Original contributionAdditional lymph node examination from entire submission of residual mesenteric tissue in colorectal cancer specimens may not add clinical and pathologic relevance
Introduction
The status of lymph node metastasis (the pN qualifier) in colorectal cancer is an integral component of pathologic tumor staging, which in turn determines the prognosis and the need for adjuvant therapy [1], [2], [3], [4]. The pN stage has been subclassified into the pN0, pN1, and pN2 categories, according to the presence or absence of lymph node metastasis and the number of metastatic lymph nodes; the pN0 stage refers to the absence of positive lymph nodes, whereas pN1 refers to the presence of 1 to 3 lymph nodes positive for metastatic tumor and pN2 designates 4 or more positive lymph nodes [1]. Studies have shown that the lymph node status, as described hereinabove, is an independent prognostic factor [1]. The minimum number of harvested lymph nodes needed to correctly assess the pN status in colorectal cancer is a controversial topic [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]. The College of American Pathologists recently published a consensus statement recommending that examination of at least 12 lymph nodes is necessary for accurate staging [6], [14], [15].
The fat clearance technique was first used in 1938, and since then, other similar methods have been developed to isolate lymph nodes in colon resection specimens [16], [17], [18], [19]. Although this technique may be optimal to improve the yield of lymph nodes, it is time consuming, labor intensive, and cost ineffective, and it delays reporting. There has been significant variation and inconsistency among the different methods regarding harvesting and processing of lymph nodes [14]. Recently, Brown et al [16] reported that complete submission of the mesentery, a variation of the fat clearance technique, may be necessary to assess the correct pN status within the pN1 group.
We investigated the efficacy of additional lymph node dissection by entire submission of residual mesenteric tissue (ESMT) with its potential impact on the pN status and also the characteristics of lymph nodes found by ESMT.
Section snippets
Case selection
Forty-eight patients with colorectal cancer who underwent surgical procedures were consecutively selected and prospectively investigated from 3 different institutions (Ulsan University Hospital, Ulsan, Korea; Asan Medical Center, Seoul, Korea; and National Cancer Center, Ilsan, Korea) between April and October of 2004. Resection specimens without mesenteric tissue were not included in our study. Cases with other tumor types such as gastrointestinal stromal tumor, carcinoid tumor, lymphoma, or
Clinicopathologic features
The mean patient age was 60.5 years (range, 41-79 years; median, 61 years), and the male-to-female ratio was 1.7 (30 males, 18 females). Of the 48 cases, there were 6 T1, 7 T2, 29 T3, and 6 T4 cases. Designation of pN status resulted in 29 pN0, 10 pN1, and 9 pN2 cases. With respect to tumor location, there was 1 descending, 11 sigmoid, 2 rectosigmoid, and 34 rectal carcinoma cases. No cases of right colon or transverse colon cancer were included in this study. The mean resection specimen length
Discussion
Retrieval of an adequate number of lymph nodes is essential for correct tumor staging, choice of the therapy, and determination of prognosis. However, there is frequently wide variation in the total number of harvested lymph nodes and the number of metastatic lymph nodes identified in individual cases [2], [11], [12]. Possible reasons include variations in the patients' immune system, anatomic location, surgical technique, tumor T or N stage, method of lymph node retrieval, and examining
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