Surgery Today

, 41:1370 | Cite as

Adequate lymph node examination is essential to ensure the prognostic value of the lymph node ratio in patients with stage III colorectal cancer

  • Manabu Shimomura
  • Satoshi Ikeda
  • Yuji Takakura
  • Yasuo Kawaguchi
  • Masakazu Tokunaga
  • Hiroyuki Egi
  • Takao Hinoi
  • Masazumi Okajima
  • Hideki Ohdan
Original Article



This study aimed to assess the prognostic value of the lymph node ratio (LNR), estimated by dividing the number of positive lymph nodes (LNs) by the number of LNs examined, for stage III colorectal cancer in comparison to the new tumor, nodes, and metastasis (TNM) system, and to evaluate the relationship between the number of LNs examined and the prognostic value of the LNR.


We retrospectively reviewed the clinicopathological data of a cohort of 266 patients with stage III colorectal cancer. We assessed the impact of LNR on the prediction of cancer recurrence in comparison to the TNM system, as well as the prognostic value of LNR in patients with a low LN count.


In multivariate analysis, the LNR was found to be an independent risk factor of cancer recurrence. The application of the LNR, in addition to the new TNM system, was more predictive of survival than the TNM system alone. A prognostic separation by LNR was observed in patients who had an adequate number of LNs examined, but not in patients with a low LN count.


A stronger prognostic separation can be obtained by using the LNR together with the new TNM system. Adequate lymph node examination is important to ensure the prognostic value of LNR in patients with stage III colorectal cancer.

