Significance of isolated tumor cells in lymph nodes among gastric cancer patients

Purpose To determine the frequency and prognostic impact of isolated tumor cells (ITC) in regional lymph nodes judged to be tumor free in conventional histopathology among gastric cancer patients.Methods Among 161 patients who underwent gastrectomy and D2-lymphadenectomy, 56 were staged pN0 (35%). Archival paraffin blocks of 1148 resected regional lymph nodes of those pN0 patients were reevaluated for ITC using monoclonal antibody Ber-EP4. Patients with and without ITC were compared with regard to the distribution of various clinicopathological factors. Prognostic impact of ITC was tested in uni- and multivariate analysis.Results Of 56 pN0 patients, 33 (59%) exhibited single Ber-Ep4 immunoreactive cells or small cell clusters in at least one lymph node. The occurrence of ITC was not dependent on other clinicopathological factors. ITC impaired patients prognoses significantly in uni- as well as multivariate analyses [estimated 5-year survival rate: 82% for pN0_(i–) vs 58% for pN0_(i+) (p=0.059) and 15% for pN1/2 (p=0.0005 and p<0.0001, respectively)].Conclusion ITC are a frequent event in apparently tumor-free lymph nodes of gastric cancer patients and are overlooked by conventional histopathology. They are encountered even in limited stages of disease and impair patients prognoses. This should be borne in mind when advocating local resection for early gastric cancer.     

Frequency and prognostic significance of occult tumor cells in lymph nodes in patients with adenocarcinoma of the papilla of Vater

Background: Occurrence of tumor relapse is frequent in patients with carcinoma of the papilla of Vater despite the absence of residual tumor detectable at primary surgery. Therefore it has to be assumed that current tumor staging procedures fail to identify minimal amounts of tumor cells disseminated to secondary organs, which might be precursors of subsequent metastatic relapse. The aim of the study was to assess the frequency and prognostic impact of minimal tumor cell spread in lymph nodes classified as ‘tumor-free’ in routine histopathologic evaluation. Materials and methods: A total of 41 ‘tumor-free’ lymph nodes from 23 patients with adenocarcinoma of the papilla of Vater who underwent curative tumor resection (R0) were examined by immunohistochemistry with the monoclonal anti-EpCAM antibody Ber-EP4 for minimal disseminated tumor cells. Results: Twelve (29.3%) of the 41 ‘tumor-free’ lymph nodes obtained from 9 (39.1%) of the 23 patients displayed EpCAM-positive cells. Kaplan–Meier survival analysis revealed that patients with EpCAM-positive cells in lymph showed a clearly reduced relapse-free and overall survival compared with patients without such cells. However, these differences were not statistically significant (p = 0.13 for relapse-free survival, p = 0.11 for overall survival). Discussion: Immunohistochemical assessment may refine the staging of resected lymph nodes in patients with carcinoma of the papilla of Vater. However, the presence of minimal disseminated tumor cells in lymph nodes had no significant impact on the prognosis in these patients.     

Strong prognostic value of nodal and bone marrow micro-involvement in patients with pancreatic ductal carcinoma receiving no adjuvant chemotherapy

AIM: To study the prognostic value of adjuvant chemotherapy in patients with pancreatic, ductal adenocarcinoma.METHODS: Lymph nodes from 106 patients with resectable pancreatic ductal adenocarcinoma were systematically sampled. A total of 318 lymph nodes classified histopathologically as tumor-free were examined using sensitive immunohistochemical assays.Forty-three (41%) of the 106 patients were staged as pT1/2, 63 (59%) as pT3/4, 51 (48%) as pN0, and 55 (52%)as pN1. The study population included 59 (56%) patients exhibiting G1/2, and 47 (44%) patients with G3 tumors.Patients received no adjuvant chemo- or radiation therapy and were followed up for a median of 12 (range:3.5 to 139) mo.RESULTS: Immunostaining with Ber-EP4 revealed nodal microinvolvement in lymph nodes classified as "tumor free" by conventional histopathology in 73(69%) out of the 106 patients. Twenty-nine (57%)of 51 patients staged histopathologically as pN0 had nodal microinvolvement. The five-year survival probability for pN0-patients was 54% for those without nodal microinvolvement and 0% for those with nodal microinvolvement. Cox-regression modeling revealed the independent prognostic effect of nodal microinvolvement on recurrence-free (relative risk 2.92,P=0.005) and overall (relative risk 2.49, P=0.009) survival.CONCLUSION: The study reveals strong and independent prognostic significance of nodal microinvolvement in patients with pancreatic ductal adenocarcinoma who have received no adjuvant therapy. The addition of immunohistochemical findings to histopathology reports may help to improve risk stratification of patients with pancreatic cancer.     

