Risk Factors for Occult Lymph Node Metastasis of Colorectal Cancer Invading the Submucosa and Indications for Endoscopic Mucosal Resection

Purpose Although risk factors for histologically overt lymph node metastasis in patients with early-stage colorectal cancer have been clarified, the risk factors for occult lymph node metastasis are not clear. This study was designed to clarify risk factors for lymph node metastasis, including occult metastasis, in patients with colorectal cancer invading the submucosa and to determine the criteria for endoscopic resection of early colorectal cancer. Methods The risk factors for lymph node metastasis, including occult metastasis, were analyzed in 86 cases of surgically resected colorectal cancer invading the submucosa. The lymph nodes were assessed by immunohistochemistry with cytokeratin antibody CAM5.2. Results The frequencies of overt and occult metastasis to the lymph nodes were 13 percent (11/86) and 13 percent (10/75), respectively. Multivariate analysis showed vascular invasion (P = 0.001) and tumor budding (P = 0.003) to be independent risk factors for lymph node metastasis, including occult metastasis. For tumors with submucosal invasion ≤1,000 μm, no lymph node metastasis was found. The frequencies of lymph node metastasis for tumors with submucosal invasion of 1,000 to 2,000 μm and >2,000 μm were 21 and 37 percent, respectively. In considering combinations of risk factors, there was no lymph node metastasis in tumors having neither vascular invasion nor tumor budding and submucosal invasion of ≤3,000 μm. Conclusions Vascular invasion, tumor budding, and the degree of submucosal invasion were significant risk factors for lymph node metastasis, including occult metastasis. These three factors can be used in combination to identify patients requiring additional surgery after endoscopic resection. Supported in part by a Grant-in-Aid for Scientific Research (no. 15390401) from the Japanese Ministry of Education, Science, and Culture. Presented at the Congress of Japan Surgery Society, Tokyo, Japan, March 29 to 31, 2006. Reprints are not available.     

结直肠癌淋巴结转移相关因素的研究进展

结直肠癌淋巴结转移受多种因素的影响,众多因素之间相互联系、相互作用,临床工作中需对各种因素综合分析才能正确地做出诊断和治疗,本文查阅近十年关于结直肠癌淋巴结转移的相关因素的文献,初步总结了目前被普遍认同的影响结直肠癌淋巴结转移的相关因素,为研究结直肠癌淋巴结转移的独立因素提供思路。目前认为肿瘤的浸润深度、原发部位、分化程度、病理类型以及患者的术前血清CEA水平等与结直肠癌的淋巴结转移具有相关性。而肿瘤的大小和大体形态等因素与结直肠癌淋巴结转移是否具有相关性,目前的认识还不一致。造成以上研究结果出现差异的原因可能有:不同学者对于患者选择的差异、样本数量的多少以及采用的标准不同等。     

Tumor Invasion of Lymph Node Capsules in Patients with Dukes C Colorectal Adenocarcinoma

Purpose The objective of this study was to investigate the correlation between the microscopic findings of positive lymph nodes, especially focusing on capsular invasion, and the outcome after curative surgical resection of colorectal cancer. Methods We analyzed 480 positive lymph nodes from 155 consecutive patients with Stage III colorectal cancer to determine the frequency and significance of lymph node capsular invasion. Recurrence-free and cancer-specific survival rates were assessed in the patients with and without lymph node capsular invasion. Results Between April 1995 and December 2000, 406 consecutive patients with primary colorectal cancer underwent curative resection. Regional lymph node metastases were present in 155 cases (38.2 percent). During the median follow-up period of 4.8 years, 41 patients (26.5 percent) developed recurrent disease and 28 patients died of cancer. Lymph node capsular invasion was detected in one or more lymph nodes from 75 cases (48.3 percent). The five-year recurrence-free rate was 56.1 percent in this group, whereas in the 80 patients without lymph node capsular invasion the rate was 88 percent (P<0.01). Features that were associated with recurrent disease were greater number of positive lymph nodes, venous invasion in primary tumor, infiltrative growth pattern of intranodal tumor, and presence of lymph node capsular invasion. Multivariate analysis identified lymph node capsular invasion as the only significant prognostic factor for recurrence. In multivariate analysis with regard to survival, lymph node capsular invasion, venous invasion, and number of positive nodes remained as significant prognostic factors. Conclusions Lymph node capsular invasion, determined by routine hematoxylin-eosin staining, is a potent prognostic factor in Stage III colorectal cancer. Read in part at the meeting of The International Society of University Colon and Rectal Surgeons, Budapest, Hungary, June 9, 2004. Reprints are not available.     

