Challenging the feasibility and clinical significance of current guidelines on lymph node examination in rectal cancer in the era of neoadjuvant therapy Journal Article


Authors: Govindarajan, A.; Gonen, M.; Weiser, M. R.; Shia, J.; Temple, L. K.; Guillem, J. G.; Paty, P. B.; Nash, G. M.
Article Title: Challenging the feasibility and clinical significance of current guidelines on lymph node examination in rectal cancer in the era of neoadjuvant therapy
Abstract: Purpose: We sought to examine the feasibility and clinical significance of current guidelines on nodal assessment in patients with rectal cancer (RC) treated with neoadjuvant radiation. Methods: All patients with RC treated with curative surgery from 1991 to 2003 were included. Number of lymph nodes (LNs) assessed was compared between patients who received neoadjuvant therapy and surgery (NEO) and patients who underwent surgery alone (SURG). Impact of node retrieval on node positivity and disease-specific survival (DSS) in NEO patients was assessed. Results: In total, 708 patients were identified, of whom 429 (61%) were in the NEO group. These patients had significantly fewer nodes assessed than SURG patients (unadjusted mean, 10.8 v 15.5; adjusted mean difference, -5.0 nodes; P < .001). In the NEO group, 63% of patients had fewer than 12 nodes retrieved (P < .001 v SURG). The proportion of patients diagnosed with node-positive disease in the NEO group was significantly and monotonically associated with the number of lymph nodes retrieved, with no plateau in the relationship. Fewer nodes retrieved was not associated with inferior DSS. Conclusion: In a tertiary cancer center, the 12-LN threshold was not relevant and often not achievable in patients with RC treated with neoadjuvant therapy. Lower LN count after neoadjuvant treatment was not associated with understaging or inferior survival. Although we support the critical importance of careful pathologic examination and adequate nodal staging, we challenge the relevance of LN count both in clinical practice and as a quality indicator in RC. © 2011 by American Society of Clinical Oncology.
Keywords: adult; cancer survival; treatment outcome; cancer surgery; major clinical study; cancer adjuvant therapy; cancer radiotherapy; antineoplastic agent; patient assessment; retrospective study; feasibility study; lymph node; rectum cancer; chemoradiotherapy
Journal Title: Journal of Clinical Oncology
Volume: 29
Issue: 34
ISSN: 0732-183X
Publisher: American Society of Clinical Oncology  
Date Published: 2011-12-01
Start Page: 4568
End Page: 4573
Language: English
DOI: 10.1200/jco.2011.37.2235
PROVIDER: scopus
PUBMED: 21990400
PMCID: PMC3646313
DOI/URL:
Notes: --- - "Export Date: 3 January 2012" - "CODEN: JCOND" - "Source: Scopus"
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MSK Authors
  1. Philip B Paty
    359 Paty
  2. Mithat Gonen
    687 Gonen
  3. Jose Guillem
    361 Guillem
  4. Jinru Shia
    445 Shia
  5. Martin R Weiser
    330 Weiser
  6. Garrett Nash
    129 Nash
  7. Larissa Temple
    177 Temple