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Picciariello A, Annicchiarico A, Gallo G, Dezi A, Grossi U. Evaluation of the da Vinci single-port system in colorectal cancer surgery: a scoping review. Updates Surg 2024; 76:2515-2520. [PMID: 39369142 DOI: 10.1007/s13304-024-02014-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Accepted: 09/25/2024] [Indexed: 10/07/2024]
Abstract
Minimally invasive surgery for the treatment of colon and rectal cancer has gained popularity due to its association with reduced postoperative pain, shorter hospital stays, and quicker recovery. The Da Vinci Single-Port (SP) System combines single-port laparoscopy with robotic assistance. This scoping review aims to evaluate the safety and short-term postoperative outcomes of utilizing the Da Vinci SP platform in colorectal cancer surgery. A scoping review was conducted adhering to the PRISMA-ScR guidelines. Data were collected from PubMed, Embase, and the Web of Science Library as of December 22, 2023. Studies were screened and selected based on predefined criteria, focusing on the application of the SP robotic system in colorectal procedures. Data extraction included demographics, surgical details, intraoperative and postoperative outcomes. A narrative summary of the results was provided due to the heterogeneity in study designs. From an initial 2312 articles, 22 studies were selected for analysis, encompassing 465 patients undergoing robotic SP colorectal surgeries. Of these, 384 (82.6%) had a cancer diagnosis. The median age was 65 years, with approximately 60% being male. The median operative time was 225 min, with docking times averaging 12-20 min. Conversion to multi-port laparoscopy occurred in 4.2% of cases, with no conversions to open surgery. Mean intraoperative blood loss ranged from 50 to 150 ml. The mean number of lymph nodes retrieved ranged from 15 to 28. A diverting ileostomy was constructed in 20.3% of patients. Median times to flatus and soft diet were 2.5 and 3 days, respectively, with hospital stays ranging from 3 to 11 days. Perioperative complications occurred in 15.1% of patients, including wound infections (5.1%), anastomotic leakage (3.7%), and postoperative ileus (2.8%). Negative margin status (R0 resection) was achieved in 95% of cases. The Da Vinci SP robotic platform demonstrates promising safety and effectiveness in colorectal cancer surgery. It achieves high rates of successful oncological resection, adequate lymph node retrieval, and minimal intraoperative blood loss. Postoperative outcomes indicate quicker recovery times and manageable complication rates. However, longer follow-up studies are necessary to fully assess recurrence rates and long-term survival benefits associated with this innovative surgical approach.
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Affiliation(s)
| | - Alfredo Annicchiarico
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Department of General Surgery, Vaio Hospital, Fidenza, Italy
| | - Gaetano Gallo
- Department of Surgery, La Sapienza" University of Rome, Rome, Italy
| | - Agnese Dezi
- Department of Precision and Regenerative Medicine and Ionian Area, University Aldo Moro of Bari, Piazza G. Cesare, 11, 70124, Bari, Italy.
| | - Ugo Grossi
- Department of Surgery, Oncology and Gastroenterology-DiSCOG, University of Padova, Padua, Italy
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Mohan H, Harji D, Drami I, Griffiths B, Larkins K, Boyle K, Daniels IR, Baker R, Jenkins JT. Developing a curriculum for advanced fellowship training in complex cancer for the UK. Colorectal Dis 2024; 26:1551-1559. [PMID: 38992945 DOI: 10.1111/codi.17084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/15/2024] [Indexed: 07/13/2024]
Abstract
AIM Surgery for complex colorectal cancer is elaborate: preoperative assessment, patient selection, radiological interpretation, operative strategy, operative technical skills, operative standardization, postoperative care and management of complications are all critical components. Given this complexity, training that encompasses all these crucial aspects to generate suitably edified surgeons is essential. To date, no curriculum exists to guide training in advanced and recurrent pelvic malignancy, particularly for complex colorectal cancer. Such a curriculum would potentially offer numerous advantages, not only for individual surgeons but also for research, governance, international collaboration and benchmarking. The aim of this study was to design and develop a framework for a curriculum for fellowship training in complex colorectal cancer that encompasses pelvic exenteration surgery. METHOD Kern described a six-step method for curriculum design that is now widely adopted in medical education. Our study utilizes steps 1-4 of Kern's method to develop a syllabus and assessment framework for curriculum development for fellowship training in complex colorectal cancer encompassing pelvic exenteration. A literature review was conducted to address step 1, followed by targeted needs assessment in step 2 by conducting focus groups with trainees, fellows and experts to identify learning needs and goals with objective setting for step 3. An expert consensus group then voted on these recommendations and developed educational strategy recommendations as step 4. For the purposes of brevity, 'pelvic exenteration' in the text is taken to also encompass extended and multivisceral resections that fall under the remit of complex [colorectal] cancer. RESULTS Step 1 of Kern's method identified a gap in the literature on curricula in complex cancer surgery. Step 2 identified key areas regarded as learning needs by trainees, including anatomy, hands-on experience and case volume. Step 3 defined the goals and objectives of a fellowship curriculum, defined in six domains including theoretical knowledge, decision-making, technical skills, postoperative management and continuing professional development. Finally, as a prelude to stages 5 and 6, a strategy for implementation and for feedback and assessment was agreed by an expert consensus meeting that defined case volume (a minimum of 20 pelvic exenteration operations within a fellowship period) and coverage of this syllabus with derived metrics. CONCLUSIONS Our working group has developed a curriculum framework for advanced fellowship training in complex cancer in the UK. Validation is needed through implementation, and affirmation of its utility, both nationally and internationally, must be sought.
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Affiliation(s)
- Helen Mohan
- Complex Cancer Clinic, St Mark's The National Bowel Hospital, London, UK
| | - Deena Harji
- Complex Cancer Clinic, St Mark's The National Bowel Hospital, London, UK
| | - Ioanna Drami
- Complex Cancer Clinic, St Mark's The National Bowel Hospital, London, UK
| | - Ben Griffiths
- Complex Cancer Clinic, St Mark's The National Bowel Hospital, London, UK
| | - Kirsten Larkins
- Complex Cancer Clinic, St Mark's The National Bowel Hospital, London, UK
| | - Kirsten Boyle
- Complex Cancer Clinic, St Mark's The National Bowel Hospital, London, UK
| | - Ian R Daniels
- Complex Cancer Clinic, St Mark's The National Bowel Hospital, London, UK
| | - Richard Baker
- Complex Cancer Clinic, St Mark's The National Bowel Hospital, London, UK
| | - John T Jenkins
- Complex Cancer Clinic, St Mark's The National Bowel Hospital, London, UK
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Donnelly C, Or M, Toh J, Thevaraja M, Janssen A, Shaw T, Pathma-Nathan N, Harnett P, Chiew KL, Vinod S, Sundaresan P. Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators. Asia Pac J Clin Oncol 2024; 20:259-274. [PMID: 36726222 DOI: 10.1111/ajco.13917] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/19/2022] [Accepted: 12/26/2022] [Indexed: 02/03/2023]
Abstract
AIM To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs). METHODS The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance. RESULTS A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level. CONCLUSION This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.
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Affiliation(s)
- Candice Donnelly
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Michelle Or
- Radiation Oncology Network, Western Sydney Local Health District, Westmead, Australia
| | - James Toh
- Department of Surgery, Westmead Hospital, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
| | | | - Anna Janssen
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | | | - Paul Harnett
- Westmead Clinical School, University of Sydney, Sydney, Australia
- Crown Princess Mary Cancer Centre, Western Sydney Local Health District, Westmead, Australia
| | - Kim-Lin Chiew
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, Australia
- South Western Clinical School, University of New South Wales, Randwick, Australia
- Princess Alexandra Hospital, Division of Cancer Services, Brisbane, Australia
| | - Shalini Vinod
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, Australia
- South Western Clinical School, University of New South Wales, Randwick, Australia
| | - Puma Sundaresan
- Radiation Oncology Network, Western Sydney Local Health District, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
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Pinheiro M, Moreira DN, Ghidini M. Colon and rectal cancer: An emergent public health problem. World J Gastroenterol 2024; 30:644-651. [PMID: 38515957 PMCID: PMC10950624 DOI: 10.3748/wjg.v30.i7.644] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/22/2023] [Accepted: 01/22/2024] [Indexed: 02/21/2024] Open
Abstract
Colorectal cancer ranks third globally, with a high mortality rate. In the United States, and different countries in Europe, organized population screenings exist and include people between 50 and 74 years of age. These screenings have allowed an early diagnosis and consequently an improvement in health indicators. Colon and rectal cancer (CRC) is a disease of particular interest due to the high global burden associated with it and the role attributed to prevention and early diagnosis in reducing morbidity and mortality. This study is a review of CRC pathology and includes the most recent scientific evidence regarding this pathology, as well as a diagnosis of the epidemiological situation of CRC. Finally, the recommendation from a public health perspective will be discussed in detail taking into account the context and the most current recommendations.
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Affiliation(s)
- Marina Pinheiro
- LAQV, REQUIMTE, Department of Chemistry, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Unidade de Saúde Pública, Unidade Local de Saúde Barcelos/Esposende, Barcelinhos 4755-069, Braga, Portugal
| | - David Nascimento Moreira
- Unidade de Saúde Pública, Unidade Local de Saúde Barcelos/Esposende, Barcelinhos 4755-069, Braga, Portugal
| | - Michele Ghidini
- Medical Oncology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
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Gangi A, Ferrone CR. What Is the Role of Lymph Node Resections in Small Islet Tumors? Adv Surg 2023; 57:47-58. [PMID: 37536861 DOI: 10.1016/j.yasu.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Well-differentiated nonfunctional pancreatic neuroendocrine tumors are often indolent neoplasms without lymph node (LN) metastasis at diagnosis. Patients with PNETs that are functional or >2 cm should have surgical resection as per the standard of care. However, in appropriately selected patients with NF PNETs <2 cm who are at low risk of LN metastasis, the extent of surgery and lymphadenectomy could be limited.
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Affiliation(s)
- Alexandra Gangi
- Gastrointestinal Tumor Program, Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Boulevard North Tower, Suite 8215, Los Angeles, CA 90048, USA.
| | - Cristina R Ferrone
- Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Boulevard North Tower, Suite 8215, Los Angeles, CA 90048, USA
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Emile SH, Maron DJ, Horesh N, Garoufalia Z, Gefen R, Zhou P, Wexner SD. Predictors of Nodal Disease in Rectal Cancer Patients with Complete Mucosal Response to Neoadjuvant Therapy. World J Surg 2023; 47:2013-2022. [PMID: 37084107 DOI: 10.1007/s00268-023-07012-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Some patients with locally advanced rectal cancer (LARC) achieve complete mucosal response following neoadjuvant therapy (NAT) and may be candidates for watch and wait strategy. This study aimed to identify predictors of nodal disease in patients with LARC who had a complete mucosal response to NAT. METHODS This case-control study included patients with LARC who were treated with NAT in the National Cancer Database between 2004 and 2019. Patients with complete mucosal response, defined as pathologic T0, were identified and classified according to the status of the pathologic N stage into complete response (pT0, pN0) and complete mucosal response with positive nodal disease (pT0, pN +). The two groups were compared regarding baseline demographics and tumor characteristics to determine the predictors of nodal disease after NAT. RESULTS A total of 5529 patients (59.7% male) with a mean age of 59.6 ± 12.2 years had a complete mucosal response following NAT. Nodal disease was detected in 443 (8%) patients with a complete mucosal response. Independent predictors of nodal disease were clinical N + stage (OR: 1.87, p < 0.001), mucinous histology (OR: 3.8, p = 0.003), and lymphovascular invasion (OR = 4.01, p < 0.001). The clinical T stage was inversely related to the risk of nodal disease. CONCLUSIONS Despite having a complete mucosal response following NAT, 8% of patients had nodal disease. Clinical evidence of nodal involvement on preoperative assessment, mucinous tumor histology, and lymphovascular invasion predicted nodal disease after NAT. These findings should be considered when making a decision on watch and wait strategy in patients with clinical complete response.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - David J Maron
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of Surgery and Transplantation, Sheba Medical Center, Ramat Gan, Tel Aviv University, Tel Aviv, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peige Zhou
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Dowlati A, Towe CW, Linden PA. Who Are You "KITTING"? The Use of Kits to Collect Lymph Nodes During Lung Cancer Surgery. J Thorac Oncol 2023; 18:838-840. [PMID: 37348990 DOI: 10.1016/j.jtho.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Afshin Dowlati
- Division of Medical Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio.