Distribution of lymph node metastasis in T1 sigmoid colon carcinoma: Should we ligate the inferior mesenteric artery?

In standard oncological sigmoid colectomy, the inferior mesenteric artery is ligated either at its origin or at the level of the left colic artery. However, in patients with early-stage carcinoma, the distribution of metastatic nodes may be limited. The aim of this study was to clarify the prevalence and distribution of lymph node metastasis in T1 sigmoid colon carcinoma and to determine the adequate range of lymph node dissection.

Material and methods

The study included 121 consecutive patients treated for T1 sigmoid colon carcinoma. Clinicopathologic factors associated with nodal metastasis and the distribution of metastatic nodes were analyzed.

Results

Conclusions

Of 121 patients, 12 (10%) had nodal involvement. The depth of invasion and the presence of lymphatic and vascular invasion were significantly associated with nodal metastasis. Of these 12 patients, 11 (92%) had lymph node metastasis confined to pericolic nodes. Nodes along the sigmoidal artery were involved in one patient. There was no involved node along the superior rectal artery or at the root of the inferior mesenteric artery. Lymph node dissection for T1 sigmoid colon carcinoma should be limited to the root of the sigmoidal artery, and the inferior mesenteric artery should be preserved.     

Predictive Histopathologic Factors for Lymph Node Metastasis in Patients With Nonpedunculated Submucosal Invasive Colorectal Carcinoma

PURPOSE Risk factors for lymph node metastasis in patients with nonpedunculated submucosal invasive colorectal carcinoma remain to be characterized. This study examines the relationship between lymph node metastasis and clinicopathologic factors in nonpedunculated submucosal invasive colorectal carcinoma.METHODS The study cohort comprised 155 patients who had undergone surgical treatment for nonpedunculated submucosal invasive colorectal carcinoma. The clinicopathologic factors investigated included gender, age, tumor location, macroscopic type, tumor size, histologic type and grade, intramucosal growth pattern, lymphatic invasion, venous invasion, degree of focal dedifferentiation at the submucosal invasive front, status of the remaining muscularis mucosa, and the depth and width of submucosal invasion.RESULTS Lymph node metastases were found in 19 patients (12.3 percent). Univariate analysis showed that lymphatic invasion, focal dedifferentiation at the submucosal invasive front, status of the remaining muscularis mucosa, and depth of submucosal invasion all had a significant influence on lymph node metastasis. Multivariate analysis showed lymphatic invasion (P = 0.014) and high-grade focal dedifferentiation at the submucosal invasive front (P = 0.049) to be independent factors predicting lymph node metastasis. No lymph node metastasis was found in tumors with a depth of submucosal invasion of <1.3 mm.CONCLUSIONS Lymphatic invasion and high-grade focal dedifferentiation at the submucosal invasive front are important predictors of lymph node metastasis in patients with nonpedunculated submucosal invasive colorectal carcinoma. Depth of submucosal invasion can be used as an identifying marker for patients who do not require subsequent surgery after endoscopic resection.Supported in part by a grant-in-aid for cancer research from the Ministry of Health and Welfare of Japan.     

黏膜下层早期胃癌淋巴结转移290例

目的:研究黏膜下层早期胃癌淋巴结转移的预测因素.方法:回顾性分析解放军总医院1996-2010年手术治疗的290例黏膜下层早期胃癌中与淋巴结转移相关的临床病理资料.结果:黏膜下层早期胃癌淋巴结转移率为21.4%.单因素分析表明影响黏膜下层早期胃癌淋巴结转移的因素主要有肿瘤大小、组织学类型、浸润深度和脉管浸润.多因素分析显示肿瘤大小、组织学类型和脉管浸润与黏膜下层早期胃癌淋巴结转移独立相关.结论:黏膜下层早期胃癌淋巴结转移与肿瘤大小、组织学类型和脉管浸润因素有关.内镜治疗等微创治疗可考虑应用于肿瘤<2cm同时为分化型的黏膜下层早期胃癌中.     

