Number of retrieved lymph nodes and survival in node-negative patients undergoing laparoscopic colorectal surgery for cancer

Background

The number of retrieved lymph nodes in colorectal cancer resection may have an impact on staging and survival. Examination of at least 12 nodes has become a quality measure for adequate surgical practice. To evaluate the impact of the number of retrieved lymph nodes in laparoscopic colorectal surgery for cancer on node-negative patients’ survival.

Methods

Evaluation of our prospective in-hospital collected data of patients that underwent laparoscopic surgery for curable colorectal cancer over a 5-year period. Long-term data were collected from our outpatient’s clinic data and personal contact when necessary.

Results

During a 5-year period since September 2003,173 patients were operated laparoscopically for curable colorectal cancer. Of the 117 patients who were node negative, 85 node-negative patients (72%) had 12 or more evaluated lymph nodes (mean, 18.3 + 2.4), while 32 node-negative patients had less than 12 (mean, 8.3 + 6.2). Patients with fewer than 12 nodes evaluated had significantly more left-sided tumors, while patients with 12 nodes or more had more right-sided tumors. A comparison of 5-year disease free and overall Kaplan–Meier survival curves revealed no statistically significant difference between the two groups.

Conclusions

Evaluation of less than 12 nodes may not necessarily impact patients’ survival in node-negative patients undergoing laparoscopic resection for curable colorectal cancer. A lower number of nodes may be sufficient.     

K-19 mRNA RT-PCR in detecting micrometastasis in regional lymph nodes of gastric cancer

AIM: To investigate the value and prospect of RT-PCR in detecting micrometastasis in regional lymph nodes of gastric cancer. METHODS: Histopathology was used and K19 mRNA expression was detected by RT-PCR in tumor tissues and lymph nodes from gastric cancer patients undergoing radical resection of gastric carcinoma. RESULTS: K19 mRNA was expressed in all tumor specimens of 30 cases; of the 126 lymph nodes, 26 were histopathologically positive (20.6%), and 42 positive (33.3%) by RT-PCR. Amplification fragments of 460 and 540 bp were shown in all the tumor tissues and metastatic lymph nodes after K19 andβ-actin RT-PCR, while only a 540 bp fragment appeared in the lymph nodes of non-tumor patients. CONCLUSION: K19 mRNA RT-PCR is sensitive and specific in testing micrometastasis in regional lymph nodes of gastric cancer, and it is superior to routine histopathology.     

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.     

结直肠癌患者淋巴结微转移与外周血NK细胞活性、IL-2、IL-12水平的关系

目的探讨结直肠癌患者淋巴结微转移与外周血NK细胞活性及IL-2、IL-12水平的关系。方法采用流式细胞仪检测21例结直肠癌患者外周血NK细胞活性,ELLISA法检测患者外周血中的IL-2、IL-12;手术取肿瘤周围系膜淋巴结281枚,采用RT-PCR法检测淋巴结组织中的细胞角蛋白20（CK20）mRNA,以判断淋巴结微转移情况。结果 21例中有淋巴结微转移（CK20 mRNA阳性）者10例（140枚）;无淋巴结微转移者外周血NK细胞活性及IL-2、IL-12水平高于有微转移者（P均〈0.05）;且淋巴结微转移与NK细胞活性及IL-2、IL-12水平呈负相关（r分别为-0.532、-0.834、-0.819,P均〈0.05）。结论结直肠癌患者淋巴结微转移的发生与外周血NK细胞活性及IL-2、IL-12水平低下有关。     

Prognosis of gastric cancer patients with node-negative metastasis following curative resection: outcomes of the survival and recurrence

