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In vivo lymph node mapping and pattern of metastasis spread in locally advanced mid/low rectal cancer after neoadjuvant chemoradiotherapy

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

The lymph node status is one of the strongest prognostic determinants in rectal cancers. After chemoradiotherapy (CRT), lymph nodes are difficult to detect. This study aims to evaluate the feasibility of lymph node mapping in the mesorectum after CRT to analyze the pattern of metastasis spread and to assess the reliability of blue dye injection in sentinel lymph node detection.

Method

Ten patients with cN+ mid/low RCs after CRT were prospectively enrolled. The protocol scheduled intraoperative blue dye injection, surgery, and specimen examination with fat clearance technique. The mesorectum was divided into three equal “levels” (upper, middle, and lower); each level was divided into three equal “sectors” (right anterolateral, posterior, and left anterolateral). Lymph nodes were defined “small” if ≤5 mm.

Results

Two hundred seventy-six lymph nodes were retrieved in ten patients; 76.5 % were small lymph nodes. Six patients were pN+ (33 metastatic lymph nodes, 76 % small); small lymph node analysis upstaged one patient from N0 to N1 and four patients from N1 to N2. Metastasis distribution across sectors was continuous, without “skip sectors.” The blue dye detected the sentinel lymph node in all patients; in half of the cases, it was out of the tumor sector. Blue dye identified 69.7 % of metastatic lymph nodes; its sensitivity decreased together with the metastatic deposit size (84 % macrometastases, 28.6 % micrometastases, 0 % occult tumor cells; p = 0.004).

Conclusion

The fat clearance technique should be the standard pathological examination in patients with RCs after CRT; N staging was improved by small lymph node identification. Lymph node metastases have a continuous spread through mesorectal sectors. Blue dye injection is effective in sentinel lymph node detection.

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References

  1. WHO (2013) World Health Organization statistical information system. WHO Mortality Database http//www3.who.int/whosis/menu.cfm. Accessed 6 Jan 2013

  2. Colombo PE, Patani N, Bibeau F, Assenat E, Bernard MM, Senesse P, Rouanet P (2011) Clinical impact of lymph node status in rectal cancer. Surg Oncol 20(4):e227–e233

    Article  PubMed  CAS  Google Scholar 

  3. Andre T, Boni C, Mounedji-Boudiaf L et al (2004) Oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer. N Engl J Med 350:2343–2351

    Article  PubMed  CAS  Google Scholar 

  4. NCCN (2009) Practice guideline for rectal cancer. 1st edn. NCCN http//www.nccn.org. Accessed 6 Jan 2013

  5. Baxter NN, Morris AM, Rothenberger DA, Tepper JE (2005) Impact of preoperative radiation for rectal cancer on subsequent lymph node evaluation: a population-based analysis. Int J Radiat Oncol Bio Phys 61:426–431

    Article  Google Scholar 

  6. Wichmann MW, Molar C, Meyer G, Strauss T, Hornung HM, Lau-Werner U, Angele MK, Schildberg FW (2002) Effect of preoperative radiochemotherapy on lymph node retrieval after resection of rectal cancer. Arch Surg 137:206–210

    Article  PubMed  Google Scholar 

  7. Saha S, Monson KM, Belchik A, Beutler T, Dan AG, Schochet E, Wiese D, Kaushal S, Ganatra B, Desai D (2004) Comparative analysis of nodal upstaging between colon and rectal cancers by sentinel lymph node mapping: a prospective trial. Dis Colon Rectum 47:1767–1772

    Article  PubMed  Google Scholar 

  8. Wood TF, Saha S, Morton DL, Tsioulias GJ, Rangel D, Hutchinson W Jr, Foshag LJ, Bilchik AJ (2001) Validation of lymphatic mapping in colorectal cancer: in vivo, ex vivo, and laparoscopic techniques. Ann Surg Oncol 8:150–157

    Article  PubMed  CAS  Google Scholar 

  9. Rullier E, Vendrely V (2011) Can mesorectal lymph node excision be avoided in rectal cancer surgery? Color Dis 13(7):37–42

    Article  Google Scholar 

  10. Garcia-Aguilas J, Shi Q, Thomas CR Jr, Chan E, Cataldo P, Marcet J, Medich D, Pigazzi A, Oommen S, Posner MC. (2012) A phase II trial of neoadjuvant chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann Surg Oncol doi:10.1245/s10434-011-1933-7

  11. Dworak O, Keilholz L, Hoffmann A (1997) Pathological features of rectal cancer after preoperative radiochemotherapy. Int J Color Dis 12:19.23

    Article  Google Scholar 

  12. Kim JS, Sohn DK, Park JW, Kim DY, Chang HJ, Choi HS, Oh JH (2011) Prognostic significance of distribution of lymph node metastasis in advanced mid or low rectal cancer. J Surg Oncol 104(5):486–492

    Article  PubMed  Google Scholar 

  13. Scott KW, Grace RH, Gibbons P (1994) Five-year follow-up study of the fat clearance techinique in colorectal carcinoma. Dis Colon Rectum 37:126–128