| | - Christopher W Towe
- Division of Thoracic Surgery, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic Surgery, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, Ohio
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Weis JJ, Pryor A, Alseidi A, Tellez J, Goldblatt MI, Mattar S, Murayama K, Awad M, Scott DJ. Defining benchmarks for fellowship training in foregut surgery: a 10-year review of fellowship council index cases. Surg Endosc 2022; 36:8856-8862. [PMID: 35641699 DOI: 10.1007/s00464-022-09317-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 04/27/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Surgical treatment of foregut disease is a complex field that demands advanced expertise to ensure favorable outcomes for patients. To address the growing need for foregut surgeons, leaders within several national societies have become interested in developing a foregut fellowship. The aim of this study was to develop data-driven benchmarks that will aid in defining appropriate accreditation criteria for these fellowships. METHODS We obtained case log data for Fellowship Council fellows trained from 2009-2019. We identified 78 complex foregut (non-bariatric) case codes and divided them into 5 index case categories including (1) hiatal/paraoesophageal hernia repair, (2) fundoplication, (3) esophageal myotomy, (4) major organ resection, and (5) minor organ resection. Median volumes in each index category were compared over time using Kruskall-Wallis tests. The share of cases done using open, laparoscopic, or robotic approaches were analyzed using linear regression analysis. RESULTS For the 10 years analyzed, 1362 fellows logged 82,889 operations and 111,799 endoscopies. Median foregut cases per fellow grew significantly from 42 (IQR = 24-74) cases in 2010 to 69 (IQR = 33-106) cases in 2019. Median endoscopy volumes also grew significantly from 42 (IQR = 7-88) in 2010 to 69 (IQR 32-123) in 2019.The volume of hiatal/paraoesophageal hernia repairs increased significantly over time while volumes in the remaining 4 index categories remained stable. The share of robotic cases exhibited near perfect linear growth from 2.2% of all foregut cases in 2010 to 14.4% in 2019 (R = 0.99, p < 0.0001). Open cases exhibited linear decay from 7.2% of cases in 2010 to 4.7% of cases in 2019 (R = 0.92, p = 0.0001). Laparoscopic/thoracoscopic cases also exhibited linear decay from 90.6% of cases in 2010 to 80.9% of cases in 2019 (R = 0.98, p < 0.00001). CONCLUSIONS FC fellows are exposed to robust volumes of foregut cases. This rich data set provides an evidence-based guide for establishing criteria for potential foregut fellowships.
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Affiliation(s)
- Joshua J Weis
- University of Texas Health Science Center at Houston, Houston, USA.
| | | | | | - Juan Tellez
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Michael Awad
- Washington University in St. Louis, St. Louis, USA
| | - Daniel J Scott
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Zhou M, Thompson TD, Lin HY, Chen VW, Karlitz JJ, Fontham ETH, Theall KP, Zhang L, Hsieh MC, Pollack LA, Wu XC. Impact of Relative Dose Intensity of FOLFOX Adjuvant Chemotherapy on Risk of Death Among Stage III Colon Cancer Patients. Clin Colorectal Cancer 2022; 21:e62-e75. [PMID: 34756680 PMCID: PMC8971135 DOI: 10.1016/j.clcc.2021.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/25/2021] [Accepted: 09/16/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The National Comprehensive Cancer Network (NCCN) guidelines have recommended tailored chemotherapy for stage III high-risk (T4 and/or N2) and low-risk (T1-T3 and N1) colon cancer since 2018. Studies have investigated the effect of relative dose intensity (RDI) of FOLFOX on stage III colon cancer survival, however, none has performed a stratified analysis by risk profiles. This study aims to identify the FOLFOX optimal RDI for high-risk and low-risk stage III colon cancer patients. METHODS Data on 407 eligible patients, diagnosed with stage III colon cancer in 2011 who received FOLFOX, were collected by 8 population-based cancer registries. Multivariable Cox model and Fine-Gray competing risks model were employed to explore Optimal RDI defined as the lowest RDI administered without significant differences in either overall or cause-specific death. RESULTS Among the 168 high-risk patients, the optimal RDI cut-off was 70% (HR = 1.59 with 95% CI: 0.69-3.66 in overall mortality; HR = 1.24 with 95% CI: 0.42-3.64 in cause-specific mortality when RDI < 70% vs. RDI ≥ 70%). Among the 239 low-risk patients, none of the evaluated cut-offs were associated with significant differences in risk of death between comparison groups. The lowest assessed RDI was 45%, HR = 0.80; 95% CI: 0.24 to 2.73 for overall mortality and HR = 0.53; 95% CI: 0.06 to 4.95 for cause-specific mortality, when RDI <45% versus RDI ≥45%. CONCLUSIONS There is no significant harm on the risk of death when reducing RDI by <30% for high-risk patients. For the low-risk patients, we found that RDI as low as 45% did not significantly affect the risk of death.
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Affiliation(s)
- Meijiao Zhou
- Epidemiology Program, School of Public Health and Louisiana Tumor Registry, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Trevor D Thompson
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Hui-Yi Lin
- Biostatistics Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Vivien W Chen
- Epidemiology Program, School of Public Health and Louisiana Tumor Registry, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Jordan J Karlitz
- Division of Gastroenterology, School of Medicine, Tulane University; Gastroenterologist Southeast Louisiana Veteran Health Care System, New Orleans, LA
| | - Elizabeth T H Fontham
- Epidemiology Program, School of Public Health and Louisiana Tumor Registry, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Katherine P Theall
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Lu Zhang
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Mei-Chin Hsieh
- Epidemiology Program, School of Public Health and Louisiana Tumor Registry, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Lori A Pollack
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Xiao-Cheng Wu
- Epidemiology Program, School of Public Health and Louisiana Tumor Registry, Louisiana State University Health Sciences Center, New Orleans, LA.
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Otmani IE, Effared B, Agy FE, Abkari ME, Mazaz K, Benjelloun EB, Ousadden A, Benbrahim Z, Bouhafa T, Chbani L. Lymph Nodes With Germinal Centers Are Not Associated With Tumor Response After Neoadjuvant Treatment in Locally Advanced Rectal Cancer. CLINICAL PATHOLOGY 2022; 15:2632010X221132974. [PMCID: PMC9629553 DOI: 10.1177/2632010x221132974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022]
Abstract
In patients with locally advanced rectal cancer, neoadjuvant radiotherapy or chemoradiotherapy followed by total mesorectal excision as a standard of care. We aimed to explore the number, size, germinal centers, extracapsular invasion of lymph nodes (LN), and their impact on overall survival and disease free survival. Furthermore we also investigated the characteristics of lymph nodes in patients who received neoadjuvant therapy and those who underwent surgery between 2011 and 2018. The count and measurement of lymph nodes was assessed by careful visual inspection and manual palpation. The predictive cut-off value of the lymph node ratio (LNR) was determined based on the receiver operating characteristic (ROC), method and the survival outcomes based on Kaplan-Meier curves. We found that the size and the number of lymph nodes decreased significantly after neoadjuvant treatment. The mean LN for patients who received neoadjuvant therapy was 12.68 ± 6.69 and for patients who did not receive neoadjuvant therapy was 16.29 ± 5.61 ( P = .012). The average size for patients who received neoadjuvant therapy followed by surgery was 3.30 ± 1.10 versus 4.22 ± 1.18 mm for control group (surgery only) ( P < .001), an LNR of 0.13 (sensitivity: 86%, specificity: 47%, AUC: 60%, 95% CI, 0.41%-0.76%) predicted recurrence and metastasis. Presence of lymph nodes with germinal centers was significantly associated with absence of vascular invasion, nodal tumor deposits, distant metastasis, and lower age group (<50 years). However there was no association seen between overall survival and relapse free, total number of lymph nodes enlarged and extracapsular invasion in positive nodes. Finally there is no association between lymph nodes with germinal centers and tumor response after neoadjuvant treatment in locally advanced rectal cancer.
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Affiliation(s)
- Ihsane El Otmani
- Laboratory of Biomedical and Translational Research, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
- Laboratory of Health Sciences and Technologies, Higher Institute of Health Sciences, Hassan First University of Settat, Settat, Morocco
| | - Boubacar Effared
- Laboratory of Anatomic Pathology and Molecular Pathology, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Fatima El Agy
- Laboratory of Biomedical and Translational Research, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
- Laboratory of Anatomic Pathology and Molecular Pathology, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Mohammed El Abkari
- Department of Gastroenterology, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Khalid Mazaz
- Department of General surgery, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - El Bachir Benjelloun
- Department of General surgery, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Abdelmalek Ousadden
- Department of General surgery, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Zineb Benbrahim
- Department of Medical Oncology, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Touria Bouhafa
- Department of Radiotherapy, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
| | - Laila Chbani
- Laboratory of Biomedical and Translational Research, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
- Laboratory of Anatomic Pathology and Molecular Pathology, University Hospital Hassan II, Faculty of Medicine and Pharmacy of Fez, University Sidi Mohamed BenAbdellah, Fez, Morocco
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Ogawa S, Itabashi M, Bamba Y, Tani K, Yamaguchi S, Yamauchi S, Sugihara K. Stage II colon cancer staging using the number of retrieved lymph nodes may be superior to current TNM staging for prognosis stratification: the Japanese study group for postoperative follow-up of colorectal cancer. Int J Colorectal Dis 2021; 36:2205-2214. [PMID: 34302501 DOI: 10.1007/s00384-021-03990-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of the study was to compare staging of stage II colon cancer using the number of retrieved lymph nodes (RN) to current TNM staging for stratification of prognosis. METHODS The subjects were 6307 patients with stage II colon cancer who underwent curative resection at 24 Japanese institutions. The cutoff for the number of RN was established using Akaike information criterion (AIC) values for relapse-free survival (RFS) and overall survival (OS). Comparison of survival using TNM and T + RN (TRN) staging was performed using a Cox proportional hazards regression model. RESULTS AIC was lowest for 14 retrieved lymph nodes for RFS and OS. This number was used as the cutoff. In multivariate analysis, age (≥ 69), male gender, V1, CEA (> 5), pT (T4a, T4b), and RN-L were independent factors associated with RFS and OS. Six combinations of pT and RN categories were used to establish three subgroups: TRN stages IIA, IIB, and IIC. The 5-year RFS was 83.9%, 72.3%, and 71.8% in TNM stages IIA, IIB, and IIC; and 86.0%, 76.9%, and 60.3% in TRN stages IIA, IIB, and IIC. The 5-year OS was 90.0%, 81.3%, and 82.6% for the TNM stages; and 91.6%, 85.0%, and 71.9% for the TRN stages. The AIC for RFS was lower for TRN (22,318.2) than for TNM (22,390.6), and that for OS was also lower for TRN (16,285.3) than for TNM (16,355.1). CONCLUSION Stage II colon cancer staging using the number of retrieved lymph nodes may be superior to current TNM staging for prognosis stratification.
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Affiliation(s)
- Shimpei Ogawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Michio Itabashi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yoshiko Bamba
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kimitaka Tani
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shigeki Yamaguchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shinichi Yamauchi
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kenichi Sugihara
- Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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Zhang XF, Xue F, Dong DH, Lopez-Aguiar AG, Poultsides G, Makris E, Rocha F, Kanji Z, Weber S, Fisher A, Fields R, Krasnick BA, Idrees K, Smith PM, Cho C, Beems M, Lv Y, Maithel SK, Pawlik TM. New Nodal Staging for Primary Pancreatic Neuroendocrine Tumors: A Multi-institutional and National Data Analysis. Ann Surg 2021; 274:e28-e35. [PMID: 31356277 PMCID: PMC10182888 DOI: 10.1097/sla.0000000000003478] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the prognostic role of metastatic lymph node (LN) number and the minimal number of LNs for optimal staging of patients with pancreatic neuroendocrine tumors (pNETs). BACKGROUND Prognosis relative to number of LN metastasis (LNM), and minimal number of LNs needed to evaluate for accurate staging, have been poorly defined for pNETs. METHODS Number of LNM and total number of LN evaluated (TNLE) were assessed relative to recurrence-free survival (RFS) and overall survival (OS) in a multi-institutional database. External validation was performed using Surveillance, Epidemiology and End Results (SEER) registry. RESULTS Among 854 patients who underwent resection, 233 (27.3%) had at least 1 LNM. Patients with 1, 2, or 3 LNM had a comparable worse RFS versus patients with no nodal metastasis (5-year RFS, 1 LNM 65.6%, 2 LNM 68.2%, 3 LNM 63.2% vs 0 LNM 82.6%; all P < 0.001). In contrast, patients with ≥4 LNM (proposed N2) had a worse RFS versus patients who either had 1 to 3 LNM (proposed N1) or node-negative disease (5-year RFS, ≥4 LNM 43.5% vs 1-3 LNM 66.3%, 0 LNM 82.6%; all P < 0.05) [C-statistics area under the curve (AUC) 0.650]. TNLE ≥8 had the highest discriminatory power relative to RFS (AUC 0.713) and OS (AUC 0.726) among patients who had 1 to 3 LNM, and patients who had ≥4 LNM in the multi-institutional and SEER database (n = 2764). CONCLUSIONS Regional lymphadenectomy of at least 8 lymph nodes was necessary to stage patients accurately. The proposed nodal staging of N0, N1, and N2 optimally staged patients.
