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Lymphatic mapping of colon cancer demonstrating a blue-stained lymphatic channel and sentinel node.
Hematoxylin-eosin and immunohistochemistry analysis. A, A moderately differentiated right colon cancer with focal invasion of the submucosa (T1). B, Micrometastases (<2-mm) deposit by hematoxylin-eosin staining in the sentinel node only. Forty-two other lymph nodes were negative by hematoxylin-eosin and immunohistochemistry staining. The patient's stage was, therefore, T1N1(SN)M0.
Hematoxylin-eosin and immunohistochemistry analysis. A, A normal lymph node with patent lymphatic channels. B, A tumor-replaced lymph node with obliteration of the lymphatic channels resulting in a false-negative sentinel node.
T stage correlates with the incidence of micrometastases and isolated tumor cells in the sentinel node in 28 patients.
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Bilchik AJ, DiNome M, Saha S, et al. Prospective Multicenter Trial of Staging Adequacy in Colon Cancer: Preliminary Results. Arch Surg. 2006;141(6):527–534. doi:10.1001/archsurg.141.6.527
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Lymph node evaluation is an important prognostic factor in colorectal cancer (CRC). A 25% recurrence rate in patients with node-negative CRC suggests that current staging practices are inadequate. Focused analysis of the sentinel node (SN) by multiple sectioning and immunohistochemistry improves staging accuracy.
Prospective phase 2 multicenter trial.
Tertiary referral cancer centers.
Between March 2001 and June 2005, 132 patients were enrolled with clinical stage I and II CRC in a prospective multicenter trial (R01-CA90484).
During a standard oncologic resection, lymphatic mapping was performed and the SN identified either by the surgeon or the pathologist. Hematoxylin-eosin staining was performed on all lymph nodes and immunohistochemistry, on lymph nodes negative by hematoxylin-eosin staining.
Main Outcome Measures
Micrometastases greater than 0.2 mm but less than 2 mm and isolated tumor cells less than 0.2 mm were defined according to the sixth edition of the American Joint Committee on Cancer Cancer Staging Manual.
The 63 men and 69 women had a median age of 74 years. Sixty-eight patients (52%) underwent a right hemicolectomy; 3 (2.3%), a transverse colectomy; 9 (7%), a left colectomy; 15 (11%), a sigmoid colectomy; 34 (26%), a low anterior resection; 1 (1%), an abdominal perineal resection; and 2 (2%), a total colectomy. Of the 111 evaluable primary tumors, 19 (17%) were T1 lesions; 17 (15%), T2; 72 (65%), T3; and 3 (2.7%), T4 tumors. Thirty-three patients (30%) were classified as stage I; 46 (41%), stage II, and 32 (29%), stage III. The SN was identified by the surgeon in 127 patients (96%) and by the pathologist in 5 patients (4%). The median number of SNs and total lymph nodes examined were 3 and 14.5, respectively. The sensitivity of lymphatic mapping and SN analysis was 88.2% and the false-negative rate, 7.4% (6/81). Of the 6 false-negative results, 4 were attributed to lymphatic channels obliterated by tumor. Upstaging occurred in 28 patients (23.6%).
In a multicenter trial, ultrastaging of colon cancer is feasible and accurate. In stage II CRC, 24% of patients had nodal carcinoma cells not detected by conventional staging methods. Surgical technique (adequate lymph node retrieval) and focused pathological analysis may improve staging accuracy and the selection of patients for chemotherapy. The unnecessary toxicity and expense of chemotherapy may be avoided in those patients who are truly node negative.
Colon cancer is the most common gastrointestinal malignancy in the United States and is the second most common cause of cancer mortality. This year, more than 106 000 new cases will be diagnosed and, unfortunately, approximately 57 000 people will die of the disease.1 Lymph node analysis is essential for staging colon cancer and selecting patients for adjuvant therapy.2-5 Surgery remains the only curative option but chemotherapy has been shown to improve survival in patients with positive lymph nodes.6 The role of postoperative chemotherapy for patients without nodal metastases is less clear.7One third of patients with tumor-free lymph nodes have recurrences, and therefore, adjuvant chemotherapy may be beneficial in these patients. However, if all node-negative patients are treated, 70% will be subjected to unnecessary chemotherapy because surgery alone is curative. A better understanding of high-risk, node-negative patients and improved methods of lymph node evaluation are therefore needed.
Conventional methods for examining lymph nodes have specific limitations and are subject to sampling error, which increases the risk of understaging. Since up to 70% of tumor-involved lymph nodes are less than 0.5 cm in diameter,8 nodes that contain small metastases can be easily missed in the gross dissection or microscopic examination. Furthermore, using standard techniques, often less than 1% of a lymph node is examined with single-level sectioning with hematoxylin-eosin (H&E) staining. Multilevel-step sectioning, cytokeratin immunohistochemistry (CK-IHC), and reverse transcriptase–polymerase chain reaction (RT-PCR) have been proposed to improve the identification of small nodal tumor deposits but can be labor intensive and cost prohibitive when performed on multiple lymph nodes.
The importance of more intense lymph node examination, however, beyond standard H&E staining to stage colon cancer was underscored by revised guidelines of the American Joint Committee on Cancer and the International Union Against Cancer published in 2002.9,10 Micrometastases and isolated tumor cells are defined according to the size of tumor cells detected by H&E and IHC. This change in nomenclature reflects the growing, but as yet prospectively unproven, body of evidence that the presence of micrometastases and isolated tumor cells may have prognostic importance.
