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Less Than 12 Nodes in the Surgical Specimen After Total Mesorectal Excision Following Neoadjuvant Chemoradiation: It means more than you think!

  • Colorectal Cancer
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

A minimum of 12 examined lymph nodes (LN) is recommended to ensure adequate staging and oncologic resection of patients undergoing proctectomy for rectal adenocarcinoma. However, a decreased number of LN is not unusual in patients receiving neoadjuvant chemoradiation.

Purpose

We hypothesized that a decreased number of LN in the proctectomy specimen of these patients may be an indicator of tumor response and be associated with improved prognosis.

Methods

A single-center colorectal cancer database was queried for c-stage II–III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized into two groups according to the number of LN retrieved from the proctectomy specimen: <12 LN versus ≥12 LN. Groups were compared with respect to demographics, tumor and treatment characteristics, and the following oncologic outcomes: overall-survival (OS), cancer-specific-mortality (CSM), cancer-free-survival (CFS), distant (DR), and local recurrences (LR).

Results

The query returned 237 patients. There were 173 (73 %) males, and the median age was 57 years [interquartile range (IQR) 49–66 years]. The median number of LN retrieved was 15 (IQR 10–23) and 70 (30 %) patients had less than 12 nodes examined. The <12 nodes group was older [60 (IQR 51–71 years) vs. 55 (IQR 48–65 years), p = 0.009] and had more pathologic complete responders (36 vs. 19 %, p = 0.01). No <12 nodes patient experienced a LR, whereas the 5-year LR rate was 11 % in the ≥12 nodes group (p = 0.004). Other oncologic outcomes were not significantly different.

Conclusions

Retrieval of less than 12 nodes in the proctectomy specimen of rectal cancer patients treated with neoadjuvant chemoradiation does not affect OS, CSM, CFS, or DR and may be a marker of higher tumor response and, consequently, decreased LR rate.

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References

  1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2012;62:10–29.

    Article  PubMed  Google Scholar 

  2. NCCN Guindelines. 2011. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp. Accessed 3 Nov 2012.

  3. Compton CC, Fielding LP, Burgart LJ, Conley B, Cooper HS, Hamilton SR et al. Prognostic factors in colorectal cancer. College of American Pathologists Consensus Statement 1999. Arch Pathol Lab Med. 2000;124:979–94.

    PubMed  CAS  Google Scholar 

  4. Nelson H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst. 2001;93:583–96.

    Article  PubMed  CAS  Google Scholar 

  5. Edge S, Byrd D, Compton C, Fritz A, Greene F, Trotti I. AJCC—Cancer staging manual, 7 edn. New York: Springer; 2010.

    Google Scholar 

  6. Washington MK, Berlin J, Branton P, Burgart LJ, Carter DK, Fitzgibbons PL et al. Protocol for the examination of specimens from patients with primary carcinoma of the colon and rectum. Arch Pathol Lab Med. 2009;133:153–51.

    PubMed  Google Scholar 

  7. Anthony T, Simmang C, Hyman N, Buie D, Kim D, Cataldo P et al. Practice parameters for the surveillance and follow-up of patients with colon and rectal cancer. Dis Colon Rectum. 2004;47:807–17.

    Article  PubMed  Google Scholar 

  8. Benson AB 3rd, Schrag D, Somerfield MR, Cohen AM, Figueredo AT, Flynn PJ et al. American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. J Clin Oncol. 2004;22:3408–19.

    Article  PubMed  Google Scholar 

  9. The Association of Coloproctology of Great Britain and Ireland (2012) The Association of Coloproctology of Great Britain and Ireland (2011). Guidelines for the Management of Colorectal Cancer. http://www.acpgbi.org.uk/members/guidelines/filter/documents/. Accessed 3 Nov 2012.

  10. Wang J, Kulaylat M, Rockette H, Hassett J, Rajput A, Dunn KB, Dayton M. Should total number of lymph nodes be used as a quality of care measure for stage III colon cancer? Ann Surg. 2009;249:559–63.

    Article  PubMed  Google Scholar 

  11. Stocchi L, Fazio VW, Lavery I, Hammel J. Individual surgeon, pathologist, and other factors affecting lymph node harvest in stage II colon carcinoma. Is a minimum of 12 examined lymph nodes sufficient? Ann Surg Oncol. 2011;18:405–12.

    Article  PubMed  Google Scholar 

  12. Vather R, Sammour T, Kahokehr A, Connolly AB, Hill AG. Lymph node evaluation and long-term survival in Stage II and Stage III colon cancer: a national study. Ann Surg Oncol. 2009;16:585–93.