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Affiliation(s)
- Xu-Feng Zhang
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Feng Xue
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Ding-Hui Dong
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Alexandra G. Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | | | | | - Flavio Rocha
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | - Zaheer Kanji
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | - Sharon Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Alexander Fisher
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ryan Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, WI
| | - Bradley A. Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, WI
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, TN
| | - Paula M. Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, TN
| | - Cliff Cho
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Yi Lv
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Timothy M. Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
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13
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Zhu J, Hao J, Ma Q, Shi T, Wang S, Yan J, Chen R, Xu D, Jiang Y, Zhang J, Li J. A Novel Prognostic Model and Practical Nomogram for Predicting the Outcomes of Colorectal Cancer: Based on Tumor Biomarkers and Log Odds of Positive Lymph Node Scheme. Front Oncol 2021; 11:661040. [PMID: 33937076 PMCID: PMC8085421 DOI: 10.3389/fonc.2021.661040] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/22/2021] [Indexed: 12/24/2022] Open
Abstract
Background Emerging evidence shows that serum tumor biomarkers (TBs) and log odds of positive lymph node scheme (LODDS) are closely associated with the prognosis of colorectal cancer (CRC) patients. The aim of our study is to validate the predictive value of TBs and LODDS clinically and to develop a robust prognostic model to predict the overall survival (OS) of patients with CRC. Methods CRC patients who underwent radical resection and with no preoperative chemotherapy were enrolled in the study. The eligible population were randomized into training (70%) and test (30%) cohorts for the comprehensive evaluation of the prognostic model. Clinical implications of serum biomarkers and LODDS were identified by univariate and multivariate Cox proportion regression analysis. The predictive ability and discriminative performance were evaluated by Kaplan–Meier (K–M) curves and receiver operating characteristic (ROC) curves. Clinical applicability of the prognostic model was assessed by decision curve analysis (DCA), and the corresponding nomogram was constructed based on the above factors. Results A total of 1,202 eligible CRC patients were incorporated into our study. Multivariable COX analysis demonstrated that CA199 (HR = 1.304), CA125 (HR = 1.429), CEA (HR = 1.307), and LODDS (HR = 1.488) were independent risk factors for OS (all P < 0.0001). K–M curves showed that the high-risk group possessed a shorter OS than the low-risk counterparts. The area under curves (AUCs) of the model for 1-, 3- and 5-year OS were 86.04, 78.70, and 76.66% respectively for the train cohort (80.35, 77.59, and 74.26% for test cohort). Logistic DCA and survival DCA confirmed that the prognostic model displayed more clinical benefits than the conventional AJCC 8th TNM stage and CEA model. The nomograms were built accordingly, and the calibration plot for the probability of survival at 3- or 5-years after surgery showed an optimal agreement between prediction and actual observation. Conclusions Preoperative serum TBs and LODDS have significant clinical implications for CRC patients. A novel prognostic model incorporating common TBs (CA199, CA125, and CEA) and LODDS displayed better predictive performance than both single factor and the TNM classification. A novel nomogram incorporating TBs and LODDS could individually predict OS in patients with CRC.
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Affiliation(s)
- Jun Zhu
- State Key Laboratory of Cancer Biology, Institute of Digestive Diseases, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jun Hao
- Department of Experiment Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Qian Ma
- School of Clinical Medicine, Xi'an Medical University, Xi'an, China
| | - Tingyu Shi
- Health Company, Airborne Special Operations Brigade Support Battalion, Xiaogan, China
| | - Shuai Wang
- State Key Laboratory of Cancer Biology, Institute of Digestive Diseases, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jingchuan Yan
- Department of Basic Medicine, The Fourth Military Medical University, Xi'an, China
| | - Rujie Chen
- State Key Laboratory of Cancer Biology, Institute of Digestive Diseases, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Dong Xu
- Department of Experiment Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yu Jiang
- Department of Experiment Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jian Zhang
- State Key Laboratory of Cancer Biology, Department of Biochemistry and Molecular Biology, The Fourth Military Medical University, Xi'an, China
| | - Jipeng Li
- State Key Laboratory of Cancer Biology, Institute of Digestive Diseases, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
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Crippa J, Grass F, Achilli P, Behm KT, Mathis KL, Day CN, Harmsen WS, Mari GM, Larson DW. Surgical Approach to Transverse Colon Cancer: Analysis of Current Practice and Oncological Outcomes Using the National Cancer Database. Dis Colon Rectum 2021; 64:284-292. [PMID: 33555708 DOI: 10.1097/dcr.0000000000001887] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgical treatment for transverse colon cancer involves either extended colectomy or segmental resection, depending on the location of the tumor and surgeon perspective. However, the oncological safety of segmental resection has not yet been established in large cohort studies. OBJECTIVE This study aims to compare segmental resection versus extended colectomy for transverse colon cancer in terms of oncological outcomes. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted using a nationwide cohort. PATIENTS A total of 66,062 patients who underwent colectomy with curative intent for transverse stage I to III adenocarcinoma were identified in the National Cancer Database (2004-2015). MAIN OUTCOME MEASURES Patients were divided in 2 groups based on the type of surgery received (extended versus segmental resection). The primary outcome was overall survival. Secondary outcomes were 30- and 90-day mortality, length of hospital stay, and readmission rate within 30 days of surgical discharge. RESULTS Extended colectomy was performed in 44,417 (67.2%) patients, whereas 21,645 (32.8%) patients underwent segmental resection. Extended colectomy was associated with lower survival at multivariate analysis (HR, 1.07; 95% CI, 1.04-1.10; p < 0.001). The subgroup analysis showed that extended resection was independently associated with poorer survival in mid transverse colon cancers (HR, 1.08; 95% CI, 1.04-1.12; p < 0.001) and in stage III tumors (HR, 1.11; 95% CI, 1.04-1.18; p < 0.001). The number of at least 12 harvested lymph nodes was an independent predictor of improved survival in both overall and subgroup analyses. LIMITATIONS This study was limited by its retrospective design. CONCLUSION Extended colectomy was not associated with a survival advantage compared with segmental resection. On the contrary, extended colectomy was associated with slightly poorer survival in mid transverse cancers and locally advanced tumors. Segmental resection was found to be safe when appropriate margins and adequate lymph node harvest were achieved. See Video Abstract at http://links.lww.com/DCR/B454. ABORDAJE QUIRRGICO DEL CNCER DE COLON TRANSVERSO ANLISIS DE LA PRCTICA ACTUAL Y LOS RESULTADOS ONCOLGICOS UTILIZANDO LA BASE DE DATOS NACIONAL DE CNCER ANTECEDENTES:El tratamiento quirúrgico para el cáncer de colon transverso implica colectomía extendida o resección segmentaria, según la ubicación del tumor y la perspectiva del cirujano. Sin embargo, la seguridad oncológica de la resección segmentaria aún no se ha establecido en estudios de cohortes grandes.OBJETIVO:Este estudio tiene como objetivo comparar la resección segmentaria versus la colectomía extendida para el cáncer de colon transverso en términos de resultados oncológicos.DISEÑO:Este fue un estudio de cohorte retrospectivo.ESCENARIO:Este estudio se realizó utilizando una cohorte a nivel nacional.PACIENTES:Un total de 66,062 pacientes que se sometieron a colectomía con intención curativa por adenocarcinoma de colon transverso en estadio I-III fueron identificados en la Base de Datos Nacional del Cáncer (2004-2015).PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes se dividieron en dos grupos según el tipo de cirugía recibida (resección extendida versus resección segmentaria). El resultado primario fue la supervivencia global. Los resultados secundarios fueron la mortalidad a los 30 y 90 días, la duración de la estancia hospitalaria y la tasa de reingreso dentro de los 30 días posteriores al alta quirúrgica.RESULTADOS:Se realizó colectomía extendida en 44,417 (67.2%) casos, mientras que 21,645 (32.8%) pacientes fueron sometidos a resección segmentaria. La colectomía extendida se asoció con una menor supervivencia en el análisis multivariado (HR 1.07 IC 95% 1.04-1.10; p <0.001). El análisis de subgrupos mostró que la resección extendida se asoció de forma independiente con una menor supervivencia en los cánceres de colon transverso medio (HR 1.08 IC 95% 1.04-1.12; p <0.001) y en tumores en estadio III (HR 1.11 IC 95% 1.04-1.18; p <0.001). Un número de al menos 12 ganglios linfáticos cosechados fue un predictor independiente de una mejor supervivencia en los análisis general y de subgrupos.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo.CONCLUSIÓN:La colectomía extendida no se asoció con una ventaja de supervivencia en comparación con la resección segmentaria. Por el contrario, la colectomía extendida se asoció con una supervivencia levemente menor en cánceres de colon transverso medio y tumores localmente avanzados. Se encontró que la resección segmentaria es segura cuando se logran los márgenes apropiados y la cosecha adecuada de ganglios linfáticos. Consulte Video Resumen en http://links.lww.com/DCR/B454.
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Affiliation(s)
- Jacopo Crippa
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Fabian Grass
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Pietro Achilli
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin T Behm
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Courtney N Day
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota
| | - William S Harmsen
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota
| | - Giulio M Mari
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Larson
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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15
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Tran C, Howlett C, Driman DK. Evaluating the impact of lymph node resampling on colorectal cancer nodal stage. Histopathology 2020; 77:974-983. [PMID: 32654207 DOI: 10.1111/his.14209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/09/2020] [Indexed: 12/20/2022]
Abstract
AIMS Nodal staging in colorectal cancer (CRC) informs prognosis and guides adjuvant treatment decisions. A standard minimum of 12 lymph nodes is widely used, with additional sampling being performed as required. However, there are few data on how lymph node resampling in this context has an impact on nodal stage. The aims of this study were to evaluate the effectiveness of resampling in detecting metastases and tumour deposits, and the impact on stage. METHODS AND RESULTS A retrospective cohort analysis was performed on CRC resections that underwent resampling because of an initial yield of <12 lymph nodes, from 2008 to 2018. Data relating to patient demographics, specimen, malignancy and prosection were collected. Slides were reviewed to quantify nodal metastases and tumour deposits before and after resampling. Among ≥pN1 cases, logistic regression analysis was performed to evaluate factors that predicted the finding of additional metastases and tumour deposits. The cohort comprised 395 cases: resampling identified nodal metastases and/or tumour deposits in 30 (7.6%) cases; nodal upstaging occurred in 20 (5.1%) cases; and eight (2.0%) cases changed from pN0 to ≥pN1. No factors predicted resampling of positive lymph nodes or tumour deposits, and pN upstaging occurred across a variety of cases. A subgroup analysis was performed to assess the impact of resampling on high-risk features in stage II cases (n = 117). There were 33 (8.5%) patients who no longer had any high-risk features after resampling. CONCLUSIONS Lymph node resampling has an impact on nodal staging and possible treatment decisions in a considerable proportion of patients, and is recommended in all cases with <12 lymph nodes.
