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The adequacy of lymph node clearance in colon cancer surgery performed in a non-specialist centre; implications for practice

Abstract

Background

Despite recent medical advances, surgery remains the mainstay treatment in colon cancer. It is well established that better patient outcomes are achieved when complex surgery including pancreatic, oesophageal and rectal surgeries are carried out in high-volume centres. However, it is unclear as to whether or not colon cancer patients receive the same benefit. Lymph node adequacy is a key performance indicator of successful oncological colonic resection which impacts on patient outcome.

Aim

To assess the adequacy of lymph node clearance during colonic resection performed with curative intent in a non-specialist centre post introduction of the National Cancer Strategy.

Methods

Retrospective analysis was performed of a prospectively maintained database examining the lymph node clearance of all oncological resections for colon cancer over a 7-year period (Nov 2010–Dec 2017) at a satellite unit with links to a regional specialist centre. Primary outcome measured was the number of lymph nodes retrieved. Secondary outcomes included resection margins, 30-day complication rate and survival at 1 year. Statistical analysis was performed using SPSS Statistics for Windows, version 24.0 (IBM Corp, Armonk, N.Y., USA).

Results

One hundred sixty-seven patients were included. Mean age was 71.0 ± 11.6 years. Majority were male (n = 90, 53.6%). The majority of resections was right sided (n = 112.66.7%) with 78.6% of all resections being undertaken electively. All margins were free of tumour. The average lymph node count was 19.93 ± 8.63 (4.62) with only 17 (10.2%) of specimens containing < 12 nodes. The anastomotic leak rate was 3.3%. There was no association between surgeon or pathologist volume, nor emergent status and achieving oncological lymph node count (p = 0.14, 0.29, 0.97). 90.5% of patients were alive at 1 year.

Conclusions

This study demonstrates that colonic cancer surgery can be safely performed in a non- specialist centre with technical outcomes comparable to nationally reported figures.

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References

  1. Fitzmaurice C, Akinyemiju TF, Al Lami FH, Alam T, Alizadeh-Navaei R, Allen C, Alsharif U, Alvis-Guzman N, Amini E, Anderson BO, Aremu O, Artaman A, Asgedom SW, Assadi R, Atey TM, Avila-Burgos L, Awasthi A, Ba Saleem HO, Barac A, Bennett JR, Bensenor IM, Bhakta N, Brenner H, Cahuana-Hurtado L, Castaneda-Orjuela CA, Catala-Lopez F, Choi JJ, Christopher DJ, Chung SC, Curado MP, Dandona L, Dandona R, das Neves J, Dey S, Dharmaratne SD, Doku DT, Driscoll TR, Dubey M, Ebrahimi H, Edessa D, El-Khatib Z, Endries AY, Fischer F, Force LM, Foreman KJ, Gebrehiwot SW, Gopalani SV, Grosso G, Gupta R, Gyawali B, Hamadeh RR, Hamidi S, Harvey J, Hassen HY, Hay RJ, Hay SI, Heibati B, Hiluf MK, Horita N, Hosgood HD, Ilesanmi OS, Innos K, Islami F, Jakovljevic MB, Johnson SC, Jonas JB, Kasaeian A, Kassa TD, Khader YS, Khan EA, Khan G, Khang YH, Khosravi MH, Khubchandani J, Kopec JA, Kumar GA, Kutz M, Lad DP, Lafranconi A, Lan Q, Legesse Y, Leigh J, Linn S, Lunevicius R, Majeed A, Malekzadeh R, Malta DC, Mantovani LG, McMahon BJ, Meier T, Melaku YA, Melku M, Memiah P, Mendoza W, Meretoja TJ, Mezgebe HB, Miller TR, Mohammed S, Mokdad AH, Moosazadeh M, Moraga P, Mousavi SM, Nangia V, Nguyen CT, Nong VM, Ogbo FA, Olagunju AT, Pa M, Park EK, Patel T, Pereira DM, Pishgar F, Postma MJ, Pourmalek F, Qorbani M, Rafay A, Rawaf S, Rawaf DL, Roshandel G, Safiri S, Salimzadeh H, Sanabria JR, Santric Milicevic MM, Sartorius B, Satpathy M, Sepanlou SG, Shackelford KA, Shaikh MA, Sharif-Alhoseini M, She J, Shin MJ, Shiue I, Shrime MG, Sinke AH, Sisay M, Sligar A, Sufiyan MB, Sykes BL, Tabares-Seisdedos R, Tessema GA, Topor-Madry R, Tran TT, Tran BX, Ukwaja KN, Vlassov VV, Vollset SE, Weiderpass E, Williams HC, Yimer NB, Yonemoto N, Younis MZ, Murray CJL, Naghavi M (2018) Global, regional, and National Cancer Incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 29 Cancer groups, 1990 to 2016: a systematic analysis for the global burden of disease study. JAMA oncology 4:1553–1568. https://doi.org/10.1001/jamaoncol.2018.2706

