Prognostic value of lymph node evaluation in small bowel adenocarcinoma

Abstract

BACKGROUND:The presence of distant metastases and the completeness of resection are important prognostic factors in patients with small bowel adenocarcinoma (SBA); however, the influence of lymph node metastasis on patient outcome has not been well characterized. The objective of the current study was to evaluate the impact of the number of positive and negative lymph nodes on survival after curative resection. METHODS: Patients who had SBA diagnosed between 1988 and 2005 were identified from the Surveillance, Epidemiology, and End Results (SEER) registry. Cox proportional hazards regression analyses were performed after adjusting for age, sex, race, tumor stage, tumor grade, and primary site. Five-year disease-specific survival (DSS) was determined, all patients were categorized according to the total lymph nodes (TLNs) assessed, and patients with stage III disease also were categorized according to the number of positive lymph nodes (PLNs) and the PLN-to-TLN ratio (the lymph node ratio [LNR]). RESULTS: In total, 1991 patients (n ¼ 1216 with stage I/II SBA and n ¼ 775 with stage III SBA) were analyzed. Survival depended on the TLNs assessed. The 5-year DSS rate for patients with stage II disease was associated with the TLNs assessed (44%, 69%, and 83% for 0 TLNs, 1-7 TLNs, and >7 TLNs, respectively). The 5-year DSS for patients with stage III disease was associated with the number of PLNs (58% and 37% for <3 PLNs and 3 PLNs, respectively). Among patients with stage III disease, the LNR was even more predictive of survival than stratification by the number of PLNs. CONCLUSIONS: Survival after surgical resection for stage I, II, and III SBA was associated with the TLNs assessed. Stratifying patients with stage III disease into those with <3 PLNs and 3 PLNs significantly improved prognostication. Cancer 2010;116:5374-82.

Patients with Adenocarcinoma of the Small Intestine with 9 or More Regional Lymph Nodes Retrieved Have a Higher Rate of Positive Lymph Nodes and Improved Survival

“…Overman et al 10 proposed to retrieve at least 8 lymph nodes. However, this study did not utilize the joinpoint regression model to assess the number of lymph nodes needed to detect positive lymph nodes.…”

“…Further, no statistical methodology with multivariable adjustment evaluated the impact on the oncological outcome. Even more importantly, the number of lymph nodes retrieved has increased considerably since 2005, the last time period examined by Overman et al 10 Then, in 49 % of the surgeries, 9 or more RLNs were retrieved while in 2011 the rate had risen to 69 %. Our data indicated that with more than 9 RLNs removed, the rate of positive lymph nodes still increases but only minimally.…”

“…3,6 In the absence of distant metastases, the extent of the surgical resection and RLN metastases are the main predictors of oncological outcomes. [7][8][9][10] For a number of other malignancies (e.g., colorectal cancer), the number of retrieved lymph nodes is a well-recognized prognostic factor. [11][12][13] According to international guidelines, a minimum of 12 retrieved locoregional lymph nodes is a prerequisite for adequate histopathological staging in colorectal cancer patients.…”

“…Previous research suggested at least 8 RLNs; however, the study lacked a contemporary statistical methodology for multivariable adjustment of potential confounders. 10 Therefore, the aim of this population-based analysis was to identify the minimum number of retrieved regional lymph nodes needed for optimal staging utilizing a joinpoint regression trend analysis and to assess the impact of lymph node retrieval on survival utilizing a multivariable and propensity score-matched adjustment for potential confounders.…”

Small Bowel Carcinoma in the Setting of Long Standing Crohn’s Disease

“…The 5-year survival based on stage for small bowel adenocarcinoma ranges from 59.8%-85% for Stage I disease, 39.5%-69% for stage II, 27.0%-50% for stage III, and 3.2%-4% for stage IV [3,4]. This is consistently worse than the survival of patients with similarly staged colorectal adenocarcinoma [3,4]. Treatment of the disease is mainly surgical.…”