title: Less than 12 lymph nodes in the surgical specimen after neoadjuvant chemo-radiotherapy: an indicator of tumor regression in locally advanced rectal cancer?
abstract: BACKGROUND
  The number of lymph node retrieved in the surgical specimen is important for tumor staging and has paramount impact on prognosis in colorectal cancer and imitates the adequacy of lymph node surgical clearance. The paucity of lymph node yields in patients undergoing resection after preoperative chemo radiotherapy (CRT) in rectal cancer has seen. Lower total number of lymph nodes in the total mesoractal excision (TME) specimen after CRT, could a marker of better tumor response.
  
  
  METHODS
  We retrospectively reviewed the prospectively managed data of patients underwent excision for rectal cancer, who treated by neoadjuvant radiotherapy with or without chemotherapy in locally advanced rectal cancer. From 2010 to 2014, 364 patients underwent rectal cancer surgery, of which ninety-one treated with neoadjuvant treatment. Standard surgical and pathological protocols were followed. Patients were categorized into two groups based on the number of total harvested lymph nodes with group 1, having 12 or more nodes harvested, and group 2 including patients who had <12 lymph nodes harvested. The total number of lymph nodes retrieved from the surgical specimen was correlated with grade of tumor regression with neoadjuvant treatment.
  
  
  RESULTS
  Out of 91 patients, 38 patients (42%) had less than 12 lymph nodes examined in specimen. The difference in median number of lymph nodes was observed significantly as 9 (range, 2-11) versus 16 (range, 12-32), in group 2 and 1, respectively (P<0.01). Patients with fewer lymph node group were comparable with respect to age, BMI, pre-operative staging, neoadjuvant treatment. Pathological complete response in tumor pCR was seen with significantly higher rate (40%vs. 26%, P<0.05) in group 2. As per Mandard criteria, there was significant difference in tumor regression grade (TRG) between both the groups (P<0.05). Among patients with metastatic lymph nodes, median LNR was lower in <12 lymph nodes group at 0.167 (range, 0.09-0.45) versus 0.187 (range, 0.05-0.54), difference was not statistically significant (P=0.81).
  
  
  CONCLUSIONS
  Retrieval of fewer than 12 lymph nodes in surgical specimen of rectal cancer who had received neo-adjuvant radiotherapy with or without chemotherapy should be considered as a good indicator of tumor response with better local disease control, and a good prognostic factor, rather than as a pointer of poor diligence of the surgical and pathological assessment.
authors.affiliation: Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India.
authors.forename: Jaiprakash
authors.initials: J
authors.lastname: Gurawalia
authors.affiliation: Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India.
authors.forename: Kapil
authors.initials: K
authors.lastname: Dev
authors.affiliation: Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India.
authors.forename: Sandeep P
authors.initials: SP
authors.lastname: Nayak
authors.affiliation: Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India.
authors.forename: Vishnu
authors.initials: V
authors.lastname: Kurpad
authors.affiliation: Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India.
authors.forename: Arun
authors.initials: A
authors.lastname: Pandey
keywords: Rectal carcinoma; lymph node yield; mesorectal excision; pre-operative chemo-radiotherapy; tumor regression