    Article  PubMed  Google Scholar 

  2. Matsuda T, Yamashita K, Hasegawa H, Oshikiri T, Hosono M, Higashino N, Yamamoto M, Matsuda Y, Kanaji S, Nakamura T, Suzuki S, Sumi Y, Kakeji Y (2018) Recent updates in the surgical treatment of colorectal cancer. Annals of Gastroenterological Surgery 2(2):129–136. https://doi.org/10.1002/ags3.12061

    Article  PubMed  PubMed Central  Google Scholar 

  3. Stintzing S (2014) Management of colorectal cancer. F1000Prime Reports 6:108. https://doi.org/10.12703/P6-108

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. aan de Stegge WB, van Leeuwen BL, Elferink MAG, de Bock GH (2016) The evaluation of more lymph nodes in colon cancer is associated with improved survival in patients of all ages. PLoS One 11(5):e0155608. https://doi.org/10.1371/journal.pone.0155608

    CAS  Article  Google Scholar 

  5. Backes Y, Elias SG, Bhoelan BS, Groen JN, van Bergeijk J, Seerden TCJ, Pullens HJM, Spanier BWM, Geesing JMJ, Kessels K, Kerkhof M, Siersema PD, de Vos tot Nederveen Cappel WH, van Lelyveld N, Wolfhagen FHJ, ter Borg F, Offerhaus GJA, Lacle MM, Moons LMG, Group obotDTCW (2017) The prognostic value of lymph node yield in the earliest stage of colorectal cancer: a multicenter cohort study. BMC Med 15(1):129. https://doi.org/10.1186/s12916-017-0892-7

    Article  PubMed  PubMed Central  Google Scholar 

  6. Lykke J, Jess P, Roikjaer O (2015) Increased lymph node yield is associated with improved survival in rectal cancer irrespective of neoadjuvant treatment: results from a national cohort study. Dis Colon Rectum 58(9):823–830. https://doi.org/10.1097/dcr.0000000000000429

    Article  PubMed  Google Scholar 

  7. Wu Z, Qin G, Zhao N, Jia H, Zheng X (2017) Assessing the adequacy of lymph node yield for different tumor stages of colon cancer by nodal staging scores. BMC Cancer 17:498. https://doi.org/10.1186/s12885-017-3491-2

    Article  PubMed  PubMed Central  Google Scholar 

  8. McDonald JR, Renehan AG, O’Dwyer ST, Haboubi NY (2012) Lymph node harvest in colon and rectal cancer: current considerations. World Journal of Gastrointestinal Surgery 4(1):9–19. https://doi.org/10.4240/wjgs.v4.i1.9

    Article  PubMed  PubMed Central  Google Scholar 

  9. Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Kelly KN, Hensley BJ, Rickles AS, Noyes K, Fleming FJ, Monson JR (2016) High volume improves outcomes: the argument for centralization of rectal cancer surgery. Surgery 159(3):736–748. https://doi.org/10.1016/j.surg.2015.09.021

    Article  PubMed  Google Scholar 

  10. Gooiker GA, Lemmens VE, Besselink MG, Busch OR, Bonsing BA, Molenaar IQ, Tollenaar RA, de Hingh IH, Wouters MW (2014) Impact of centralization of pancreatic cancer surgery on resection rates and survival. Br J Surg 101(8):1000–1005. https://doi.org/10.1002/bjs.9468

