Requiring Pathologists to find >12 LNs in colorectal is a HOAX

[LADoc00]

I cant believe this B.S. is actually continuing to be perpetrated on us.

For the record: THERE IS ABSOLUTELY NO CAUSATION BETWEEN O.S. IN COLORECTAL CA AND 12+ LYMPH NODES FOUND IN THE SPECIMEN.

None. Zero correlation. This absolutely absurd hoax is more ridiculous than the debunked association of vaccines and AUTISM! Yet somehow we have complete idiots that have parroted this nonsense so Pathologists are forced to return to colonic fat time and time again to mine for more nodes. Dont have 12+ nodes? No dollah dollah bills for you!

The very idea that finding more nodes and surgeons taking more nodes out being linked to overall survival and thus being some kind of quality indicator is pure snake oil.

This snake oil was first sold by MD Anderson in 2007 by Chang et al. in the most half-assed treatment of the data set I have ever read. Almost as if MD Anderson figured they would let a high school statistics class take a crack at a J. NCI article to fill out their resume for Harvard or something.

It was soundly DEBUNKED in 2009, 2 years later by U. Michigan, actual real scientists apparently that controlled for all the confounding factors like actual real adults and the correlation between OS and 12+ "magical lymph nodes" narrative went away.
Not only that:
1.) Wong et al. @michigan showed ZERO correlation between the number of nodes found and the number of POSITIVE nodes found, which makes sense because positive are larger and harder thus be found even if you dont spend 10 hours combing fat for 1mm negative nodes...common sense.
2.) Nodes are less commonly found in older patients, older patients have a worse overall survival for everything, WTF right?
3.) Having more nodes means you have a better immune system and there may be able to mount a better host immune response, but there is no scientific model for "finding more nodes means better outcome" as proposed by idiot cabal currently purporting to lead us.
4.) Shocker: more nodes are found at academic centers because they have mountains of free labor, academic centers have a better outcome in general than rural hospitals with limited labor...shocker right?

Modern medicine is literally being led by idiots. Im serious. We are doomed. If this is the shoddy statistical work and the bogus "Quality Indicators" they want us to be judged on, we are totally screwed.

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[deleted314957]

I cant believe this B.S. is actually continuing to be perpetrated on us.

For the record: THERE IS ABSOLUTELY NO CAUSATION BETWEEN O.S. IN COLORECTAL CA AND 12+ LYMPH NODES FOUND IN THE SPECIMEN.

None. Zero correlation. This absolutely absurd hoax is more ridiculous than the debunked association of vaccines and AUTISM! Yet somehow we have complete idiots that have parroted this nonsense so Pathologists are forced to return to colonic fat time and time again to mine for more nodes. Dont have 12+ nodes? No dollah dollah bills for you!

The very idea that finding more nodes and surgeons taking more nodes out being linked to overall survival and thus being some kind of quality indicator is pure snake oil.

This snake oil was first sold by MD Anderson in 2007 by Chang et al. in the most half-assed treatment of the data set I have ever read. Almost as if MD Anderson figured they would let a high school statistics class take a crack at a J. NCI article to fill out their resume for Harvard or something.

It was soundly DEBUNKED in 2009, 2 years later by U. Michigan, actual real scientists apparently that controlled for all the confounding factors like actual real adults and the correlation between OS and 12+ "magical lymph nodes" narrative went away.
Not only that:
1.) Wong et al. @michigan showed ZERO correlation between the number of nodes found and the number of POSITIVE nodes found, which makes sense because positive are larger and harder thus be found even if you dont spend 10 hours combing fat for 1mm negative nodes...common sense.
2.) Nodes are less commonly found in older patients, older patients have a worse overall survival for everything, WTF right?
3.) Having more nodes means you have a better immune system and there may be able to mount a better host immune response, but there is no scientific model for "finding more nodes means better outcome" as proposed by idiot cabal currently purporting to lead us.
4.) Shocker: more nodes are found at academic centers because they have mountains of free labor, academic centers have a better outcome in general than rural hospitals with limited labor...shocker right?

Modern medicine is literally being led by idiots. Im serious. We are doomed. If this is the shoddy statistical work and the bogus "Quality Indicators" they want us to be judged on, we are totally screwed.