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Affiliation(s)
- Christopher Tran
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Christopher Howlett
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - David K Driman
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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16
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Hardt J, Buhr HJ, Klinger C, Benz S, Ludwig K, Kalff J, Post S. [Quality indicators for colon cancer surgery : Evidence-based development of a set of indicators for the outcome quality]. Chirurg 2019; 89:17-25. [PMID: 29189878 DOI: 10.1007/s00104-017-0559-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Quality assessment in surgery is gaining in importance. Although sporadic recommendations for quality indicators (QI) in oncological colon surgery can be found in the literature, these are usually not systematically derived from a solid evidence base. Moreover, reference ranges for QI are unknown. OBJECTIVE The aim of this initiative was the development of evidence-based QI for oncological colon resections by an expert panel invited by the German Society of General and Visceral Surgery (DGAV). Reference ranges from the literature and reference values from the Study, Documentation, and Quality Center (StuDoQ)|Colon Cancer Register were compared in order to deduce recommendations which are tailored to the German healthcare system. RESULTS Based on the most recent scientific evidence and agreed by expert consensus, five QI for oncological colon surgery were defined and evaluated according to the QUALIFY tool. Mortality, MTL30 (mortality, transfer to another acute care hospital, or length of stay ≥30 days), anastomotic leakage requiring reintervention, surgical site infections necessitating reopening of the wound and ≥12 lymph nodes in the specimen qualified as QI owing to their relevance, scientific nature, and practicability. Based on the results of the systematic literature search and the statistical analysis of the StuDoQ|Colon Cancer Register, preliminary reference values are proposed for each QI. CONCLUSION The presented set of QI seems appropriate for quality assessment of oncological colon surgery in the context of the German healthcare system. The validity of the QI and the reference values must be reviewed within the framework of their implementation. The StuDoQ|Colon Cancer Register provides a suitable infrastructure for collecting clinical data for quality assessment and risk adjustment.
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Affiliation(s)
- J Hardt
- Chirurgische Klinik, Universitätsmedizin Mannheim (UMM), Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - H-J Buhr
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - C Klinger
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - S Benz
- Chirurgische Klinik, Klinikum Sindelfingen-Böblingen, Böblingen, Deutschland
| | - K Ludwig
- Chirurgische Klinik, Klinikum Südstadt Rostock, Rostock, Deutschland
| | - J Kalff
- Chirurgische Klinik, Universitätsklinikum Bonn (UKB), Bonn, Deutschland
| | - S Post
- Chirurgische Klinik, Universitätsmedizin Mannheim (UMM), Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
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17
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Zaidi MY, Lopez-Aguiar AG, Dillhoff M, Beal E, Poultsides G, Makris E, Rocha F, Crown A, Idrees K, Marincola Smith P, Nathan H, Beems M, Abbott D, Barrett JR, Fields RC, Davidson J, Cardona K, Maithel SK. Prognostic Role of Lymph Node Positivity and Number of Lymph Nodes Needed for Accurately Staging Small-Bowel Neuroendocrine Tumors. JAMA Surg 2019; 154:134-140. [PMID: 30383112 PMCID: PMC6439661 DOI: 10.1001/jamasurg.2018.3865] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Little information is available regarding the minimum number of lymph nodes needed to accurately stage patients when performing a mesenteric lymphadenectomy for small-bowel neuroendocrine tumors. Objectives To determine the prognostic role of lymph node positivity and the ideal number of lymph nodes for accurately staging patients with small-bowel neuroendocrine tumors. Design, Setting, and Participants This case series from the US Neuroendocrine Tumor Study Group, a collaboration among 8 US-based, academic tertiary care referral centers, obtained demographic, perioperative, and pathologic data from the group's database, Social Security Death Index, and publicly available obituaries. All patients in these institutions with small-bowel neuroendocrine tumors who underwent curative-intent surgical resection of a primary tumor between January 1, 2000, and December 31, 2015, were included (n = 199). Patients with duodenal or ampullary tumors, other nonneuroendocrine concurrent malignant neoplasms, mortality of fewer than 30 days after the surgical procedure, and distant metastatic disease were excluded. Data analysis was conducted from September 1, 2017, to December 1, 2017. Main Outcomes and Measures Primary study outcome was recurrence-free survival. Hypothesis was generated after data collection and data entry into the US Neuroendocrine Tumor Study Group database. Results Of the 199 patients included, 112 (56.3%) were male and 87 (43.7%) female with a mean (SD) age of 60.3 (12.5) years and a mean (SD) body mass index of 29.5 (6.0). One hundred fifty-four patients (77.4%) had lymph node-positive disease. No difference in 3-year recurrence-free survival was found between patients with lymph node-positive and lymph node-negative disease. Patients with 4 positive lymph nodes had a worse 3-year recurrence-free survival compared with those with 1 to 3 or 0 positive lymph nodes (81.6% vs 91.4% vs 92.1%; P = .01). When examining patients with fewer than 8 resected lymph nodes, no difference in 3-year recurrence-free survival was observed among patients with 4 or more, 1 to 3, or 0 positive lymph nodes (100% vs 93.8% vs 91.7%; P = .87). Retrieval of 8 or more lymph nodes, however, accurately discriminated patients with 4 or more, 1 to 3, or 0 positive lymph nodes (3-year recurrence-free survival: 79.9% vs 89.6% vs 92.9%; P = .05). Conclusions and Relevance The findings from this study suggest that, for patients undergoing curative-intent resection of small-bowel neuroendocrine tumors, accurate lymph node staging requires a minimum of 8 lymph nodes for examination, and 4 or more positive lymph nodes are associated with decreased 3-year recurrence-free survival compared with 1 to 3 or 0 positive lymph nodes; a thorough regional lymphadenectomy may be critical for accurate staging and management of this disease.
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Affiliation(s)
- Mohammad Y. Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Alexandra G. Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus
| | - Eliza Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Eleftherios Makris
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Flavio Rocha
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Angelena Crown
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paula Marincola Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hari Nathan
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Megan Beems
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Daniel Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - James R. Barrett
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jesse Davidson
- Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Okada K, Sadahiro S, Chan LF, Ogimi T, Miyakita H, Saito G, Tanaka A, Suzuki T. The Number of Natural Killer Cells in the Largest Diameter Lymph Nodes Is Associated with the Number of Retrieved Lymph Nodes and Lymph Node Size, and Is an Independent Prognostic Factor in Patients with Stage II Colon Cancer. Oncology 2018; 95:288-296. [PMID: 30138925 DOI: 10.1159/000491019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 06/18/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We previously reported that the largest diameter of retrieved lymph nodes (LNs) correlates with the number of LNs and is a prognostic factor in stage II colon cancer. We examine whether T, B, and natural killer (NK) cells in LNs are related to the number of LNs and survival. METHODS The subjects comprised 320 patients with stage II colon cancer. An LN with the largest diameter was selected in each patient. The positive area ratios of cells that stained for CD3 and CD20, and the numbers of CD56-positive cells were measured. RESULTS The CD3-positive area ratio was 0.39 ± 0.08 and CD20-positive area ratio was 0.42 ± 0.10. The mean number of CD56-positive cells was 19.3 ± 22.7. The area ratios of B cells and T cells and the number of NK cells were significantly related to the sizes of the largest diameter LNs. The number of NK cells significantly correlated with the number of LNs and was an independent prognostic factor. On multivariate analysis, pathological T stage (T4 or T3; HR 4.71; p < 0.001) and the number of CD56-positive cells (high or low; HR 0.22; p < 0.001) were found to be independent prognostic factors. CONCLUSIONS The number of NK cells in the largest diameter LNs can most likely be used as a predictor of recurrence.
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Abstract
Tumor stage, as determined by the Tumor, Node, Metastasis (TNM) staging system, is the single most influential factor determining treatment decisions and outcome among patients with colorectal cancer. Several stage-related elements in pathology reports consistently pose diagnostic challenges: recognition of serosal penetration by tumor (ie, pT3 vs pT4a), evaluation of regional lymph nodes, distinction between tumor deposits and effaced lymph nodes, and assessment of tumor stage in the neoadjuvant setting. This article discusses each of these issues in detail and provides practical tips regarding colorectal cancer staging.
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Affiliation(s)
- Rhonda K Yantiss
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA.
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20
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Abstract
Examination of the rectum by pathologists is instrumental in the management of patients affected by rectal carcinoma. That role includes evaluation of multiple gross and microscopic features that convey prognostic implications. The analysis is based on the authors' experience handling rectal specimens along with review of the pertinent literature in these areas: margins of excision, quality of the mesorectum, diligence and techniques to sample lymph nodes, tumor budding, grading of residual amount of carcinoma after preoperative therapy, vascular/perineural invasion, and staging the tumor. Pathologists must communicate the findings in a clear manner. Evaluation of margins and completeness of mesorectum are markers of the quality of surgical excision. The number of lymph nodes obtained and examined is dependent in great part on the diligence of the pathologist finding them in the mesenteric adipose tissue. There are grades for budding and response to prior chemoradiation therapy. The location of vascular invasion (extramural vs. intramural) may predict aggressive behavior. Pathologists proactively are to choose sections of tumor for molecular testing. Meticulous macro- and microscopic evaluation of specimens for rectal carcinoma by pathologist is needed to determine an accurate assessment of staging and other prognostic factors. The modern pathologists play a pivotal part in the care and management of patients suffering from rectal adenocarcinoma. That role goes from the initial histological diagnosis to the gross and microscopic examination of the excised specimens. Based on that examination pathologists issue statements that not only evaluate the quality of the surgical procedure, but also through the application of molecular tests they give light on prognostic factors and information for therapeutic purposes.
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Affiliation(s)
- Mariana Berho
- Department of Pathology, Cleveland Clinic Florida, Weston, FL, USA -
| | - Pablo A Bejarano
- Department of Pathology, Cleveland Clinic Florida, Weston, FL, USA
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Gravante G, Elshaer M, Parker R, Mogekwu AC, Drake B, Aboelkassem A, Rahman EU, Sorge R, Alhammali T, Gardiner K, Al-Hamali S, Rashed M, Kelkar A, Agarwal R, El-Rabaa S. Extended right hemicolectomy and left hemicolectomy for colorectal cancers between the distal transverse and proximal descending colon. Ann R Coll Surg Engl 2016; 98:303-7. [PMID: 27023638 DOI: 10.1308/rcsann.2016.0112] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION We report our experience with extended right hemicolectomy (ERH) and left hemicolectomy (LH) for the treatment of cancers located between the distal transverse and the proximal descending colon, and compare postoperative morbidity, mortality, pathological results and survival for the two techniques. METHODS A retrospective review was performed of a single institution series over ten years. Patients who underwent different operations, had benign disease or received palliative resections were excluded. Data collected were patient demographics, type and duration of surgery, tumour site, postoperative complications and histology results. RESULTS Ninety-eight patients were analysed (64 ERHs, 34 LHs). ERH was conducted using an open approach in 93.8% of cases compared with 73.5% for LH. The anastomotic leak rate was similar for both groups (ERH: 6.3%, LH: 5.9%). This was also the case for other postoperative complications, mortality (ERH: 1.6%, LH: 2.9%) and overall survival (ERH: 50.4 months, LH: 51.8 months). All but one patient in the ERH cohort had clear surgical margins. Nodal evaluation for staging was adequate in 78.1% of ERH cases and 58.8% of LH cases. CONCLUSIONS In our experience, both ERH and LH are adequate for tumours located between the distal transverse and the proximal descending colon.