    CAS  Article  PubMed  Google Scholar 

  11. Kilsdonk MJ, Siesling S, van Dijk BAC, Wouters MW, van Harten WH (2018) What drives centralisation in cancer care? PLoS One 13(4):e0195673. https://doi.org/10.1371/journal.pone.0195673

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  12. Wouters MWJM, Karim-Kos HE, le Cessie S, Wijnhoven BPL, Stassen LPS, Steup WH, Tilanus HW, Tollenaar RAEM (2009) Centralization of esophageal cancer surgery: does it improve clinical outcome? Ann Surg Oncol 16(7):1789–1798. https://doi.org/10.1245/s10434-009-0458-9

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. Bos AC, van Erning FN, Elferink MA, Rutten HJ, van Oijen MG, de Wilt JH, Lemmens VE (2016) No difference in overall survival between hospital volumes for patients with colorectal cancer in the Netherlands. Dis Colon Rectum 59(10):943–952

    Article  PubMed  Google Scholar 

  14. Schootman M, Lian M, Pruitt SL, Deshpande AD, Hendren S, Mutch M, Jeffe DB, Davidson N (2014) Hospital and geographic variability in thirty-day all-cause mortality following colorectal cancer surgery. Health Serv Res 49(4):1145–1164

    Article  PubMed  PubMed Central  Google Scholar 

  15. Schrag D, Cramer LD, Bach PB, Cohen AM, Warren JL, Begg CB (2000) Influence of hospital procedure volume on outcomes following surgery for colon cancer. JAMA 284(23):3028–3035. https://doi.org/10.1001/jama.284.23.3028

    CAS  Article  PubMed  Google Scholar 

  16. Wasif N, Etzioni DA, Habermann EB, Mathur A, Pockaj BA, Gray RJ, Chang Y-H (2018) Does improved mortality at low-and medium-volume hospitals lead to attenuation of the volume to outcomes relationship for major visceral surgery? J Am Coll Surg 227(1):85–93.e9

    Article  PubMed  Google Scholar 

  17. Huo YR, Phan K, Morris DL, Liauw W (2017) Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery. Journal of Gastrointestinal Oncology 8(3):534–546

    Article  PubMed  PubMed Central  Google Scholar 

  18. Forum NC (2006) A strategy for cancer control in Ireland

  19. (Ireland) DoH (2017) National Cancer Strategy 2017–2026

    Google Scholar 

  20. Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae

    Article  PubMed  PubMed Central  Google Scholar 

  21. Goldberg PA, Nicholls RJ (1995) Prediction of local recurrence and survival of carcinoma of the rectum by surgical and histopathological assessment of local clearance. Br J Surg 82(8):1054–1056

    CAS  Article  PubMed  Google Scholar 

  22. Rhoads KF, Ackerson LK, Ngo JV, Gray Hazard FK, Subramanian SV, Dudley RA (2013) Adequacy of lymph node examination in colorectal surgery: contribution of the hospital versus the surgeon. Med Care 51(12):1055–1062. https://doi.org/10.1097/MLR.1090b1013e3182a1053d72.

    Article  PubMed  Google Scholar 

  23. Jakub JW, Russell G, Tillman CL, Lariscy C (2009) Colon cancer and low lymph node count: who is to blame? Arch Surg 144(12):1115–1120. https://doi.org/10.1001/archsurg.2009.210

    Article  PubMed  Google Scholar 

  24. Bamboat ZM, Deperalta D, Dursun A, Berger DL, Bordeianou L (2011) Factors affecting lymph node yield from patients undergoing colectomy for cancer. Int J Color Dis 26(9):1163–1168. https://doi.org/10.1007/s00384-011-1240-6

    Article  Google Scholar 

  25. Nathan H, Shore AD, Anders RA, Wick EC, Gearhart SL, Pawlik TM (2011) Variation in lymph node assessment after colon cancer resection: patient, surgeon, pathologist, or hospital? J Gastrointest Surg: official journal of the Society for Surgery of the Alimentary Tract 15(3):471–479. https://doi.org/10.1007/s11605-010-1410-9

    Article  Google Scholar 

  26. Barbas A, Turley R, Mantyh C, Migaly J (2011) Advanced fellowship training is associated with improved lymph node retrieval in colon cancer resections. J Surg Res 170(1):e41–e46. https://doi.org/10.1016/j.jss.2011.03.055