Incidence and prognostic implications of isolated tumor cells in lymph nodes from patients with Dukes B colorectal carcinoma

PURPOSE: Lymph node metastasis in colorectal carcinoma is an important prognostic factor, yet the prognostic relevance of occult tumor cells in lymph nodes has not elucidated. This study was performed to investigate the correlation between isolated tumor cells in lymph nodes and malignancy potential in patients with Dukes B colorectal carcinoma and, thus, to determine whether presence of isolated tumor cells in lymph nodes has a prognostic significance. METHODS: To evaluate the incidence of isolated tumor cells in lymph nodes in patients with Dukes B colorectal carcinoma, 1,808 lymph nodes taken from 93 patients (19.4 per case) were assessed by immunohistochemical technique using a monoclonal antihuman cytokeratin (MNF 116). Clinicopathologic parameters and prognosis were compared between patients with and without isolated tumor cells. RESULTS: Isolated tumor cells were identified in 54 lymph nodes from 29 patients (31.2 percent) by the immunostaining. No correlations were observed between the incidence of positive isolated tumor cells and various clinicopathologic parameters, including preoperative carcinoembryonic level, tumor site and size, histologic differentiation, pT stage, vascular invasion and lymphatic invasion, and perineural invasion. There was no difference in five-year survival estimated by Kaplan-Meier life-table method between positive and negative groups for isolated tumor cells (82.8 and 85.9 percent, respectively). Multivariate analyses showed that sex (P = 0.0236), serum carcinoembryonic level ( 5 ng/ml, P = 0.0002), and lymphatic vessel invasion (P = 0.0002) were significant factors in the survival time. CONCLUSION: Immunohistochemical staining with an anticytokeratin antibody is useful in identifying isolated tumor cells in lymph nodes missed in routine hematoxylin-eosin staining, but clinically it seems to be of little prognostic value in patients with Dukes B colorectal carcinoma. Thus, this immunostaining technique does not offer a significant benefit of different strategies for additional therapy or follow-up during conventional pathologic staging using hematoxylin-eosin staining.     

癌胚抗原在结直肠癌淋巴结微转移检测中的应用

目的 探讨Ⅰ和Ⅱ期结直肠癌术后病理因素及淋巴结微转移对术后5年无瘤生存率的影响.方法 Ⅰ和Ⅱ期结直肠癌患者共126例,均行结直肠癌根治术.每例结直肠癌患者的淋巴结数平均为16枚(10～28枚),用癌胚抗原(CEA)指标对所有淋巴结进行免疫组化染色.统计分析临床病理因素及微转移对术后5年无瘤生存率的影响.结果 术后平均随访64.11(64～106)个月.淋巴管侵犯和肿瘤侵袭深度与淋巴结的CEA表达呈正相关,而其他临床病理因素与淋巴结CEA表达无明显相关性.10项临床病理因素对5年无瘤生存率的影响差异均无统计学意义(P＞0.05).淋巴结CEA表达阴性、孤立肿瘤细胞巢和微转移患者的5年无瘤生存率分别为75.4%、68.2%和46.2%.孤立肿瘤细胞巢患者与CEA阴性患者5年无瘤生存率比较差异无统计学意义(P=0.245).微转移患者与CEA阴性患者比较,前者5年无瘤生存率明显较低(P=0.003).结论 对于Ⅰ和Ⅱ期结直肠癌,若淋巴结中检测到微转移,其预后较差,术后复发率较高,应予以积极的术后辅助化学治疗.     