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Affiliation(s)
- G Gravante
- Kettering General Hospital NHS Foundation Trust , UK
| | - M Elshaer
- West Hertfordshire Hospitals NHS Trust , UK
| | - R Parker
- Kettering General Hospital NHS Foundation Trust , UK
| | - A C Mogekwu
- Kettering General Hospital NHS Foundation Trust , UK
| | - B Drake
- Kettering General Hospital NHS Foundation Trust , UK
| | - A Aboelkassem
- Kettering General Hospital NHS Foundation Trust , UK
| | - E U Rahman
- Northampton General Hospital NHS Trust , UK
| | - R Sorge
- University of Rome Tor Vergata , UK
| | - T Alhammali
- Kettering General Hospital NHS Foundation Trust , UK
| | - K Gardiner
- Kettering General Hospital NHS Foundation Trust , UK
| | - S Al-Hamali
- Kettering General Hospital NHS Foundation Trust , UK
| | - M Rashed
- Kettering General Hospital NHS Foundation Trust , UK
| | - A Kelkar
- Kettering General Hospital NHS Foundation Trust , UK
| | - R Agarwal
- Northampton General Hospital NHS Trust , UK
| | - S El-Rabaa
- Kettering General Hospital NHS Foundation Trust , UK
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Increased Caseload Volume is Associated With Better Oncologic Outcomes After Laparoscopic Resections for Colorectal Cancer. Surg Laparosc Endosc Percutan Tech 2016; 26:49-53. [DOI: 10.1097/sle.0000000000000221] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gravante G, Parker R, Elshaer M, Mogekwu AC, Humayun N, Thomas K, Thomson R, Hudson S, Sorge R, Gardiner K, Al-Hamali S, Rashed M, Kelkar A, El-Rabaa S. Lymph node retrieval for colorectal cancer: Estimation of the minimum resection length to achieve at least 12 lymph nodes for the pathological analysis. Int J Surg 2015; 25:153-7. [PMID: 26713777 DOI: 10.1016/j.ijsu.2015.12.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 12/15/2015] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Adequate lymph node retrieval is important in colorectal cancer staging for the selection of patients that necessitate adjuvant treatments. The minimum number of 12 lymph nodes is one of the premises and is dependent, among the other factors, from the length of bowel resected. We have reviewed our specimens to identify the high-risk operations for inadequate nodal sampling and estimate the minimum length of bowel needed to resect to achieve this purpose. MATERIALS AND METHODS A retrospective review of colorectal specimens over 10 years of activity looking at data including location of the tumor, type of operation performed, length of bowel resected and number of lymph nodes retrieved. RESULTS Abdominoperineal and Hartmann's resections produced significant lower adequate retrievals compared to other colorectal operations, corresponding to 45.4% and 59.1% of cases respectively. The measured average length of bowel was 30 cm and 25 cm respectively, increasing the length to 36 cm and 42 cm would increase the adequacy rate to 90%. CONCLUSIONS Abdominoperineal and Hartmann's resections are, in our series, high-risk operations that frequently do not produce the minimum number of lymph nodes necessary. These operations may require additional maneuvers such as mobilization of the splenic flexure to achieve the minimum length of bowel to resect.
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Affiliation(s)
- Gianpiero Gravante
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
| | - Rupert Parker
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
| | - Mohamed Elshaer
- Department of Surgery, West Hertfordshire Hospitals, Watford, United Kingdom.
| | | | - Nada Humayun
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
| | - Katie Thomas
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
| | - Rachael Thomson
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
| | - Sarah Hudson
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
| | - Roberto Sorge
- Department of Human Physiology, Laboratory of Biometry, University of Tor Vergata, Rome, Italy
| | - Katy Gardiner
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
| | - Salem Al-Hamali
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
| | - Mohamed Rashed
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
| | - Ashish Kelkar
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
| | - Saleem El-Rabaa
- Department of Surgery, Kettering General Hospital, Kettering, United Kingdom
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Märkl B. Stage migration vs immunology: The lymph node count story in colon cancer. World J Gastroenterol 2015; 21:12218-12233. [PMID: 26604632 PMCID: PMC4649108 DOI: 10.3748/wjg.v21.i43.12218] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/26/2015] [Indexed: 02/06/2023] Open
Abstract
Lymph node staging is of crucial importance for the therapy stratification and prognosis estimation in colon cancer. Beside the detection of metastases, the number of harvested lymph nodes itself has prognostic relevance in stage II/III cancers. A stage migration effect caused by missed lymph node metastases has been postulated as most likely explanation for that. In order to avoid false negative node staging reporting of at least 12 lymph nodes is recommended. However, this threshold is met only in a minority of cases in daily practice. Due to quality initiatives the situation has improved in the past. This, however, had no influence on staging in several studies. While the numbers of evaluated lymph nodes increased continuously during the last decades the rate of node positive cases remained relatively constant. This fact together with other indications raised doubts that understaging is indeed the correct explanation for the prognostic impact of lymph node harvest. Several authors assume that immune response could play a major role in this context influencing both the lymph node detectability and the tumor’s behavior. Further studies addressing this issue are need. Based on the findings the recommendations concerning minimal lymph node numbers and adjuvant chemotherapy should be reconsidered.
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Influence of Individual Surgeon Volume on Oncological Outcome of Colorectal Cancer Surgery. Int J Surg Oncol 2015; 2015:464570. [PMID: 26425367 PMCID: PMC4573626 DOI: 10.1155/2015/464570] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 08/10/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Surgery performed by a high-volume surgeon improves short-term outcomes. However, not much is known about long-term effects. Therefore we performed the current study to evaluate the impact of high-volume colorectal surgeons on survival. METHODS We conducted a retrospective analysis of our prospectively collected colorectal cancer database between 2004 and 2011. Patients were divided into two groups: operated on by a high-volume surgeon (>25 cases/year) or by a low-volume surgeon (<25 cases/year). Perioperative data were collected as well as follow-up, recurrence rates, and survival data. RESULTS 774 patients underwent resection for colorectal malignancies. Thirteen low-volume surgeons operated on 453 patients and 4 high-volume surgeons operated on 321 patients. Groups showed an equal distribution for preoperative characteristics, except a higher ASA-classification in the low-volume group. A high-volume surgeon proved to be an independent prognostic factor for disease-free survival in the multivariate analysis (P = 0.04). Although overall survival did show a significant difference in the univariate analysis (P < 0.001) it failed to reach statistical significance in the multivariate analysis (P = 0.09). CONCLUSIONS In our study, a higher number of colorectal cases performed per surgeon were associated with longer disease-free survival. Implementing high-volume surgery results in improved long-term outcome following colorectal cancer.
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Gilardoni E, Bernasconi DP, Poli S, Garancini M, Luperto M, Zucchini N, Bovo G, Totis M, Bugatti A, Gianotti L. Surveillance for early stages of colon cancer: potentials for optimizing follow-up protocols. World J Surg Oncol 2015; 13:260. [PMID: 26311420 PMCID: PMC4551712 DOI: 10.1186/s12957-015-0674-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 08/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although several meta-analyses showed the positive effects of follow-up on the prognosis of colon cancer (CC), international guidelines are not in accordance on appropriate tests and their time frequency to optimize surveillance. Furthermore, stratified strategies based upon risk grading have not been implemented. This approach may be useful to rationalize resources. METHODS From 2006, all patients operated for an early stage CC (I, IIA, IIB) according to the 7th edition of the AJCC-2010 classification entered in a prospective surveillance program in accordance to our local guidelines. Patients who underwent surgical resection after 2009 have been excluded to guarantee at least a 5-year follow-up. Classic histopathologic prognostic factors such as grade, T and N status, lymphatic and vascular invasion were assessed. Moreover, tumor budding and tumor-to-stroma proportion were evaluated. RESULTS We had complete records of 196 patients. Distribution was as follows: 65 (33.2%) in stage I, 122 (62.2%) in stage IIA, and 9 (4.6%) in stage IIB. Eleven patients (5.6%) had a disease recurrence (local or distant). The median recurrence time was 20 months (range 6-48). Nine patients (82%) had recurrence with 24 months, and 91% were asymptomatic and detected by ultrasound or CT scan. According to the log-rank test, the risk factors with significant effect on the disease-free survival (DFS) were the number of lymph nodes <12 (p = 0.027) and the vascular invasion (p = 0.021), while for the overall (OS), only the vascular invasion was significant (p = 0.043). By the univariate and multivariate analyses, DSF was significantly lower in patients with less than 12 nodes removed, with vascular invasion, and with left of double cancer. OS was negatively affected only by vascular invasion despite the hazard ratios were similar to DSF. Stage IIB was associated with a threefold-increased risk of reduced OS and DSF. CONCLUSIONS Stages I and IIA appear to behave similarly and should be considered as true early stages. The detection of fibrosis and budding do not seem to add valuable information for prognosis. In early CC stages, the surveillance program should be maximized within the first two years.
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Affiliation(s)
- Elisa Gilardoni
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Davide Paolo Bernasconi
- Department of Health Science, Centre of Biostatistics for Clinical Epidemiology, Milano-Bicocca University, Monza, Italy
| | - Silvia Poli
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Mattia Garancini
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Margherita Luperto
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | | | - Giorgio Bovo
- Unit of Pathology, San Gerardo Hospital, Monza, Italy
| | - Mauro Totis
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Alvaro Bugatti
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy.
- Department of Surgery, San Gerardo Hospital (4° piano A), Via Pergolesi 33, 20052, Monza, Italy.
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Stipa F, Burza A, Curinga R, Santini E, Delle Site P, Avantifiori R, Picchio M. Laparoscopic colon and rectal resections with intracorporeal anastomosis and trans-vaginal specimen extraction for colorectal cancer. A case series and systematic literature review. Int J Colorectal Dis 2015; 30:955-62. [PMID: 25749939 DOI: 10.1007/s00384-015-2178-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Intracorporeal anastomosis associated to trans-vaginal specimen extraction decreases the extent of colon mobilisation and the number and size of abdominal incisions, improving the benefits of minimally invasive surgery in female patients. The aim of this study was to evaluate the safety and effectiveness of this procedure for colorectal cancer. METHODS Between 2009 and 2013, 13 female patients underwent laparoscopic colon and rectal resection for colorectal cancer with intracorporeal anastomosis and trans-vaginal specimen extraction: 2 right colectomies, 1 transverse colon resection, 4 left colectomies and 6 anterior resections were performed. A MEDLINE search of publications on the presented procedure for colon neoplasms was carried out. RESULTS There were no intraoperative complications and no conversions. Postoperative visual analogue scale (VAS) score in the pelvis, abdomen and shoulder was moderate. In the postoperative period, we observed two colorectal anastomotic strictures, successfully treated with pneumatic endoscopic dilation. Median length of the specimen was 18.5 cm, with a median tumour size of 5.5 cm in diameter. Median number of retrieved lymph nodes was 12. All circumferential resection margins were negative. During a mean follow-up of 31 months (range, 6-62), there was neither evidence of recurrent disease nor disorders related to the genitourinary system. The aesthetic outcome was considered satisfactory in all patients. Nine studies were identified in the systematic review. CONCLUSIONS Our case series, according to the results of the literature, showed that intracorporeal anastomosis associated to trans-vaginal specimen extraction is feasible and safe in selected female patients.
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Affiliation(s)
- Francesco Stipa
- Department of Surgery, Colorectal Surgery Unit, Hospital "S. Giovanni-Addolorata", Via dell'Amba Aradam 8, 00186, Rome, Italy,
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Johnston MJ, Singh P, Pucher PH, Fitzgerald JEF, Aggarwal R, Arora S, Darzi A. Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes. Br J Surg 2015; 102:1156-66. [DOI: 10.1002/bjs.9860] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/12/2015] [Accepted: 04/20/2015] [Indexed: 12/11/2022]
Abstract
Abstract
Background
The number of surgeons entering fellowship training before independent practice is increasing. This may have a negative impact on surgeons in training. The impact of fellowship training on patient outcomes is not yet known. This review aimed to investigate the impact of fellowship training in surgery on patient outcomes.
Methods
A systematic review of the literature was conducted to identify studies exploring the structural and surgeon-specific characteristics of fellowship training on patient outcomes. Data from these studies were extracted, synthesized and reported qualitatively, or quantitatively through meta-analysis.
Results
Twenty-three studies were included. The mortality rate for patients in centres with an affiliated fellowship programme was lower than that for centres without (odds ratio 0·86, 95 per cent c.i. 0·84 to 0·88), as was the rate of complications (odds ratio 0·90, 0·78 to 1·02). Surgeons without fellowship training converted more laparoscopic operations to open surgery than those with fellowship training (risk ratio (RR) 1·04, 95 per cent c.i. 1·03 to 1·05). Comparison of outcomes for senior surgeons versus current fellows showed no differences in rates of mortality (RR 1·00, 1·00 to 1·01), complications (RR 1·03, 0·98 to 1·08) or conversion to open surgery (RR 1·01, 1·00 to 1·01).
Conclusion
Fellowship training appears to have a positive impact on patient outcomes.