Lymphatic mapping (LM) with focused analysis of the sentinel node (SN), originally described for melanoma11 and subsequently for breast cancer,12 is an accurate method of identifying micrometastases draining from a primary neoplasm. In 1998, we reported that the sentinel lymph node (SLN) concept is universally applicable to a variety of solid neoplasms10 and we adapted this technique to colon cancer.13,14 Several studies have subsequently reported upstaging of colon cancer by the detection of micrometastases in the SN not found by conventional techniques.15-17 However, a large variation in both the accuracy and sensitivity of LM in colon cancer has been demonstrated. Success rates vary from 58% to 100% with skipped metastases ranging from 3% to 60%.18-29 The prognostic importance of these micrometastases is also unclear. Retrospective analyses have yielded conflicting results,30-44 possibly because of inconsistent methods and reporting, lack of standardization, and a wide variation in the interpretation of micrometastases.
The purpose of this study was to evaluate the feasibility of this procedure in colon cancer in a multicenter trial, selecting experienced surgical and pathological teams that had performed LM in colorectal cancer at least 20 times.
Between March 2001 and June 2005, 187 patients with clinical stage I and II colorectal cancer were accrued at 4 tertiary referral cancer centers (John Wayne Cancer Institute [Santa Monica, Calif], Century City Doctor's Hospital [Century City, Calif], Michigan State University [Flint], and University of Colorado [Denver]). Patients were enrolled under Saint Johns Health Center/John Wayne Cancer Institute joint institutional review board–approved protocols in accordance with all institutional standard operating procedures.
Eligible patients had potentially curable colorectal cancer with no evidence of distant metastases confirmed via chest radiography and computed tomography of the abdomen and pelvis within 8 weeks of enrollment. All patients were at least 18 years of age with a performance status of less than or equal to 2 on the Eastern Cooperative Oncology Group/Zubrod scale.
Patients requiring emergency surgery and those with a history of Crohn disease, chronic ulcerative colitis, familial polyposis, or prior malignancy (except for completely resected cervical or nonmelanoma skin cancers) within 3 years of enrollment were excluded. Patients found to have metastases intraoperatively or any other exclusionary criteria after enrollment were considered screen failures and removed from the study.
The data were reviewed independently by the data and safety monitoring board and institutional review board, and 132 patients were evaluated.
A laparotomy or laparoscopy was performed and metastatic disease was excluded. The primary neoplasm was then mobilized without extensive dissection of lymphatic channels or blood vessels. Lymphatic mapping was performed by injecting 0.5 to 1 mL3 of isosulfan blue dye (Lymphazurin; BenVenue Laboratories Inc, Bedford, Ohio) circumferentially around the neoplasm using a tuberculin syringe (Figure 1). An afferent lymphatic channel was visualized within a minute after injection of the dye and was dissected to the first 1 to 3 blue-stained lymph nodes. Each of these SNs was marked with a silk suture (Figure 1).
The lymphatic channel containing the blue dye was then followed proximally to the site of the primary neoplasm to ensure that there were no SNs hidden in the mesenteric fat. On occasion, visualization of the lymphatic(s) and SNs required minor dissection of surrounding tissues. After all SNs were marked with a suture, an en bloc resection of the neoplasm and the regional lymph nodes was performed in the standard fashion.
If LM could not be undertaken before resection, it was performed after the tumor had been resected (ex vivo) and placed on a side table in the operating room. This was the preferred method for rectal cancers. If the surgeon could not identify the SN, the specimen was immediately sent to the pathology suite where a more aggressive dissection was performed and the SN identified by the pathologist.
Specimens were sectioned and processed within 4 hours of receipt in the laboratory to minimize postoperative movement of blue dye to nonsentinel nodes (NSNs). Standard processing of the tumor included reporting the tumor size and grade, T stage, and surgical margin status. Suture-tagged SNs were measured, described, and embedded in a separate cassette.
Sentinel nodes were measured and sectioned at 2- to 3-mm intervals. If the SN was smaller than 5 mm, it was processed whole. Sentinel node tissue was frozen and prepared for cryosectioning. A face section was cut at a thickness of 5 μm for H&E staining. Twelve sections, representing approximately 72 μm of node, were preserved frozen for molecular analysis. The remaining nodal tissue was placed in 10% formalin and embedded in paraffin. Two additional 4-μm sections at approximately 200-μm intervals were taken for H&E and CK-IHC stains; CK-IHC staining was performed on H&E-negative nodes with a panspecific cocktail of antibodies for human CK, AE1/AE3 (DAKO, Carpinteria, Calif) and processed with an automated immunostainer (Ventana ES 320; Ventana Medical Systems, Tucson, Ariz). A CK-IHC stain was considered positive if it demonstrated strongly positive cell clusters or individual cells with anatomical and cytologic features of tumor cells.
Non-SNs were sectioned if larger than 5 mm, formalin fixed, and embedded in paraffin. Non-SNs were assessed by the same H&E and CK-IHC techniques.
Tumor deposits within lymph nodes were classified and staged according to the revised guidelines set by the American Joint Committee on Cancer and International Union Against Cancer.9,10 Pathology reports were individually reviewed and confirmed by the principal investigators. Metastases less than 2 mm and greater than 0.2 mm were considered micrometastases; isolated tumor cells were single tumor cells or cell clusters that measured no greater than 0.2 mm and were usually detected by IHC.