Feasible endoscopic therapy for early gastric cancer

AIM: To analyze the relationship between lymph node metastasis and clinical pathology of early gastric cancer(EGC) in order to provide criteria for a feasible endoscopic therapy.METHODS: Clinical data of the 525 EGC patients who underwent surgical operations between January 2009 and March 2014 in the West China Hospital of Sichuan University were analyzed retrospectively. Clinical pathological features were compared between different EGC patients with or without lymph node metastasis, and investigated by univariate and multivariate analyses for possible relationships with lymph node metastasis.RESULTS: Of the 2913 patients who underwent gastrectomy with lymph node dissection, 529 cases were pathologically proven to be EGC and 525 cases were enrolled in this study, excluding 4 cases of gastric stump carcinoma. Among 233 patients with mucosal carcinoma, 43(18.5%) had lymph node metastasis. Among 292 patients with submucosal carcinoma, 118(40.4%) had lymph nodemetastasis. Univariate analysis showed that gender, tumor size, invasion depth, differentiation type and lymphatic involvement correlated with a high risk of lymph node metastasis. Multivariate analysis revealed that gender(OR = 1.649, 95%CI: 1.091-2.492, P = 0.018), tumor size(OR = 1.803, 95%CI: 1.201-2.706, P = 0.004), invasion depth(OR = 2.566, 95%CI: 1.671-3.941, P = 0.000), histological differentiation(OR = 2.621, 95%CI: 1.624-4.230, P = 0.000) and lymphatic involvement(OR = 3.505, 95%CI: 1.590-7.725, P = 0.002) wereindependent risk factors for lymph node metastasis. Comprehensive analysis showed that lymph node metastasis was absent in patients with tumor that was limited to the mucosa, size ≤ 2 cm, differentiated and without lymphatic involvement.CONCLUSION: We propose an endoscopic therapy for EGC that is limited to the mucosa, size ≤ 2 cm, differentiated and without lymphatic involvement.     

Prediction of the indication criteria for endoscopic resection of early gastric cancer

AIM: To find risk factors of lymph node metastasis(LNM) in early gastric cancer(EGC) and to find proper endoscopic therapy indication in EGC.METHODS: We retrospectively reviewed the 2270 patients who underwent curative operation for EGC from January 2001 to December 2008. EGC was defined as malignant lesions that do not invade beyond the submucosal layer of the stomach wall irrespective of presence of lymph node metastasis.RESULTS: Among 2270 enrolled patients, LNM was observed in 217(9%) patients. LNM in intramucosal(M) cancer and submucosal(SM) cancer was detectedin 3 8( 2. 8 %, 3 8 / 1 3 4 0) patients and 1 7 9(19%, 179/930) patients, respectively. In univariate analysis, the risk factors for LNM in EGC were size of tumor, Lauren classification, ulcer, lymphatic invasion, vascular invasion, and depth of invasion. However, in multivariate analysis, size of tumor, lymphatic invasion, vascular invasion, and depth of invasion were risk factors for LNM in EGC. Size of tumor, lymphatic invasion, vascular invasion, and depth of invasion were risk factors for LNM in cases of intramucosal cancer and submucosal cancer. In particular, there was no lymph node metastasis in cases of well differentiated early gastric cancer below 1 cm in size without ulcer regardless of lymphovascular invasion.CONCLUSION: Tumor size, perilymphatic-vascular invasion, and depth of invasion were risk factors for LNM in EGC. There was no LNM in EGC below 1 cmregardless risk factors.     

Digestive cancer surgery in the era of sentinel node and epithelial-mesenchymal transition

Lymph node involvement is one of the most important prognostic indicators of carcinoma of the digestive tract.Although the therapeutic impact of lymphadenectomy has not been proven and the number of retrieved nodes cannot be considered a measure of successful cancer surgery,an adequate lymph node count should be guaranteed to accurately assess the N-stage through the number of involved nodes,lymph node ratio,number of negative nodes,ratio of negative to positive nodes,and log odds,i.e.,the log of the ratio between the number of positive lymph nodes and the number of negative lymph nodes in digestive carcinomas.As lymphadenectomy is not without complications,sentinel node mapping has been used as the rational procedure to select patients with early digestive carcinoma in whom nodal dissection may be omitted or a more limited nodal dissection may be preferred.However,due to anatomical and technical issues,sentinel node mapping and nodal basin dissection are not yet the standard of care in early digestive cancer.Moreover,in light of the biological,prognostic and therapeutic impact of tumor budding and tumor deposits,two epithelial-mesenchymal transition-related phenomena that are involved in tumor progression,the role of staging and surgical procedures in digestive carcinomas could be redefined.     

