Wednesday, December 30, 2009

Lymph Node Retrieval in Colon Cancer Surgery

Good article in Archives here about inadequate lymph node harvests in colorectal cancer surgery.

One of the yardsticks for assessing the quality and oncologic adequacy of a surgical resection for colon cancer is to determine the number of lymph nodes harvested with the specimen. Lymph node status determines staging of the tumor and the need for adjuvant chemotherapy. We like to see at least 12 nodes in the specimen in order to state with confidence that a tumor is either node negative or node positive. Assessing fewer than 12 nodes risks understaging the disease and suggests the need for chemotherapy even if the seven or eight nodes available are negative. It also is construed as proof of "inadequate surgical resection" in many academic circles.

This paper suggests otherwise. Lymph node harvesting is affected by multiple factors including patient age, tumor stage, location of tumor in the colon, and the year the surgery was performed. Attributing a failure to harvest at least 12 nodes solely to the performing surgeon is overly presumptive.

I can attest to the findings of this paper. As surgeons, we've all done low anterior resections for a rectosigmoid tumor via the total mesorectal excision technique that completely cleans out the pelvis only to find that on the path report, only ten nodes were seen. It's disappointing but what can you do? There isn't anything else to cut out, other than to go back in there and start scraping against the sacrum with a rake. You know you've done an adequate oncologic resection but the cold hard numbers suggest some sort of failure. Papers like this perhaps will help attentuate some of the blame mentality (patient should have seen me, I always harvest 12 nodes!) that occurs within the surgical community...

2 comments:

Frank Drackman said...

Like it's YOUR fault the patient doesn't have more lymph nodes....
Reminds me of the bad old days when I had to do Pap Smears...Brrrr..almost get the PTSD just thinkin about it...and if the report came back with "No Endocervical Cells seen" I had to call the patient up to tell them umm OK, I just pretended to call them and they got the postcard from the Health Dept tellin them to come back cause there Pap Schmear was "Inadequate"...
Maybe it was Inadequate because they gave us a Q-tip and a Popsicle Stick to stick in the Cervix instead of that Copper thing with the bristles that looks like what I used to run through the barrell of my .357 Magnum that they use nowadays....
Then sometime in the 90's they stopped requiring Endocervical cells be present, and now, they admit Pap Schmears are basically worthless....

That "Scraping the Sacrum with a Rake" description is gonna give me nightmares...

Have a Great 2010,

Frank

Anonymous said...

There is also an article in November's (I think) Journal of Clinical Oncology saying that it doesn't matter half as much as we thought in T1-2 lesions.

pat