All data were reviewed and analyzed by the Biostatistical Unit at the John Wayne Cancer Institute. A χ2 test was used to compare the proportions of positive to total SNs with positive to total NSNs. A P value of <.05 was considered statistically significant.
The percentage of upstaging, or improvement in the detection of positive SNs afforded by CK-IHC staining, was computed as the number of positive SNs detected by CK-IHC only (not by H&E staining) divided by the total number of SNs deemed negative by H&E staining.
The 63 men and 69 women had a median age of 74 years. Sixty-eight patients (52%) underwent a right hemicolectomy; 3 (2.3%), a transverse colectomy; 9 (7%), a left colectomy; 15 (11%), a sigmoid colectomy; 34 (26%), a low anterior resection; 1 (1%), an abdominal perineal resection; and 2 (2%), a total colectomy.
The SN procedure was performed in vivo in 109 patients (82.6%) and ex vivo in 23 tumors (17.4%). Of the 109 in vivo patients, 16 underwent laparoscopic LM (14.7%). At least 1 blue-stained SN was identified by the surgeon in 127 cases (96%) and in 5 (4%), by the pathologist. The median number of SNs and total lymph nodes identified were 3 and 14.5, respectively.
The primary tumor was not available for analysis in 21 patients because of complete polypectomy at the time of colonoscopy or a complete response to neoadjuvant therapy in patients with rectal cancer. Sentinel lymph node mapping was performed in these patients by injecting the scar or biopsy site circumferentially. Of the 111 evaluable primary tumors, 19 (17%) were T1; 17 (15%), T2; 72 (65%), T3; and 3 (2.7%), T4. The mean tumor size was 3.58 cm, the median was 3.5 cm, and the range was 0.2 to 10.5 cm. Histological grade of the evaluable primary tumors was high (25 [18%]), intermediate (62 [46%]), and low (24 [17%]).
Seventeen patients (12.9%) had SN macrometastases (>2 mm). Of the other 115 patients, 24 (20.1%) had isolated tumor cell clusters (≤0.2 mm) in the SN, 4 (3.5%) had SN micrometastases (≤2 mm), and 87 (75.6%) had no evidence of tumor in the SN. All the micrometastases and isolated tumor cells had morphologic characteristics of tumor cells. Isolated tumor cells without cytologic features were not considered tumor cells. Of the 28 patients with micrometastases or isolated tumor cells in an SN, only 7 patients had isolated tumor cells in the NSNs.
Of the 45 patients with tumor-positive SNs, 22 had 1 positive node, 10 had 2 positive nodes, and 13 had 3 to 6 positive nodes. Twenty-eight patients (23.6%) were therefore upstaged by focused analysis (Figure 2). In the 21 patients with no residual primary tumor at the time of surgery, only 1 patient had an SN positive for an isolated tumor cell. The SNs and NSNs in the remaining patients were all negative by both H&E and CK-IHC staining. The sensitivity of LM-SN analysis (ie, the probability of detecting tumor in an SN when nodal metastasis is present) was 88.2% (45 patients with tumor-positive SNs divided by 51 patients with tumor-positive nodes). The false-negative rate (ie, the probability of not finding tumor in an SN when nodal metastasis is present) was 7.4% (6 patients with tumor-negative SNs but tumor-positive NSNs divided by 81 patients with tumor-negative nodes). Of the 6 false-negative results, 4 were attributed to lymphatic channels obliterated by tumor (Figure 3), and 3 of these were in patients with rectal cancer. Thirty-three patients (30%) were classified as stage I; 46 (41%), as stage II; and 32 (29%), as stage III.
There was a much greater likelihood of tumor in SNs than NSNs. Of 496 SNs examined, 87 (18%) were positive (ratio, 0.175 [95% confidence interval, 0.143-0.212]); by comparison, of 1764 NSNs examined, 109 (6%) were positive (ratio, 0.062 [95% confidence interval, 0.051-0.074]). By binomial testing, the ratios were significantly different (P = .001).
Of the 17 patients with SN macrometastases, 14 had T3 lesions (82.3%), 1 patient had a T2 lesion (5.9%), and 2 patients had T4 lesions (11.8%). Of the 28 patients with micrometastases, 20 had T3 lesions (71%), 7 had T2 lesions (25%), and 1 had a T1 lesion (4%) (Figure 4).
One third of patients with node-negative colon cancers have a recurrence and die of the disease. A likely explanation for this is missed micrometastases or aberrant drainage pathways to lymph nodes beyond the field of resection. Retrospective analyses of recurrences in patients with H&E-negative nodes have identified more tumor deposits by multiple sectioning and IHC30-44 but the prognostic relevance is unclear. Prospective studies have been limited because the process of identifying micrometastases and isolated tumor cells in all draining lymph nodes is expensive and of unproven value.