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Affiliation(s)
- M J Johnston
- Patient Safety Translational Research Centre, Department of Surgery and Cancer, London, UK
| | - P Singh
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - P H Pucher
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - J E F Fitzgerald
- Department of General Surgery, Royal Free London, Barnet Hospital Campus, London, UK
| | - R Aggarwal
- Department of Surgery, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - S Arora
- Patient Safety Translational Research Centre, Department of Surgery and Cancer, London, UK
| | - A Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
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Cianchi F, Trallori G, Mallardi B, Macrì G, Biagini MR, Lami G, Indennitate G, Bagnoli S, Bonanomi A, Messerini L, Badii B, Staderini F, Skalamera I, Fiorenza G, Perigli G. Survival after laparoscopic and open surgery for colon cancer: a comparative, single-institution study. BMC Surg 2015; 15:33. [PMID: 25887554 PMCID: PMC4376079 DOI: 10.1186/s12893-015-0013-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 02/24/2015] [Indexed: 12/14/2022] Open
Abstract
Background Some recent studies have suggested that laparoscopic surgery for colorectal cancer may provide a potential survival advantage when compared with open surgery. This study aimed to compare cancer-related survivals of patients who underwent laparoscopic or open resection of colon cancer in the same, high volume tertiary center. Methods Patients who had undergone elective open or laparoscopic surgery for colon cancer between January 2002 and December 2010 were analyzed. A clinical database was prospectively compiled. Survival analysis was calculated by using the Kaplan-Meier method. Results A total of 460 resections were performed. There were no significant differences between the laparoscopic (n = 227) and the open group (n = 233) apart from tumor stage: stage I tumors were more frequent in the laparoscopic group whereas stage II tumors were more frequent in the open group. The mean number of harvested lymph nodes was significantly higher in the laparoscopic than in the open group (20.0 ± 0.7 vs 14.2 ± 0.5, P < 0.01). The 5-year cancer-related survival for patients undergoing laparoscopic resection was significantly higher than that following open resections (83.1% vs 68.5%, P = 0.01). By performing a stage-to-stage comparison, we found that the improvement in survival in the laparoscopic group occurred mainly in patients with stage II tumors. Conclusions Our study shows a survival advantage for patients who had undergone laparoscopic surgery for stage II colon cancer. This may be correlated with a higher number of harvested lymph nodes and thus a better stage stratification of these patients.
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Affiliation(s)
- Fabio Cianchi
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy.
| | - Giacomo Trallori
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | - Giuseppe Macrì
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Maria Rosa Biagini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Gabriele Lami
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | - Siro Bagnoli
- Unit of Gastroenterology, AOU Careggi, Florence, Italy
| | | | - Luca Messerini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Benedetta Badii
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy
| | - Fabio Staderini
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy
| | - Ileana Skalamera
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy
| | - Giulia Fiorenza
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy
| | - Giuliano Perigli
- Center of Oncological Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Italy Largo Brambilla 3, 50134, Florence, Italy
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Frankel WL, Jin M. Serosal surfaces, mucin pools, and deposits, oh my: challenges in staging colorectal carcinoma. Mod Pathol 2015; 28 Suppl 1:S95-108. [PMID: 25560604 DOI: 10.1038/modpathol.2014.128] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 07/11/2014] [Accepted: 07/12/2014] [Indexed: 02/06/2023]
Abstract
Colorectal carcinoma is the third most common cancer in the United States. Proper and standardized pathologic staging is vital for prognostic assessment and impacts therapeutic decisions. The Tumor Node Metastasis (TNM) staging system was developed by the American Joint Committee on Cancer (AJCC) to be a data-driven, evidence-based staging system providing an accurate prediction of outcome. The AJCC 7th edition (2010) included several changes clarifying some issues and leading to new controversies. We aim to address selected challenging issues in tumor T staging, neoadjuvant treatment effects in rectal cancer, and definition of lymph node vs tumor deposit. Serosal involvement in colorectal cancer is staged as T4, which is associated with decreased survival and may impact additional therapy decisions. Although careful sampling and sectioning are helpful, challenges remain in interpretation of tumor within 1 mm of serosal surface with a reaction. Elastic stain as a surrogate marker for serosal invasion has been studied, but its usefulness remains unclear. Some unique issues in rectal cancer include the presence of serosa in proximal but not in distal tumors and post-neoadjuvant effects. Tumor should be staged based on tumor cells rather than acellular mucin pools. Additionally, tumor response should be graded only in primary tumor but not in lymph nodes or metastatic sites. The distinction between tumor deposits and lymph nodes has been modified in AJCC TNM from using size in the 5th edition, to the round contour in the 6th edition, to only features of residual lymph node architecture in the 7th edition. Interobserver variability remains but tumor deposits should be documented when present. The number of deposits should not be added to the total number of positive lymph nodes, and the N1c designation should only be used in cases without any positive lymph nodes. Future clarification will likely evolve as more data become available.
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Affiliation(s)
- Wendy L Frankel
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ming Jin
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Okada K, Sadahiro S, Suzuki T, Tanaka A, Saito G, Masuda S, Haruki Y. The size of retrieved lymph nodes correlates with the number of retrieved lymph nodes and is an independent prognostic factor in patients with stage II colon cancer. Int J Colorectal Dis 2015; 30:1685-93. [PMID: 26260481 PMCID: PMC4675793 DOI: 10.1007/s00384-015-2357-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE In stage II colon cancer, patients with many retrieved lymph nodes (LNs) have been reported to have better oncological outcomes. We tested the hypothesis that the greater number of retrieved LNs is related to a larger LN size. METHODS The subjects comprised 320 patients with stage II colon cancer who underwent curative resection. All operations were elective and were performed by the same surgeons. The maximum long axis and short axis diameters of LNs were measured on hematoxylin-eosin-stained specimens. RESULTS A total of 4,744 LNs were evaluated. The number of retrieved LNs was 14.8 ± 10.1 (mean ± SD). The long axis diameter was 4.8 ± 2.6 mm, with a median value of 4.3 mm, a maximum value of 20.4 mm, and a minimum value of 0.6 mm. The corresponding short axis diameters were 3.4 ± 1.7, 3.0, 15.1, and 0.5 mm, respectively. The highest correlation coefficient for the association with the number of LNs was obtained for the maximum value of the long axis diameter (0.59). Multivariate analysis revealed that age, tumor location, pathological T stage, and the maximum long axis diameter were independent prognostic factors. The number of LNs was not a significant factor. Patients with less than 12 LNs and a maximum long axis diameter of less than 10 mm had significantly poorer outcomes (p < 0.001). CONCLUSION In patients with stage II colon cancer, the maximum long axis diameter of LNs correlated with the number of LNs and was an independent prognostic factor.
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Affiliation(s)
- Kazutake Okada
- />Department of Surgery, Tokai University, 143 Shimokasuya Isehara, Kanagawa, 259-1193 Japan
| | - Sotaro Sadahiro
- />Department of Surgery, Tokai University, 143 Shimokasuya Isehara, Kanagawa, 259-1193 Japan
| | - Toshiyuki Suzuki
- />Department of Surgery, Tokai University, 143 Shimokasuya Isehara, Kanagawa, 259-1193 Japan
| | - Akira Tanaka
- />Department of Surgery, Tokai University, 143 Shimokasuya Isehara, Kanagawa, 259-1193 Japan
| | - Gota Saito
- />Department of Surgery, Tokai University, 143 Shimokasuya Isehara, Kanagawa, 259-1193 Japan
| | - Shinobu Masuda
- />Department of Pathology, Nihon University, Tokyo, Japan
| | - Yasuo Haruki
- />Department of Basic Medical Science, Tokai University, Isehara, Japan
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Araujo SEA, Seid VE, Klajner S, Bertoncini AB. Left colectomy with intracorporeal anastomosis: technical aspects. EINSTEIN-SAO PAULO 2014; 12:386-8. [PMID: 25295460 PMCID: PMC4872958 DOI: 10.1590/s1679-45082014md3030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 04/22/2014] [Indexed: 12/19/2022] Open
Abstract
Oncologic laparoscopic colectomy represents a fully validated surgical approach to the management of colorectal cancer. However, laparoscopic surgery for distal transverse and descending colon lesions remains a challenging procedure. A total laparoscopic approach to the left colectomy is an interesting option for critically ill patients although reports in the literature on this subject are scarce and its approach still not standardized because of its selective nature for indication. There are several advantages associated with conduction of totally laparoscopic approach to the left colon. Intracorporeal vessel sealing ensures an adequate lymph node dissection. Moreover, it enables the construction of a well-vascularized anastomosis. Ultimately, the occurrence of late wound complications are possibly reduced for the placement of a low abdominal incision exclusively used for specimen extraction. This paper aimed at describing our technique for a totally laparoscopic left colectomy for distal transverse and descending colon lesions.
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Affiliation(s)
| | | | - Sidney Klajner
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Berho M, Bejarano PA. Judging pathological assessment in cancer specimens. J Surg Oncol 2014; 110:543-50. [PMID: 25132357 DOI: 10.1002/jso.23738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 07/08/2014] [Indexed: 11/08/2022]
Abstract
The pathologist plays a critical role in the multidisciplinary team in charge of treating cancer patients, as many of the therapeutic decisions rely on the information conveyed through the pathology reports. The task of the pathologist includes not only an accurate assessment of pathological T and N categories, but also the evaluation of other indicators of prognosis including quality of surgery, margins of resection, as well as additional histopathological and molecular markers that influence prognosis and could predict response to therapy.
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Affiliation(s)
- Mariana Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida
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Leong SPL, Tseng WW. Micrometastatic cancer cells in lymph nodes, bone marrow, and blood: Clinical significance and biologic implications. CA Cancer J Clin 2014; 64:195-206. [PMID: 24500995 DOI: 10.3322/caac.21217] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 11/25/2013] [Accepted: 11/25/2013] [Indexed: 01/09/2023] Open
Abstract
Cancer metastasis may be regarded as a progressive process from its inception in the primary tumor microenvironment to distant sites by way of the lymphovascular system. Although this type of tumor dissemination often occurs in an orderly fashion via the sentinel lymph node (SLN), acting as a possible gateway to the regional lymph nodes, bone marrow, and peripheral blood and ultimately to distant metastatic sites, this is not a general rule as tumor cells may enter the blood and spread to distant sites, bypassing the SLN. Methods of detecting micrometastatic cancer cells in the SLN, bone marrow, and peripheral blood of patients have been established. Patients with cancer cells in their SLN, bone marrow, or peripheral blood have worse clinical outcomes than patients with no evidence of spread to these compartments. The presence of these cells also has important biologic implications for disease progression and the clinician's understanding of the process of cancer metastasis. Further characterization of these micrometastatic cancer cells at each stage and site of metastasis is needed to design novel selective therapies for a more "personalized" treatment.
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Affiliation(s)
- Stanley P L Leong
- Chief of Cutaneous Oncology, Associate Director of the Melanoma Program, Center for Melanoma Research and Treatment, California Pacific Medical Center and Sutter Pacific Medical Foundation, Senior Scientist, California Pacific Medical Center Research Institute, San Francisco, CA
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Sloothaak DAM, Grewal S, Doornewaard H, van Duijvendijk P, Tanis PJ, Bemelman WA, van der Zaag ES, Buskens CJ. Lymph node size as a predictor of lymphatic staging in colonic cancer. Br J Surg 2014; 101:701-6. [PMID: 24676735 DOI: 10.1002/bjs.9451] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND In colonic cancer, the number of harvested lymph nodes is associated with prognosis. The aim of this study was to determine the contribution of small lymph nodes to pathological staging, and to analyse the hypothesis that node size is a confounder in the relationship between prognosis and nodal harvest. METHODS Nodal harvest and size were analysed in patients who underwent elective surgery for colonic cancer. Visible and palpable nodes were harvested without fat clearance techniques, and conventional histology was performed. RESULTS Metastases were found in 99 of 2043 measured lymph nodes in 150 patients. Lymph nodes smaller than 3 mm were positive in 8.0 per cent of patients (12 of 150), but were the sole reason for upstaging in only 1.3 per cent (2 of 150). No metastases were found among 95 nodes of 1 mm or less. Metastatic nodes were larger than those without metastasis (median (i.q.r.) 5.0 (3.2-7.0) versus 3.8 (2.4-5.2) mm; P < 0·001), but a receiver operating characteristic (ROC) curve did not identify a relevant cut-off point to predict metastatic involvement. A hazard ratio of 0.71 (95 per cent confidence interval 0.50 to 1.01) was suggestive of an association between disease recurrence and increased node size, although not significant (P = 0.056). In patients with N0 disease, there was a correlation between node size and harvest (Pearson's correlation 0.317, P = 0.002), and a nodal yield of at least 12 was associated with a larger median node size (4.3 (3.3-5.0) versus 3.4 (2.7-4.0) mm; P = 0.015). CONCLUSION The contribution of lymph nodes smaller than 3 mm to nodal staging is limited. Increased node size is associated with increased nodal yield, and could be a confounder in the relationship between prognosis and nodal harvest in patients with N0 disease.
