In addition,

the period of diagnosis was also important, as patients in our cohort diagnosed after 2000 had higher LNCs. While this suggests some change over time, we cannot readily identify the source of that change. We suspect that increased awareness among treating physicians and pathologists might have contributed to the improvement in LNCs. Another potential explanation for the increase in LNCs could be a shift in the operative techniques being employed. We did not observe any increase in the frequency of TME performance but noticed an increase in LNCs in those patients undergoing a TME. As suggested earlier, we believe the impact of surgical Inhibitors,research,lifescience,medical techniques of rectal resection on LNCs deserves more attention. Unfortunately, larger, population-based data sets do not FK228 in vitro provide this level of detail. Another potentially important factor in rectal cancer and LNCs is the delivery of preoperative, pelvic radiotherapy. Inhibitors,research,lifescience,medical Neoadjuvant radiotherapy is known to decrease LNCs in the resected rectal cancer specimen. Since neoadjuvant chemoradiotherapy has been accepted

as a standard treatment for node positive and Stage II rectal cancers, efforts to use LNCs as a quality indicator will have to consider the impact of this approach on this metric. One would assume that minimum LNCs would necessarily be adjusted downward. Other clinical factors, such as the clinical and or pathologic Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical response to the preoperative therapy might also have an impact on LNCs. Prior studies have not considered

patients who had undergone neoadjuvant therapy (14,15). In the current study, there did not appear to be any difference in LNCs between patients who received preoperative chemoradiotherapy and those who did not. One possible explanation for this negative result might be that more patients received neoadjuvant chemoradiatherapy in the later period, during which LNCs increased. It is possible, therefore, that the negative impact on LNCs expected because of preoperative radiotherapy was masked by improved identification during the later period Inhibitors,research,lifescience,medical of the study. Another possible explanation is that our study simply lacked the power to detect a difference in LNCs caused by preoperative radiotherapy. In either case, future population-based studies should attempt to characterize LNCs in patients who have undergone preoperative radiotherapy and to determine whether LNCs in this clinical Rutecarpine setting carry the same importance as they appear to carry in untreated patients. While the improvement in staging accuracy with increasing LNCs has been firmly established, the relationship between lymph node counts and survival is less settled. In the current study, no statistically significant improvement in 5-yr OS was detected with increasing LNCs. In fact, in Kaplan Meier analysis, higher lymph node counts correlated with worse survival, albeit not statistically significant either.