Optimal Lymph Node Harvest in Neoadjuvantly Treated Colorectal Cancer Using Methylene Blue Assisted Lymph Node Dissection Technique
Abstract
Lymph node staging is still of crucial importance in rectal cancer. However, the recommendation to evaluate at least 12 lymph nodes for a sufficient staging is often not achieved in daily practice. This problem is even more pronounced after neoadjuvant treatment. The methylene blue assisted lymph node dissection technique (MBLND) has been shown to improve lymph node harvest in gastrointestinal cancers very effectively. A retrospective analysis enrolling 54 cases was performed to investigate the effect of MBLND in neoadjuvantly treated rectal cancer cases. Two historical collections evaluated using conventional dissection technique (n = 47) and fat clearance (FC) technique, respectively served as controls (n = 12). The lymph node harvest was highly significantly improved in the methylene group compared to fat clearance and conventional dissection with mean LN numbers of 29 ± 11, 21 ± 13, and 9 ± 4 (P < 0.001), respectively. Insufficient LN harvest occurred in 72 % of the control group cases, in 17 % of the FC-group and in no case of the Methylene group. Node positivity was found in 24%, 25% and 28% in the MB-, FC- and control group, respectively. MBLND is a highly effective method guaranteeing an optimal lymph node harvest in colorectal cancer even under the difficult conditions of preoperative chemo-radiation. In our hands it was even more effective than a fat clearance technique.
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References
Compton CC. Colorectal carcinoma: diagnostic, prognostic, and molecular features. Mod Pathol. 2003;16(4):376-388.
Smith AJ, Driman DK, Spithoff K, et al. Guideline for optimization of colorectal cancer surgery and pathology. J Surg Oncol. 2010;101(1):5-12.
Sobin LH, Gospodarowicz MK, Wittekind C, eds. TNM classification of malignant tumours. West Sussex: John Wiley & Sons Ltd; 2010.
Maurel J, Launoy G, Grosclaude P, et al. Lymph node harvest reporting in patients with carcinoma of the large bowel: a French population-based study. Cancer. 1998;82(8):1482-1486.
Ricciardi R, Madoff RD, Rothenberger DA, Baxter NN. Population-based analyses of lymph node metastases in colorectal cancer. Clin Gastroenterol Hepatol. 2006;4(12):1522-1527.
Wright FC, Law CH, Last L, et al. Lymph node retrieval and assessment in stage II colorectal cancer: a population-based study. Ann Surg Oncol. 2003;10(8):903-909.
Tekkis PP, Smith JJ, Heriot AG, Darzi AW, Thompson MR, Stamatakis JD. A national study on lymph node retrieval in resectional surgery for colorectal cancer. Dis Colon Rectum. 2006;49(11):1673-1683.
Cohen SM, Wexner SD, Schmitt SL, Nogueras JJ, Lucas FV. Effect of xylene clearance of mesenteric fat on harvest of lymph nodes after colonic resection. Eur J Surg. 1994;160(12):693-697.
Gehoff A, Basten O, Sprenger T, et al. Optimal lymph node harvest in rectal cancer (UICC stages II and III) after preoperative 5-FU-based radiochemotherapy. Acetone compression is a new and highly efficient method. Am J Surg Pathol. 2012;36(2):202-213.
Jass JR, Miller K, Northover JM. Fat clearance method versus manual dissection of lymph nodes in specimens of rectal cancer. Int J Colorectal Dis. 1986;1(3):155-156.
Vogel C, Kirtil T, Oellig F, Stolte M. Lymph node preparation in resected colorectal carcinoma specimens employing the acetone clearing method. Pathol Res Pract. 2008;204(1):11-15.
Hernanz F, Garcia-Somacarrera E, Fernandez F. The assessment of lymph nodes missed in mesenteric tissue after standard dissection of colorectal cancer specimens. Colorectal Dis. 2010;12(7 Online):e57-60.
Basten O, Bandorski D, Bismarck C, Neumann K, Fisseler-Eckhoff A. [Acetone compression. A fast, standardized method to investigate gastrointestinal lymph nodes]. Pathologe. 2010;31(3):218-224.
Märkl B, Kerwel TG, Wagner T, Anthuber M, Arnholdt HM. Methylene blue injection into the rectal artery as a simple method to improve lymph node harvest in rectal cancer. Mod Pathol. 2007;20(7):797-801.
Kerwel TG, Spatz J, Anthuber M, Wunsch K, Arnholdt H, Markl B. Injecting methylene blue into the inferior mesenteric artery assures an adequate lymph node harvest and eliminates pathologist variability in nodal staging for rectal cancer. Dis Colon Rectum. 2009;52(5):935-941.
Märkl B, Kerwel TG, Jähnig HG, et al. Methylene Blue-Assisted Lymph Node Dissection in Colon Specimens: A Prospective, Randomized Study. Am J Clin Pathol. 2008;130(6):913-919.