Strong prognostic value of nodal and bone marrow micro-involvement in patients with pancreatic ductal carcinoma receiving no adjuvant chemotherapy

INTRODUCTIONPancreatic adenocarcinoma is the fifth leading cause of death among all malignancies[1],leading to approximately40000deaths each year in Europe[2].Reported probabilities of five-year survival after curative surgery are still below10percent[3].Stage,grade and resection margin status are currently accepted as the most accurate pathologic variables predicting survival[4-10].Pathologic staging only insufficiently reflects the individual risk to develop tumor recurrence which is ev…     

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.     

Lymph node evaluation in colorectal cancer

BACKGROUND: In Brazil, colorectal carcinoma is the third cause of death by malignant tumors among women, and the fifth among men. Lymph node involvement is one of the most relevant prognostic maker in these tumors. AIM: To study lymph node involvement in colorectal carcinoma in relationship to biological behavior and tumor location. PATIENTS AND METHODS: One hundred and eight five colorectal carcinoma cases were studied. Lymph node involvement was analyzed according to tumor location, diameter, vessel invasion, and TNM staging. RESULTS: Three thousand nine hundred and six lymph nodes were harvested in 185 patients (21.1 lymph nodes/patient). Metastasis were detected in 399/2,573 peritumoral lymph nodes (15.5%) and in 72/1,333 non-peritumoral lymph nodes (5.4%). Eighty-six patients presented metastasis; in these patients 471/1942 lymph nodes were compromised. In 26 patients peritumoral and non-peritumoral lymph nodes were involved; in 57 cases metastasis were detected only in peritumoral lymph nodes and in 3, only non-peritumoral lymph nodes were involved. The number of lymph node was higher among cecal tumors and smaller in the rectum and sigmoid. There was a positive correlation between the number of metastatic lymph node and pT, tumor diameter and lymphatic and venous invasion; there was a negative correlation between lymph node involvement and lymphocytic response; pN was significantly associated with pT. CONCLUSIONS: Colorectal carcinoma involves preferentially peritumoral lymph node, but in 29 patients (15,7%) non-peritumoral lymph nodes were affected, which is important for tumor staging and prognosis. pN and the number of metastatic lymph nodes were associated with other behaviour markers.     

Micrometastases from HBP malignancies and metastatic cancer

Despite advances in early diagnosis and surgical treatment, the prognosis for patients with primary malignant tumors of the hepatobiliary tract and pancreas has not changed markedly over the last decades. Early metastatic relapse after complete resection indicates the presence of disseminated tumor cells undetectable by current tumor staging methods. Sensitive immunohistocytochemical and nucleic acid‐based assays have been developed to detect single tumor cells present in lymph nodes, bone marrow, or blood. Standardization of the current occult tumor cell detection protocols are needed before “micrometastatic” tumor staging can be used in clinical practice. We present an overview of recent studies on the frequency and prognostic value of occult disseminated tumor cells in the lymph nodes, bone marrow, and blood of patients with hepatopancreatobiliary malignancies and metastatic colorectal cancer identified by immunohistocytochemistry or nucleic acid‐based assays.     

The survival rate and prognostic factors in 26 perforated colorectal cancer patients