    Article  PubMed  CAS  Google Scholar 

  14. Van der Pas MH, Meijer S, Hoekstra OS, Riphagen II, de Vet HC, Knol DL, van Grieken NC, Meijerink WJ (2011) Sentinel-lymph-node procedure in colon and rectal cancer: a systematic review and meta-analysis. Lancet Oncol 12(6):540–550

    Article  PubMed  Google Scholar 

  15. Herrera-Ornelas L, Justiniano J, Castillo N, Petrelli NJ, Stulc JP, Mittelman A (1987) Metastases in small lymph nodes from colon cancer. Arch Surg 122:1253–1256

    Article  PubMed  CAS  Google Scholar 

  16. Kotanagi H, Fukuoka T, Shibata Y, Yoshioka T, Aizawa O, Saito Y, Tur GE, Koyama K (1993) The size of regional lymph nodes does not correlate with the presence or absence of metastasis in lymph nodes in rectal cancer. J Surg Oncol 54:252–254

    Article  PubMed  CAS  Google Scholar 

  17. Leibold T, Shia J, Ruo L, Minsky BD, Akhurst T, Gollub MJ, Ginsberg MS, Larson S, Riedel E, Wong WD, Guillem JG (2008) Prognostic implications of the distribution of lymph node metastases in rectal cancer after neoadjuvant chemoradiotherapy. J Clin Oncol 26:2106–2111

    Article  PubMed  Google Scholar 

  18. Cserni G (2002) The influence of nodal size on the staging of colorectal carcinomas. J Clin Pathol 55:386–390

    Article  PubMed  CAS  Google Scholar 

  19. Rodriguez-Bigas MA, Maamoun S, Weber TK, Penetrante RB, Blumenson LE, Petrelli NJ (1996) Clinical significance of colorectal cancer: metastases in lymph nodes <5 mm in size. Ann Surg Oncol 3:124–130

    Article  PubMed  CAS  Google Scholar 

  20. Yun-Feng Yao, Lin Wang, Yi-Qiang Liu, Ji-You Li, Jin Gu (2011) Lymph node distribution and pattern of metastases in the mesorectum following total mesorectal excision using the modified fat clearing technique. J Clin Pathol. doi: 10.1136/jclinpath-2011-200190

  21. Toper B, Acland R, Kolodko V, Galandiuk S (2003) Mesorectal lymph nodes: their location and distribution within the mesorectum. Dis Colon Rectum 46:779–785

    Article  Google Scholar 

  22. Canessa CE, Badìa F, Fierro S, Fiol V, Háyek G (2001) Anatomic study of the lymph nodes of the mesorectum. Dis Colon Rectum 44:1333–1336

    Article  PubMed  CAS  Google Scholar 

  23. Pezer RO, Seid VE, Bresciani EH, Proscurshim I, Pereira DD, Kruglensky D, Rawet V, Habr-Gama A, Kiss D (2008) Distribution of lymph nodes in the mesorectum: how deep is TME necessary? Tech Coloproctol 12:39–43

    Article  Google Scholar 

  24. Pirro N, Pignodel C, Cathala P, Fabbro-Peray P, Godlewski G, Prudhomme M (2008) The number of lymph nodes is correlated with mesorectal morphometry. Surg Radiol Anat 30:297–302

    Article  PubMed  CAS  Google Scholar 

  25. Cserni G, Tarjàn M, Bori R (2001) Distance of lymph nodes from the tumour, an important feature in colorectal cancer specimens. Arch Pathol Med 125:246–249

    CAS  Google Scholar 

  26. Hida J, Yasutomi M, Maruyama T, Fujimoto K, Uchida T, Okuno K (1997) Lymph node metastases detected in the mesorectum distal to carcinoma of the rectum by the clearing method: justification of total mesorectal excision. J Am Coll Surg 184:584–588

    PubMed  CAS  Google Scholar 

  27. Ono C, Yoshinaga K, Enomoto M, Sugihara K (2002) Discontinuos rectal cancer spread in the mesorectum and the optimal distal clearance margin in situ. Dis Colon Rectum 45:744–799

    Article  PubMed  Google Scholar 

  28. Park JS, Choi GS, Kim HJ, Park SY, Park YJ, Lee SW, Xu Z, Bae HI (2011) The feasibility of an ex-vivo sentinel lymph mapping using preoperative radioisotope injection in cases of extraperitoneal rectal cancer. J Korean Soc Coloproctol 27(2):83–89

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Largo Turati 62, 10129, Turin, Italy

    E. Farinella, L. Viganò, M. Mineccia, F. Bertolino & L. Capussotti

  2. Department of Pathology, Ospedale Mauriziano Umberto I, Turin, Italy

    M. C. Fava

Authors
  1. E. Farinella
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  2. L. Viganò
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  3. M. C. Fava
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  4. M. Mineccia
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  5. F. Bertolino
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  6. L. Capussotti
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Correspondence to L. Capussotti.

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Farinella, E., Viganò, L., Fava, M.C. et al. In vivo lymph node mapping and pattern of metastasis spread in locally advanced mid/low rectal cancer after neoadjuvant chemoradiotherapy. Int J Colorectal Dis 28, 1523–1529 (2013). https://doi.org/10.1007/s00384-013-1727-4

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  • DOI: https://doi.org/10.1007/s00384-013-1727-4

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