Clinical Science Metastatic lymph node ratio in stage III rectal carcinoma is a valuable prognostic factor even with less than 12 lymph nodes retrieved: a prospective study Khaled M. Madbouly, M.D., Ph.D., M.R.C.S.(Glasg.)*, Khaled S. Abbas, M.D., Ph.D., Ahmed M. Hussein, M.Ch., Dr.Ch. Department of Surgery, University of Alexandria, El Raml Station, Alexandria 21321, Egypt KEYWORDS: Metastatic lymph node ratio; Rectal cancer; Recurrence Abstract BACKGROUND: The aim of this study was to assess the prognostic value of metastatic lymph node (LN) ratio (MLNR) in stage III rectal cancer and whether this prognostic value remains significant when ,12 LNs are retrieved. METHODS: This prospective study included 115 patients with stage III rectal cancer from 2006 to 2010. All patients underwent neoadjuvant long-course chemoradiation, curative resection, and postop- erative adjuvant therapy (5-fluorouracil and leucovorin). Data collected included demographics, tumor pathology, tumor-node-metastasis staging, number of LNs retrieved, MLNR, recurrence, and mortality. RESULTS: The mean number of examined LNs was 12.1, and the mean number of metastatic LNs was 3.5 (range, 1 to 19). The mean MLNR was .37 (range, 0 to 1.00). The mean duration of follow-up was 37 months (range, 24 to 63). Forty patients died during the follow-up period (overall mortality, 34.8%), only 31 because of cancer (cancer-specific mortality, 27%). Univariate analysis revealed that ypN stage, lymphovascular invasion, and follow-up duration were significantly associated with in- creased recurrence and decreased survival. Number of positive nodes and ypT stage significantly af- fected recurrence, with no effect on overall survival. Multivariate analysis proved that MLNR was the only independent risk factor for both mortality and recurrence. Prognostic capability was not af- fected by having ,12 nodes retrieved. The best sensitivity and specificity of MLNR as a prognostic factor for both tumor recurrence and overall survival were achieved at a cutoff value of .375. CONCLUSIONS: MLNR is an independent prognostic factor for recurrence and survival after the resection of stage III rectal cancer, with high sensitivity and specificity in patients who received neoad- juvant chemoradiation and postoperative chemotherapy. The total number of LN retrieved did not affect the prognostic value of MLNR even if ,12. Ó 2014 Elsevier Inc. All rights reserved. Rectal cancer remains a challenge to surgeons and oncol- ogists. The use of neoadjuvant chemoradiation therapy (CRT), total mesorectal excision, and new generations of chemother- apeutic agents has improved recurrence and survival. However, local and systemic recurrence remains high. 1,2 Dis- tant metastases occur in 25% to 30% of patients at 5 year The authors declare no conflicts of interest. This study was presented as a poster at the annual meeting of the American Society of Colon and Rectal Surgeons, San Antonio, Texas, June 2012. * Corresponding author. Tel.: 120-1002033676; fax: 1203 4802375. E-mail address: khaled.madbouly@alexmed.edu.eg Manuscript received May 1, 2013; revised manuscript July 17, 2013 0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2013.07.022 The American Journal of Surgery (2014) 207, 824-831