Techniques in Coloproctology

, Volume 18, Issue 8, pp 709–717 | Cite as

Establishing the optimum lymph node yield for diagnosis of stage III rectal cancer

  • A. BhanguEmail author
  • R. P. Kiran
  • G. Brown
  • R. Goldin
  • P. Tekkis
Original Article



The optimum lymph node yield for tumour staging following surgery for rectal cancer remains controversial. This study aimed to determine the optimum number of lymph nodes needed to accurately determine stage III rectal cancer.


Sixty-three thousand three hundred and eighty-one patients from the surveillance, epidemiology and end resulted database, who underwent surgery for rectal adenocarcinoma in 1995–2009, were included. The primary outcome was detection of stage III rectal cancer, assessed by multivariable logistic regression.


Each additional node examined increased the chance of stage III diagnosis by 3.9 % (adjusted odds ratio 1.039, p < 0.001). Optimum histopathological stage was reached following retrieval of 18 nodes in patients treated without neoadjuvant radiotherapy (n = 49,162) and 16 nodes in those treated with neoadjuvant radiotherapy (n = 14,219). For stage I and II cancer, retrieval of a minimum of 8 and 14 nodes, respectively, was associated with optimum five-year overall survival. For stage III cancer, increasing number of positive lymph nodes and increasing lymph node ratio (>0.5) were independent negative predictors of survival; total lymph node yield did not correlate with survival.


Eighteen lymph nodes for those treated without neoadjuvant radiotherapy and 16 nodes for those treated with it were needed to prevent stage migration in rectal cancer. These findings provide further evidence of the importance of the technique of proctectomy and of careful pathologic assessment.


Rectal cancer Staging Lymph node yield Lymph node ratio SEER 


Conflict of interest


Supplementary material

10151_2013_1114_MOESM1_ESM.docx (26 kb)
Supplementary material 1 (DOCX 25 kb)