BACKGROUND: The purpose of the present study was to provide valuable prognostic information on lymph node-negative gastric cancer patients following curative resection. METHODS: Data from 112 lymph node-negative gastric cancer patients who underwent curative resection were reviewed to identify the independent factors of overall survival and recurrence. RESULTS: The five-year survival rate of lymph node-negative gastric cancer patients was 85.7%, and recurrence was identified in 25 patients after curative surgery. The five-year survival rate of lymph node-negative gastric cancer patients was higher than that of lymph node-positive gastric cancer patients (P<0.001). Recurrence in lymph node-negative gastric cancer patients was less than that of lymph node-positive gastric cancer patients (P=0.001). The median survival after recurrence of lymph node-negative gastric cancer patients was longer than that of lymph node-positive gastric cancer patients (P=0.021). Using multivariate analyses, the following results were determined for lymph node-negative gastric cancer patients: sex, operative type and the presence of serosal involvement were independent factors of overall survival; and lymphadenectomy, number of dissected nodes and the presence of serosal involvement were independent factors of recurrence. CONCLUSIONS: The prognosis of lymph node-negative gastric cancer patients was better than that of lymph node-positive gastric cancer patients. Male sex, subtotal gastrectomy and nonserosal involvement should be considered to be the favourable predictors of postoperative long-term survival of lymph node-negative gastric cancer patients. Conversely, limited lymphadenectomy, few dissected nodes and serosal involvement should be considered to be risk factors of postoperative recurrence of lymph node-negative gastric cancer patients.     

Impact of the number of negative nodes on disease-free survival in colorectal cancer patients

PURPOSE: Between 1995 and 1999, we observed an increasing number of nodes being recovered from colorectal specimens. Patients with colorectal cancer were studied to determine whether increasing the number of negative nodes recovered would better stage the patient and more accurately predict disease-free survival. METHODS: All patients undergoing colorectal resection with curative intent between 1995 and 1999 at a tertiary referral hospital were retrospectively reviewed. Tumor stage, grade, number of nodes recovered, and the association of these factors with disease-free survival was analyzed. RESULTS: Three hundred forty-five patients with M0 disease undergoing surgical resection of carcinoma of the colon or rectum were studied. There was no statistically significant difference in tumor stage or grade during the study period. A statistically significant increase in the mean number of nodes recovered was observed during the study period. Node-positive patients did substantially worse than node-negative individuals. When compared with a national cancer registry (OncoPool), we observed a significantly greater number of nodes sampled in our study population and a statistically significant improved disease-free survival between our node-negative patients and that of the national cancer registry population. CONCLUSION: The extent of the pathologic assessment of the nodal status of colorectal cancer patients as determined by the number of nodes examined affects disease-free survival. The need for quality control for uniform pathologic assessments is critical.     

Circulating Vascular Endothelial Growth Factor in Patients With Colorectal Cancer

Objective : The expression of vascular endothelial growth factor (VEGF), a glycoprotein that selectively promotes proliferation of endothelial cells, has been associated with cancer development. The aim of the present study was to determine whether serum levels of VEGF correlate with disease progression in patients with colorectal cancer. Methods : VEGF levels were measured by a highly sensitive enzyme-linked immunosorbent assay in sera from 67 patients with colorectal cancer, 14 patients with colorectal adenomas, and 72 healthy volunteers, and in tissue homogenates from 10 patients with colorectal cancer. Results : Serum VEGF levels were significantly higher in patients with colorectal cancer than in patients with colorectal adenomas or in normal controls (   p < 0.01  ). In patients with colorectal cancer, serum VEGF levels were significantly associated with Dukes stage (   p < 0.01  ) and with carcinoembryonic antigen levels (   r = 0.725  ,   p < 0.001  ). Patients with hepatic and/or lymph node metastasis had higher serum VEGF levels than those without. Surgical resection of the colorectal tumor led to a decrease in serum VEGF levels whether or not metastasis was present (   p < 0.05  ). The tumor-bearing tissue contained significantly more VEGF than normal-appearing mucosa (   p < 0.05  ). Conclusions : VEGF is involved in the development of colorectal cancer. Measurement of VEGF in the serum may be a useful noninvasive clinical marker for evaluating the disease status.     