Budding as a risk factor for lymph node metastasis in pT1 or pT2 well-differentiated colorectal adenocarcinoma

PURPOSE: Lymph node metastasis is an important indicator of tumor stage and prognosis in pT1 and pT2 colorectal adenocarcinomas. Lymphovascular invasion is an established risk factor of lymph node metastasis, whereas budding at the invasive front of tumors is also reported to correlate with lymph node metastasis. We examined whether the coexistence of lymphovascular invasion and budding provides any better information than lymphovascular invasion alone in the prediction of lymph node metastasis of pT1 or pT2 well-differentiated colorectal adenocarcinomas. METHODS: Surgically resected specimens of 101 pT1 or pT2 well-differentiated colorectal adenocarcinomas were studied. Using sections stained with hematoxylin-eosin, we examined lymphovascular invasion and budding according to Morodomis definition. RESULTS: Lymphovascular invasion was present in 39 lesions (38 percent), whereas budding was found in 42 lesions (41 percent). Budding was more frequently detected in pT2 tumors than in pT1 tumors. The presence of budding significantly correlated with lymphovascular invasion. Sensitivity, specificity, positive predictive value, and negative predictive value of lymphovascular invasion alone for lymph node metastasis were 79, 76, 34, and 96 percent, respectively, whereas those of the combination of lymphovascular invasion and budding (either lymphovascular invasion or budding) were 93, 52, 24, and 98 percent, respectively. CONCLUSION: Because the risk of lymph node metastasis in pT1 or pT2 well-differentiated colorectal adenocarcinomas having neither lymph node metastasis nor budding is very low, budding in combination with lymphovascular invasion seems to be a simple and inexpensive pathologic marker in predicting lymph node metastasis. Therefore, the presence or absence of budding should be examined in the routine pathologic diagnosis of pT1 or pT2 well-differentiated colorectal adenocarcinomas.     

Metastasis of primary gallbladder carcinoma in lymph node and liver

AIM: To evaluate the patterns with metastasis of gallbladder carcinoma in lymph nodes and liver. METHODS: A total of 45 patients who had radical surgery were selected. The patterns with metastasis of primary gallbladder carcinoma in lymph nodes and liver were examined histopathologically and classified as TNM staging of the American Joint Committee on Cancer. RESULTS: Of the 45 patients, 29 (64.4%) had a lymph node positive disease and 20 (44.4%) had a direct invasion of the liver. The frequency of involvement of lymph nodes was strongly influenced by the depth of the primary tumor (P= 0.0001). The postoperative survival rate of patients with negative lymph node metastasis was significantly higher than that of patients with positive lymph node metastasis (P= 0.004), but the postoperative survival rate of patients with Nl lymph node metastasis was not significantly different from that of patients with N2 lymph node metastasis (P= 0.3874). The postoperative survival rate of patients without hepatic invasion was significantly better than that of patients with hepatic invasion (P= 0.0177). CONCLUSION: Complete resection of the regional lymph nodes is important in advanced primary gallbladder carcinoma (PGC). The initial sites of liver spread are located mostly in segments IV and V. It is necessary to achieve negative surgical margins 2 cm from the tumor. In patients with hepatic hilum invasion, extended right hepatectomy with or without bile duct resection or portal vein resection is necessary for curative resection.     

早期胃癌淋巴结转移规律及其影响因素分析

目的 探讨早期胃癌淋巴结转移规律及其影响因素,为选择合适的治疗方法提供依据.方法 对北京大学第三医院1988年3月-2009年3月于外科行胃癌根治术治疗的103例早期胃癌患者临床资料进行回顾性研究,对患者的年龄、性别,肿瘤的大小、部位、大体类型、分化程度及浸润深度与淋巴结转移的关系进行单因素及多因素分析.结果 早期胃癌的淋巴结转移率为17.5%(18/103),其中黏膜内癌的淋巴结转移率为4.1%(2/49),黏膜下层癌的淋巴结转移率为29.6%(16/54).logistic回归分析显示,浸润至黏膜下层(P=0.001)及肿瘤>2 cm(P=0.003)为早期胃癌淋巴结转移的独立危险因子.黏膜内癌发生淋巴结转移的2例均为直径>2 cm的印戒细胞癌;黏膜下层癌中,≤2 cm肿瘤的淋巴结转移率为16.1%(5/31),>2 cm肿瘤的淋巴结转移率高达47.8%(11/23)(P=0.012).高分化程度的早期胃癌的淋巴结转移率为0(0/13),中分化癌转移率为18.2%(4/22),低分化癌转移率为16.7%(5/30),印戒细胞癌转移率为23.7%(9/38),各组间差异无统计学意义(P=0.294).患者的年龄、性别、肿瘤部位(胃上部、中部、下部)和大体分型(隆起型、平坦型和凹陷型)与淋巴结转移无相关性.结论 肿瘤大小和浸润深度与早期胃癌淋巴结转移相关,决定早期胃癌治疗方案时,可参考上述因素判断淋巴结转移风险.     

