Annals of Surgical Oncology

, Volume 19, Issue 12, pp 3713–3718 | Cite as

Evaluation of Lymphadenectomy in Patients Receiving Neoadjuvant Radiotherapy for Rectal Adenocarcinoma

  • Maithao Le
  • Rebecca Nelson
  • Wendy Lee
  • Brian Mailey
  • Marjun Duldulao
  • Yi-Jen Chen
  • Julio Garcia-Aguilar
  • Joseph Kim
Colorectal Cancer



Accurate pathologic staging has been shown to correlate with outcome in rectal cancer. Because the exact number of examined lymph nodes (LNs) may vary with preoperative therapies, our objective was to measure the impact of neoadjuvant radiation on LN number for rectal adenocarcinoma.


Patients who underwent curative-intent radical surgery for rectal adenocarcinoma in Los Angeles County (LAC) were identified from the Cancer Surveillance Program (CSP) of California (1988–2006). Patients were grouped according to receipt of radiotherapy (neoadjuvant or none), and the number of examined LNs was assessed.


Query of CSP identified 2,727 patients meeting eligibility criteria; 70 and 30 % of patients received no radiotherapy or neoadjuvant radiotherapy (NRT), respectively. When comparing LNs, a lower mean number was observed in the neoadjuvant group than the no-radiation group (7 vs. 8.9 LNs, respectively; p < 0.001). When matching the cohorts for age and sex, the neoadjuvant group still had fewer examined LNs (7.1 vs. 9.8, respectively, p < 0.001). In patients who received NRT, no optimal LN number was associated with improved survival. However, on subset analysis of patients with N0 disease, a LN number of ≥8 was associated with best rates of 5 year and overall survival.


Within the LAC population, we observed a lower number of LNs retrieved in patients receiving radical surgery for rectal cancer than guideline recommendation. This number is reduced further in those who received NRT independent of age and sex. Our results highlight the limitations in adhering to minimum LN requirements for rectal cancer when NRT is provided.


Rectal Cancer Total Mesorectal Excision National Comprehensive Cancer Network National Comprehensive Cancer Network Rectal Cancer Patient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank Nicola Solomon, PhD, for assistance in writing and editing this article.