Lymphatic mapping, as originally described in melanoma,11 allows the pathologist to focus on a limited number of lymph nodes, usually 1 or 2, that are representative of the lymph node basin. The SN paradigm is based on the premise that lymphatic drainage from a primary organ site occurs in an orderly and progressive fashion. In colon cancer, the lymphatic drainage proceeds from the submucosal lymphoid follicles through the bowel wall to the epicolic, paracolic, and finally the para-aortic nodes.45 The SLN is the first node to receive lymphatic drainage from a primary anatomical site and is therefore the most likely node to harbor a metastasis. In a previous feasibility study, we demonstrated that LM is applicable to colon cancer and improves staging accuracy.14 It has also been shown to assist with the identification of more lymph nodes, particularly nodes less than 5 mm.16 Despite this, the sensitivity and accuracy of LM in several studies in colorectal cancer have been inconsistent.18-29
This may be explained by the lack of standardization, training, and interpretation of micrometastases. We therefore began a prospective trial at cancer centers that had successfully performed LM in colorectal cancer at least 20 times. Surgical technique as well as pathological analysis was standardized and closely monitored by the data and safety monitoring board. Our preliminary finding indicates a high rate of SN identification (96%) and a low rate of false-negative results (7.4%). These differ from a recently reported prospective multicenter colon SN trial in which 25 surgeons at 13 member institutions enrolled 72 patients.30,46 The SN was successfully identified in only 66% of patients and the false-negative rate was 54%. These results may be attributed to inadequate pathological evaluation or to surgical inexperience. In that study, 18 (72%) of 25 surgeons performed fewer than 5 LM procedures, and only 2 performed more than 10. Only half of the SNs in the study underwent multilevel sectioning and the majority of primary tumors (65%) were locally advanced (T3 and T4).
The original technical success rates of LM in melanoma and breast cancer were 82% and 60%, respectively.11,12 With well-orchestrated training programs and clinical trials, these rates have increased to 98%47,48 and are widely reproducible. The precise number of cases required in colon cancer to be proficient is unknown, but the learning curve appears less than breast cancer and melanoma.
Paramo and colleagues29 have demonstrated that the sensitivity of LM in colon cancer increased after 5 LM procedures were performed and then remained consistently high in a study of 7 surgeons. In a similar feasibility study in 100 patients, we demonstrated that all of the technical failures occurred in the first 50 patients undergoing LM and SLN analysis, with 3 of the 5 false-negative results in the first 30 operations.49 In the present trial, 3 of the 6 false-negative results occurred in rectal cancer in patients treated with neoadjuvant chemotherapy.
Lymphatic mapping has not only been shown to improve the detection of micrometastases but is also associated with an increase in lymph node retrieval, possibly because, with time, more smaller nodes stain blue. The median number of lymph nodes in this study was 14.5, significantly more than the number of lymph nodes retrieved at our institution prior to performing LM.16 Intuitively, the more nodes that are recovered the greater the likelihood of discovering an occult metastasis. In a study of 1816 patients with Dukes B colon cancer, Prandi et al50 noted lower overall survival when fewer lymph nodes were recovered in the colectomy specimen. They suggested that patients with Dukes B colon cancer with fewer than 7 nodes in the surgical specimen are potentially understaged and should be considered for adjuvant chemotherapy. However, because chemotherapy benefits only 30% of node-positive patients,6 its routine use would unnecessarily expose many patients to drug toxic effects.
Despite this, there is no consensus on the number of nodes necessary for adequate staging. Both the American Joint Committee on Cancer and the International Union Against Cancer recommend the examination of at least 12 lymph nodes per specimen.9,10 In a review of 108 patients with stage II colon cancer, Burdy et al51 found that the recovery of fewer than 14 uninvolved lymph nodes in the colectomy specimen was significantly associated with tumor recurrence. Joseph et al52 found that the prediction of nodal status with an 85% certainty required examination of more than 40 nodes for T1 and T2 lesions and at least 40 nodes for T3 lesions. While more than 40 nodes may be harvested from a properly resected specimen, thorough examination of these nodes would be costly and labor intensive.
The prognostic value of micrometastases is a subject of much debate. It is unclear whether IHC-detected cells within lymph nodes represent part of a metastatic cascade or hyperplastic mesothelial cells. Micrometastases have been reported in 10% to 76% of H&E-negative nodes by retrospective analysis.30-44 Broll et al36 examined the nodes of 32 patients with stage I and II colorectal carcinoma. With a median follow-up of 84 months, 33% of IHC-positive patients developed disease recurrence, as opposed to only 12% of patients with IHC-negative nodes. This difference did not translate into a difference in overall survival, however. Greenson et al33 used IHC for CK and tumor-associated glycoprotein (TAG-72) to examine the lymph nodes of 50 patients with node-negative Dukes B colon cancer. The rate of cancer-related deaths within 66 months was 43% for IHC-positive patients but only 3% for IHC-negative patients. While promising, several studies have failed to reveal a difference between patients with IHC-positive and IHC-negative lymph nodes with respect to disease recurrence or survival.42
These inconsistent results may be attributed to different sectioning techniques or antibodies used to stain CK. Some groups have suggested that RT-PCR is a more sensitive method for the detection of micrometastases than IHC. Using a multimarker RT-PCR assay, we upstaged 46% of cases identified as node negative by both H&E and IHC staining.18 Similarly, Liefers et al53 used RT-PCR for carcinoembryonic antigen to study the nodes of 26 patients with node-negative colorectal cancer; 54% of cancers were upstaged. More importantly, the 5-year survival rate was 91% for those who were node negative by RT-PCR compared with only 50% for those who were node positive by RT-PCR.