Increased lymph node retrieval decreases adjuvant chemotherapy rate for stage II colon cancer

Objective: Investigation of lymph nodes in colorectal specimens after surgery due to cancer is important for staging the cancer. There has to be an adequate number of lymph nodes to conclude a node-negative status. Our aim was to investigate if change in fixative could give increased lymph node yield, and if this could result in a potential decrease of adjuvant treatment for stage II patients. In addition, we wanted to evaluate if the change in fixative could potentially affect subsequent molecular testing. Material and methods: All resection specimens from one hospital were from 2011 fixed in GEWF while resection specimens from two other hospitals were fixed in conventional buffered formalin. Number of lymph nodes harvested were compared from two periods; 2009/2010 and 2012/2013. In addition, tumors fixed in GEWF and tumors fixed in formalin were tested separately with immunohistochemical staining and molecular testing. Results: There was a significant increase in lymph node retrieval in specimens fixed in GEWF compared to number of lymph nodes found before the implementation of this fixative (p?Conclusions: GEWF enhances lymph node detection in colorectal cancer specimens, leading to fewer patients being falsely defined as high-risk stage II. The loss of stability when staining for MMR-proteins can be overcome by molecular analysis when needed.     

How many lymph nodes should be examined in Dukes' B colorectal cancer? Determination on the basis of cumulative survival rate

BACKGROUND/AIMS: We analyzed how many lymph nodes should be examined to establish the presence or absence of lymph node metastasis, a staging factor, based on cumulative survival rate in colorectal cancer. METHODOLOGY: Among those who had undergone curative resection of colorectal cancer and lymphadenectomy exceeding D2, 94 patients with Dukes' B colorectal cancer (group B) and 108 patients with Dukes' C colorectal cancer (group C) were investigated, excluding obvious deaths from other diseases. Group B was divided into two groups by the number of lymph nodes examined, and the minimum number of retrieved lymph nodes yielding significant difference in survival rate was determined. RESULTS: Dividing group B into two groups by the number of lymph nodes examined, survival rate was studied. The minimum number of retrieved lymph nodes yielding significant difference in survival rate between the two groups was observed when group B was divided into one group with 9 or more lymph nodes (72 patients) and the other with less than 9 (22 patients), with cumulative five-year survival rate of 86.7% and 66.7%, respectively. More favorable prognoses were observed in the 9 or more group compared with the less than 9 group or Dukes' C group (p=0.0284, p=0.0032, respectively). On the other hand, survival rate of the less than 9 group was similar to that of the Dukes' C group (p=0.8167). CONCLUSIONS: Based on survival rate, 9 or more lymph nodes should be examined in order to correctly ascertain nodal negativity in lymphadenectomy exceeding D2 for Dukes' B colorectal cancer.     

Extracapsular invasion as a risk factor for disease recurrence in colorectal cancer

AIM: To evaluate the presence of extracapsular invasion (ECI) in positive nodes as a predictor of disease recurrence disease in colorectal cancer. METHODS: Two hundred and twenty-eight consecutive patients who underwent colorectal resection were identified for inclusion in this study, of which 46 had positive lymph nodes. Among 46 cases with stage Ⅲcolorectal cancer, 16 had ECI at positive nodes and 8 had disease recurrence. The clinical and pathological features of these cases were reviewed. RESULTS: In th...     

Approaches to resection of recurrent solitary mediastinal lymph nodes after esophagectomy

Esophageal cancer recurrence in solitary mediastinal lymph node that may possibly been left behind in the first surgery differs from other recurrence patterns because it is still local disease and offers the possibility of complete cure through resection, but it is technically difficult. We resected recurrent mediastinal lymph nodes in six cases. A left transthoracic approach was used in three patients. Other approaches were left thoracoabdominal, right open transthoracic and transcervical. R0 resections were achieved in five patients without severe surgical stress or postoperative complications. Overall survival after resection of recurrent lymph nodes was 43 (16–82) months. Approaches to resection of recurrent solitary mediastinal lymph nodes after esophagectomy should be consider to perform curative treatment safely and less invasively.