Clinicopathological features associated with lymph node metastasis in early gastric cancer: Analysis of a single-institution experience in China

BACKGROUND:

An accurate assessment of potential lymph node metastasis is an important issue for the appropriate treatment of early gastric cancer. Minimizing the number of invasive procedures used in cancer therapy is critical for improving the patient’s quality of life.

OBJECTIVE:

To evaluate the clinicopathological features associated with lymph node metastasis of early gastric cancer in patients from a single institution in China.

METHODS:

A retrospective review of data from 410 patients surgically treated for early gastric cancer at the First Affiliated Hospital (Nanjing, China) between 1998 and 2007, was conducted. The clinicopathological variables associated with lymph node metastasis were evaluated.

RESULTS:

Lymph node metastasis was observed in 12.20% of patients. The macroscopic type, tumour size, location in the stomach, depth of gastric carcinoma infiltration, and presence of vascular or lymphatic invasion showed a positive correlation with the incidence of lymph node metastasis by univariate analysis. Multivariate analyses revealed histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion to be significantly and independently related to lymph node metastasis. The depth of gastric carcinoma infiltration was the strongest predictive factor for lymph node metastasis. For intramucosal cancer, tumour size was the unique risk factor for lymph node metastasis. For submucosal cancer, histological classification and tumour size were independent risk factors for lymph node metastasis.

CONCLUSIONS:

Histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion are independent risk factors for lymph node metastasis in patients with early gastric cancer in China. Minimal invasive treatment, such as endoscopic mucosal resection, may be possible for highly selected cancers.     

Individualization of lymphadenectomy in superficial esophageal squamous cell cancer

Background As the result of the development of imaging means, the incidence of discovery of superficial esophageal squamous cell cancer (ESCC) has recently increased. Various treatment methods such as endoscopic mucosal resection and reduction of lymphadenectomy have been performed to preserve the quality of life. Because lymph node metastasis occurs even in the early stage of esophageal cancer, we should carefully select the treatment method, including lymphadenectomy. Methods We analyzed the distribution of solitary lymph metastasis of 27 superficial esophageal cancers. To analyze the distribution of micrometastasis, a total of 1542 lymph nodes obtained from 46 patients with pN0 submucosal cancer were immunohistochemically examined by cytokeratin antibody. Sentinel node mapping was performed in 23 patients with clinical T1 tumors. Results The location of lymph node metastasis in the 22 patients with solitary lymph metastasis in superficial cancer was limited to recurrent nerve nodes in the upper thoracic esophagus, recurrent nerve nodes, paraesophageal nodes, or perigastric nodes in the middle or lower thoracic esophagus. For eight patients with lymph node micrometastasis in pN0 patients with superficial esophageal cancer, the locations of micrometastasis were similar to those of solitary metastasis. In sentinel node mapping, all nodal metastasis was included in sentinel nodes with a single exception. Conclusions Individual lymphadenectomy in superficial ESCC will be established using methods such as analysis of past data, clinical diagnosis of lymph node metastasis by imaging, and sentinel node navigation surgery, including the diagnosis of micrometastasis.     

Clinical significance of lymph node metastasis in gastric cancer

Gastric cancer,one of the most common malignancies in the world,frequently reveals lymph node,peritoneum,and liver metastases.Most of gastric cancer patients present with lymph node metastasis when they were initially diagnosed or underwent surgical resection,which results in poor prognosis.Both the depth of tumor invasion and lymph node involvement are considered as the most important prognostic predictors of gastric cancer.Although extended lymphadenectomy was not considered a survival benefit procedure and was reported to be associated with high mortality and morbidity in two randomized controlled European trials,it showed significant superiority in terms of lower locoregional recurrence and disease related deaths compared to limited lymphadenectomy in a 15-year followup study.Almost all clinical investigators have reached a consensus that the predictive efficiency of the number of metastatic lymph nodes is far better than the extent of lymph node metastasis for the prognosis of gastric cancer worldwide,but other nodal metastatic classifications of gastric cancer have been proposed as alternatives to the number of metastatic lymph nodes for improving the predictive efficiency for patient prognosis.It is still controversial over whether the ratio between metastatic and examined lymph nodes is superior to the number of metastatic lymph nodes in prognostic evaluation of gastric cancer.Besides,the negative lymph node count has been increasingly recognized to be an important factor significantly associated with prognosis of gastric cancer.     

