Annals of Surgical Oncology

, Volume 19, Issue 12, pp 3719–3726 | Cite as

Prognostic Relevance of Occult Metastases Detected by Cytokeratin 20 and Mucin 2 mRNA Levels in Sentinel Lymph Nodes from Colon Cancer Patients

  • Oddmund Nordgård
  • Satu Oltedal
  • Ole Gunnar Aasprong
  • Jon Arne Søreide
  • Kjetil Søreide
  • Kjersti Tjensvoll
  • Bjørnar Gilje
  • Reino Heikkilä
  • Marianne Guriby
  • Ragnhild A. Lothe
  • Rune Smaaland
  • Hartwig Kørner
Colorectal Cancer



To investigate the prognostic value of occult metastases detected by quantitative measurements of candidate biomarkers in sentinel lymph nodes (SLNs) from patients curatively resected for colon cancer.


Resection specimens from consecutive patients undergoing surgery for localized colon cancer were subjected to ex vivo SLN mapping. SLNs were examined for the presence of metastases by routine hematoxylin–erythrosin–safranin staining and by cytokeratin 20 (CK20) and mucin 2 (MUC2) mRNA quantification. The patients were stratified according to KRAS and BRAF mutation status and microsatellite instability status in their primary tumors. Survival end points were analyzed by Kaplan–Meier survival estimates and log-rank tests.


A total of 817 SLNs were identified in 206 (97 %) of the 213 included patients. Routine histological examination of SLNs and other regional lymph nodes identified 63 patients with positive nodes (pN+), of which 42 (67 %) were positive in one or more SLNs (sensitivity 67 %, false-negative rate 33 %). On the basis of the CK20 and MUC2 mRNA levels in SLNs, occult metastases were suggested in 86 (60 %) and 52 (36 %) of the 143 otherwise LN-negative (pN0) patients, respectively. Survival analysis with a median 3.6-year follow-up revealed that MUC2 mRNA quantification had significant prognostic value in SLNs from all patients; however, occult SLN metastasis detection did not.


Occult SLN metastases detected by CK20 and MUC2 mRNA quantification had limited prognostic value.


Sentinel Lymph Node Colon Cancer Patient Sentinel Lymph Node Mapping Sentinel Lymph Node Metastasis Occult Metastasis 
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.



This work was supported by the Norwegian Cancer Society, the Western Norway Regional Health Authority, the Folke Hermansen Fund, and Stavanger University Hospital.

Conflict of interest

Reino Hekkilä is presently employed at Roche Norway, AS.


