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      Clinical impact of fat clearing technique in nodal staging of rectal cancer after preoperative chemoradiotherapy

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          Abstract

          Purpose

          This study was designed to evaluate the efficacy of a fat clearing technique for accurate nodal staging of rectal cancer patients after preoperative chemoradiotherapy (CRT).

          Methods

          A total of 19 patients with rectal cancer within 10 cm from anal verge were divided into two groups: non-CRT group (n = 10) and CRT group (n = 9). For pathologic assessment, lymph node (LN) harvest was performed using conventional manual dissection followed by a fat clearing technique.

          Results

          A median of 3.0 additional LNs in non-CRT group and 3.8 LNs in CRT group were identified by the fat clearing technique. When subanalysis was performed in patients with fewer than 12 retrieved LNs, a median of 4.0 extra LNs in non-CRT group and 3.5 extra LNs in CRT group were identified after the fat clearing technique. None of additionally identified nodes were metastatic. In both groups, the median size of retrieved LNs following the fat clearing technique was smaller than that obtained by manual dissection (2.0 mm vs. 3.0 mm, P < 0.001).

          Conclusion

          The fat clearing technique allowed detection of additional LNs that were missed by the manual method, but these detected LNs were not proven to be metastatic.

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          Most cited references18

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          Impact of preoperative radiation for rectal cancer on subsequent lymph node evaluation: a population-based analysis.

          Nancy N Baxter, Arden M Morris, David A Rothenberger … (2005)
          To determine the impact of preoperative radiotherapy (RT) on the accuracy of lymph node staging (LNS). Preoperative RT is a well-established component of rectal cancer treatment but its impact on LNS is unknown. The Surveillance, Epidemiology and End Results (SEER) registry, representing 14% of the U.S. population, was used to assess the impact of preoperative RT on LNS. Our study population consisted of adults with rectal cancer between 1998 and 2000 who underwent radical resection. In our 3-year study period, 5647 patients met the selection criteria and 1034 (19.5%) underwent preoperative RT. The preoperative RT group was younger (average age, 61 years) than those who did not undergo preoperative RT (average age, 69 years) and more likely to be male (22% of men vs. 16% of women). On average, fewer nodes were examined in patients who underwent preoperative RT (7 nodes) vs. those who did not (10 nodes); this difference was statistically significant, controlling for potential confounders (p < or = 0.0001). In 16% of the preoperative RT patients (vs. 7.5% without), no nodes were identified (p < or = 0.0001). If one used a minimum of 12 nodes as the standard, only 20% of patients who underwent preoperative RT underwent adequate LNS. Lymph node staging in patients who undergo preoperative RT must be interpreted with caution. Studies are needed to evaluate the clinical relevance of node number and pathologic staging after preoperative RT for rectal cancer.
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            Clinical and pathologic factors that predict lymph node yield from surgical specimens in colorectal cancer: a population-based study.

            Kenny Chou, Hai-yue Liu, Deborah Schrag … (2010)
            The National Quality Forum endorses the recommendation of examining at least 12 lymph nodes (LNs) from colorectal cancer (CRC) specimens. However, heterogeneity in LN harvest exists. The objective of this study was to investigate the clinicopathologic factors that influence LN yield. The authors used the Surveillance, Epidemiology, and End Results database to identify patients who were diagnosed with stage I, II, and III CRC between 1994 and 2005. Poisson regression was used to model the number of LNs examined as a function of individual clinicopathologic factors, including age, sex, race, year of diagnosis, geographic region, anatomic site, preoperative radiation, tumor size, tumor classification, tumor differentiation, and LN positivity. In total, 153,483 patients with CRC were identified. The mean number of LNs examined (+/- standard deviation) was 12 (+/-9.3). Separate multivariate analyses revealed that age, year of diagnosis, tumor size, and tumor classification were significant predictors of LN yield for colon and extraperitoneal rectal cancers (P < .01 for all covariates). Tumor location and radiotherapy were significant predictors of LN yield in patients with colon cancer and rectal cancer, respectively. Overall LN yields increased between 2% and 3% annually. Despite the increasing yields observed over time, patients with rectal cancer and older patients who had distally located, early colon cancer were less likely to meet the benchmark yield of 12 LNs. Further investigation into how LN yield is influenced by alterable factors, such as the extent of mesenteric resection and the pathologic technique, as well as nonalterable factors, such as patient age and tumor location, may reveal innovative ways to improve current staging methods. (c) 2010 American Cancer Society.
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              No downstaging after short-term preoperative radiotherapy in rectal cancer patients.

              R Leer, Iris Nagtegaal, … (2001)
              In retrospective studies, total mesorectal excision (TME) surgery has been demonstrated to result in a reduction in the number of local recurrences of rectal cancer. Reports on improved local control after preoperative, hypofractionated radiotherapy have led to the introduction of a randomized multicenter trial to evaluate the effect of TME surgery with and without preoperative radiotherapy. Treatment with preoperative radiotherapy might have an effect on the pathologic characteristics that determine staging of rectal cancer. We investigated the occurrence of downstaging in rectal cancer patients treated with and without preoperative radiotherapy. We analyzed the differences in tumor size, number of examined lymph nodes, tumor-node-metastasis stage, and histopathologic features in 1,321 patients entered onto a randomized trial. The trial compared preoperative radiotherapy (5 x 5 Gy) followed by TME surgery with TME surgery alone. Patients who had an interval of more than 10 days between the start of radiotherapy and surgery were excluded from analysis. Differences were observed in tumor size (P <.001) and total number of examined lymph nodes (P <.001). No difference in tumor or node classification was detected. The irradiated group demonstrated more poorly differentiated tumors as well as more mucinous tumors. In rectal cancer patients, short-term, preoperative radiotherapy with 5 x 5 Gy does not lead to downstaging if the interval between the start of radiotherapy and surgery does not exceed 10 days.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Korean Surg Soc
                Journal ID (iso-abbrev): J Korean Surg Soc
                Journal ID (publisher-id): JKSS
                Title: Journal of the Korean Surgical Society
                Publisher: The Korean Surgical Society
                ISSN (Print): 2233-7903
                ISSN (Electronic): 2093-0488
                Publication date (Print): July 2013
                Publication date (Electronic): 26 June 2013
                Volume: 85
                Issue: 1
                Pages: 30-34
                Affiliations
                Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
                [1 ]Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
                Author notes
                Corresponding Author: Kang Young Lee. Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 135-720, Korea. TEL: +82-2-2019-3378, FAX: +82-2-3462-5994, kylee117@ 123456yuhs.ac

                *These authors contributed equally to this study.

                Article
                DOI: 10.4174/jkss.2013.85.1.30
                PMC ID: 3699685
                PubMed ID: 23833758
                SO-VID: 0197ea79-4352-4f51-8143-a71f451da8f1
                Copyright © Copyright © 2013, the Korean Surgical Society
                License:

                Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 13 February 2013
                Date revision received : 26 April 2013
                Date accepted : 26 April 2013
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Surgery
                Keywords: fat clearing technique,preoperative chemoradiotherapy,rectal neoplasms
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: fat clearing technique, preoperative chemoradiotherapy, rectal neoplasms

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