  1. 1.
    Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351:1731–40.PubMedCrossRefGoogle Scholar
  2. 2.
    Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345:638–46.PubMedCrossRefGoogle Scholar
  3. 3.
    Roh MS, Colangelo LH, O’Connell MJ, et al. Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03. J Clin Oncol. 2009;27:5124–30.PubMedCrossRefGoogle Scholar
  4. 4.
    Parfitt JR, Driman DK. The total mesorectal excision specimen for rectal cancer: a review of its pathological assessment. J Clin Pathol. 2007;60:849–55.PubMedCrossRefGoogle Scholar
  5. 5.
    Edge SB. American Joint Committee on Cancer. AJCC cancer staging manual. 7th ed. New York: Springer; 2010.Google Scholar
  6. 6.
    Engstrom P, Arnoletti J, Benson AB 3rd, et al. NCCN clinical practice guidelines in oncology: rectal cancer. J Natl Compr Cancer Netw. 2009;7:838–81.Google Scholar
  7. 7.
    Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg. 1995;181:335–46.PubMedGoogle Scholar
  8. 8.
    MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet. 1993;341(8843):457–60.PubMedCrossRefGoogle Scholar
  9. 9.
    Senthil M, Trisal V, Paz IB, Lai LL. Prediction of the adequacy of lymph node retrieval in colon cancer by hospital type. Arch Surg. 2010;145:840–3.PubMedCrossRefGoogle Scholar
  10. 10.
    Norwood MG, Sutton AJ, West K, Sharpe DP, Hemingway D, Kelly MJ. Lymph node retrieval in colorectal cancer resection specimens: national standards are achievable, and low numbers are associated with reduced survival. Colorectal Dis. 2010;12:304–9.PubMedCrossRefGoogle Scholar
  11. 11.
    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;33:1547–53.PubMedCrossRefGoogle Scholar
  12. 12.
    Ha YH, Jeong SY, Lim SB, et al. Influence of preoperative chemoradiotherapy on the number of lymph nodes retrieved in rectal cancer. Ann Surg. 2010;252:336–40.PubMedCrossRefGoogle Scholar
  13. 13.
    Morcos B, Baker B, Al Masri M, Haddad H, Hashem S. Lymph node yield in rectal cancer surgery: effect of preoperative chemoradiotherapy. EurJ Surg Oncol. 2010;36:345–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Baxter NN, Morris AM, Rothenberger DA, Tepper JE. Impact of preoperative radiation for rectal cancer on subsequent lymph node evaluation: a population-based analysis. Int J Radiat Oncol Biol Phys. 2005;61:426–31.PubMedCrossRefGoogle Scholar
  15. 15.
    Kim J, Sun CL, Mailey B, et al. Race and ethnicity correlate with survival in patients with gastric adenocarcinoma. Ann Oncol. 2010;21:152–60.PubMedCrossRefGoogle Scholar
  16. 16.
    California Cancer Registry. California cancer registry visual editing standards: informational packet for cancer reporting facilities. 2008. Accessed 20 Apr 2012.
  17. 17.
    Bergstralh EJ, Kosanke JL, Jacobsen SJ. Software for optimal matching in observational studies. Epidemiology. 1996;7:331–2.PubMedGoogle Scholar
  18. 18.
    van Gijn W, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. Lancet Oncol. 2011;12:575–82.PubMedCrossRefGoogle Scholar
  19. 19.
    Kapiteijn E, Kranenbarg EK, Steup WH, et al. Total mesorectal excision (TME) with or without preoperative radiotherapy in the treatment of primary rectal cancer. Prospective randomised trial with standard operative and histopathological techniques. Dutch ColoRectal Cancer Group. Eur J Surg. 1999;165:410–20.PubMedCrossRefGoogle Scholar
  20. 20.
    Sprenger T, Rothe H, Homayounfar K, et al. Preoperative chemoradiotherapy does not necessarily reduce lymph node retrieval in rectal cancer specimens—results from a prospective evaluation with extensive pathological work-up. J Gastrointest Surg. 2010;14:96–103.PubMedCrossRefGoogle Scholar
  21. 21.
    Perez RO, Pereira DD, Proscurshim I, et al. Lymph node size in rectal cancer following neoadjuvant chemoradiation—can we rely on radiologic nodal staging after chemoradiation? Dis Colon Rectum. 2009;52:1278–84.PubMedCrossRefGoogle Scholar
  22. 22.
    Koh DM, Chau I, Tait D, Wotherspoon A, Cunningham D, Brown G. Evaluating mesorectal lymph nodes in rectal cancer before and after neoadjuvant chemoradiation using thin-section T2-weighted magnetic resonance imaging. Int J Radiat Oncol Biol Phys. 2008;71:456–61.PubMedCrossRefGoogle Scholar
  23. 23.
    Wright FC, Law CH, Berry S, Smith AJ. Clinically important aspects of lymph node assessment in colon cancer. J Surg Oncol. 2009;99:248–55.PubMedCrossRefGoogle Scholar
  24. 24.
    Scott KW, Grace RH, Gibbons P. Five-year follow-up study of the fat clearance technique in colorectal carcinoma. Dis Colon Rectum. 1994;37:126–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Parkash V, Bifulco C, Feinn R, Concato J, Jain D. To count and how to count, that is the question: interobserver and intraobserver variability among pathologists in lymph node counting. Am J Clin Pathol. 2010;134:42–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Prall F, Wohlke M, Klautke G, Schiffmann L, Fietkau R, Barten M. Tumour regression and mesorectal lymph node changes after intensified neoadjuvant chemoradiation for carcinoma of the rectum. APMIS. 2006;114:201–10.PubMedCrossRefGoogle Scholar
  27. 27.
    Fajardo LF. Effects of ionizing radiation on lymph nodes. A review. Front Radiat Ther Oncol. 1994;28:37–45.PubMedGoogle Scholar
  28. 28.
    Wichmann MW, Muller C, Meyer G, et al. Effect of preoperative radiochemotherapy on lymph node retrieval after resection of rectal cancer. Arch Surg. 2002;137:206–10.PubMedCrossRefGoogle Scholar
  29. 29.
    Marks J, Valsdottir E, Rather A, Nweze I, Newman D, Chernick M. Fewer than 12 lymph nodes can be expected in a surgical specimen after high-dose chemoradiation therapy for rectal cancer. Dis Colon Rectum. 2010;53:1023–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Caplin S, Cerottini JP, Bosman FT, Constanda MT, Givel JC. For patients with Dukes’ B (TNM stage II) colorectal carcinoma, examination of six or fewer lymph nodes is related to poor prognosis. Cancer. 1998;83:666–72.PubMedCrossRefGoogle Scholar
  31. 31.
    Tepper JE, O’Connell MJ, Niedzwiecki D, et al. Impact of number of nodes retrieved on outcome in patients with rectal cancer. J Clin Oncol. 2001;19:157–63.PubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • Maithao Le
    • 1
  • Rebecca Nelson
    • 2
  • Wendy Lee
    • 1
  • Brian Mailey
    • 1
  • Marjun Duldulao
    • 1
  • Yi-Jen Chen
    • 3
  • Julio Garcia-Aguilar
    • 1
  • Joseph Kim
    • 1
  1. 1.Department of SurgeryCity of Hope Comprehensive Cancer CenterDuarteUSA
  2. 2.Department of BiostatisticsCity of Hope Comprehensive Cancer CenterDuarteUSA
  3. 3.Department of Radiation OncologyCity of Hope Comprehensive Cancer CenterDuarteUSA

Personalised recommendations