Purpose The treatment for perforated colorectal cancer is not easy and the prognosis for this disease is not so predictable. There are some controversies about performing radical operations because colorectal cancer perforation was considered as an advanced stage disease due to the possibility of tumor cell dissemination through the perforation site. Methods We selected and enrolled 26 patients with perforated colorectal cancers among the 1,227 patients who underwent operation for colorectal cancer. These cases were retrospectively analyzed by using their medical records and clinicopathological data. Results Twenty-eight cases (2.3%) with perforated colorectal cancers were studied and the overall operative mortality rate was 11%. The overall 5-year survival rate was 57.8% when excluding the operative mortality. The overall 5-year cancer-free survival rate was 52.8%. There were significant differences in the survival rate and the cancer-free survival rate between the stages (p=0.008 and p<0.001, respectively). A univariate analysis of the prognostic factors revealed that the number of the metastatic lymph nodes (p=0.018) and the perforation proximal to the cancer (p=0.005) were significantly correlated to worse survival, and the higher number of the metastatic lymph nodes was correlated to a poorer cancer-free survival rate (p<0.001). Conclusion For the perforated colorectal cancers, the stage, the perforation proximal to the cancer, and the number of the metastatic lymph nodes were correlated, with the survival and the cancer-free survival as factors of a poor prognosis. The surgical approach selected for perforated colorectal cancer should be in line with the principles of an appropriate cancer operation because the clinical pathway of perforated colorectal cancer is similar to that of uncomplicated colorectal cancer.     

Prognostic relevance of occult tumor cells in lymph nodes of colorectal carcinomas

PURPOSE: Whereas lymph node metastases in colorectal carcinoma are an important prognostic factor, the prognostic relevance of occult tumor cells in lymph nodes is not elucidated at present. Therefore, our study intended to assess the rate of patients with occult tumor cells in histopathologically negative lymph nodes. Furthermore, we tried to evaluate an eventual influence of these occult tumor cells on patients' prognoses. METHODS: For examination, we used paraffin blocks of lymph nodes, tumor-negative by conventional histopathology, from 49 patients with colorectal carcinoma (Stage I–III) after a curative (RO) tumor resection in 1987. After preparation of tissue blocks using the serial sectioning technique, the specimens were stained with the alkaline phosphatase, antialkaline phosphatase method and two monoclonal antibodies (AE1/AE3 and Ber-EP4). RESULTS: In 13 of 49 patients (26.5 percent), we disclosed tumor cells, mostly located in subcapsular sinuses as single cells or in groups. There was a good correlation between the detection rate and N category, tumor stage, and grading. Moreover, 33 percent of patients in Stage I/II with occult tumor cells (NO+) developed a local relapse and/or distant metastases in contrast to 12 percent of patients without tumor cells (NO–). With a median follow-up of 84 months, we found no difference in disease-free survival between the tumor cell negative and positive groups in Stage I/II patients. CONCLUSION: The results show that occult tumor cells might increase the risk for development of a local tumor relapse and/or distant metastases but do not influence patients' prognoses at all.Presented at the Walter Brendel Prize Session of the XXXIst Congress of the European Society for Surgical Research, Southampton, United Kingdom, March 31 to April 3, 1996.     

Detection of Lymph Node Micrometastases in Colorectal Cancer

The presence of lymph node metastases is the single most important prognostic factor of colorectal cancer. However, almost one-third of patients considered metastases-free by routine histochemical analysis of lymph nodes subsequently develop tumour recurrence. More sensitive methods capable of detecting the small deposits of disseminated cancer cells forming micrometastases may provide a basis for powerful new prognostic markers and enhanced staging and treatment of patients with colorectal cancer. We present a review of recent methodology utilized to detect lymph node micrometastases in colorectal cancer, focusing on immunohistochemical staining and DNA- and RNA-based methods. Immunohistochemical staining is sensitive when single tissue sections are in focus, but is highly dependent upon the sectioning level, giving low overall sensitivity for whole lymph nodes unless the number of sections is high. Recent nucleic acid-based methods seem to have higher overall sensitivity, but have so far been used in a relatively limited number of studies, mostly without data on clinical outcome. Using multiple markers and sentinel node mapping can enhance the specificity and sensitivity of micrometastasis detection. Further investigation, however, is required before the most recent methodological developments can be incorporated in routine pathological examination.     