     

Character of the invasive margin in colorectal cancer

PURPOSE: The clinical significance and prognostic value of the histopathologic parameters used in both the Dukes and Jass classifications were evaluated to select those with an independent effect on survival after radical surgery for colorectal cancer. METHODS: The depth of local spread (limited to the bowel wall or extended beyond it), the number of metastatic lymph nodes (none, 1–4, more than 4), the character of the invasive margin (pushing or infiltrating), and the presence or absence of conspicuous peritumoral lymphocytic infiltration were assessed in 235 patients who had undergone radical resection for colorectal cancer. The influence of these variables on survival was studied by univariate and multivariate analysis. RESULTS: No significant difference in survival was found between patients with conspicuous peritumoral infiltrate and those without it; moreover, multivariate analysis failed to show any independent prognostic value for either lymphocytic infiltration or depth of local invasion. However, the character of the invasive margin and the number of metastatic lymph nodes were identified as the only variables with any independent importance on survival. Based on these data, a new prognostic model may be proposed; it uses the character of the infiltrative margin as a discriminating factor among patients within the lymph node-negative (Dukes A and B stages) and lymph node-positive (Dukes C1 and C2 subsets) groups. A good prognosis for Dukes A, B, and C1 patients was associated with pushing tumors; C1 and C2 patients with infiltrating tumors had a poor prognosis. On the whole, the new prognostic model has allowed for the placement of 59.6 percent of our patients into groups that provide a confident prognosis. The clinical outcome of Dukes A and B patients with infiltrating tumors is still uncertain. CONCLUSIONS: The character of the invasive margin is an important prognostic factor in colorectal cancer. The association of this parameter with the traditional Dukes classification may provide additional useful prognostic information and aid in the selection of those patients who could most benefit from adjuvant therapy.     

外周血CK20 mRNA表达与结直肠癌临床病理和预后的关系

目的:探讨外周静脉血中CK20 mRNA表达及其与结直肠癌临床病理及预后的关系.方法:选取结直肠癌术前患者61例、健康志愿者20例和结直肠息肉患者10例,采用RT-PCR法检测其外周静脉血中CK20 mRNA的表达,并结合其临床病理特点和随访资料进行综合分析.结果:61例结直肠癌患者术前外周血CK20 mRNA阳性率为41.0%(25/61);其表达与肿瘤TNM分期、浸润深度、远处转移和区域淋巴结转移有关(P<0.05).20例健康志愿者和10例结直肠息肉患者外周血均无CK20 mRNA表达.在61例结直肠癌患者中,术后46mo完整随访的有37例,其中有17例死亡,有10例外周血CK20 mRNA表达阳性.结论:外周静脉血中CK20 mRNA的表达与结直肠癌患者的肿瘤分期和浸润转移有关.血液中CK20是反映结直肠癌患者发生肿瘤微转移较为特异的肿瘤标志物,外周血液中CK20 mRNA的表达可作为评估患者预后的指标.     

Risk of Lymph Node and Distant Metastases in Patients With Early Invasive Colorectal Cancer Classified as Haggitt’s Level 4 Invasion

PURPOSE: Tumor invasion in patients with early invasive colorectal cancer has been classified into four levels proposed by Haggitt. Level 4 invasion into the submucosa has been defined as a risk factor for lymph node metastasis; however, the false-positive rate remains high. This study was designed to determine risk factors for lymph node and distant metastases in addition to Haggitt's Level 4 invasion. METHODS: Seventy-one of 142 patients with submucosa-invasive colorectal cancer underwent intestinal resection as an initial surgical treatment between 1975 and 2000. The subjects of this study were 65 of these 71 patients, all of whom were diagnosed as having Haggitt's Level 4 invasion. The depth, width, and area of submucosal invasion were measured with an image analyzer. RESULTS: Lymph node metastasis was noted in 11 (16.9 percent) of the 65 patients. There were no significant differences in the depth or area of submucosal invasion between node-positive and node-negative patients. However, the width of submucosal invasion was significantly greater in node-positive than in node-negative patients (P = 0.001). When 5-mm-wide submucosal invasion was used as an indicator for intestinal resection, 37 patients were found to have indications for bowel resection, and 11 (29.7 percent) of the 37 had lymph node metastases. Distant metastasis was noted in five patients (7.7 percent). The depth, width, and area of submucosal invasion in patients with distant metastasis did not differ significantly from those without distant metastasis. CONCLUSION: Although further prospective investigation is required, the positive predictive value increases from 17 to 30 percent when the width of submucosal invasion is added to Haggitt's Level 4 as an indicator for bowel resection.