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LETTER TO THE EDITOR |
Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands.
A Response to Lee M. Ellis’s Editorial: A Perspective on Sentinel Lymph Node Biopsy in Colorectal Cancer: The Race Between Surgical Technology and Molecular Oncology
In a very informative recent Editorial, Lee M. Ellis1 describes how new technologic advances can identify molecular alterations that indicate the biologic behavior of neoplastic diseases. Information obtained by these advanced technologies provides important prognostic information and is helpful in selecting patients for adjuvant regional and systemic therapy.
Sentinel lymph node biopsy serves the same purposes. Ellis suggests that, in patients with colorectal cancer, sentinel node biopsy may prove to be of less value because the information that we will soon be able to routinely acquire from the primary lesion may be more relevant. He indicates that a race is going on between these competing two diagnostic approaches.
My view is different. Mutations cause tumor cells to change at the molecular (DNA) level. These changes lead to different clones of cells with different biologic behaviors. Some clones have the potential to spread to lymph nodes which renders them more aggressive. These malignant cells may undergo further dedifferentiation within a lymph node. On average, therefore, tumor cells in lymph nodes tend to be more aggressive than cells in the primary lesion. These more aggressive clones determine the prognosis and should guide our adjuvant therapeutic strategy. It is these disseminated cells that we need to examine with our new molecular technologies, more so than the cells obtained from the primary lesion. Sentinel node biopsy identifies these cells that we need to scrutinize for aberrant genes. Therefore, I suspect that we will see a combination of surgical technology and molecular technology instead of a competition.
REFERENCES
Associate Professor of Surgery and Cancer Biology, The University of Texas, MD Anderson Cancer Center.
Reply to Letter to the Editor From Omgo E. Nieweg, MD, PhD
Dr. Nieweg’s Letter to the Editor is insightful, and I do agree with his sentiment that evaluation of malignant cells within lymph nodes may be the best source of tumor tissue for the evaluation of molecular markers of aggressive disease. His suggestions challenge our ability to use technology to its maximum potential. At the present time, it is possible to harvest RNA from tumors and evaluate gene expression by numerous techniques. To evaluate gene expression from micrometastic tumor cells in lymph nodes is theoretically possible, but in practicality, a technological challenge. To accomplish the latter task, the pathology department must be equipped with a laser capture microdissection unit which would isolate these cells, and then subject them to molecular analysis. So, in fact, I do agree with Dr. Nieweg that evaluation of metastatic clones in lymph nodes yield the best prognostic information, and, in turn, may better direct our therapy. In the editorial that I submitted to the Annals of Surgical Oncology, I alluded to where we would perhaps be in 10 years. I believe Dr. Nieweg’s proposal is insightful and meaningful, and it would be a tremendous technological advance to be able to investigate gene expression in micrometastatic disease from lymph nodes. Only time will tell if our technology can keep pace with the innovative ideas that are outlined in this letter.
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