Ultrastaging techniques are promising but remain costly and time-consuming for use on all nodes in a colectomy specimen. By concentrating the pathologist's efforts on a few lymph nodes that are most likely to harbor a metastatic cancer, the potential to upstage cancer can be greatly increased without significantly increasing time and cost. Lymphatic mapping, by helping to identify high-risk lymph nodes, particularly those that may be small or in aberrant locations and difficult to see, would assist in the upstaging of colon cancer. Lymphatic mapping may allow an effective, focused pathological ultrastaging review of 1 or more SNs, without compromising standard pathological assessment of NSNs.
Preliminary studies from this prospective phase 2 trial suggest that LM and SLN techniques are feasible and accurate in colon cancer. Focused pathological review identified micrometastases and/or isolated tumor cells in 24% of patients who otherwise may have been considered node negative. The full impact of the prognostic effect of micrometastases continues to be evaluated in this trial. The improved risk stratification afforded by standardization of both surgical and pathological techniques may improve the selection of patients for chemotherapy, thereby avoiding the unnecessary toxic effects and expense for those cured by surgery alone.
Correspondence: Anton J. Bilchik, MD, PhD, John Wayne Cancer Institute, 2200 Santa Monica Blvd, Santa Monica, CA 90404 (firstname.lastname@example.com).
Accepted for Publication: February 16, 2006.
Funding/Support: This study was supported in part by grant CA090848 from the National Cancer Institute and by funding from the Rod Fasone Memorial Cancer Fund (Indianapolis, Ind), the Henry L. Guenther Foundation (Los Angeles, Calif), the William Randolph Hearst Foundation (San Francisco, Calif), the family of Jeanne and Eric Li, the Davidow Charitable Fund (Los Angeles), and the Harold J. McAlister Charitable Foundation (Los Angeles).
Previous Presentations: This paper was presented at the Western Surgical Association meeting; November 7, 2005; Rancho Mirage, Calif; and is published after peer review and revision. The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript.
Jan H. Wong, MD, Honolulu, Hawaii: In 1991, I, along with my coauthors Drs Cagle and Morton, published what has turned out to be, unfortunately, an infrequently cited manuscript describing an operative technique to identify the sentinel lymph node in a feline model (Wong JH, Cagle LA, Morton DL. Ann Surg. 1991;214:637-641). Approximately 1 year later and some 2 years after being presented at the annual meeting of the Society of Surgical Oncology, the technical details of intraoperative lymphatic mapping and sentinel node dissection was published. The difficulty in getting that report accepted for publication attests to the considerable skepticism that sentinel node staging was met with. History, however, has confirmed and now repeatedly validated the simple yet eloquent hypothesis that solid tumors, if they metastasize to the regional lymph node, will do so in an orderly fashion to a sentinel lymph node—at least in cutaneous melanoma and breast cancer.
Dr Bilchik and his colleagues report today on a multicenter trial evaluating the feasibility and accuracy of sentinel node staging in carcinoma of the colon and rectum. His results demonstrate that not only is sentinel node staging of the colon and rectum technically feasible (their success rate of identifying the sentinel node was 96%), but with the addition of 2-level sections and immunohistochemical staining to the routine analysis of the sentinel lymph nodes, there is a dramatic increase in the identification of tumor cells in the hematoxylin-eosin–negative nodes. Sentinel node staging in their hands has a sensitivity of 88% and false-negative rate of 6.9%, results that are comparable with those observed in cutaneous melanoma and breast cancer.
Although there is general uniformity in the sensitivity and false-negative rates reported in melanoma and breast cancer, the same cannot be said for carcinoma of the colon or rectum. We have reported similar results to those reported here today utilizing ex vivo lymphatic mapping techniques in carcinoma of the colon and rectum. However, other investigators have not been nearly as successful in reproducing Dr Bilchik's outstanding results. My first question addresses these apparent discrepancies. Are these simply technical issues that can be overcome with experience or is this tumor model just not amenable to this approach?
If experience is a key and given the workload of the average general surgeon as compiled at the time of recertification, is sentinel node staging so precise that it can only be performed in experienced, high-volume settings? We have described the ex vivo technique to map the lymphatics of the colon and rectum in pathology (Wong JH, Johnson DS, Namiki T, Tauchi-Nishi P. Ann Surg Onc. 2004;11:772-777). Might this technique, in which all colorectal cancer specimens are examined and mapped by a single laboratory, perhaps shorten the ability to implement this approach to improved staging?
The majority of your upstaging (85% to be exact) was the result of the identification of isolated tumor cells. Is the upstaging that you observed, particularly of isolated tumor cells, simply the result of a more thorough examination of the sentinel lymph node or does this truly represent the initial site of metastases to the regional lymphatics?
Finally, as you discussed in your manuscript, the biologic and prognostic relevance of these immunohistochemical findings are controversial. It is apparent that if we look we will find. Do you have recommendations for what we should do when these small volumes of apparent disease are identified? Should these individuals be candidates for adjuvant systemic therapy? Is it feasible to design a clinical trial to address the prognostic relevance of these findings or should we focus on the burgeoning technology of gene expression signatures and proteomic profiles?
Dr Bilchik: Thank you, Dr Wong. The pioneering investigations of sentinel node (SN) mapping conducted by you and Dr Morton have revolutionized the management of both melanoma and breast cancer.