Key words

Colorectal cancer Lymph node ratio Lymph node examination TNM 7th edition 


  1. 1.
    Sobin LH Gospodarowicz MK, Wittekind C. UICC. TNM classification of malignant tumors. 7th ed. New York: Wiley-Liss; 2009.Google Scholar
  2. 2.
    Le Voyer TE, Sigurdson ER, Hanlon AL, Mayer RJ, Macdonald JS, Catalano PJ, et al. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 2003;21:2912–2919.PubMedCrossRefGoogle Scholar
  3. 3.
    Peschaud F, Benoist S, Julie C, Beauchet A, Penna C, Rougier P, et al. The ratio of metastatic to examined lymph nodes is a powerful independent prognostic factor in rectal cancer. Ann Surg 2008;248:1067–1073.PubMedCrossRefGoogle Scholar
  4. 4.
    Vaccaro CA, Im V, Rossi GL, Quintana GO, Benati ML, Perez de Arenaza D, et al. Lymph node ratio as prognosis factor for colon cancer treated by colorectal surgeons. Dis Colon Rectum 2009;52:1244–1250.PubMedCrossRefGoogle Scholar
  5. 5.
    Bando E, Yonemura Y, Taniguchi K, Fushida S, Fujimura T, Miwa K. Outcome of ratio of lymph node metastasis in gastric carcinoma. Ann Surg Oncol 2002;9:775–784.PubMedCrossRefGoogle Scholar
  6. 6.
    Voordeckers M, Vinh-Hung V, Van de Steene J, Lamote J, Storme G. The lymph node ratio as prognostic factor in node-positive breast cancer. Radiother Oncol 2004;70:225–230.PubMedCrossRefGoogle Scholar
  7. 7.
    Iwase H, Yamamoto Y, Kawasoe T, Ibusuki M. Advantage of sentinel lymph node biopsy before neoadjuvant chemotherapy in breast cancer treatment. Surg Today 2009;39:374–380.PubMedCrossRefGoogle Scholar
  8. 8.
    Berger AC, Watson JC, Ross EA, Hoffman JP. The metastatic/examined lymph node ratio is an important prognostic factor after pancreaticoduodenectomy for pancreatic adenocarcinoma. Am Surg 2004;70:235–240.PubMedGoogle Scholar
  9. 9.
    Berger AC, Sigurdson ER, LeVoyer T, Hanlon A, Mayer RJ, Macdonald JS, et al. Colon cancer survival is associated with decreasing ratio of metastatic to examined lymph nodes. J Clin Oncol 2005;23:8706–8712.PubMedCrossRefGoogle Scholar
  10. 10.
    De Ridder M, Vinh-Hung V, Van Nieuwenhove Y, Hoorens A, Sermeus A, Storme G. Prognostic value of the lymph node ratio in node positive colon cancer. Gut 2006;55:1681.PubMedCrossRefGoogle Scholar
  11. 11.
    Lee HY, Choi HJ, Park KJ, Shin JS, Kwon HC, Roh MS, et al. Prognostic significance of metastatic lymph node ratio in nodepositive colon carcinoma. Ann Surg Oncol 2007;14:1712–1717.PubMedCrossRefGoogle Scholar
  12. 12.
    Schumacher P, Dineen S, Barnett C Jr, Fleming J, Anthony T. The metastatic lymph node ratio predicts survival in colon cancer. Am J Surg 2007;194:827–831.PubMedCrossRefGoogle Scholar
  13. 13.
    Derwinger K, Carlsson G, Gustavsson B. A study of lymph node ratio as a prognostic marker in colon cancer. Eur J Surg Oncol 2008;34:771–775.PubMedGoogle Scholar
  14. 14.
    Derwinger K, Gustavsson B. A study of lymph node ratio in stage IV colorectal cancer. World J Surg Oncol 2008;6:127.PubMedCrossRefGoogle Scholar
  15. 15.
    Peng J, Xu Y, Guan Z, Zhu J, Wang M, Cai G, et al. Prognostic significance of the metastatic lymph node ratio in node-positive rectal cancer. Ann Surg Oncol 2008;15:3118–3123.PubMedCrossRefGoogle Scholar
  16. 16.
    Rosenberg R, Friederichs J, Schuster T, Gertler R, Maak M, Becker K, et al. 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 2008;248:968–978.PubMedCrossRefGoogle Scholar
  17. 17.
    Wang J, Hassett JM, Dayton MT, Kulaylat MN. The prognostic superiority of log odds of positive lymph nodes in stage III colon cancer. J Gastrointest Surg 2008;12:1790–1796.PubMedCrossRefGoogle Scholar
  18. 18.
    Wang J, Hassett JM, Dayton MT, Kulaylat MN. Lymph node ratio: role in the staging of node-positive colon cancer. Ann Surg Oncol 2008;15:1600–1608.PubMedCrossRefGoogle Scholar
  19. 19.
    Chin CC, Wang JY, Yeh CY, Kuo YH, Huang WS, Yeh CH. Metastatic lymph node ratio is a more precise predictor of prognosis than number of lymph node metastases in stage III colon cancer. Int J Colorectal Dis 2009;24:1297–1302.PubMedCrossRefGoogle Scholar
  20. 20.
    Galizia G, Orditura M, Ferraraccio F, Castellano P, Pinto M, Zamboli A, et al. The lymph node ratio is a powerful prognostic factor of node-positive colon cancers undergoing potentially curative surgery. World J Surg 2009;33:2704–2713.PubMedCrossRefGoogle Scholar
  21. 21.
    Kim YS, Kim JH, Yoon SM, Choi EK, Ahn SD, Lee SW, et al. Lymph node ratio as a prognostic factor in patients with stage III rectal cancer treated with total mesorectal excision followed by chemoradiotherapy. Int J Radiat Oncol Biol Phys 2009;74:796–802.PubMedCrossRefGoogle Scholar
  22. 22.
    Moug SJ, Saldanha JD, McGregor JR, Balsitis M, Diament RH. Positive lymph node retrieval ratio optimises patient staging in colorectal cancer. Br J Cancer 2009;100:1530–1533.PubMedCrossRefGoogle Scholar
  23. 23.
    Ng M, Roy-Chowdhury S, Lum SS, Morgan JW, Wong JH. The impact of the ratio of positive to total lymph nodes examined and outcome in colorectal cancer. Am Surg 2009;75:873–876.PubMedGoogle Scholar
  24. 24.
    Park IJ, Choi GS, Jun SH. Nodal stage of stage III colon cancer: the impact of metastatic lymph node ratio. J Surg Oncol 2009;100:240–243.PubMedCrossRefGoogle Scholar
  25. 25.
    Priolli DG, Cardinalli IA, Pereira JA, Alfredo CH, Margarido NF, Martinez CA. Metastatic lymph node ratio as an independent prognostic variable in colorectal cancer: study of 113 patients. Tech Coloproctol 2009;13:113–121.PubMedCrossRefGoogle Scholar
  26. 26.
    Vather R, Sammour T, Kahokehr A, Connolly AB, Hill AG. Lymph node evaluation and long-term survival in Stage II and Stage III colon cancer: a national study. Ann Surg Oncol 2009;16:585–593.PubMedCrossRefGoogle Scholar
  27. 27.
    Wang J, Kulaylat M, Rockette H, Hassett J, Rajput A, Dunn KB, et al. Should total number of lymph nodes be used as a quality of care measure for stage III colon cancer? Ann Surg 2009;249:559–563.PubMedCrossRefGoogle Scholar
  28. 28.
    Japanese Society for Cancer of the Colon and Rectum. General rules for clinical and pathological studies on cancer of the colon, rectum and anus. 7th ed., revised version. Tokyo: Kanehara; 2009.Google Scholar
  29. 29.
    Chang GJ, Rodriguez-Bigas MA, Skibber JM, Moyer VA. Lymph node evaluation and survival after curative resection of colon cancer: systematic review. J Natl Cancer Inst 2007;99:433–441.PubMedCrossRefGoogle Scholar
  30. 30.
    Johnson PM, Porter GA, Ricciardi R, Baxter NN. Increasing negative lymph node count is independently associated with improved long-term survival in stage IIIB and IIIC colon cancer. J Clin Oncol 2006;24:3570–3575.PubMedCrossRefGoogle Scholar
  31. 31.
    Chen SL, Bilchik AJ. More extensive nodal dissection improves survival for stages I to III of colon cancer: a population-based study. Ann Surg 2006;244:602–610.PubMedGoogle Scholar
  32. 32.
    Chau I, Cunningham D. Adjuvant therapy in colon cancer — what, when and how? Ann Oncol 2006;17:1347–1359.PubMedCrossRefGoogle Scholar
  33. 33.
    Kuebler JP, Wieand HS, O’Connell MJ, Smith RE, Colangelo LH, Yothers G, et al. Oxaliplatin combined with weekly bolus fluorouracil and leucovorin as surgical adjuvant chemotherapy for stage II and III colon cancer: results from NSABP C-07. J Clin Oncol 2007;25:2198–2204.PubMedCrossRefGoogle Scholar
  34. 34.
    Andre T, Boni C, Mounedji-Boudiaf L, Navarro M, Tabernero J, Hickish T, et al. Oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer. N Engl J Med 2004;350:2343–2351.PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2011

Authors and Affiliations

  • Manabu Shimomura
    • 1
  • Satoshi Ikeda
    • 2
  • Yuji Takakura
    • 1
  • Yasuo Kawaguchi
    • 1
  • Masakazu Tokunaga
    • 1
  • Hiroyuki Egi
    • 2
  • Takao Hinoi
    • 2
  • Masazumi Okajima
    • 2
  • Hideki Ohdan
    • 1
  1. 1.Department of Surgery, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical SciencesHiroshima UniversityHiroshimaJapan
  2. 2.Department of Endoscopic Surgery and Surgical ScienceHiroshima UniversityHiroshimaJapan

Personalised recommendations