Have things actually devolved to the point where you don't get
paid if you don't find 12 nodes??!! Having retired 4 1/2 yrs ago
I have been kinda out of the loop. I think we all knew a long time ago that
you can only find the nodes that are there. This is the kind of B.S.
that drives folks out of medicine prematurely. Path used to be a
fun, autonomous, interesting and remunerative field. My god how
times have changed!

 

[LADoc00]

No its worse than that because the way its set up both the surgeon AND the pathologist get dinged. So not only are you not getting paid, you have crazed surgeon yelling at you claiming he knows he took out more than 12 nodes and you are just lazy for not finding them.

I feel like Im in some warped nightmare of lunatics and I need to take the red pill to wake up but cant find where I left it...

 

[yaah]

During residency I asked the surgical oncologist (who was mad at me because I only found 8 nodes in her "complete D2 lympadenectomy" in a gastrectomy) if she seriously thought it would help for me to go back and try to find sub-mm "nodes" in the remaining fat, which was mostly omentum. And she said yes it would. I stopped there because I was a peon at the time. But it is insane. It is perhaps possibly true that patients who have more negative nodes will have a better prognosis, but that may be because they have a better immune system response and have more nodes, not because the idiot fat squisher found more of them.

The dumbest conclusion one can make from studies like that is that finding more nodes will help the patient. WRONG.

I always wanted to say, "you mean, I will improve the patient's prognosis by going back to the bucket and digging through fat for more lymph nodes?"

 

[octopusprime]

Have things actually devolved to the point where you don't get
paid if you don't find 12 nodes??!! Having retired 4 1/2 yrs ago
I have been kinda out of the loop. I think we all knew a long time ago that
you can only find the nodes that are there. This is the kind of B.S.
that drives folks out of medicine prematurely. Path used to be a
fun, autonomous, interesting and remunerative field. My god how
times have changed!

It's been like that for years, not a new thing...probably depends on region/payer....no less asinine than getting paid 88307 dollars for a placenta vs 88305 dollars for a melanoma excision...it's all arbitrary...medicine is arbitrary...so is the payment system...

love how histrionic LA gets when forced to deviate from his opulent and glamorous life, lol

 

[Pathbusiness]

As a resident you know how to make 12 nodes!

 

[jupiterianvibe]

****ing hell yes LA this is awesome!
The node crap is so unscientific that it does nothing but reflect the sorry state of pathologist recruitment. We've gone from being the thinkers and the questioners to a gaggle of desperate head nodders. Smarter more confident people would not accept this as the status quo.

 

[coroner]

love how histrionic LA gets when forced to deviate from his opulent and glamorous life, lol

Probably just got an angry phone call from a surgeon and came here to rant...

We've all been there. I once got a 12cm segmental resection of colon with barely any fat and found maybe like 6 nodes. The surgeon called back once he got the report and said, "I need 12 nodes!" To which I replied, "I can't give you what's not there". Depending on your relationship and/or how demanding the surgeon may be, some pathologists (or in academic places, residents) submit more or even the entire amount of pericolonic fat which is ridiculous. Where do you draw the line? And do you really want to look at an additional 60 blocks?

As a resident you know how to make 12 nodes!

Bisecting one node and submitting it as two doesn't count...

 

[Euchromatin]

I could not agree more that the magic 12 lymph node rule is asinine.

We just have our PAs automatically submit an extra 10 blocks of fat whenever they are not 100% sure they found 12 good/real nodes - then we just note in the case that we already "additional adipose tissue was submitted for microscopic examination to search for possible microscopic lymph nodes" and leave it at that (usually that is enough to prevent a phone call). I also stopped specifying the exact number of nodes in resection cases without invasive carcinoma (e.g. a TVA) and just put "benign lymph nodes" as the diagnostic line since I had a surgeon call me to ask for more lymph nodes on such a case once.

 

[Pathbusiness]

Probably just got an angry phone call from a surgeon and came here to rant...

We've all been there. I once got a 12cm segmental resection of colon with barely any fat and found maybe like 6 nodes. The surgeon called back once he got the report and said, "I need 12 nodes!" To which I replied, "I can't give you what's not there". Depending on your relationship and/or how demanding the surgeon may be, some pathologists (or in academic places, residents) submit more or even the entire amount of pericolonic fat which is ridiculous. Where do you draw the line? And do you really want to look at an additional 60 blocks?