In colon cancer, the accuracy of lymphatic mapping and focused analysis of the sentinel node depends on careful patient selection and on technical issues. For example, patients with large primary tumors (T4) are poor candidates for sentinel node mapping because injection of the mapping agent around the tumor is difficult; also, a large tumor may obliterate lymphatic channels. Moreover, these patients probably will receive systemic chemotherapy regardless of the tumor status of the sentinel node. We would not expect the accuracy of lymphatic mapping to be as high in small studies that included patients with advanced tumors or in any study not based on standardized techniques and close communication between surgeon and pathologist.
Ex vivo lymphatic mapping may facilitate standardization because it can be performed in the pathology suite. Often the pathologist is able to identify small blue-stained lymph nodes not identified intraoperatively. The only drawback of ex vivo lymphatic mapping is its inability to identify aberrant or unexpected lymphatic drainage that might change the operative approach. We favor the ex vivo approach when the presence of rectal cancer or a thickened mesentery would complicate in vivo identification of the sentinel node.
In our study, most upstaging of colon cancer was based on identification of tumor cell clusters; both immunohistochemical and molecular studies suggest that these clusters represent biologically active metastasis. Cells that stained positive by immunohistochemistry but had no morphologic characteristics of tumor cells were not considered a basis for upstaging. However, immunohistochemistry often detected small tumor cells initially missed by H&E but confirmed by rereview of H&E-stained sections.
Should a patient with micrometastases receive chemotherapy? Although most medical oncologists are inclined to say yes, the issue remains controversial. Retrospective studies have been limited by small numbers, inadequate lymph node retrieval, and lack of standardized methodology. We hope that results of our ongoing prospective multicenter trial will yield a more definitive answer. The design of a prospective trial based on gene expression is somewhat problematic given the need for adequate nodal sampling, standardized pathological and molecular analysis, and consensus on the selection of marker panels. At this time, the most important criterion for a successful trial of staging in patients with colon cancer is a carefully planned oncologic operation with adequate lymphadenectomy.
Baiba J. Grube, MD, Galveston, Tex: I do have one question regarding the whole concept of regional metastases as opposed to systemic disease, much like the Halstedian principle of regional spread in breast cancer as opposed to Fischer's principle of disease being metastatic from the beginning. How will your trial answer the possibility of metastatic disease as an initial event rather than regional spread?
Dr Bilchik: The purpose of our trial is to evaluate the accuracy of sentinel node mapping and then to determine whether nodal micrometastasis impacts overall survival. The trial was not designed to address the possibility of metastatic disease without regional nodal involvement.
Tyler Hughes, MD, McPherson, Kan: One question is about lymphazurin in the breast. We are starting to see moving away from it because of allergic reactions, etc. So I wonder about potential morbidities of lymphazurin.
The other question I have, being an average general surgeon, if I were to use this technique and find an aberrant node, because in small towns everything turns out to be aberrant, what operation do I do at the point where I have a right colon lesion and I get a blue node in the sigmoid mesentery?
Dr Bilchik: In our experience, use of isosulfan blue dye to visualize lymphatic drainage to the sentinel node is safe and effective. There is essentially no morbidity and we have not encountered any anaphylactic reactions. The blue dye is inexpensive, and mapping adds only minutes to the operation. Fortunately, aberrant or unexpected drainage pathways are extremely unusual; in our experience, the tumor is usually a right-sided colon cancer that drains to a sentinel node located to the left of the middle colic artery. To change the operation from a right colectomy to an extended right hemicolectomy adds no morbidity and is undeniably gratifying when the SN tests positive for tumor. The possibility of aberrant drainage has major consequences for the laparoscopic surgeon, who otherwise might be tempted to skip sampling of the mesenteric nodes when the SN is at the root of the mesentery.
Anthony M. Vernava, MD, Rochester, NY: I would like to compliment you and your coauthors on attempting to deal with stage migration and would like to ask you a question regarding your sentinel lymph node study. Earlier studies which have evaluated patients for the presence of micrometastases have been successful in upstaging patients in whom micrometastases have been identified. However, those same studies did not demonstrate a clinical harm for those patients upstaged by micrometastases comparable to conventional stage III patients. For the most part, patients upstaged using micrometastases as an indicator of node-positive disease continued to behave biologically as having node-negative disease. How do your results using sentinel lymph node evaluation compare to those earlier studies using cytokeratin identify micrometastases? Does upstaging a patient using sentinel node technique confer useful clinical information beyond conventional operation and pathologic staging?
Dr Bilchik: We recently performed a meta-analysis of all retrospective studies evaluating micrometastases in lymph nodes of colon cancer patients. In most studies, immunohistochemistry and/or reverse transcriptase–polymerase chain reaction identified micrometastases in nodes that stained negative by H&E. Interestingly, identification of nodal micrometastasis by RT-PCR but not by immunohistochemistry was associated with a statistically significant difference in overall survival. However, the techniques were not standardized, the studies were retrospective, and most of the patients underwent inadequate nodal sampling. Databases on standardized, prospective assessment are necessary to resolve the clinical relevance of upstaging based on nodal micrometastasis.


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According to the American Chiropractic Association, they don't support or endorse any one of the techniques. Chiropractors tend to have a skillset that covers multiple techniques. You should also ask whether the chiropractor uses hand manipulation, instruments or a combination depending on the patient's need and preference.