  1. 1.
    Edge S, Byrd D, Compton C, et al., editors. AJCC cancer staging manual. 7th ed. New York: Springer; 2010.Google Scholar
  2. 2.
    International Multicentre Pooled Analysis of Colon Cancer Trials (IMPACT) investigators. Efficacy of adjuvant fluorouracil and folinic acid in colon cancer. Lancet. 1995;345:939–44.CrossRefGoogle Scholar
  3. 3.
    Wolmark N, Fisher B, Wieand HS. The prognostic value of the modifications of the Dukes’ C class of colorectal cancer. An analysis of the NSABP clinical trials. Ann Surg. 1986;203:115–22.PubMedCrossRefGoogle Scholar
  4. 4.
    Andre T, Boni C, Mounedji-Boudiaf L, et al. Oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer. N Engl J Med. 2004;350:2343–51.PubMedCrossRefGoogle Scholar
  5. 5.
    Figueredo A, Charette ML, Maroun J, et al. Adjuvant therapy for stage II colon cancer: a systematic review from the Cancer Care Ontario Program in Evidence-based Care’s Gastrointestinal Cancer Disease Site Group. J Clin Oncol. 2004;22:3395–407.PubMedCrossRefGoogle Scholar
  6. 6.
    Andre T, Sargent D, Tabernero J, et al. Current issues in adjuvant treatment of stage II colon cancer. Ann Surg Oncol. 2006;13:887–98.PubMedCrossRefGoogle Scholar
  7. 7.
    Greene FL, Stewart AK, Norton HJ. A new TNM staging strategy for node-positive (stage III) colon cancer: an analysis of 50,042 patients. Ann Surg. 2002;236:416–21.PubMedCrossRefGoogle Scholar
  8. 8.
    Iddings D, Ahmad A, Elashoff D, et al. The prognostic effect of micrometastases in previously staged lymph node negative (N0) colorectal carcinoma: a meta-analysis. Ann Surg Oncol. 2006;13:1386–92.PubMedCrossRefGoogle Scholar
  9. 9.
    Doekhie FS, Kuppen PJ, Peeters KC, et al. Prognostic relevance of occult tumour cells in lymph nodes in colorectal cancer. Eur J Surg Oncol. 2006;32:253–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Nicastri DG, Doucette JT, Godfrey TE, et al. Is occult lymph node disease in colorectal cancer patients clinically significant? A review of the relevant literature. J Mol Diag. 2007;9:563–71.CrossRefGoogle Scholar
  11. 11.
    van der Pas MH, Meijer S, Hoekstra OS, et al. Sentinel-lymph-node procedure in colon and rectal cancer: a systematic review and meta-analysis. Lancet Oncol. 2011;12:540–50.PubMedCrossRefGoogle Scholar
  12. 12.
    de Haas RJ, Wicherts DA, Hobbelink MG, et al. Sentinel lymph node mapping in colon cancer: current status. Ann Surg Oncol. 2007;67:347–55.Google Scholar
  13. 13.
    Lim SJ, Feig BW, Wang H, et al. Sentinel lymph node evaluation does not improve staging accuracy in colon cancer. Ann Surg Oncol. 2008;15:46–51.PubMedCrossRefGoogle Scholar
  14. 14.
    Koyanagi K, Bilchik AJ, Saha S, et al. Prognostic relevance of occult nodal micrometastases and circulating tumor cells in colorectal cancer in a prospective multicenter trial. Clin Cancer Res. 2008;14:7391–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Nordgard O, Oltedal S, Kørner H, et al. Quantitative RT-PCR detection of tumor cells in sentinel lymph nodes isolated from colon cancer patients with an ex vivo approach. Ann Surg. 2009;249:602–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Dahl O. Adjuvant behandling ved operabel kolorektalcancer. NGICG, 2007. Accessed 27 Sep 2011.
  17. 17.
    Nordgard O, Oltedal S, Korner H, et al. The potential of cytokeratin 20 and mucin 2 mRNA as metastasis markers in regional lymph nodes of colon cancer patients investigated by quantitative RT-PCR. Int J Colorectal Dis. 2009;24:261–268.PubMedCrossRefGoogle Scholar
  18. 18.
    Thorstensen L, Lind GE, Løvig T, et al. Genetic and epigenetic changes of components affecting the WNT pathway in colorectal carcinomas stratified by microsatellite instability. Neoplasia. 2005;7:99–108.PubMedCrossRefGoogle Scholar
  19. 19.
    Wu Q, Lothe RA, Ahlquist T, et al. DNA methylation profiling of ovarian carcinomas and their in vitro models identifies HOXA9, HOXB5, SCGB3A1, and CRABP1 as novel targets. Mol Cancer. 2007;6:45.PubMedCrossRefGoogle Scholar
  20. 20.
