Lymph Node Evaluation as a Predictor of Survival after Resection for Colorectal Cancer
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LETTERS Lymph Node Evaluation as a Predictor of Survival after Resection for Colorectal Cancer Giuseppe Pappalardo, MD, FACS Aldo Nunziale, MD Rome, Italy We read with great interest the article by Jan H Wong and colleagues, “Lymph node counts as an indicator of quality at the hospital level in colorectal surgery.” 1 If the number of lymph nodes evaluated after surgical resection of colorectal cancer (CRC) has a significant impact on survival, it rep- resents an item frequently discussed in the last decades. There was no statistically significant difference in disease- specific survival for N1 or N2 patients between 3 groups with median number of nodes examined, respectively, of 4, 8, 10 in Region 5 of the California Cancer Registry. These data contradict other reports, which demonstrated a dra- matic impact of lymph node harvest on survival for both N1 and N2 positive disease. 2 These findings in stage III disease could show an impact that transcends simple un- derstaging and undertreatment in N negative patients with less than 12 examined nodes. At the present time, there is great confusion about lymph node counts as a predictor of survival and quality at the hospital level in CRC patients. Many factors can contribute to the difficulties in evaluating data regarding the relationships between lymph nodes and survival: the extent of lymphadenectomy, the number of nodes examined, the significance and the role of microme- tastases, the ratio of positive to total nodes harvested, etc. We believe that one additional factor could be underesti- mated: the lack of standardization of specimen handling techniques. Should only palpable nodes be evaluated? Are fat-clearing techniques mandatory or optional? The lack of this standardization creates a bias that makes pathologic examination operator dependent. In other words, the same specimen can give different results on lymph nodes re- moved. Any effort to obtain a standardized pathologic ex- amination should be made to improve results and analysis of quality in the treatment of CRC patients. REFERENCES 1. Wong JH, Lum SS, Morgan JW. Lymph node counts as an indi- cator of quality at the hospital level in colorectal surgery. J Am Coll Surg 2011;213:226–230. 2. Le Voyer TE, Sigurdson ER, Hanlon AL, 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. Disclosure Information: Nothing to disclose. Reply Jan H Wong, MD, FACS Greenville, NC Sharon S Lum, MD, FACS John W Morgan, DRPH Loma Linda, CA We thank Drs Pappalardo and Nunziale for their review of our article on the potential use of lymph node counts as an indicator of quality at the hospital level. In their letter, the authors reinforce the association of lymph node counts and survival in patients with colorectal cancer, which we and oth- ers have previously demonstrated. Drs Pappalardo and Nun- ziale suggest that our results contrast with those from these earlier reports. It should be re-emphasized that our intent was not to re-examine whether lymph node counts affect survival in patients with N0, N1, or N2 disease, but rather, to examine whether the median number of nodes exam- ined at the hospital level was associated with improved staging and outcomes in patients with colorectal cancer cared for within that hospital, so therefore might be a useful quality indicator. Drs Pappalardo and Nunziale raise a valid concern that the lack of standardized handling of the specimen might contribute to variability in the number of nodes examined between hospitals and might obscure any association be- tween the number of nodes examined at the hospital level and outcomes. It is reasonable to presume that variability exists not only in the pathologic handling of the specimen but in the conduct of the surgical resection. Data used in our study were extracted from R5 CCR, a population- based cancer registry serving a large and diverse segment of the California population. Unlike a single pathology ser- vice, the population-based registry findings used in our analyses included data from 33 hospitals that were reported by as many as 100 different pathologists during the 10 years assessed. Use of specialized techniques for discovery of 125 © 2012 by the American College of Surgeons ISSN 1072-7515/12/$36.00 Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2011.09.013