The potential of cytokeratin 20 and mucin 2 mRNA as metastasis markers in regional lymph nodes of colon cancer patients investigated by quantitative RT-PCR

Purpose  The presence of regional lymph node metastases is one of the most important prognostic factors in colon cancer. Nevertheless, up to 30% of the lymph node negative patients experience disease recurrence. Possibly, this patient group may be identified by more sensitive techniques than routine histopathological examination of the lymph nodes. Methods  In the present study, we have evaluated the detection of colon cancer lymph node metastases by real-time RT-PCR quantitation of the epithelial-specific cytokeratin 20 (CK20) and mucin 2 (MUC2) mRNAs. Results  Both assays were able to detect dilutions of tumor cells down to one tumor cell in 10⁶ normal lymphocytes. CK20 and MUC2 mRNA were quantitated in 52 normal lymph nodes from 12 patients undergoing surgery for benign bowel diseases and in 144 primary colon tumors. The median tumor level of both markers were more than 10⁴-fold higher than the highest level in normal lymph nodes, indicating that the markers had a potential for metastasis detection in a clinical context. We applied the assays to 61 lymph nodes with known metastases detected by routine staining. Elevated CK20 or MUC2 mRNA levels were detected in 57 (95%) of the 61 LNs. Conclusions  Thus, CK20 and MUC2 quantitation by real-time RT-PCR seems to be a promising, sensitive tool to detect metastases in regional lymph nodes from colon cancer patients.     

Detection of tumor cell dissemination in pancreatic ductal carcinoma patients by CK 20 RT-PCR indicates poor survival

Purpose: This prospective study evaluates the diagnostic potential of Cytokeratin 20 (CK 20) RT-PCR for the detection of disseminated tumor cells in bone marrow and blood of a large cohort of patients with ductal adenocarcinoma of the pancreas and the prognostic value on overall survival prediction. Methods: Between 1994 and 2003, 172 patients (83 male, 89 female; 13–82 years) with pancreatic ductal adenocarcinoma underwent surgery. Bone marrow samples and venous blood were taken preoperatively and analyzed for disseminated tumor cells by nested CK 20 RT-PCR. Results: Disseminated tumor cells were detected in 81 (47.1%) of the 172 patients in the bone marrow and/or the venous blood. Overall, in 45 of the 135 (33.3%) bone marrow samples and in 52 of the 154 (33.8%) blood samples, CK 20 positive cells were detected. Detection rates increased with the UICC-tumor stage. According to Kaplan-Meier, univariate survival analysis of all 172 patients (n=78 R0-; n=18 R1- and n=5 R2-resected; n=71 palliative surgery) showed a statistically significant relationship of overall survival to radicality of the operation (P<0.0001), the UICC-stage of the tumors (P=0.0011) and the detection of disseminated tumor cells in bone marrow and/or venous blood (P=0.05). Patients with well- and moderately- differentiated tumors (G1 and G2) had a significantly longer survival (P=0.045) than patients suffering from poorly differentiated tumors (G3). A positive CK 20 status in the bone marrow and/or blood within the group of patients with G1 and G2 tumors had a significantly negative prognostic impact on their survival (P=0.046). Conclusions: Disseminated tumor cells can be detected in patients with pancreatic ductal adenocarcinoma by CK 20 RT-PCR. Detection rates are stage dependent, and survival analysis demonstrated statistically relevant data. From a clinical point of view, this finding is especially noteworthy for the group of well- and moderately-differentiated tumors.     

Analysis of micrometastatic disease in histologically negative lymph nodes of patients with adenocarcinoma of the distal esophagus or gastric cardia

SUMMARY. Lymphatic dissemination is the most important prognostic factor in patients with esophageal carcinoma. However, the clinical significance of lymph node micrometastases is still debated due to contradictory results. The aim of the present study was to identify the incidence of potentially relevant micrometastatic disease in patients with histologically node‐negative esophageal adenocarcinoma and to analyze the sensitivity and specificity of three different immunohistochemical assays. From a consecutive series of 79 patients who underwent a transthoracic resection with extended 2‐field lymphadenectomy, all 20 patients with pN0 esophageal adenocarcinoma were included in this study. A total of 578 lymph nodes were examined for the presence of micrometastases by immunohistochemical analysis with the antibodies Ber‐EP4, AE1/AE3 and CAM 5.2. Lymph node micrometastases were detected in five of the 20 patients (25%). They were identified in 16 of the 578 lymph nodes examined (2.8%) and most frequently detected with the Ber‐EP4 and AE1/AE3 antibody (sensitivity 95% and 79% respectively). In 114 of the 559 negative lymph nodes (20.4%), positive single cells were found that did not demonstrate malignant characteristics. These false‐positive cells were more frequently found with the AE1/AE3 staining (specificity of the Ber‐Ep4 and AE1/AE3 antibody 94% and 84% respectively). The presence of nodal micrometastases was associated with the development of locoregional recurrences (P=0.01), distant metastases (P=0.01), and a reduced overall survival (log rank test, P=0.009). For the detection of clinically relevant micrometastatic disease in patients operated upon for adenocarcinoma of the distal esophagus or gastric cardia, Ber‐EP4 is the antibody of first choice because of its high sensitivity and specificity. Immunohistochemically detected micrometastases in histologically negative lymph nodes have potential prognostic significance and are associated with a high incidence of both locoregional and systemic recurrence. Therefore, this technique has the potential to refine the staging system for esophageal cancer and to help identify patients who will not be cured by surgery alone.     