  1. 1.
    Morris EJ, Maughan NJ, Forman D, Quirke P (2007) Identifying stage III colorectal cancer patients: the influence of the patient, surgeon, and pathologist. J Clin Oncol 25:2573–2579PubMedCrossRefGoogle Scholar
  2. 2.
    Sjo OH, Merok MA, Svindland A, Nesbakken A (2012) Prognostic impact of lymph node harvest and lymph node ratio in patients with colon cancer. Dis Colon Rectum 55:307–315PubMedCrossRefGoogle Scholar
  3. 3.
    Parsons HM, Tuttle TM, Kuntz KM, Begun JW, McGovern PM, Virnig BA (2011) Association between lymph node evaluation for colon cancer and node positivity over the past 20 years. JAMA 306:1089–1097PubMedCrossRefGoogle Scholar
  4. 4.
    Caplin S, Cerottini JP, Bosman FT, Constanda MT, Givel JC (1998) For patients with Dukes’ B (TNM Stage II) colorectal carcinoma, examination of six or fewer lymph nodes is related to poor prognosis. Cancer 83:666–672PubMedCrossRefGoogle Scholar
  5. 5.
    Tekkis PP, Smith JJ, Heriot AG, Darzi AW, Thompson MR, Stamatakis JD (2006) A national study on lymph node retrieval in resectional surgery for colorectal cancer. Dis Colon Rectum 49:1673–1683PubMedCrossRefGoogle Scholar
  6. 6.
    Berger AC, Sigurdson ER, LeVoyer T et al (2005) Colon cancer survival is associated with decreasing ratio of metastatic to examined lymph nodes. J Clin Oncol 23:8706–8712PubMedCrossRefGoogle Scholar
  7. 7.
    Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK (1998) Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 133:894–899PubMedCrossRefGoogle Scholar
  8. 8.
    Bhangu A, Brown G, Nicholls RJ, Wong J, Darzi A, Tekkis P (2013) Survival outcome of local excision versus radical resection of colon or rectal carcinoma: a surveillance, epidemiology, and end results (SEER) population-based study. Ann Surg 258:563–569PubMedGoogle Scholar
  9. 9.
    Johnson PM, Porter GA, Ricciardi R, Baxter NN (2006) Increasing negative lymph node count is independently associated with improved long-term survival in stage IIIB and IIIC colon cancer. J Clin Oncol 24:3570–3575PubMedCrossRefGoogle Scholar
  10. 10.
    Wong RK, Tandan V, De Silva S, Figueredo A (2007) Pre-operative radiotherapy and curative surgery for the management of localized rectal carcinoma. Cochrane Database Syst Rev 2:CD002102PubMedGoogle Scholar
  11. 11.
    Habr-Gama A, Perez RO, Proscurshim I et al (2008) Absence of lymph nodes in the resected specimen after radical surgery for distal rectal cancer and neoadjuvant chemoradiation therapy: what does it mean? Dis Colon Rectum 51:277–283PubMedCrossRefGoogle Scholar
  12. 12.
    Manilich EA, Kiran RP, Radivoyevitch T, Lavery I, Fazio VW, Remzi FH (2011) A novel data-driven prognostic model for staging of colorectal cancer. J Am Coll Surg 213:579–588PubMedCrossRefGoogle Scholar
  13. 13.
    Warren JL, Klabunde CN, Schrag D, Bach PB, Riley GF (2002) Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care 40 (8 Suppl):IV-3–18Google Scholar
  14. 14.
    Schofield JB, Mounter NA, Mallett R, Haboubi NY (2006) The importance of accurate pathological assessment of lymph node involvement in colorectal cancer. Colorectal Dis 8:460–470PubMedCrossRefGoogle Scholar
  15. 15.
    Miller ED, Robb BW, Cummings OW, Johnstone PA (2012) The effects of preoperative chemoradiotherapy on lymph node sampling in rectal cancer. Dis Colon Rectum 55:1002–1007PubMedCrossRefGoogle Scholar
  16. 16.
    Doll D, Gertler R, Maak M et al (2009) Reduced lymph node yield in rectal carcinoma specimen after neoadjuvant radiochemotherapy has no prognostic relevance. World J Surg 33:340–347PubMedCrossRefGoogle Scholar
  17. 17.
    Sprenger T, Rothe H, Homayounfar K et al (2010) Preoperative chemoradiotherapy does not necessarily reduce lymph node retrieval in rectal cancer specimens–results from a prospective evaluation with extensive pathological work-up. J Gastrointest Surg 14:96–103PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Rosenberg R, Friederichs J, Schuster T et al (2008) Prognosis of patients with colorectal cancer is associated with lymph node ratio: a single-center analysis of 3,026 patients over a 25-year time period. Ann Surg 248:968–978PubMedCrossRefGoogle Scholar
  19. 19.
    Wang J, Hassett JM, Dayton MT, Kulaylat MN (2008) Lymph node ratio: role in the staging of node-positive colon cancer. Ann Surg Oncol 15:1600–1608PubMedCrossRefGoogle Scholar
  20. 20.
    Rutegard M, Hemmingsson O, Matthiessen P, Rutegard J (2012) High tie in anterior resection for rectal cancer confers no increased risk of anastomotic leakage. Br J Surg 99:127–132PubMedCrossRefGoogle Scholar
  21. 21.
    Tiernan J, Ansari I, Hirst N, Millner P, Hughes T, Jayne D (2012) Intra-operative tumour detection and staging in colorectal cancer surgery. Colorectal Dis 14:e510–e520PubMedCrossRefGoogle Scholar
  22. 22.
    Kim YM, Suh JH, Cha HJ et al (2007) Additional lymph node examination from entire submission of residual mesenteric tissue in colorectal cancer specimens may not add clinical and pathologic relevance. Hum Pathol 38:762–767PubMedCrossRefGoogle Scholar
  23. 23.
    Morikawa T, Tanaka N, Kuchiba A et al (2012) Predictors of lymph node count in colorectal cancer resections: data from US nationwide prospective cohort studies. Arch Surg 147:715–723PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2014

Authors and Affiliations

  • A. Bhangu
    • 1
    • 2
    Email author
  • R. P. Kiran
    • 3
  • G. Brown
    • 4
  • R. Goldin
    • 5
  • P. Tekkis
    • 1
    • 2
  1. 1.Division of Colorectal SurgeryRoyal Marsden HospitalLondonUK
  2. 2.Division of SurgeryImperial CollegeLondonUK
  3. 3.Division of Colorectal Surgery, New York Presbyterian HospitalColumbia University Medical CenterNew YorkUSA
  4. 4.Department of RadiologyThe Royal Marsden HospitalLondonUK
  5. 5.Centre for PathologyImperial College, St. Mary’s HospitalLondonUK

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