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Transcript of Lymph Node Evaluation as a Predictor of Survival after Resection for Colorectal Cancer
LETTERS
Lymph Node Evaluation as aPredictor of Survival after Resectionfor Colorectal Cancer
Giuseppe Pappalardo, MD, FACS
Aldo Nunziale, MD
Rome, Italy
We read with great interest the article by Jan H Wong andcolleagues, “Lymph node counts as an indicator of qualityat the hospital level in colorectal surgery.”1 If the number oflymph nodes evaluated after surgical resection of colorectalcancer (CRC) has a significant impact on survival, it rep-resents an item frequently discussed in the last decades.There was no statistically significant difference in disease-specific survival for N1 or N2 patients between 3 groupswith median number of nodes examined, respectively, of 4,8, 10 in Region 5 of the California Cancer Registry. Thesedata contradict other reports, which demonstrated a dra-matic impact of lymph node harvest on survival for bothN1 and N2 positive disease.2 These findings in stage IIIdisease could show an impact that transcends simple un-derstaging and undertreatment in N negative patients withless than 12 examined nodes. At the present time, there isgreat confusion about lymph node counts as a predictor ofsurvival and quality at the hospital level in CRC patients.Many factors can contribute to the difficulties in evaluatingdata regarding the relationships between lymph nodes andsurvival: the extent of lymphadenectomy, the number ofnodes examined, the significance and the role of microme-tastases, the ratio of positive to total nodes harvested, etc.We believe that one additional factor could be underesti-mated: the lack of standardization of specimen handlingtechniques. Should only palpable nodes be evaluated? Arefat-clearing techniques mandatory or optional? The lack ofthis standardization creates a bias that makes pathologicexamination operator dependent. In other words, the samespecimen can give different results on lymph nodes re-moved. Any effort to obtain a standardized pathologic ex-amination should be made to improve results and analysisof quality in the treatment of CRC patients.
REFERENCES
1. Wong JH, Lum SS, Morgan JW. Lymph node counts as an indi-cator of quality at the hospital level in colorectal surgery. J Am
Coll Surg 2011;213:226–230.125© 2012 by the American College of SurgeonsPublished by Elsevier Inc.
2. Le Voyer TE, Sigurdson ER, Hanlon AL, et al. Colon cancersurvival is associated with increasing number of lymph nodesanalyzed: A secondary survey of intergroup trial INT-0089. J ClinOncol 2003;21:2912–2919.
Disclosure Information: Nothing to disclose.
Reply
Jan H Wong, MD, FACS
Greenville, NC
Sharon S Lum, MD, FACS
John W Morgan, DRPH
Loma Linda, CA
We thank Drs Pappalardo and Nunziale for their review ofour article on the potential use of lymph node counts as anindicator of quality at the hospital level. In their letter, theauthors reinforce the association of lymph node counts andsurvival in patients with colorectal cancer, which we and oth-ers have previously demonstrated. Drs Pappalardo and Nun-ziale suggest that our results contrast with those from theseearlier reports. It should be re-emphasized that our intentwas not to re-examine whether lymph node counts affectsurvival in patients with N0, N1, or N2 disease, but rather,to examine whether the median number of nodes exam-ined at the hospital level was associated with improvedstaging and outcomes in patients with colorectal cancercared for within that hospital, so therefore might be a usefulquality indicator.
Drs Pappalardo and Nunziale raise a valid concern thatthe lack of standardized handling of the specimen mightcontribute to variability in the number of nodes examinedbetween hospitals and might obscure any association be-tween the number of nodes examined at the hospital leveland outcomes. It is reasonable to presume that variabilityexists not only in the pathologic handling of the specimenbut in the conduct of the surgical resection. Data used inour study were extracted from R5 CCR, a population-based cancer registry serving a large and diverse segment ofthe California population. Unlike a single pathology ser-vice, the population-based registry findings used in ouranalyses included data from 33 hospitals that were reportedby as many as 100 different pathologists during the 10 years
assessed. Use of specialized techniques for discovery ofISSN 1072-7515/12/$36.00doi:10.1016/j.jamcollsurg.2011.09.013
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