    Article  PubMed  Google Scholar 

  13. Wang H, Safar B, Wexner S, Zhao R, Cruz-Correa M, Berho M. Lymph node harvest after proctectomy for invasive rectal adenocarcinoma following neoadjuvant therapy: does the same standard apply? Dis Colon Rectum. 2009;52:549–57.

    Article  PubMed  Google Scholar 

  14. de la Fuente SG, Manson RJ, Ludwig KA, Mantyh CR. Neoadjuvant chemoradiation for rectal cancer reduces lymph node harvest in proctectomy specimens. J Gastrointest Surg. 2009;13:269–74.

    Article  PubMed  Google Scholar 

  15. de Campos-Lobato LF, Stocchi L, da Luz Moreira A, Geisler D, Dietz DW, Lavery IC et al. Pathologic complete response after neoadjuvant treatment for rectal cancer decreases distant recurrence and could eradicate local recurrence. Ann Surg Oncol. 2011;18:1590–8.

    Article  PubMed  Google Scholar 

  16. de Campos-Lobato LF, Geisler DP, da Luz Moreira A, Stocchi L, Dietz D, Kalady MF. Neoadjuvant therapy for rectal cancer: the impact of longer interval between chemoradiation and surgery. J Gastrointest Surg. 2011;15:444–50.

    Article  PubMed  Google Scholar 

  17. de Campos-Lobato LF, Wells B, Wick E, Pronty K, Kiran R, Remzi F, Vogel JD. Predicting organ space surgical site infection with a nomogram. J Gastrointest Surg. 2009;13:1986–92.

    Article  PubMed  Google Scholar 

  18. Lavery IC, Lopez-Kostner F, Fazio VW, Fernandez-Martin M, Milsom JW, Church JM. Chances of cure are not compromised with sphincter-saving procedures for cancer of the lower third of the rectum. Surgery. 1997;122:779–84; discussion 784–5.

    Article  PubMed  CAS  Google Scholar 

  19. Lopez-Kostner F, Lavery IC, Hool GR, Rybicki LA, Fazio VW. Total mesorectal excision is not necessary for cancers of the upper rectum. Surgery. 1998;124:612–7; discussion 617–8.

    Article  PubMed  CAS  Google Scholar 

  20. Lavery IC, Lopez-Kostner F, Pelley RJ, Fine RM. Treatment of colon and rectal cancer. Surg Clin North Am. 2000;80:535–69.

    Article  PubMed  CAS  Google Scholar 

  21. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg. 1982;69:613–6.

    Article  PubMed  CAS  Google Scholar 

  22. de Campos-Lobato LF, Stocchi L, Dietz DW, Lavery IC, Fazio VW, Kalady MF. Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes. Dis Colon Rectum. 2011;54:939–46.

    Article  PubMed  Google Scholar 

  23. Compton CC. Updated protocol for the examination of specimens from patients with carcinomas of the colon and rectum, excluding carcinoid tumors, lymphomas, sarcomas, and tumors of the vermiform appendix: a basis for checklists. Cancer Committee. Arch Pathol Lab Med. 2000;124:1016–25.

    PubMed  CAS  Google Scholar 

  24. Sobin LH, Fleming ID. TNM classification of malignant tumors. Fifth edition. Union Internationale Contre le Cancer and the American Joint Committee on Cancer. Cancer. 1997. pp.1803–4.

  25. Greene FL, Page DL, Fleming ID, Fritz A, Balch CM, Haller DG, Morrow M. AJCC cancer staging manual, 6 edn. Chicago: Springer; 2002.

    Book  Google Scholar 

  26. American Society of Colon & Rectal Surgeons. Screening & Surveillance for Colorectal Cancer. 2008. http://www.fascrs.org/patients/treatments_and_screenings/assess_your_risk_for_colorectal_cancer/screening/. Accessed 3 Nov 2012.

  27. Wirtzfeld DA, Mikula L, Gryfe R, Ravani P, Dicks El, Parfrey P et al. Concordance with clinical practice guidelines for adjuvant chemotherapy in patients with stage I-III colon cancer: experience in 2 Canadian provinces. Can J Surg. 2009;52:92–7.

    PubMed  Google Scholar 

  28. Pocock SJ, Clayton TC, Altman DG. Survival plots of time-to-event outcomes in clinical trials: good practice and pitfalls. Lancet. 2002;359:1686–9.

    Article  PubMed  Google Scholar 

  29. Marks JH, Valsdottir EB, Rather AA, Nweze IC, Newman DA, Chernick MR. Fewer than 12 lymph nodes can be expected in a surgical specimen after high-dose chemoradiation therapy for rectal cancer. Dis Colon Rectum. 2010;53:1023–9.