    Article  PubMed  Google Scholar 

  27. Moro-Valdezate D, Pla-Martí V, Martín-Arévalo J, Belenguer-Rodrigo J, Aragó-Chofre P, Ruiz-Carmona MD, Checa-Ayet F (2013) Factors related to lymph node harvest: does a recovery of more than 12 improve the outcome of colorectal cancer? Color Dis 15(10):1257–1266. https://doi.org/10.1111/codi.12424

    CAS  Article  Google Scholar 

  28. Lorenzon L, Montebelli F, Mercantini P, Sebastiani S, Ziparo V, Ferri M (2016) Right colectomy for cancer: a matched comparison of three different surgical approaches. J Investig Surg 29(6):405–412. https://doi.org/10.1080/08941939.2016.1183735

    Article  Google Scholar 

  29. Willaert W, Mareel M, Van De Putte D, Van Nieuwenhove Y, Pattyn P, Ceelen W (2014) Lymphatic spread, nodal count and the extent of lymphadenectomy in cancer of the colon. Cancer Treat Rev 40(3):405–413. https://doi.org/10.1016/j.ctrv.2013.09.013

    Article  PubMed  Google Scholar 

  30. Nedrebo BS, Soreide K, Nesbakken A, Eriksen MT, Soreide JA, Korner H (2013) Risk factors associated with poor lymph node harvest after colon cancer surgery in a national cohort. Colorectal Dis : the official journal of the Association of Coloproctology of Great Britain and Ireland 15(6):e301–e308. https://doi.org/10.1111/codi.12245

    CAS  Article  Google Scholar 

  31. Del Paggio JC, Nanji S, Wei X, MacDonald PH, Booth CM (2017) Lymph node evaluation for colon cancer in routine clinical practice: a population-based study. Curr Oncol 24(1):e35–e43. https://doi.org/10.3747/co.24.3210

    Article  PubMed  PubMed Central  Google Scholar 

  32. Lykke J, Jess P, Roikjaer O (2016) A high lymph node yield in colon cancer is associated with age, tumour stage, tumour sub-site and priority of surgery. Results from a prospective national cohort study. Int J Color Dis 31(7):1299–1305. https://doi.org/10.1007/s00384-016-2599-1

    Article  Google Scholar 

  33. Chou JF, Row D, Gonen M, Liu Y-H, Schrag D, Weiser MR (2010) Clinical and pathologic factors that predict lymph node yield from surgical specimens in colorectal cancer: a population-based study. Cancer 116(11):2560–2570. https://doi.org/10.1002/cncr.25032

    Article  PubMed  Google Scholar 

  34. Betge J, Harbaum L, Pollheimer MJ, Lindtner RA, Kornprat P, Ebert MP, Langner C (2017) Lymph node retrieval in colorectal cancer: determining factors and prognostic significance. Int J Color Dis 32(7):991–998. https://doi.org/10.1007/s00384-017-2778-8

    Article  Google Scholar 

  35. Del Paggio JC, Peng Y, Wei X, Nanji S, MacDonald PH, Krishnan Nair C, Booth CM (2017) Population-based study to re-evaluate optimal lymph node yield in colonic cancer. Br J Surg 104(8):1087–1096. https://doi.org/10.1002/bjs.10540

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  36. Stocchi L, Fazio VW, Lavery I, Hammel J (2011) Individual surgeon, pathologist, and other factors affecting lymph node harvest in stage II colon carcinoma. Is a minimum of 12 examined lymph nodes sufficient? Ann Surg Oncol 18(2):405–412

    Article  PubMed  Google Scholar 

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Correspondence to Patrick Higgins.

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Higgins, P., Nemeth, T., Bennani, F. et al. The adequacy of lymph node clearance in colon cancer surgery performed in a non-specialist centre; implications for practice. Ir J Med Sci 189, 75–81 (2020). https://doi.org/10.1007/s11845-019-02044-1

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  • DOI: https://doi.org/10.1007/s11845-019-02044-1

Keywords

  • Colon cancer
  • Colorectal
  • General surgery
  • Lymph node
  • Non-specialist
  • Surgery