title: Preoperative endoscopic tattooing to mark the tumour site does not improve lymph node retrieval in colorectal cancer: a retrospective cohort study.
abstract: BACKGROUND
  A direct correlation between number of lymph nodes retrieved and evaluated after a colectomy for colorectal cancer and survival of the patient has been reported, and consensus guidelines recommend to assess at least 12 lymph nodes for adequate staging. Many factors (i.e., patients' and tumour characteristics, surgeon, and pathologist) may influence the evaluation of the presence of neoplastic disease in lymph nodes as well as the total number of lymph nodes examined. Preoperative endoscopic tattooing to mark the site of the tumour has recently been suggested to facilitate the retrieval of lymph nodes in colorectal specimens. The aim of this study was to investigate its association with adequate lymphadenectomy (≥12 nodes) after colorectal resection for cancer.
  
  
  RESULTS
  All patients undergoing elective colorectal resection for cancer between 2009 and 2011 at the S. Anna University Hospital in Ferrara, Italy (N = 250) were retrospectively divided into two cohorts according to whether ink tattooing to mark the tumour site was performed during preoperative colonoscopy. The two cohorts were comparable regarding age, gender, body mass index, tumour location and size, TNM staging, and DNA microsatellite instability-high status. No difference between the tattoo (N = 107) and control (N = 143) groups could be detected in the rate of adequate lymphadenectomies performed (78% vs. 79%, p = 0.40). All factors known to influence lymph nodes retrieval from colorectal specimen were specifically evaluated. Rectal and colonic cancers were analysed together and separately. Full adjusted logistic regression analysis in patients who underwent colonic resection showed that right hemicolectomy (OR 4.72; CI95% 1.09-20.36) was the only factor associated to adequate lymphadenectomy. No association between ink tattooing performed preoperatively to mark the site of the tumour and adequate lymphadenectomy after colorectal resection was found with logistic regression analysis.
  
  
  CONCLUSIONS
  This study shows that preoperative ink tattooing utilized to mark the site of the tumour does not improve adequate lymphadenectomy and lymph nodes yield from colorectal cancer specimens. Further studies are therefore needed to determine if preoperative colonoscopic tattooing to mark the tumour site can refine staging.
authors.affiliation: Department of Surgery, Unit of Clinica Chirurgica, S. Anna University Hospital of Ferrara, and University of Ferrara, Via Aldo Moro, 8 Room 2 34 03 (1C2), 44124, Ferrara, Cona, Italy. cvfeo@unife.it.
authors.forename: Carlo V
authors.initials: CV
authors.lastname: Feo
authors.affiliation: Department of Surgery, Unit of Clinica Chirurgica, S. Anna University Hospital of Ferrara, and University of Ferrara, Via Aldo Moro, 8 Room 2 34 03 (1C2), 44124, Ferrara, Cona, Italy. mattia.portinari@unife.it.
authors.forename: Mattia
authors.initials: M
authors.lastname: Portinari
authors.affiliation: Department of Surgery, Unit of Clinica Chirurgica, S. Anna University Hospital of Ferrara, and University of Ferrara, Via Aldo Moro, 8 Room 2 34 03 (1C2), 44124, Ferrara, Cona, Italy. zlumhl@unife.it.
authors.forename: Michele
authors.initials: M
authors.lastname: Zuolo
authors.affiliation: Department of Surgery, Unit of Clinica Chirurgica, S. Anna University Hospital of Ferrara, and University of Ferrara, Via Aldo Moro, 8 Room 2 34 03 (1C2), 44124, Ferrara, Cona, Italy. trgsmn@unife.it.
authors.forename: Simone
authors.initials: S
authors.lastname: Targa
authors.affiliation: Department of Medicine, Unit of Gastroenterology, S. Anna University Hospital of Ferrara, Ferrara, Italy. mtv@unife.it.
authors.forename: Vincenzo G
authors.initials: VG
authors.lastname: Matarese
authors.affiliation: Department of Diagnostic Imaging and Laboratory Medicine, Unit of Anatomic Pathology, S. Anna University Hospital of Ferrara, and University of Ferrara, Ferrara, Italy. gfr@unife.it.
authors.forename: Roberta
authors.initials: R
authors.lastname: Gafà
authors.affiliation: Unit of Statistics, S. Anna University Hospital of Ferrara, Ferrara, Italy. e.forini@ospfe.it.
authors.forename: Elena
authors.initials: E
authors.lastname: Forini
authors.affiliation: Department of Diagnostic Imaging and Laboratory Medicine, Unit of Anatomic Pathology, S. Anna University Hospital of Ferrara, and University of Ferrara, Ferrara, Italy. lng@unife.it.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Lanza
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000601:surgery*; D004724:Endoscopy / Q000379:methods* / Q000592:standards; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods* / Q000592:standards; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care / Q000379:methods* / Q000592:standards; D012189:Retrospective Studies; D013653:Tattooing / Q000379:methods* / Q000592:standards