The risk of lymph node metastasis in colorectal polyps with invasive adenocarcinoma

One hundred fifty-one patients with colorectal polyps containing invasive adenocarcinoma treated by resection were studied to determine the incidence of lymph node metastasis and whether lymph node metastasis was related to the depth of invasion. Other variables evaluated included size and configuration of the polyp, grade of adenocarcinoma, presence or absence of lymphovascular invasion, and degree of differentiation. In patients with sessile polyps, the incidence of lymph node metastasis was 10 percent. Eighty percent of these lesions had lymphovascular invasion. For pedunculated polyps, the overall incidence of lymph node metastasis was 6 percent. However, there was no incidence of lymph node metastasis when the depth of invasion was limited to the head, neck, and stalk of the polyp (Levels 1, 2, and 3). Only when the depth of invasion reached to the base of the stalk (Level 4) was the risk of lymph node metastasis high (27 percent). The other risk factors were not associated with lymph node metastasis. We concluded that the most significant risk factor for lymph node metastasis in patients with invasive carcinoma in a polyp was invasion into the submucosa of the bowel wall (Level 4).Presented in part at the Tripartite Meeting, Birmingham, United Kingdom, June 19–21, 1989.     

Characteristics of early colorectal carcinoma with lymph node metastatic disease

BACKGROUND/AIMS: Endoscopic resection may safely and effectively remove early colorectal cancers. However, additional surgical treatment is needed in cases with metastatic lymph nodes for curative treatment. The purpose of this study was to investigate the correlation between lymph node metastasis and various pathological parameters in early colorectal cancers. METHODOLOGY: The clinicopathological records of 3,557 colorectal adenocarcinoma patients who underwent surgical resection at the Samsung Medical Center from August 1995 to June 2005 were reviewed. One hundred forty seven tissue samples with early colorectal cancer were used in this study. Various parameters were studied including gender, location, macroscopic appearance, differentiation, lymphatic tumor emboli, and the depth of tumor invasion. RESULTS: Twenty five patients (17.0%) had lymph node metastasis. Male gender, left colon, macroscopically depressed lesions, moderately or poorly differentiated carcinoma, depth of tumor invasion (Sm2 or Sm3), and presence of lymphatic tumor emboli were the risk factors for lymph node metastasis. CONCLUSIONS: Early colorectal cancers with male gender, location in the left colon, macroscopically depressed lesion, moderate or poor differentiation, depth in Sm2 or Sm3, and the presence of lymphatic tumor emboli have higher risk of lymph node metastasis than those without. The early colorectal cancers with these risk factors should have surgical resection.     

Risk of Lymph Node Metastasis in T1 Carcinoma of the Colon and Rectum

PURPOSE: Several recent reports of high local recurrence and lymph node metastasis in T1 carcinoma of the rectum prompted us to study the risk factors for lymph node metastasis in these lesions. METHODS: We reviewed the clinical records of 7,543 patients who underwent operative treatment for carcinoma of the colon and rectum from 1979 to 1995. Only patients with sessile T1 lesions who underwent colorectal resection were included in the study, yielding an analysis cohort of 353 patients. The following carcinoma-related variables were assessed: size, mucinous subtype, carcinomatous component, grade, site in colon and rectum, lymphovascular invasion, and depth of submucosal invasion. For the depth, the submucosa was divided into upper third (sm1), middle third (sm2), and lower third (sm3). Chi-squared tests and logistic regression were used to evaluate the variables as potential risk factors for lymph node metastasis. RESULTS: The incidence of T1 lesions was 8.6 percent. In the analysis cohort, the lymph node metastasis rate was 13 percent. Significant predictors of lymph node metastasis both univariately and multivariately were sm3 (P = 0.001), lymphovascular invasion (P = 0.005), and lesions in the lower third of the rectum (P = 0.007). Poorly differentiated carcinoma was significant univariately (P = 0.001) but not in the multivariate model. No other parameter was associated with a significant risk. CONCLUSIONS: T1 colorectal carcinomas with lymphovascular invasion, sm3 depth of invasion, and location in the lower third of the rectum have a high risk of lymph node metastasis. These lesions should have an oncologic resection. In a case of the lesion in the lower third of the rectum, local excision plus adjuvant chemoradiation may be an alternative.