Märkl B, Wünsch K, Hebick KU, et al. Methylene blue-assisted lymph node dissection in combination with ex vivo sentinel lymph node mapping in gastric cancer. Histopathology. 2009;54(4):433-441.
Mekenkamp LJ, van Krieken JH, Marijnen CA, van de Velde CJ, Nagtegaal ID. Lymph node retrieval in rectal cancer is dependent on many factors--the role of the tumor, the patient, the surgeon, the radiotherapist, and the pathologist. Am J Surg Pathol. 2009;33(10):1547-1553.
Märkl B, Rössle J, Arnholdt HM, et al. The clinical significance of lymph node size in colon cancer. Mod Pathol. 2012;25(10):1413-1422.
Miller ED, Robb BW, Cummings OW, Johnstone PA. The effects of preoperative chemoradiotherapy on lymph node sampling in rectal cancer. Dis Colon Rectum. 2012;55(9):1002-1007.
Le M, Nelson R, Lee W, et al. Evaluation of Lymphadenectomy in Patients Receiving Neoadjuvant Radiotherapy for Rectal Adenocarcinoma. Ann Surg Oncol. 2012.19(12):3713-3718.
Govindarajan A, Gonen M, Weiser MR, et al. Challenging the feasibility and clinical significance of current guidelines on lymph node examination in rectal cancer in the era of neoadjuvant therapy. J Clin Oncol. 2011;29(34):4568-4573.
Morcos B, Baker B, Al Masri M, Haddad H, Hashem S. Lymph node yield in rectal cancer surgery: Effect of preoperative chemoradiotherapy. Eur J Surg Oncol. 2010;36(4):345-349.
Wang H, Safar B, Wexner SD, Denoya P, Berho M. The clinical significance of fat clearance lymph node harvest for invasive rectal adenocarcinoma following neoadjuvant therapy. Dis Colon Rectum. 2009;52(10):1767-1773.
Brown HG, Luckasevic TM, Medich DS, Celebrezze JP, Jones SM. Efficacy of manual dissection of lymph nodes in colon cancer resections. Mod Pathol. 2004;17(4):402-406.
Hata M, Machi J, Mamou J, et al. Entire-volume serial histological examination for detection of micrometastases in lymph nodes of colorectal cancers. Pathol Oncol Res. 2011;17(4):835-841.
Frasson M, Faus C, Garcia-Granero A, et al. Pathological evaluation of mesocolic resection quality and ex vivo methylene blue injection: what is the impact on lymph node harvest after colon resection for cancer? Dis Colon Rectum. 2012;55(2):197-204.
Jepsen RK, Ingeholm P, Lund EL. Upstaging of early colorectal cancers following improved lymph node yield after methylene blue injection. Histopathology. 2012;61(5):788-794.
Klepsyte E, Samalavicius NE. Injection of methylene blue solution into the inferior mesenteric artery of resected rectal specimens for rectal cancer as a method for increasing the lymph node harvest. Tech Coloproctol. 2012;16(3):207-211.
Martijnse IS, Dudink RL, Kusters M, Rutten HJ, Nieuwenhuijzen GA, Wasowicz-Kemps DK. Patent blue staining as a method to improve lymph node detection in rectal cancer following neoadjuvant treatment. Eur J Surg Oncol. 2012;38(3):252-258.
Törnroos A, Shabo I, Druvefors B, Arbman G, Olsson H. Postoperative intra-arterial methylene blue injection of colorectal cancer specimens increases the number of lymph nodes recovered. Histopathology. 2011;58(3):408-413.
Goldstein NS. Lymph node recoveries from 2427 pT3 colorectal resection specimens spanning 45 years: recommendations for a minimum number of recovered lymph nodes based on predictive probabilities. Am J Surg Pathol. 2002;26(2):179-189.
Swanson RS, Compton CC, Stewart AK, Bland KI. The prognosis of T3N0 colon cancer is dependent on the number of lymph nodes examined. Ann Surg Oncol. 2003;10(1):65-71.
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(3):585-593.
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(6):433-441.
Wong SL, Ji H, Hollenbeck BK, Morris AM, Baser O, Birkmeyer JD. Hospital lymph node examination rates and survival after resection for colon cancer. JAMA. 2007;298(18):2149-2154.
Feinstein AR, Sosin DM, Wells CK. The Will Rogers phenomenon. Stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer. N Engl J Med. 1985;312(25):1604-1608.
Abbassi-Ghadi N, Boshier PR, Goldin R, Hanna GB. Techniques to increase lymph node harvest from gastrointestinal cancer specimens: a systematic review and meta-analysis. Histopathol. 2012;61(4):531-542.
Parsons HM, Tuttle TM, Kuntz KM, Begun JW, McGovern PM, Virnig BA. Association between lymph node evaluation for colon cancer and node positivity over the past 20 years. JAMA. 2011;306(10):1089-1097.
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