If you favor a special technique, you should choose a chiropractor that has experience with it. You can also consider diversifying from what you've used in the past, and try a new technique to treat your condition.
Some common chiropractic techniques are:
Keep in mind you might not be aware of what you prefer or dislike until after you've had your first few treatments. You should be comfortable expressing yourself. Your Lake Clarke Shores chiropractor should listen to your wishes.
Some offices might offer additional services, such as massage or injury rehabilitation. View additional services as a bonus if the office offers them.
If your chiropractor suggests these services as part of your treatment plan, you will want to make sure your insurance covers them. Your insurance might place different limitations on those services, such as number of allowable visits.
Each state requires chiropractors to hold a doctorate in chiropractic medicine. If you're unfamiliar with their college, you can search the school's name on the Council of Chiropractic Education to ensure it's an accredited institution.
Websites exist for patients to review their doctors, which includes chiropractors. Unlike testimonials that focus on the positive only, you can expect to see good, in between, and negative reviews from actual patients.
Take the time to read them, and don't use star ratings to guide your decision. Some reviewers, for example, might dock stars for issues that don't matter or relate to you. Be sure to note the date on negative reviews as well as any follow up comments from the practice.
Skill and technique do improve with time, so you might prefer an experienced Lake Clarke Shores chiropractor. A few years or longer, in addition to their education, is a decent amount of time for a chiropractor to hone their skills.
However, one with less hands-on experience might offer you the same results. Unless you have a specific preference, the length a chiropractor has been in practice might not matter to you.
Whether you have one chiropractor or a few in mind, you should meet face-to-face before you agree to services. Consider this first meeting like a job interview, but you're the boss. Be prepared with a list of questions as well as addressing any concerns that arise during your visit.
Make visible inspections upon your visit. Is the office and waiting room clean? Are the staff pleasant and prompt? How long did you have to wait before the chiropractor saw you? Take your answers to these questions as part of the bigger picture.
Before you settle on a chiropractor, you should have a basic idea of what to expect during your course of treatment. This includes talking about your expectations as well as your chiropractor's opinion on your treatment.
Ask about the length of treatment before you should see results. Time invested does vary and depends on the area you require treatment and the severity of your condition. Also, be sure to inquire about what happens if you don't see improvements.
You should get along well with your Lake Clarke Shores chiropractor and feel comfortable around them. This includes speaking to them about your care as well as when they touch you. If you don't feel at-ease, you should consider finding a new chiropractor.
The vast majority of chiropractors will put your health and goals first, but you should be cautious of chiropractors pushing unconventional options. Those may include:
As with any doctor, picking a chiropractor is a personal decision. Take your time to find the right one. If something feels off, you can likely change chiropractors.
Lake Clarke Shores is a town in Palm Beach County, Florida, United States. The town is part of the Miami metropolitan area of South Florida. The 2020 census recorded a population of 3,564. The town was named after John Newton Clarke, who first filed a homestead claim in the area in 1897. Clarke intended to capitalize on the business of growing pineapples, but his efforts were ultimately unsuccessful. Very few people lived in the area until local attorney Walter Travers created a plan to develop a community around Lake Clarke and purchased 250 acres (100 ha) of land for $10,000 in the late 1940s. The completion of a bridge across the West Palm Beach Canal in 1953 spurred a further growth in population. With rumors spreading that West Palm Beach intended to annex the community, residents voted by a wide margin to support the incorporation of Lake Clarke Shores as a town on April 10, 1956, which the Florida Legislature officially approved in July 1, 1957.Today, Lake Clarke Shores maintains a small population. The town is primarily a bedroom community, with most of its businesses and other commercial buildings located along Forest Hill Boulevard (State Road 882).
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Graduate Algebraic Geometry Seminar Spring 2018: Difference between revisions
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[[Graduate Algebraic Geometry Seminar
Fall 2017]
Latest revision as of 00:22, 28 February 2019
When: Wednesdays 3:40pm
Where:Van Vleck B321 (Spring 2018)
Who: All undergraduate and graduate students interested in algebraic geometry, commutative algebra, and related fields are welcome to attend.
Why: The purpose of this seminar is to learn algebraic geometry and commutative algebra by giving and listening to talks in a informal setting. Talks are typically accessible to beginning graduate students and take many different forms. Sometimes people present an interesting paper they find. Other times people give a prep talk for the Friday Algebraic Geometry Seminar. Other times people give a series of talks on a topic they have been studying in-depth. Regardless the goal of GAGS is to provide a supportive and inclusive place for all to learn more about algebraic geometry and commutative algebra.
How:If you want to get emails regarding time, place, and talk topics (which are often assigned quite last minute) add yourself to the gags mailing list: firstname.lastname@example.com. The list registration page is here.
Give a talk!
We need volunteers to give talks this semester. If you're interested contact Juliette or Moisés, or just add yourself to the list (though in that case we might move your talk later without your permission). Beginning graduate students are particularly encouraged to give a talk, since it's a great way to get your feet wet with the material.
Being an audience member
The goal of GAGS is to create a safe and comfortable space inclusive of all who wish to expand their knowledge of algebraic geometry and commutative algebra. In order to promote such an environment in addition to the standard expectations of respect/kindness all participants are asked to following the following guidelines:
- Do Not Speak For/Over the Speaker:
- Ask Questions Appropriately:
The List of Topics that we Made February 2018
On February 21st of the Month of February of The 2018th Year of the Seventh Age of The Sun, the People Present at GAGS Compiled Ye Followinge Liste of Topics They Wished to Hear Aboute:
Feel free to edit the list and/or add references to learn this stuff from.
