Elsevier

Surgery

Volume 158, Issue 2, August 2015, Pages 486-493
Surgery

Oncology
Prognostic relevance of lymph node ratio and total lymph node count for small bowel adenocarcinoma

Presented at the 10th Annual Academic Surgical Congress in Las Vegas, NV, February 3−5, 2015.
https://doi.org/10.1016/j.surg.2015.03.048Get rights and content

Background

Nodal metastasis is a known prognostic factor for small bowel adenocarcinoma. The goals of this study were to evaluate the number of lymph nodes (LNs) that should be retrieved and the impact of lymph node ratio (LNR) on survival.

Methods

Surveillance, Epidemiology, and End Results was queried to identify patients with small bowel adenocarcinoma who underwent resection from 1988 to 2010. Survival was calculated with the Kaplan-Meier method. Multivariate analysis identified predictors of survival.

Results

A total of 2,772 patients underwent resection with at least one node retrieved, and this sample included equal numbers of duodenal (n = 1,387) and jejunoileal (n = 1,386) adenocarcinomas. There were 1,371 patients with no nodal metastasis (N0, 49.4%), 928 N1 (33.5%), and 474 N2 (17.1%). The median numbers of LNs examined for duodenal and jejunoileal cancers were 9 and 8, respectively. Cut-point analysis demonstrated that harvesting at least 9 for jejunoileal and 5 LN for duodenal cancers resulted in the greatest survival difference. Increasing LNR at both sites was associated with decreased overall median survival (LNR = 0, 71 months; LNR 0–0.02, 35 months; LNR 0.21–0.4, 25 months; and LNR >0.4, 16 months; P < .001). Multivariate analysis confirmed number of LNs examined, T-stage, LN positivity, and LNR were independent predictors of survival.

Conclusion

LNR has a profound impact on survival in patients with small bowel adenocarcinoma. To achieve adequate staging, we recommend retrieving a minimum of 5 LN for duodenal and 9 LN for jejunoileal adenocarcinomas.

Section snippets

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients diagnosed with small bowel adenocarcinoma in the United States from 1988 to 2010. SEER is a population-based database of the National Cancer Institute on cancer incidence and survival. SEER comprises approximately 28% of the US population with cancer. Data in the SEER database include demographic characteristics, tumor size, depth of tumor invasion, surgery, LN count, number of positive LNs, and

Results

A total of 2,773 patients with histologic diagnosis of small bowel adenocarcinoma met the inclusion criteria for the study. Clinicopathologic characteristics are detailed in Table I. The primary site of small bowel adenocarcinoma was distributed evenly between duodenal and jejunoileal cancers (each 50%). No differences were observed in tumor differentiation, number of LN examined, and number of positive LN between the 2 sites. Patients with duodenal cancers were slightly older than those with

Discussion

Adenocarcinoma of the small intestine presents a therapeutic challenge, given its relative rarity and advanced stage of diagnosis. Although it is intuitive that examination of more LNs would translate into more reliable pathologic staging, the survival advantage of retrieving more LNs has not been substantiated. Using the SEER database, we found that both LNR and the number of LNs examined were strong predictors of survival. Even after we controlled for patient and tumor characteristics, the

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