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Affiliation(s)
- D A M Sloothaak
- Departments of Surgery and Pathology, Gelre Hospital, Apeldoorn, The Netherlands; Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Abstract
BACKGROUND The purpose of this study was to examine the utility of remnant uptake on postoperative radioiodine scans as an oncologic indicator after thyroidectomy for differentiated thyroid cancer (DTC). METHODS We conducted a retrospective review of patients undergoing total thyroidectomy for DTC and subsequent radioactive iodine (RAI) treatment. Of the eight surgeons included, three were considered high volume, performing at least 20 thyroidectomies per year. Patients with distant metastases at diagnosis or poorly differentiated variants were excluded. To control for the effect of varying RAI doses, the remnant uptake was analyzed as a ratio of the percentage uptake to the dose received (uptake to dose ratio [UDR]). Multivariate logistic regression was used to determine the influence of UDR on recurrence. RESULTS Of the 223 patients who met inclusion criteria, 21 patients (9.42%) experienced a recurrence. Those with a recurrence had a 10-fold higher UDR compared with those who did not (0.030 vs. 0.003, p=0.001). Similarly, patients with increasing postoperative thyroglobulin measurements (0.339 vs. 0.003, p<0.001) also had significantly greater UDRs compared with those with stable thyroglobulin. The UDRs of high-volume surgeons were significantly smaller than low-volume surgeons (0.003 vs. 0.025, p=0.002). When combined with other known predictors for recurrence, UDR (OR 3.71 [95%CI 1.05-13.10], p=0.041) was significantly associated with recurrence. High-volume surgeons maintained a low level of permanent complications across all UDRs, whereas low-volume surgeons had greater permanent complications associated with higher uptake. CONCLUSIONS Remnant uptake is a useful postoperative oncologic quality indicator that can predict a patient's risk of disease recurrence and indicate the completeness of resection.
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Affiliation(s)
- David F Schneider
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin , Madison, Wisconsin
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Surgical quality surrogates do not predict colon cancer survival in the setting of technical credentialing: a report from the prospective COST trial. Ann Surg 2013; 257:102-7. [PMID: 23059506 DOI: 10.1097/sla.0b013e318260a8e6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We tested the hypothesis that the 12 lymph node (LN) count and other surgical variables would not predict survival in a setting where surgical techniques were standardized and surgeons were credentialed and audited. BACKGROUND The National Quality Forum has adopted the 12-node minimum as a surgical quality metric due to the strong association between node count and survival. METHODS We performed a secondary analysis of data from the Clinical Outcomes of Surgical Therapy (COST) multicenter randomized trial testing laparoscopic versus open colectomy. Surgeons were credentialed and video-audited for adherence to technical standards. Patients with noninvasive and stage IV disease were excluded, leaving 787 subjects (267 stage I, 284 stage II, and 236 stage III). Median age was 70 years and 50% were male. The overall 5-year survival was 77.2%. RESULTS Five-year overall and disease-free survival was not influenced by LN count (< 12 vs ≥ 12), sex, tumor location (right vs left vs sigmoid), surgical technique (laparoscopic vs open), total bowel length, proximal margin, distal margin, radial margin, or mesenteric length (P > 0.05 for all). Univariate predictors of survival included age and cancer stage, and these remained significant in the multivariate model. Across all stages of disease, after adjusting for age and stage, LN count did not predict overall or disease-free survival (P = 0.60). CONCLUSIONS Despite the known association between LN count and survival, we could not confirm an association between surgical surrogates and cancer outcomes. We postulate that standardization, credentialing, and monitoring may be more important than traditional surgical quality surrogates.
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Wichmann MW, Beukes E, Esufali ST, Plaumann L, Maddern G. Five-year results of surgical colorectal cancer treatment in rural Australia. ANZ J Surg 2013; 83:112-7. [PMID: 23336805 DOI: 10.1111/ans.12065] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND The incidence of colorectal cancer in Australia is among the highest worldwide. We investigate whether similar treatment results for colorectal cancer can be achieved in rural surgery as reported from metropolitan centres. METHODS Retrospective analysis of prospectively collected follow-up data in a rural surgical centre in South Australia has been carried out. Results of all patients undergoing surgical treatment for colorectal cancer are analysed, and all cancer stages and interventions over a 5-year period are included. RESULTS Five-year survival of all patients (n = 194) treated for colorectal cancer independent of stage and cause of death was 56%, cancer-specific 5-year survival was 64%. Perioperative mortality was 1.7%. Overall survival was 96% in stage 1, 92% in stage 2, 58% in stage 3 and 0% for patients with metastatic disease at the time of diagnosis. Cancer-specific survival ranged from 100% in stage 1 to 0% for patients with metastatic disease. CONCLUSIONS Assessment of overall and cancer-specific survival of all patients undergoing surgery for colorectal cancer over a 5-year time period in a rural South Australian centre shows that good long-term results can be achieved with low perioperative mortality. These findings compare well with the results of other groups.
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Affiliation(s)
- Matthias W Wichmann
- Department of General Surgery, Mount Gambier General Hospital, Mount Gambier, South Australia, Australia.
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AC133 expression associated with poor prognosis in stage II colorectal cancer. Med Oncol 2013; 30:356. [PMID: 23322518 DOI: 10.1007/s12032-012-0356-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 08/08/2012] [Indexed: 01/16/2023]
Abstract
Identification of high-risk prognostic markers for stage II colorectal cancer (CRC) is currently a big challenge. CD133 is one of the most commonly used CRC stem cell markers. However, its specificity is controversial. Recent studies have demonstrated that the AC133 epitope of CD133, not the CD133 protein, is responsible for cancer stem cell identification. The aim of this study was to investigate the clinical significance of AC133 expression in stage II CRC. Two antibodies against CD133, including AC133 and Ab19898, were compared for their expression characteristics. AC133 was chosen for further immunohistochemical assessment on 176 stage II CRC primary tumors with at least 12 examined lymph nodes. The cutoff value for positive rate of AC133 expression was determined by ROC curve analysis. AC133 was analyzed for correlations with clinicopathological and prognostic parameters. The results indicated that AC133 was negative in adjacent noncancerous colorectal mucosa while positive in 116 cases (65.9 %) of primary tumors. AC133 expression was significantly correlated with preoperative serum carcinoembryonic antigen level (p = 0.006) and tumor differentiation grade (p = 0.019). Furthermore, high AC133 expression was identified as a significant predictor for poor disease-free survival and overall survival at both univariate (p = 0.009, 0.013, respectively) and multivariate levels (p = 0.022, 0.026, respectively). Our data suggest that AC133 is an independent adverse prognostic factor and a potential marker for survival classification in stage II CRC patients.
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Evaluation of lymph nodes in patients with colon cancer undergoing colon resection: a population-based study. World J Surg 2012; 36:1906-14. [PMID: 22484567 DOI: 10.1007/s00268-012-1568-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Though lymph node status may predict long-term outcome of patients with non-metastatic colon cancer, discordant findings exist among various expressions of lymph node status. The present study was designed to assess the prognostic value among these lymph node evaluations. METHODS The analysis was based on surgical patients with newly diagnosed colon adenocarcinoma registered in the Taiwan Cancer Database from 2003 to 2005. Exclusion criteria included those patients who had stage IV disease, those whose survival period was <1 month, or those whose lymph node information was unavailable. Studied variables included total number of lymph nodes (LNT), number of positive lymph nodes (LNP), number of negative lymph nodes (LNN), ratio of positive lymph nodes (LNR), and log odds of positive lymph nodes (LODDS). RESULTS Of 16,790 newly diagnosed colon cancer patients, there were 9,644 (65.4 ± 13.5 years; male 54.9 %) patients with non-metastatic disease who met the criteria. Correlation analyses for patients with stage III disease showed that LNR and LODDS were highly correlated, as were LNT and LNN. By the Cox proportional hazard model, LNT was prognostic of long-term survival in patients with stage II disease, while LNR and LNP were the most powerful prognosticators for patients with stage III disease (p < 0.001). Both the receiver operating characteristics curve analysis and area under the curve indicated that LNR had the best discriminating capability to predict 5-year survival (0.704, 0.700, and 0.709 for overall, disease-free, and disease-specific survival, respectively), followed by LODDS. CONCLUSIONS For patients undergoing resection for colon cancer, LNR, LODDS, and LNP are better prognostic factors for those with stage III disease than LNT is for patients with stage III disease.
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Ferris RL, Lotze MT, Leong SPL, Hoon DSB, Morton DL. Lymphatics, lymph nodes and the immune system: barriers and gateways for cancer spread. Clin Exp Metastasis 2012; 29:729-36. [PMID: 22851005 PMCID: PMC3485421 DOI: 10.1007/s10585-012-9520-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Accepted: 07/14/2012] [Indexed: 12/23/2022]
Abstract
Metastasis to the regional lymph node is the most important prognostic indicator for the outcomes of patients with sold cancer. In general, it is well recognized that cancer development is genetically determined with progression from the microenvironment of the primary tumor site, oftentimes via the SLN gateway, to the distant sites. In about 20 % of the time, the cancer cells may spread directly through the blood vascular system to the distant sites. Thus, in general, cancer progression is consistent with Hellman's spectrum theory in that development of nodal and systemic metastasis from a localized cancer growth is a progressive process. Cancer proliferation within the tumor microenvironment may give rise to increased tumor heterogeneity, which is further complicated by its continuous change through its evolution within the host in a Darwinian sense. It is crucial to understand the molecular process of lymphangiogenesis and hemangiogenesis in the tumor microenvironment with respect to the initial steps of cancer cells entering into the lymphatic and vascular systems so that rational therapy can be developed to curb the process of specific routes of metastasis. This chapter elucidates the role of lymphatics, nodal metastasis and antitumor immunity. We present novel immune targets in nodal metastases, the importance of the lymph node as a pre-metastatic niche, and immune-related proteins as biomarkers of metastasis.
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Affiliation(s)
- Robert L Ferris
- Hillman Cancer Center Research, Pavilion 5117 Centre Avenue, Room 2.26b, Pittsburgh, PA 15213, USA.
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Märkl B, Rößle J, Arnholdt HM, Schaller T, Krammer I, Cacchi C, Jähnig H, Schenkirsch G, Spatz H, Anthuber M. The clinical significance of lymph node size in colon cancer. Mod Pathol 2012; 25:1413-22. [PMID: 22684222 DOI: 10.1038/modpathol.2012.92] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
To date, the clinical value of lymph node size in colon cancer has been investigated only in a few studies. Only in radiological diagnosis is lymph node size routinely recognized, and nodes ≥10 mm in diameter are considered pathologic. However, the few studies regarding this topic suggest that lymph node size is not a reliable indicator of metastatic disease. Moreover, we hypothesized that increasing lymph node size is associated with favorable outcome. By performing a morphometric study, we investigated the clinical significance of lymph node size in colon cancer in terms of metastatic disease and prognosis. A cohort of 237 cases with excellent lymph node harvest (mean lymph node count: 33±17) was used. The size distribution in node-positive and -negative cases was almost identical. In all, 151 out of the 305 metastases detected (49.5%) were found in lymph nodes with diameters ≤5 mm. Only 25% of lymph nodes >10 mm showed metastases. Minute lymph nodes ≤1 mm were involved only very rarely (2 of 81 cases). In 67% of the cases, the largest positive lymph node was <10 mm. The prognostic relevance of lymph node size was investigated in a subset of 115 stage I/II cases. The occurrence of ≥7 lymph nodes that were >5 mm in diameter was significantly associated with better overall survival. Our data show that lymph node size is not a suitable factor for preoperative lymph node staging. Minute lymph nodes have virtually no role in correct histopathological lymph node staging. Finally, large lymph nodes in stage I/II disease might indicate a favorable outcome.
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Affiliation(s)
- Bruno Märkl
- Institute of Pathology, Klinikum Augsburg, Augsburg, Germany.
