Hospital Lymph Node Examination Rates and Survival After Resection for Colon Cancer

Wong, Sandra L.; Ji, Hong; Hollenbeck, Brent K.; Morris, Arden M.; Başer, Onur; Birkmeyer, John D.

doi:10.1001/jama.298.18.2149

Cited by 296 publications

(273 citation statements)

References 20 publications

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“…There is a controversy, however, in the literature about whether the number of lymph nodes resected and evaluated impacts patient outcomes [29,30]. Further ambiguity exists even among the proponents of this quality metric regarding the exact number of lymph nodes needed to accurately stage a patient with colon cancer [5,[7][8][9][10][11][12][13][14][15][16][17][18].…”

Section: Journal Of Surgical Oncologymentioning

confidence: 99%

Meeting the 12 lymph node (LN) benchmark in colon cancer

Rajput

Romanus

Weiser

et al. 2010

Journal of Surgical Oncology

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Background: Examining 12 LN in colon cancer has been suggested as a quality metric. The purpose of this study was to determine whether the 12 LN benchmark is achieved at NCCN centers compared to a US population-based sample. Methods: Patients with stage I-III disease resected at NCCN centers were identified from a prospective database (n ¼ 718) and were compared to 12,845 stage I-III patients diagnosed in a SEER region. Age, gender, location, stage, number of positive nodes were compared for NCCN and SEER data in regards to number of nodes evaluated. Multivariate logistic regression models were developed to identify factors associated with evaluating 12 LNs. Results: 92% of NCCN and 58% of SEER patients had 12 LN evaluated. For patients treated at NCCN centers, factors associated with not meeting the 12 LN target were left-sided tumors, stage I disease and BMI >30. Conclusions: 12 LN are almost always evaluated in NCCN patients. In contrast, this target is achieved in 58% of SEER patients. With longer follow-up of the NCCN cohort we will be able to link this quality metric to patterns of recurrence and survival and thereby better understand whether increasing the number of nodes evaluated is a priority for cancer control.

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Section: Journal Of Surgical Oncologymentioning

confidence: 99%

Meeting the 12 lymph node (LN) benchmark in colon cancer

Rajput

Romanus

Weiser

et al. 2010

Journal of Surgical Oncology

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“…24 Moreover, one could hypothesize that lymphatic hyperplasia in colon cancer could be a prognostic marker indicating an especially effective immunological response against the cancer. [25][26][27][28] As large lymph nodes are easier to find, this could be an alternative explanation for the phenomenon that high lymph node counts are associated with a favorable outcome in stage II and even in stage III colon cancer. 29 Until now, insufficient surgical techniques and, even more likely, stage migration are thought to explain this well-investigated effect.…”

mentioning

confidence: 99%

The clinical significance of lymph node size in colon cancer

et al. 2012

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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 Z10 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 r5 mm. Only 25% of lymph nodes 410 mm showed metastases. Minute lymph nodes r1 mm were involved only very rarely (2 of 81 cases). In 67% of the cases, the largest positive lymph node was o10 mm. The prognostic relevance of lymph node size was investigated in a subset of 115 stage I/II cases. The occurrence of Z7 lymph nodes that were 45 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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“…Cautious interpretation of the data, however, is necessary given the fact that a significant proportion of the patients in this analysis was treated in university and academic hospitals. As previously reported by Wang et al 40 hospital factors may influence both, the lymph node count and the prognosis. This phenomenon can not be ruled out in the present study and therefore our data are not necessarily transferable to other cancer cohorts.…”

mentioning

confidence: 53%

“…14,27 This mechanism, however, has been questioned in some studies discussing an association of a low lymph node number with biologically relevant tumour or patient factors. 21,29,30,40,41 In this study, we aimed in elucidating the contributions of both discussed mechanisms to the prognostic role of the lymph node count. Reasoning that improvement of lymph node examination should have an effect on an understaging mechanism but not on patient or tumour factors we studied a cohort of 1,899 colorectal cancers with a 12 node performance rate markedly higher than in previous analyses.…”

Section: Discussionmentioning

confidence: 99%

Lymph node count and prognosis in colorectal cancer: The influence of examination quality

Bläker

Hildebrandt

Riess

et al. 2014

Intl Journal of Cancer

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Colorectal cancer guidelines recommend adjuvant chemotherapy in stage II disease when less than 12 lymph nodes are assessed. The recommendation bases on previous studies showing an association of a low lymph node count and adverse outcome. Compared to current standards, however, the quality of lymph node examination in the studies was low. We, therefore, investigated the prognostic role of <12 lymph nodes in cancers diagnosed adherent to current quality measures. Stage I-IV colorectal cancers from 1,899 patients enrolled into a population-based cohort study were investigated for the prognostic impact of a lymph node count <12. The stage specific share of patients diagnosed with 12 nodes (stage I-IV: 62, 85, 85, 78%, respectively) was used to compare lymph node examination quality to other studies. We found no impact of a lymph node count <12 on overall, cancer-specific or recurrence-free survival for any tumour stage. Compared to studies reporting an adverse prognostic impact of a low lymph node count in stages II and III the stage-specific shares of patients with 12 nodes were markedly higher in this study (85% vs. 24-58% in previous analyses) and this correlated with increased rates of stage III compared to stage II cancers. In conclusion our data indicate, that the previously reported effect of a low lymph node count on the patients' outcomes is eliminated by improved lymph node examination quality and thus question the general applicability of a 12 lymph node cut off for adjuvant chemotherapy decision making in stage II disease.

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Hospital Lymph Node Examination Rates and Survival After Resection for Colon Cancer

Cited by 296 publications

References 20 publications

Meeting the 12 lymph node (LN) benchmark in colon cancer

Meeting the 12 lymph node (LN) benchmark in colon cancer

The clinical significance of lymph node size in colon cancer

Lymph node count and prognosis in colorectal cancer: The influence of examination quality

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