rectal cancer who had received neo-adjuvant radiotherapy with or without chemotherapy should be considered as a good indicator of tumor response with better local disease control, and a good prognostic factor, rather than as a pointer of poor diligence of the surgical and pathological assessment.

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Section: Discussionsupporting

confidence: 82%

“…Although, the standardized treatment including preoperative chemo-radiation followed by TME and complete pathological evaluation is unanimously followed worldwide, but the number of lymph nodes harvested varies greatly with ranging 29% to 72% (17,(29)(30)(31)39,40).…”

Section: Discussionmentioning

confidence: 99%

Less than 12 lymph nodes in the surgical specimen after neoadjuvant chemo-radiotherapy: an indicator of tumor regression in locally advanced rectal cancer?

Gurawalia¹,

Dev²,

Nayak³

et al. 2016

J. Gastrointest. Oncol.

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“…Retrieval of fewer lymph nodes after chemoradiation treatment may be a marker of a higher tumour response and better prognosis. 15,16 In the subset analysis, it was seen that females showed improved clinical response of 92.9% vs. 71.4% (p=0.285); R0 resection 78.6% vs. 76.2%; inoperability 7.1% vs. 19% (p= 0.489); pathologic response 78.6% vs. 76.2% (p = 0.869) and less toxicities though the results were not statistically significant. Moderately differentiated tumours showed better clinical response of 85.7% vs. 78.6% (p=0.849) and pathologic response of 85.7% vs. 75% (p=0.546) to chemoradiation compared to welldifferentiated tumours.…”

Section: Total (N)mentioning

confidence: 95%

A Prospective Study on Preoperative Concurrent Chemoradiation With Capecitabine in Stage Ii/Iii Carcinoma of Rectum

Soman¹,

Thomas²,

Lekshmikutty³

et al. 2017

jebmh

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“…AJCC TNM 7th edition requires at 3 while CAP suggests regrossing when less than 12 nodes are identified. 45,46 Even if less than the suggested number of lymph nodes is identified, then the tumor should still be given an N stage rather than designated Nx. It has been shown that many factors affect lymph node recovery including the experience/diligence of the surgeon and grossing pathologist; patient age, gender, body habitus, immune response; and tumor site, size and length of colon resected.…”

Section: Required Number Of Lymph Nodesmentioning

confidence: 99%

“…As many lymph nodes as possible should still be evaluated, however, it has been shown that the number of lymph nodes is reduced in these cases. 51,52 A recent study by de Campos-Lobato et al 45 concluded that the identification of less than 12 lymph nodes may be a marker of higher tumor response and decreased local recurrences. They studied 237 patients treated with neoadjuvant chemoradiation followed by total mesorectal excision and compared outcome in those with less than 12 lymph nodes with those with greater than or equal to 12 lymph nodes harvested.…”

Section: Required Number Of Lymph Nodesmentioning

confidence: 99%

Serosal surfaces, mucin pools, and deposits, Oh my: challenges in staging colorectal carcinoma

Frankel

Jin

2015

Modern Pathology

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Colorectal carcinoma is the third most common cancer in the United States. Proper and standardized pathologic staging is vital for prognostic assessment and impacts therapeutic decisions. The Tumor Node Metastasis (TNM) staging system was developed by the American Joint Committee on Cancer (AJCC) to be a data-driven, evidence-based staging system providing an accurate prediction of outcome. The AJCC 7th edition (2010) included several changes clarifying some issues and leading to new controversies. We aim to address selected challenging issues in tumor T staging, neoadjuvant treatment effects in rectal cancer, and definition of lymph node vs tumor deposit. Serosal involvement in colorectal cancer is staged as T4, which is associated with decreased survival and may impact additional therapy decisions. Although careful sampling and sectioning are helpful, challenges remain in interpretation of tumor within 1 mm of serosal surface with a reaction. Elastic stain as a surrogate marker for serosal invasion has been studied, but its usefulness remains unclear. Some unique issues in rectal cancer include the presence of serosa in proximal but not in distal tumors and post-neoadjuvant effects. Tumor should be staged based on tumor cells rather than acellular mucin pools. Additionally, tumor response should be graded only in primary tumor but not in lymph nodes or metastatic sites. The distinction between tumor deposits and lymph nodes has been modified in AJCC TNM from using size in the 5th edition, to the round contour in the 6th edition, to only features of residual lymph node architecture in the 7th edition. Interobserver variability remains but tumor deposits should be documented when present. The number of deposits should not be added to the total number of positive lymph nodes, and the N1c designation should only be used in cases without any positive lymph nodes. Future clarification will likely evolve as more data become available.

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Less Than 12 Nodes in the Surgical Specimen After Total Mesorectal Excision Following Neoadjuvant Chemoradiation: It means more than you think!

Abstract: Retrieval of less than 12 nodes in the proctectomy specimen of rectal cancer patients treated with neoadjuvant chemoradiation does not affect OS, CSM, CFS, or DR and may be a marker of higher tumor response and, consequently, decreased LR rate.

Cited by 64 publications

References 32 publications

Less than 12 lymph nodes in the surgical specimen after neoadjuvant chemo-radiotherapy: an indicator of tumor regression in locally advanced rectal cancer?

Less than 12 lymph nodes in the surgical specimen after neoadjuvant chemo-radiotherapy: an indicator of tumor regression in locally advanced rectal cancer?

A Prospective Study on Preoperative Concurrent Chemoradiation With Capecitabine in Stage Ii/Iii Carcinoma of Rectum

Serosal surfaces, mucin pools, and deposits, Oh my: challenges in staging colorectal carcinoma

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