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Adequacy of lymphadenectomy in laparoscopic colorectal cancer surgery: a single-centre, retrospective study. Surg Laparosc Endosc Percutan Tech 2012; 22:33-7. [PMID: 22318057 DOI: 10.1097/sle.0b013e31824332dc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE This study aimed at evaluating the lymph node (LN) harvest after both open and laparoscopic colorectal cancer surgery. METHODS In the period between 1996 and 2009, 404 patients with colorectal cancer underwent open resection, whereas 147 patients underwent laparoscopic surgery. RESULTS The overall number of harvested LNs was significantly higher in the laparoscopic group than in the open one (16.5 vs. 14.3, P<0.001). A higher number of LNs was found in moderately differentiated tumors of the laparoscopic group when compared with the open surgery group (16.7 vs. 14.2, P<0.01). The numbers of harvested LNs in the proximal tumors and in stage II and III tumors were higher in the laparoscopic group than in the open group (18.9 vs. 15.4, P<0.001; 17.9 vs. 14.2, P=0.002; 17.3 vs. 15.3, P=0.02, respectively). CONCLUSIONS Laparoscopic surgery for colorectal cancer can achieve LN retrieval similar to that achieved by the open approach.
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Abstract
BACKGROUND The prognostic impact of the number of lymph nodes and ratio in colon cancer is still debated. OBJECTIVES The aim of this study was to evaluate lymph node harvest in patients with colon cancer over time, and to test the hypotheses that investigation of more lymph nodes, and low lymph node ratio in stage III patients, has positive prognostic impact. DESIGN This is a prospective, observational study. SETTINGS This study was conducted in a single institution treating all patients with colon cancer in a defined catchment area. PATIENTS All patients admitted in the period 1993 to 2009 (n = 1481) were included. MAIN OUTCOME MEASURES The primary outcomes measured were the number of examined regional lymph nodes according to treatment period, 5-year overall survival and time to recurrence, and univariate (Kaplan-Meier) and multivariate (Cox regression) analyses of prognostic factors. RESULTS Nine hundred fifty (65%) patients underwent curative resection. Median number of examined lymph nodes increased from 7 to 15 (p < 0.001), and the proportion of patients with stage III disease increased from 25% to 33% (p = 0.02) during the study period. In patients with stage I to III disease, time to recurrence (proportion of patients without recurrence or death of colon cancer) improved from 65% to 82% during the period (p < 0.001). An association between lymph node count (<8 compared with ≥ 12) and overall survival was found for patients with stage II disease (57% vs 71%, p = 0.004). Hazard ratio for death within 5 years was 0.7 (p = 0.043) when 8 to 11 nodes were examined and 0.6 (p = 0.001) when ≥ 12 nodes were examined (<8 reference). In patients with stage III disease, increasing lymph node ratio was associated with reduced overall survival and time to recurrence in uni- and multivariate analyses. LIMITATIONS This study was limited by the small number of patients in each stage. CONCLUSIONS The number of examined lymph nodes increased in the study period. A stage migration was observed, and time to recurrence improved in patients with stage I to III disease. In patients with stage III disease, lymph node ratio was a stronger prognostic factor than the total number of lymph nodes examined.
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Application of propensity score model to examine the prognostic significance of lymph node number as a care quality indicator. Surg Oncol 2012; 21:e75-85. [PMID: 22221938 DOI: 10.1016/j.suronc.2011.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 12/04/2011] [Indexed: 01/25/2023]
Abstract
PURPOSE There is a controversy about whether lymph node yield can be used as a proxy of quality care for patient with colorectal cancer. We aim to use propensity score models to investigate the association between lymph node number and long-term survival for colorectal cancer patients. MATERIALS AND METHODS Taiwan Cancer Database was employed to review all patients with newly diagnosed colorectal cancer from 2003 to 2005. Exclusion criteria included those patients with stage IV disease or without information of lymph node. Propensity score models (examined lymph node >12 or <12 as dependent variable) were applied to group of patients with Stage II or Stage III disease and primary end point was 5-year survival (and mortality). We also report results of Stage I-III for comparison. RESULTS We identified 15,731 newly diagnosed colorectal cancers during study period, among which a total of 10,517 colorectal cancer patients treated at 32 hospitals fulfilled the inclusion criteria. Pathology reports of about 63 % (6658/10517) patients revealed lymph node retrieval >12. After propensity score matching, there were 2888, 1079, 1094 pairs recruited for Stage I-III, Stage II and Stage III, respectively. According to analysis of these matched pairs, the 5-year risk adjusted overall mortality were lower for lymph node examined ≥12 than <12 among Stage II (24.3% vs. 31.1%, p=0.012) and Stage I-III (20.8% vs. 23.6%, p=0.003), but insignificant for Stage III (40.2% vs. 45.6%, p=0.073). Similar situation happened with regard to disease-free and disease-specific mortality. CONCLUSION For patients with colorectal cancer undergoing colorectal surgery, the quality metric of lymph node is associated with significantly better 5-year survival except for Stage III disease.
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Benhaim L, Benoist S, Bachet JB, Julié C, Penna C, Nordlinger B. Salvage colectomy for endoscopically removed malignant colon polyps: is it possible to determine the optimal number of lymph nodes that need to be harvested? Colorectal Dis 2012; 14:79-86. [PMID: 22145739 DOI: 10.1111/j.1463-1318.2011.02533.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM The total number of lymph nodes examined after salvage colectomy for endoscopically removed malignant polyps was evaluated and an attempt was made to determine whether there was an optimal number of lymph nodes that should be harvested. METHOD From 2000 to 2009, 531 patients underwent segmental resection for non-metastatic colon cancer. Of these, 22 underwent a salvage colectomy for an endoscopically removed malignant polyp, the main indication for which was a resection margin of < 1 mm. The surgical procedure was identical to that used for all colon cancers. RESULTS The mean number of lymph nodes examined was 11.6 ± 7.6 for the 22 patients with an endoscopically removed malignant polyp and 26.2 ± 13.9 for the remaining 509 patients (P = 0.0006). Fewer than 12 lymph nodes were examined in 62 (12%) of the 509 patients and in 13 (59%) of the 22 patients with an endoscopically removed malignant polyp (P < 0.0001). In the group of 22 patients who underwent a salvage colectomy, the total number of lymph nodes examined ranged from 2 to 33. At a mean follow up of 41 ± 15.6 months, no local or distant recurrence was observed in the 22 patients. CONCLUSION The total number of lymph nodes examined after colectomy for endoscopically removed malignant polyps varies and is less than the recommended number of 12 in most cases: this does not appear to have long-term prognostic significance. There is no biological reason to explain this clinical observation.
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Affiliation(s)
- L Benhaim
- Department of Surgery, Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne, France
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Porter GA, Urquhart R, Bu J, Johnson P, Rayson D, Grunfeld E. Improving nodal harvest in colorectal cancer: so what? Ann Surg Oncol 2011; 19:1066-73. [PMID: 21969083 DOI: 10.1245/s10434-011-2073-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adequate nodal harvest (≥12 lymph nodes) in colorectal cancer has been shown to optimize staging and has been proposed as a quality indicator of colorectal cancer care. We previously demonstrated a population-based improvement in adequate nodal harvest over time, particularly with the use of an audit and feedback strategy. The goal of this current study is to evaluate the impact of improved adequate nodal harvest on 3 relevant clinical outcomes: node positivity rate, use of adjuvant chemotherapy, and survival. METHODS This current population-based study included all patients undergoing resection for primary stage I-III colorectal cancer in Nova Scotia, Canada, from January 1, 2001 to December 31, 2005. Linkage of the provincial cancer registry with other administrative databases (hospital discharge data, physician claims data, and national census data) provided clinical, demographic, diagnostic, treatment event, and survival data. The association between increase in adequate node harvest and relevant clinical outcomes was examined for all patients and in a subgroup analysis of patients who received care in a health district that used audit and feedback to improve nodal harvest. RESULTS Among the 2,250 patients, the median nodal harvest was 8, and the overall node positive rate was 35.9%. Despite significant improvement in the proportion of patients undergoing adequate nodal harvest over time (P<.0001), no significant change was observed in the node positivity rate (P=.51), proportion of patients undergoing adjuvant chemotherapy (P=.83), or survival (P=.25). In the subgroup analysis confined to patients where audit and feedback was used to improve nodal harvest rates, clinical outcomes were not improved. CONCLUSIONS Although improvements in the rate of adequate nodal harvest did occur over time, no corresponding meaningful improvement in clinical outcomes was noted. Given the need that quality indicators not only be associated with outcome, but also that outcome improves as such indicators are optimized, this study questions the inclusion of a nodal harvest≥12 lymph nodes as a quality indicator of colorectal cancer care.
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Affiliation(s)
- Geoffrey A Porter
- Department of Surgery, QEII Health Sciences Centre, Dalhousie University, Halifax, NS, Canada.
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Abstract
AIM The review aimed to offer a contemporary perspective of the quality of current colorectal surgery. METHOD A literature search was undertaken to identify relevant indicators. Citations were included if they related to quality in colorectal surgery. The search terms used included the Medical Subject Heading terms and Boolean characters: 'colon' OR 'colorectal', OR 'rectal' OR 'rectum' AND 'Quality Indicators', OR 'Quality Assurance', OR 'Quality of healthcare', OR 'Reference Standards', OR 'Quality' plus a variable floating term. A two-person independent review was undertaken from resulting citations and their consequent reference lists. The search was limited to citations from 2000 to 2010 in humans and to the English language. RESULTS Metrics identified as potential quality indicators in colorectal surgery are discussed according to the structure, process and outcome framework. CONCLUSION A clear appreciation of the scope of individual metrics for quality appraisal purposes is necessary if they are to be used meaningfully for performance benchmarking.
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Affiliation(s)
- A M Almoudaris
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
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Leong SPL, Zuber M, Ferris RL, Kitagawa Y, Cabanas R, Levenback C, Faries M, Saha S. Impact of nodal status and tumor burden in sentinel lymph nodes on the clinical outcomes of cancer patients. J Surg Oncol 2011; 103:518-30. [PMID: 21480244 DOI: 10.1002/jso.21815] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The validation of sentinel lymph node (SLN) concept in melanoma and breast cancer has established a new paradigm in cancer metastasis that, in general, cancer cells spread in a orderly fashion from the primary site to the SLNs in the regional nodal basin and then to the distant sites. In this review article, we examine the development of SLN concept in penile carcinoma, melanoma and breast carcinoma and its application to other solid cancers with emphasis of the relationship between micrometastasis in SLNs and clinical outcomes.
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Affiliation(s)
- Stanley P L Leong
- Center for Melanoma Research and Treatment, Department of Surgery, California Pacific Medical and Research Institute, San Francisco, California 94115, USA.
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Alexandraki KI, Griniatsos J, Bramis KI, Ballian N, Dimitriou N, Giannakakis T, Tsigris C, Felekouras E, Kaltsas GA. Clinical value of right hemicolectomy for appendiceal carcinoids using pathologic criteria. J Endocrinol Invest 2011; 34:255-9. [PMID: 20935447 DOI: 10.1007/bf03347081] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Appendiceal carcinoids (AC) are usually adequately treated by appendectomy. The European Neuroendocrine Tumours Society (ENETS) has recently reconsidered the previous pathologic criteria to identify patients at high risk of extra-appendiceal disease, who are thought to require right hemicolectomy (RHC). AIM The aim of this retrospective, observational study was to evaluate previous and currently introduced criteria, in identifying patients with AC in whom RHC is justified. SUBJECTS AND METHODS Twelve patients who underwent RHC for AC were retrospectively identified. Demographic and follow-up data were collected and appendectomy specimens were reviewed for the presence of indications leading to RHC defined as: tumor diameter ≥2 cm, tumor location at the base, mesoappendiceal extension, mitotic index Ki-67≥2%. RHC specimens were examined to identify evidence of extra-appendiceal disease, remaining and/or metastatic disease. RESULTS Four patients fulfilled two criteria and 8 one criterion for RHC. Two patients had tumors ≥2.0 cm, 5 located at the base, 8 invading the mesoappendix and periappendiceal fat; Ki-67 PI was 1% in all cases measured except one, in which it was 3%. Post-RHC, 3 patients (25%) had extra-appendiceal disease (no residual disease was identified in surgical margins); 1 had tumor at the colon specimen and 2 had lymph node metastasis. All 3 patients fulfilled only one pathologic criterion; 1 had tumor mesoappendiceal extension and 2 tumor location at the base of the appendix. CONCLUSIONS Applying previous and currently introduced pathologic criteria, 25% of high-risk patients with AC had identifiable extra-appendiceal disease following RHC that might be not detected following the recently introduced ENETS criteria.
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Affiliation(s)
- K I Alexandraki
- Endocrine Unit, Department of Pathophysiology, Laiko University Hospital, Athens Medical School, Mikras Asias 75, 115 27, Athens, Greece.
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