title: Apical node metastasis independently predicts poor survival in Dukes C colorectal cancer.
abstract: OBJECTIVE
  The prognostic significance of apical node metastasis in node-positive colorectal cancer (CRC) is disregarded by the Fourth American Joint Committee on Cancer and the International Union Against Cancer (AJCC/UICC) TNM classification system. The influence of apical node metastases on overall 5-year survival among patients with Dukes stage C CRC was examined.
  
  
  METHODS
  Patients who underwent operative resection for CRC between 1999 and 2003 were reviewed.
  
  
  RESULTS
  Two-hundred and ninety patients were included in the study, including 203 with Dukes C apical node-negative cancers, 39 with Dukes C apical node-positive cancers and 48 with Dukes D cancers. The respective prevalence of extramural vascular invasion was 35%vs 64%vs 56% (P = 0.0005), T4-stage 24%vs 38%vs 48% (P = 0.013), positive resection margin 16%vs 41%vs 23% (P = 0.001), more than three positive nodes harvested 28%vs 85%vs 52% (P < 0.0001) and poorer tumour differentiation grade 9%vs 21%vs 23% (P = 0.009). Multivariate analyses of all Dukes C cancer patients (n = 242) showed a positive apical node to be a highly significant independent predictor of mortality (hazard ratio 2.281, 95% confidence interval 1.421-3.662, P = 0.0006). Extramural vascular invasion and a positive resection margin were also independent predictors of poor survival. Patients with Dukes C apical node-positive cancers had a significantly poorer overall 5-year survival compared to patients with Dukes C apical node-negative cancers (P < 0.0001) but survival was not significantly different compared to patients with distant metastases at initial presentation (P = 0.504).
  
  
  CONCLUSIONS
  Apical node metastasis appears to be a strong independent, negative prognostic factor of poor survival in Dukes C CRC.
authors.affiliation: Department of Colorectal Surgery Department of Pathology, Royal Liverpool University Hospital NHS Trust, Liverpool, UK. acwee@doctors.org.uk
authors.forename: C W
authors.initials: CW
authors.lastname: Ang
authors.forename: E M
authors.initials: EM
authors.lastname: Tweedle
authors.forename: F
authors.initials: F
authors.lastname: Campbell
authors.forename: P S
authors.initials: PS
authors.lastname: Rooney
mesh_terms: D002288:Adenocarcinoma, Mucinous / Q000401:mortality* / Q000473:pathology*; D000368:Aged; D015179:Colorectal Neoplasms / Q000401:mortality* / Q000473:pathology*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008198:Lymph Nodes / Q000473:pathology*; D008207:Lymphatic Metastasis; D008297:Male; D009367:Neoplasm Staging; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015996:Survival Rate