    Article  PubMed  CAS  Google Scholar 

  30. Govindarajan A, Gonen M, Weiser MR, Shia J, Temple LK, Guillem JG et al. Challenging the feasibility and clinical significance of current guidelines on lymph node examination in rectal cancer in the era of neoadjuvant therapy. J Clin Oncol. 2011;29:4568–73.

    Article  PubMed  CAS  Google Scholar 

  31. Habr-Gama A, Perez RO, Proscurshim I, Nunes Dos Santos RM, Kiss D, Gama-Rodrigues J, Cecconello I. Interval between surgery and neoadjuvant chemoradiation therapy for distal rectal cancer: does delayed surgery have an impact on outcome? Int J Radiat Oncol Biol Phys. 2008;71:1181–8.

    Article  PubMed  Google Scholar 

  32. Rullier A, Laurent C, Capdepont M, Vendrely V, Belleannee G, Bioulac-Sage P, Rullier E. Lymph nodes after preoperative chemoradiotherapy for rectal carcinoma: number, status, and impact on survival. Am J Surg Pathol. 2008;32:45–50.

    Article  PubMed  Google Scholar 

  33. de Campos-Lobato LF, Stocchi L, da Luz Moreira A, Kalady MF, Geisler D, Dietz D et al. Downstaging without complete pathologic response after neoadjuvant treatment improves cancer outcomes for cIII but not cII rectal cancers. Ann Surg Oncol. 2010;17:1758–66.

    Article  PubMed  Google Scholar 

  34. Fajardo LF. Effects of ionizing radiation on lymph nodes. A review. Front Radiat Ther Oncol. 1994;28:37–45.

    PubMed  CAS  Google Scholar 

  35. Shvero J, Koren R, Marshak G, Sadov R, Hadar T, Yaniv E et al. Histological changes in the cervical lymph nodes after radiotherapy. Oncol Rep. 2001;8:909–11.

    PubMed  CAS  Google Scholar 

  36. Stipa F, Zernecke A, Moore HG, Minsky BD, Wong WD, Weiser M et al. Residual mesorectal lymph node involvement following neoadjuvant combined-modality therapy: rationale for radical resection? Ann Surg Oncol. 2004;11:187–91.

    Article  PubMed  Google Scholar 

  37. Zmora O, Dasilva GM, Gurland B, Pfeffer R, Koller M, Nogueras JJ, Wexner SD. Does rectal wall tumor eradication with preoperative chemoradiation permit a change in the operative strategy? Dis Colon Rectum. 2004;47:1607–12.

    Article  PubMed  Google Scholar 

  38. Mignanelli ED, de Campos-Lobato LF, Stocchi L, Lavery IC, Dietz DW. Downstaging after chemoradiotherapy for locally advanced rectal cancer: is there more (tumor) than meets the eye? Dis Colon Rectum. 2010;53:251–6.

    Article  PubMed  Google Scholar 

  39. National Cancer Institute—Surveillence Epidemiology and End Results. SEER Cancer Statistics Review. 2009. http://seer.cancer.gov/csr/1975_2006/. Accessed 3 Nov 2012.

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Acknowledgment

The authors acknowledge Patricia Cristina-Alves Ferreira and Jeff Hammel for their critical review of this manuscript.

Disclosures

The authors of this manuscript have no conflicts of interest to disclose.

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Authors and Affiliations

  1. Desk A 30, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA

    Luiz Felipe de Campos-Lobato, Luca Stocchi MD, FACS, FASCRS, Ian C. Lavery MD, Victor W. Fazio MD, David W. Dietz MD & Matthew F. Kalady MD

  2. Division of Coloproctology, Department of Surgery, University of Brasília School of Medicine, Brasília, DF, Brazil

    Luiz Felipe de Campos-Lobato & João Batista de Sousa

  3. Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA

    Martin Buta MD

Authors
  1. Luiz Felipe de Campos-Lobato
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  2. Luca Stocchi MD, FACS, FASCRS
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  5. Ian C. Lavery MD
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Corresponding author

Correspondence to Luca Stocchi MD, FACS, FASCRS.

Additional information

Presented at the poster session of American Society of Colon and Rectal Surgeons Annual Meeting in Vancouver, BC, Canada, May 2011. Podium presentation at the Tripartite Colorectal Meeting, Cairns, Australia, July, 2011. Podium presentation at the International Society of University Colon & Rectal Surgeons Bologna, Italy, June, 2012. This paper is part of Dr. de Campos-Lobato LF’s PhD thesis.

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de Campos-Lobato, L.F., Stocchi, L., de Sousa, J.B. et al. Less Than 12 Nodes in the Surgical Specimen After Total Mesorectal Excision Following Neoadjuvant Chemoradiation: It means more than you think!. Ann Surg Oncol 20, 3398–3406 (2013). https://doi.org/10.1245/s10434-013-3010-x

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