What is your count? An observational study of lymph node counting in 2,028 colorectal cancer resections.

ABSTRACT

BACKGROUND: Lymph node status and lymph node count (LNC) are predictors of colorectal cancer outcome. Under-sampling of lymph nodes may lead to clinically relevant stage migration. METHODS: Colorectal cancer (CRC) cases with a synoptic report, accessioned 2012-2020 at a regional laboratory, were extracted and retrospectively studied. LNC, positive lymph node count (PLNC), tumour deposits present (TDpos), and 'y' (staging) prefix (YS) were retrieved and tabulated by pathologist using custom software. Statistical analyses were done with R. DATA AND RESULTS: The cohort had 2,543 CRC resections. Seventeen pathologists interpreted >50 cases (range 56-356) each and collectively saw 2,074. After cases with unavailable data were purged, 2,028 cases remained with 43,996 lymph nodes, of which 2,637/43,996 were positive. 368 cases had a 'y' prefix, and 379 had TDpos. The 17 pathologists' median LNC/case was 19.0 (range 14.0-24.0), and the mean PLNC per case was 1.4 (range 1.0-2.0). Kruskal-Wallis rank sum tests showed there were differences in LNC (p<0.001) among pathologists; however, PLNC did not show this association (p = 0.2917). T-tests showed that mean LNC (p<0.001) and PLNC (p<0.035) differed between YS. 138 of 2,028 cases had less than the 12 LNC target. Logistic regression revealed a strong association between meeting the LNC target and pathologist (p<0.001) but TDpos was non-predictive (p = 0.4736). CONCLUSIONS: Positive lymph node call rate has a good consistency in the laboratory; however, lymph node count varies significantly between pathologists. Standardized counting criteria are needed to improve uniformity and could be aided by synoptic reporting data.