淋巴结微转移检测对大肠癌病理分期的影响

目的 研究淋巴结微转移对结肠癌患者病理分期的影响.方法 对1120枚结直肠癌患者淋巴结进行常规HE染色和CK20、CEA免疫组化微转移的检测,并对结果进行统计学分析.结果 CK20检测出有微转移淋巴结103枚,占9.2％(103/1120),CEA检测出有微转移淋巴结88枚,占7.9％ (88/1120).CK20联合CEA检测出130枚淋巴结检出有微转移,占11.6％ (130/1120).肿瘤浸润愈深,微转移愈易发生(P＜0.05),分化程度低者,微转移阳性率高(P＜0.05).130枚淋巴结检出有微转移,13例TNM分期提高,其中Ⅰ期→Ⅲ期2例,Ⅱ期→Ⅲ期11例,HE染色重新分期率为18.6％ (13/70).结论 结直肠癌淋巴结免疫组化检测有助于更准确地进行结直肠癌的临床病理分期.     

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.     

Clinicopathologic factors correlated with number of metastatic lymph nodes in oesophageal cancer

BACKGROUND: The number of metastatic lymph nodes is applied to the staging system of gastric cancer and colorectal cancer. However, it has not been evaluated in oesophageal cancer. PATIENTS AND METHODS: Of 258 patients with primary squamous cell carcinoma of the thoracic oesophagus between February 1981 and December 1999, 160 underwent three-field oesophagectomy with a curative intent. Clinicopathologic characteristics of those 160 patients were retrospectively investigated according to the number of metastatic lymph nodes. RESULTS: Seventy-eight patients had no lymph node metastases and 82 (51.3%) had lymph node metastases; 51 [31.9%)] had between 1 and 4 positive lymph nodes, and 31 (19.4%) had > or =5. The number of metastatic lymph nodes was significantly correlated with tumour size, macroscopic classification, histological differentiation, pT, pN, and vessel invasions. Multivariate analysis showed that lymph vessel invasion (relative risk 12.6), histological differentiation (relative risk 4.2), and tumour size (relative risk 3.8) were independent factors correlated with number of metastatic lymph nodes. The number of metastatic lymph nodes was also well correlated with the Japanese nodal level and TNM stage, respectively (p<0.001). The 5-year disease-specific survival rate according to the number of positive lymph nodes was 90% for patients without lymph node metastases, 52.2% with 1-4, and 28.9% with > or =5, respectively, p<0. 0001; 0 vs 1-4, p<0.05; 1-4 vs > or =5). CONCLUSION: The number of positive lymph nodes is well correlated with tumour progression and provides a useful prognostic indicator after oesophagectomy for oesophageal cancer.     

Prognostic relevance of minimal residual disease in colorectal cancer

Presence of occult minimal residual disease in patients with colorectal cancer (CRC) has a strong prognostic impact on survival. Minimal residual disease plays a major role in disease relapse and formation of metastases in CRC. Analysis of circulating tumor cells (CTC) in the blood is increasingly used in clinical practice for disease monitoring of CRC patients. In this review article the role of CTC, disseminated tumor cells (DTC) in the bone marrow and micrometastases and isolated tumor cells (ITC) in the lymph nodes will be discussed, including literature published until September 2013. Occult disease is a strong prognostic marker for patient survival in CRC and defined by the presence of CTC in the blood, DTC in the bone marrow and/or micrometastases and ITC in the lymph nodes. Minimal residual disease could be used in the future to identify patient groups at risk, who might benefit from individualized treatment options.