Ratto C, Sofo L, Ippoliti M, Merico M, Bossola M, Vecchio F M, Doglietto G B, Crucitti F
Department of Clinica Chirurgica, Catholic University, Rome, Italy.
Dis Colon Rectum. 1999 Feb;42(2):143-54; discussion 154-8. doi: 10.1007/BF02237119.
Lymph-node involvement is the most important prognostic factor in colorectal cancers. Many staging systems adopted node status as a parameter of tumor classification. However, the number of identified and positive glands varies across articles, depending on specimen examination. There is a consistent risk of substaging tumors and undertreating patients. Aim of this study was to investigate the prognostic significance of different pathologic methods.
Eight hundred one patients who underwent curative resection of colorectal cancer entered the study and were divided into two groups. In Group 1 the specimen was "en bloc" fixed, and nodes were identified by sight and palpation. In Group 2 the mesentery of the excised specimen was dissected away from the bowel, stretched, and pinned to cork board. The mesenteric segment surrounding the origin of principal vessels was divided from the segment surrounding the colic vessels. All specimen segments were fixed, node identification being performed by sight and palpation. Examined and positive nodes were recorded, and metastatic rate and incidence was calculated in the two groups. Patients were classified with use of different staging systems. Survival rates were calculated, related to tumor stage, and compared statistically. Pathologic procedures were included in a multivariate analysis.
A significantly higher number of detected and positive nodes and metastatic rate (37.5 vs. 30.2 percent; P < 0.05) were observed in Group 2; 45.2 percent of Group 2 and 25.3 percent of Group 1 cases had more than three positive nodes (P < 0.05). In Group 2 several patients shifted from earlier to more advanced stages compared with Group 1 cases. Five-year and ten-year survival rates were significantly higher (P = 0.04) in Group 2 (81.5 and 77.2 percent) than in Group 1 (76.7 and 61.5 percent), mostly in patients with TNM Stage N0. Survival analysis related to Astler and Coller's and Tang's classifications confirmed such features. Higher rates of local recurrences and distant metastases were found in Group 1, particularly if related to node status (P < 0.05). Multivariate analysis demonstrated the pathologic method is an independent prognostic factor.
This study demonstrates the prognostic impact of specimen examination. Inaccurate methods could down-stage the tumor and exclude the patient from adjuvant therapies, with detrimental effects on the outcome of the case.
淋巴结受累是结直肠癌最重要的预后因素。许多分期系统将淋巴结状态作为肿瘤分类的一个参数。然而，根据标本检查情况，不同文章中识别出的阳性腺体数量各不相同。对肿瘤进行亚分期及对患者治疗不足的风险始终存在。本研究的目的是探讨不同病理方法的预后意义。
801例行结直肠癌根治性切除术的患者进入本研究并被分为两组。第1组标本“整块”固定，通过肉眼观察和触诊识别淋巴结。第2组将切除标本的肠系膜从肠管上剥离，伸展后用大头针固定在软木板上。围绕主要血管起始部的肠系膜段与围绕结肠血管的段分开。所有标本段均固定，通过肉眼观察和触诊进行淋巴结识别。记录检查到的和阳性的淋巴结，计算两组的转移率和发生率。使用不同的分期系统对患者进行分类。计算生存率，与肿瘤分期相关，并进行统计学比较。将病理程序纳入多因素分析。
第2组检测到的阳性淋巴结数量和转移率显著更高（37.5%对30.2%；P<0.05）；第2组45.2%的病例和第1组25.3%的病例有超过3个阳性淋巴结（P<0.05）。与第1组病例相比，第2组有几名患者从较早分期转变为更晚期。第2组的5年和10年生存率显著高于第1组（分别为81.5%和77.2%对76.7%和61.5%）（P=0.04），主要是TNM分期为N0的患者。与阿斯特勒和科勒分类法以及唐分类法相关的生存分析证实了这些特征。第1组局部复发和远处转移率更高，尤其是与淋巴结状态相关时（P<0.05）。多因素分析表明病理方法是一个独立的预后因素。
本研究证明了标本检查对预后的影响。不准确的方法可能会使肿瘤分期降低，并使患者无法接受辅助治疗，对病例结果产生不利影响。