    Umar A, Boland CR, Terdiman JP, et al. Revised Bethesda guidelines for hereditary nonpolyposis colorectal cancer (Lynch syndrome) and microsatellite instability. J Natl Cancer Inst. 2004;96:261–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Gilje B, Heikkila R, Oltedal S, et al. High-fidelity DNA polymerase enhances the sensitivity of a peptide nucleic acid clamp PCR assay for K-ras mutations. J Mol Diagn. 2008;10:325–31.PubMedCrossRefGoogle Scholar
  22. 22.
    Oltedal S, Gilje B, Kørner H, et al. Detection of occult metastases in sentinel lymph nodes from colon cancer patients by K-ras mutation peptide nucleic acid clamp PCR. Ann Surg. 2010;251:1087–91.PubMedCrossRefGoogle Scholar
  23. 23.
    Ahlquist T, Bottillo I, Danielsen SA, et al. RAS signaling in colorectal carcinomas through alteration of RAS, RAF, NF1, and/or RASSF1A. Neoplasia. 2008;10:680–6.PubMedGoogle Scholar
  24. 24.
    Cahill RA, Leroy J, Marescaux J. Could lymphatic mapping and sentinel node biopsy provide oncological providence for local resectional techniques for colon cancer? A review of the literature. BMC Surg. 2008;8:17.PubMedCrossRefGoogle Scholar
  25. 25.
    Nordgard O, Smaaland R. SLN mapping in colorectal cancer. Lancet Oncol. 2011;12:990.PubMedCrossRefGoogle Scholar
  26. 26.
    Waldman SA, Hyslop T, Schulz S, et al. Association of GUCY2C expression in lymph nodes with time to recurrence and disease-free survival in pN0 colorectal cancer. JAMA. 2009;301:745–52.PubMedCrossRefGoogle Scholar
  27. 27.
    Doekhie FS, Mesker WE, Kuppen PJ, et al. Detailed examination of lymph nodes improves prognostication in colorectal cancer. Int J Cancer. 2010;126:2644–52.PubMedGoogle Scholar
  28. 28.
    Faerden AE, Sjo OH, Bukholm IRK, et al. Lymph node micrometastases and isolated tumor cells influence survival in stage I and II colon cancer. Dis Colon Rectum. 2011;54:200–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Hyslop T, Weinberg DS, Schulz S, et al. Occult tumor burden predicts disease recurrence in lymph node–negative colorectal cancer. Clin Cancer Res. 2011;17:3293–303.PubMedCrossRefGoogle Scholar
  30. 30.
    Ohlsson L, Israelsson A, Oberg A, et al. Lymph node CEA and MUC2 mRNA as useful predictors of outcome in colorectal cancer. Int J Cancer. 2012;130:1833–43.PubMedCrossRefGoogle Scholar
  31. 31.
    Rosenberg R, Hoos A, Mueller J, et al. Prognostic significance of cytokeratin-20 reverse transcriptase polymerase chain reaction in lymph nodes of node-negative colorectal cancer patients. J Clin Oncol. 2002;20:1049–55.PubMedCrossRefGoogle Scholar
  32. 32.
    Wong JH, Johnson DS, Namiki T, et al. Validation of ex vivo lymphatic mapping in hematoxylin–eosin node-negative carcinoma of the colon and rectum. Ann Surg Oncol. 2004;11:772–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Faerden AE, Sjo OH, Andersen SN, et al. Sentinel node mapping does not improve staging of lymph node metastasis in colonic cancer. Dis Colon Rectum. 2008;51:891–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Wiese D, Sirop S, Yestrepsky B, et al. Ultrastaging of sentinel lymph nodes (SLNs) vs. non-SLNs in colorectal cancer: do we need both? Am J Surg. 2010;199:354–8.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • Oddmund Nordgård
    • 1
  • Satu Oltedal
    • 1
  • Ole Gunnar Aasprong
    • 2
  • Jon Arne Søreide
    • 3
    • 4
  • Kjetil Søreide
    • 3
    • 4
  • Kjersti Tjensvoll
    • 1
  • Bjørnar Gilje
    • 1
  • Reino Heikkilä
    • 1
  • Marianne Guriby
    • 5
    • 6
  • Ragnhild A. Lothe
    • 5
    • 6
  • Rune Smaaland
    • 1
  • Hartwig Kørner
    • 3
    • 4
  1. 1.Department of Hematology and OncologyStavanger University HospitalStavangerNorway
  2. 2.Department of PathologyStavanger University HospitalStavangerNorway
  3. 3.Department of SurgeryStavanger University HospitalStavangerNorway
  4. 4.Department of Surgical SciencesUniversity of BergenBergenNorway
  5. 5.Department of Cancer Prevention, Institute for Cancer ResearchOslo University HospitalOsloNorway
  6. 6.Centre for Cancer Biomedicine, Faculty of MedicineUniversity of OsloOsloNorway

Personalised recommendations