C. J. Buskens

Improving staging accuracy in colon and rectal cancer by sentinel lymph node mapping: a comparative study

AIM To compare the predictive value of sentinel lymph node (SN) mapping between patients with colon and rectal cancer. PATIENTS AND METHODS An ex vivo SN procedure was performed in 100 patients with colon and 32 patients with rectal cancer. If the sentinel node was negative, immunohistochemical analyses using two different antibodies against cytokeratins (Cam5.2 and CK 20) and one antibody against BerEp-4 were performed to detect occult tumour cells. Isolated tumour cells (<0.2mm) were discriminated from micrometastases (0.2-2mm). RESULTS An SN was identified in 117 patients (89%), and accurately predicted nodal status in 106 patients (accuracy 91%). Both sensitivity and negative predictive value were higher in colon carcinomas than in rectal carcinomas (83% versus 57%, p=0.06 and 93% versus 65%, p=0.002 respectively). In patients with extensive lymph node metastases the SN procedures were less successful. Eleven of the 13 unsuccessful SN procedures were performed in patients with rectal cancer who had pre-operative radiotherapy. After immunohistochemical analysis 21 of the 73 N0 patients had occult tumour cells in their SN; eight patients had micrometastases and 13 patients had isolated tumour cells. CONCLUSION SN mapping accurately predicts nodal status in patients with colonic cancer. Immunohistochemical analysis demonstrates micrometastatic disease in eight out of 73 N0 patients, with a true upstaging rate of 11%. SN mapping is less reliable in patients with rectal cancer after pre-operative radiotherapy.

The prognostic value of micrometastases and isolated tumour cells in histologically negative lymph nodes of patients with colorectal cancer: A systematic review and meta-analysis

INTRODUCTION Detection of occult tumour cells in lymph nodes of patients with stage I/II colorectal cancer is associated with decreased survival. However, according to recent guidelines, occult tumour cells should be categorised in micrometastases (MMs) and isolated tumour cells (ITCs). This meta-analysis evaluates the prognostic value of MMs and of ITCs, separately. METHODS PubMed, Embase, Biosis and the World Health Organization International Trials Registry Platform were searched for papers published until April 2013. Studies on the prognostic value of MMs and ITCs in lymph nodes of stage I/II colorectal cancer patients were included. Odds ratios (ORs) for the development of disease recurrence were calculated to analyse the predictive value of MMs and ITCs. RESULTS From five papers, ORs for disease recurrence could be calculated for MMs and ITCs separately. In patients with colorectal cancer, disease recurrence was significantly increased in the presence of MMs in comparison with absent occult tumour cells (OR 5.63; 95%CI 2.4-13.13). This was even more pronounced in patients with colon cancer (OR 7.25 95% CI 1.82-28.97). In contrast, disease recurrence was not increased in the presence of ITCs (OR 1.00 95% CI 0.53-1.88). CONCLUSION Patients with stage I/II colorectal cancer and MMs have a worse prognosis than patients without occult tumour cells. However, ITCs do not have a predictive value. The distinction between ITCs and MMs should be made if the detection of occult tumour cells is incorporated in the clinical decision for adjuvant treatment.

The effects of physical prehabilitation in elderly patients undergoing colorectal surgery : a systematic review

Prehabilitation, defined as enhancement of the preoperative condition of a patient, is a possible strategy for improving postoperative outcome. Lack of muscle strength and poor physical condition, increasingly prevalent in older patients, are risk factors for postoperative complications. Eighty‐five per cent of patients with colorectal cancer are aged over 60 years. Since surgery is the cornerstone of their treatment, this review systemically examined the literature on the effect of physical prehabilitation in older patients undergoing colorectal surgery.

Diagnosing occult tumour cells and their predictive value in sentinel nodes of histologically negative patients with colorectal cancer

PURPOSE Most studies on the sentinel node (SN) procedure in patients with colorectal cancer include immunohistochemical analysis of the SN only. To evaluate the real diagnostic accuracy of the SN procedure with immunohistochemical analysis, the presence of occult tumour cells in all histologically negative lymph nodes was compared to the presence of these cells in SNs. Also the reproducibility of diagnosing occult tumour cells (OTC) and the sensitivity of three different antibodies was assessed. METHODS Between November 2006 en July 2007, an ex vivo SN procedure was performed in 58 histologically N0 patients with colorectal cancer. All lymph nodes (n = 908, mean 15.7) were step-sectioned and immunohistochemistry was performed using two antibodies against cytokeratins (Cam5.2, and CK 20) and one antibody against BerEp-4. RESULTS OTC were identified in 19 of 58 patients, with micrometastases (0.2-2 mm) in 7 and isolated tumour cells (ITC)(<0.2 mm) in 12 patients. The overall agreement in diagnosing OTC between two independent pathologists was 86%. An SN was identified in 53 of 58 patients. All micrometastases were found in SNs. In two patients with negative SNs, ITCs were demonstrated in non-SNs (sensitivity 88%, and overall accuracy 96%). CONCLUSION Additional immunohistochemical analysis of histologically negative lymph nodes demonstrates occult tumour cells in 33% of the patients resulting in an upstaging rate of 12%. Occult tumour cells are predominantly found in the SN, therefore SN mapping has the potential to refine the staging system for patients with colorectal cancer.

Lymph node size as a predictor of lymphatic staging in colonic cancer

In colonic cancer, the number of harvested lymph nodes is associated with prognosis. The aim of this study was to determine the contribution of small lymph nodes to pathological staging, and to analyse the hypothesis that node size is a confounder in the relationship between prognosis and nodal harvest.

Treatment of chronic presacral sinus after low anterior resection

The aim of this retrospective study was to determine patient and treatment characteristics with corresponding clinical outcome of symptomatic chronic presacral sinus after low anterior resection.

Implications of sentinel lymph node mapping on nodal staging and prognosis in colorectal cancer.

Aim  Sentinel lymph node (SN) mapping for staging in colorectal cancer remains controversial and needs to be validated before it can be implemented in daily practice. We prospectively assessed the effect of SN mapping on nodal staging and its implication on survival in patients with colorectal cancer.

Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines

Treatment of perianal fistula has evolved with the introduction of new techniques and biologicals in Crohns disease (CD). Several guidelines are available worldwide, but many recommendations are controversial or lack high‐quality evidence. The aim of this work was to provide an overview of the current available national and international guidelines for perianal fistula and to analyse areas of consensus and areas of conflicting recommendations, thereby identifying topics and questions for future research.

The association between intensified medical treatment, time to surgery and ileocolic specimen length in Crohn's disease

During the last decade, treatment protocols have changed for patients with ileocolic Crohns disease. Anti‐tumour necrosis factor (anti‐TNF) has become part of standard medical treatment, usually in a step‐up approach. The aim was to analyse if improved medical treatment has resulted in more limited ileocolic resections and a longer interval between diagnosis and surgery.

Single port laparoscopic ileocaecal resection for Crohn's disease: a multicentre comparison with multi-port laparoscopy

Single port (SP) ileocaecal resection (ICR) is an established technique but there are no large studies comparing SP and multi‐port (MP) laparoscopic surgery in Crohns disease (CD). The aim of this study was to compare postoperative pain scores and analgesia requirements after SP and MP laparoscopic ICR for CD.