Identifying Stage III Colorectal Cancer Patients: The Influence of the Patient, Surgeon, and Pathologist

Morris, Eva; Maughan, Nicola; Forman, David; Quirke, Philip

doi:10.1200/jco.2007.11.0445

Cited by 113 publications

(92 citation statements)

References 33 publications

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“…False nodal negative staging due to inadequate lymph node sampling is the favoured explanation. 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.…”

Section: Discussionmentioning

confidence: 99%

“…1) in order to avoid a time consuming second and third look preparation, the standard procedure for cancer resections with less than 12 sampled lymph nodes after initial preparation. As also documented by others [9][10][11][12][13][14] optimization of these conventional standard procedures results in a high rate of 12 node minimum cancer resections even though fat clearance techniques are not routinely used.…”

Section: Lymph Node Examinationmentioning

confidence: 92%

“…[11][12][13][14] Parsons et al reported that the overall rate of cancers diagnosed compliant with the 12 node minimum developed from 46.8% in 2000-2002 to 73.6% in [2006][2007][2008] in the United States. 11 Raised awareness for the lymph node topic has also resulted from the implementation of the 12 lymph node measure, defined as the percentage of cancer patients who have at least 12 nodes investigated, as a means of quality surveillance.…”

mentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

Section: Lymph Node Examinationmentioning

confidence: 92%

mentioning

confidence: 99%

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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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“…The examination of the specimen resulted in the reporting of the radial or circumferential margin (CRM), a parameter confirmed to be of great prognostic significance in determination of LRR [5]. In addition, the number of lymph nodes removed became as important as the diagnosis of disease in the lymph nodes, serving as a surrogate marker of an adequate resection as well as a marker of prognosis [6,7]. The importance of the CRM and lymph nodes reinforced the rationale behind TME resections, leading to the widespread adoption of this technique as the gold standard in surgical treatment of rectal cancer.…”

Section: Total Mesorectal Excision Decreases Local Recurrencementioning

confidence: 99%

The Changing Role of Radiation in the Post-TME ERA of Rectal Cancer

Lai¹,

Thomas²

2010

CCTR

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Total mesorectal excision (TME) for rectal cancer is now considered standard in the surgical treatment of rectal cancer. The application of this technique has resulted in a pooled pelvic recurrence rate of approximately 7%. Preoperative and postoperative radiation further decreases the local regional recurrence (LRR) rate in patients with rectal cancer but the reduction in risk is counterbalanced by increased short and long term toxicity. Lower LRR rates have not uniformly translated into more favorable overall survival. In addition, advances in imaging have resulted in more accurate pretreatment staging and have improved the ability to stratify patients based on risk of recurrence. Given low pelvic recurrence rates after TME-based surgery alone, the risks and toxicities of pelvic radiation, and superior imaging to select high risk patients, radiation may not be requisite in the treatment of all rectal cancer patients. In this review, we discuss the current status of radiation and LRR rates in rectal cancer after definitive surgical resection with respect to specific subsites and stages of disease, examine the impact of imaging in the selection of patients for radiation, and raise the possibility that predictive biomarkers may help to identify patients who may not require pelvic radiation.

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“…Classification may also be imprecise as patients may be classified incorrectly due to the variable quality of pathology or be "understaged" (i.e. incorrectly assigned a earlier stage at diagnosis due to unidentified lymph node metastases) (Morris, Maughan, Forman, & Quirke, 2007). Statistical analyses using regression modelling may yield biased results where model covariates have measurement error (Greenwood, 2012) or missing values (Carroll, Ruppert, Stefanski, & Crainiceanu, 2006;Fuller, 1987), and this bias is exacerbated when considering product interaction terms (Greenwood, Gilthorpe, & Cade, 2006).…”

Section: Introductionmentioning

confidence: 99%

Multilevel Latent Class Modelling of Colorectal Cancer Survival Status at Three Years and Socioeconomic Background Whilst Incorporating Stage of Disease

Harrison

Gilthorpe²,

Downing³

et al. 2013

IJSP

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Previous studies investigating survival from colorectal cancer have typically considered potential confounders to include stage of disease. Stage however may lie on the causal path and statistical adjustment with stage as a confounder can then introduce bias known as the reversal paradox. Classification of stage may also be imprecise and incomplete. Modelling using Latent Class Analysis (LCA) may minimise bias by including covariates on the causal path as 'class predictors' and by accommodating uncertainty associated with confounder values explicitly via the latent class part of the model. We construct multilevel latent class models to allow for the multilevel structure of the data: patients nested within NHS Trusts. We use a dataset of patients in a large UK regional population diagnosed with colorectal cancer between 1998 and 2004. Death within three years is the outcome. The optimum number of latent classes at patient and Trust level is determined with reference to likelihood-based modelfit criteria. The three-patient five-Trust class multilevel LCA model was chosen. Patient classes were identified as good, reasonable or poor prognosis groups. The impact of stage differed across the patient classes. Socioeconomic background and older age were clearly associated with increased odds of death in all patient classes. Females had significantly decreased odds of death compared with males in the good prognosis class. The five Trust classes identified outlying Trusts, indicating that the standard multilevel model would not have been sufficient to model these data.

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Identifying Stage III Colorectal Cancer Patients: The Influence of the Patient, Surgeon, and Pathologist

Abstract: Variations in nodal yield are due to idiosyncratic patient and tumor characteristics and differences in the quality of surgery and pathology undertaken. Adequate lymphadenectomy is essential to ensure correct stage allocation and optimal survival.

Cited by 113 publications

References 33 publications

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

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

The Changing Role of Radiation in the Post-TME ERA of Rectal Cancer

Multilevel Latent Class Modelling of Colorectal Cancer Survival Status at Three Years and Socioeconomic Background Whilst Incorporating Stage of Disease

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