Bisecting one node and submitting it as two doesn't count...

Really??

 

[SEpathguy]

I could not agree more that the magic 12 lymph node rule is asinine.

We just have our PAs automatically submit an extra 10 blocks of fat whenever they are not 100% sure they found 12 good/real nodes - then we just note in the case that we already "additional adipose tissue was submitted for microscopic examination to search for possible microscopic lymph nodes" and leave it at that (usually that is enough to prevent a phone call). I also stopped specifying the exact number of nodes in resection cases without invasive carcinoma (e.g. a TVA) and just put "benign lymph nodes" as the diagnostic line since I had a surgeon call me to ask for more lymph nodes on such a case once.

That's a good idea. One of the surgeons where I work (who does a lot of colons) requests we find 12 nodes on colons taken out for TAs. At least they don't ask for 12 on diverticulitis colons, although that'd be just as beneficial as it is on the TA ones.

 

[jupiterianvibe]

These hard-and-fast rules regarding nodes are nothing more than a thought-terminating-cliche.

Will I ever do a node hunt, wasting precious time at the scope and at the bench, on cases where it is not warranted like flat adenoma resections, tics or ischemic bowel? No. If the surgeon wants it they're free to come down, hunt for the nodes, and then go to the scope. It's not indicated, so I don't do it.

Will I hunt for nodes in a patient with prior pelvic radiation that has an aggressive high-grade neuroendocrine rectal malignancy that extends far beyond what the macroscopic examination would have me believe? Of course I will. One of my cases required 75 blocks to get the 12 nodes because of the radiation history. I feel I owe it to these patients to determine the extent of nodal metastatic disease, if present, regardless of the difficulty in finding them. This was a sneaky tumor, as some of the microscopic nodes had involvement, which changed the stage and thereby the prognosis.

But a blanket statement of 12 nodes for every case is downright asinine and removes the professional judgment from pathologists. Even worse is knowing that the research that came to this conclusion is incredibly flawed.

 

[deleted314957]

These hard-and-fast rules regarding nodes are nothing more than a thought-terminating-cliche.

Will I ever do a node hunt, wasting precious time at the scope and at the bench, on cases where it is not warranted like flat adenoma resections, tics or ischemic bowel? No. If the surgeon wants it they're free to come down, hunt for the nodes, and then go to the scope. It's not indicated, so I don't do it.

Will I hunt for nodes in a patient with prior pelvic radiation that has an aggressive high-grade neuroendocrine rectal malignancy that extends far beyond what the macroscopic examination would have me believe? Of course I will. One of my cases required 75 blocks to get the 12 nodes because of the radiation history. I feel I owe it to these patients to determine the extent of nodal metastatic disease, if present, regardless of the difficulty in finding them. This was a sneaky tumor, as some of the microscopic nodes had involvement, which changed the stage and thereby the prognosis.

But a blanket statement of 12 nodes for every case is downright asinine and removes the professional judgment from pathologists. Even worse is knowing that the research that came to this conclusion is incredibly flawed.

Amen. I didn’t tell surgeons how to operate and they didn’t tell me how to
practice pathology. Just ( nicely, professionally and tactfully) tell them
why.

 

[moneybreh]

During residency I asked the surgical oncologist (who was mad at me because I only found 8 nodes in her "complete D2 lympadenectomy" in a gastrectomy) if she seriously thought it would help for me to go back and try to find sub-mm "nodes" in the remaining fat, which was mostly omentum. And she said yes it would. I stopped there because I was a peon at the time. But it is insane. It is perhaps possibly true that patients who have more negative nodes will have a better prognosis, but that may be because they have a better immune system response and have more nodes, not because the idiot fat squisher found more of them.

The dumbest conclusion one can make from studies like that is that finding more nodes will help the patient. WRONG.

I always wanted to say, "you mean, I will improve the patient's prognosis by going back to the bucket and digging through fat for more lymph nodes?"

IDIOT FAT SQUISHER is the perfect description!!

 

[Torsed]

As a resident you know how to make 12 nodes!

Damn thats classic!