- Schubert Calculus, aka how many lines intersect four given lines in three-dimensional space? The answer to this question is prettiest when you think about it as a problem of intersecting subvarieties in the Grassmanian. What is the Grassmanian, you say? That's probably a talk we should have every year, so you should give it!
- Kindergarten GAGA. GAGA stands for Algebraic Geometry - Analytic Geometry. Serre wrote a famous paper explaining how the two are related, and you could give an exposition suitable to kindergardeners.
- Katz and Mazur explanation of what a modular form is. What is it?
- Kindergarten moduli of curves.
- What is a dualizing sheaf? What is a dualizing complex? What is Serre duality? What is local duality? Can local duality help us understand Serre duality?
- Generalizations of Riemann - Roch. (Grothendieck - Riemann - Roch? Hirzebruch - Riemann - Roch?)
- Hodge theory for babies
- What is a Néron model?
- What is a crystal? What does it have to do with D-modules? Here's an encouragingly short set of notes on it.
- What and why is a dessin d'enfants?
- DG Schemes.
Ed Dewey's Wish List Of Olde
Back in the day Ed and Nathan made this list of topics they wanted to hear. They all sound super duper cool, but it's also true that they had many years of AG behind their backs, so this list might not be very representative of what the GAGS audience wants to hear bout.
Here are the topics we're DYING to learn about! Please consider looking into one of these topics and giving one or two GAGS talks.
Specifically Vague Topics
- D-modules 101: basics of D-modules, equivalence between left and right D-modules, pullbacks, pushforwards, maybe the Gauss-Manin Connection. Claude Sabbah's introduction to the subject could be a good place to start.
- Sheaf operations on D-modules (the point is that then you can get a Fourier-Mukai transform between certain O-modules and certain D-modules, which is more or less how geometric Langlands is supposed to work)
Famous Theorems
Interesting Papers & Books
- Symplectic structure of the moduli space of sheaves on an abelian or K3 surface - Shigeru Mukai.
- Residues and Duality - Robin Hatshorne.
- Have you heard of Serre Duality? Would you like to really understand the nuts and bolts of it and its generalizations? If so this book is for you. (You wouldn't need to read the whole book to give a talk ;).)
- Coherent sheaves on P^n and problems in linear algebra - A. A. Beilinson.
- In this two page paper constructs the semi-orthogonal decomposition of the derived category of coherent sheaves on projective space. (This topic is very important, and there are a ton of other resources for this result and the general theory of derived categories.)
- Frobenius splitting and cohomology vanishing for Schubert varieties - V.B. Mehta and A. Ramanathan.
- In characteristic p the fact that (x+y)^p=x^p+y^p means that one has the Frobenius morphism, which sends f to f^p. In this paper the authors introduce the notion of what it means for a variety to be Frobenius split, and use this to prove certain cohomologcal vanishing results for Schubert varieties. Since then Frobenius splitting -- and its related cousins (F-regularity, strong F-regularity, F-purity, etc.) have played large roles in geometry and algebra in characteristic p. This is a good place to get a sense for what kicked all this stuff off!
- Schubert Calculus - S. L. Kleiman and Dan Laksov.
- An introduction to Schubert calculus suitable for those of all ages. I am told the paper essentially only uses linear algebra!
- Rational Isogenies of Prime Degree - Barry Mazur.
- In this paper Mazur classifies all isogenies of rational elliptic curves of prime order. As a result of this he deduces his famous result that the torsion subgroup of an elliptic curve (over Q) is one of 15 abelian groups. This definitely stares into the land of number theory, but certainly would still be of interest to many.
- Esquisse d'une programme - Alexander Grothendieck.
- Originating from a grant proposal in the mid 1980's this famous paper outlines a tantalizing research program, which seeks to tie numerous different areas of math (algebraic geometry, Teichmuller theory, Galois theory, etc.) together. This is where Grothendieck introduced his famous Lego game and dessin d'enfant. While just a research proposal this paper has seemingly inspired a ton of cool math, and will allow you to "blow peoples' minds". (The original paper is in French, but there are English translations out there.)
- Géométrie algébraique et géométrie analytique - J.P. Serre.
- A projective variety X over the complex numbers has two lives, an algebraic and an analytic, depending on which topology one wishes to work with. That is one can think about X as a complex manifold and work with holomorphic functions or as an algebraic variety and work with regular functions. Hence to any complex projective variety we have two sheaf theories and as a result two cohomology theories. In this famous paper Serre compares these two and shows they are in fact the same. (Note: This is a super fundamental result that is used all the time; normally in the following way: Uhh... What do you mean by cohomology? Well by GAGA or something it doesn't really mater.) (The original paper is in French, but there are English translations out there.)
- Limit linear series: Basic theory- David Eisenbud and Joe Harris.
- One of the more profitable tools -- especially when studying moduli spaces -- in a geometers tool box is the theory of degenerations. However, sometimes we care about more than just the variety we are degenerating and want to keep track of things like vector/line bundles. In this paper Eisenbud and Harris develop the theory of degenerating a curve together with a linear series. From this they prove a ton of cool results: M_g is of general type for g>24, Brill-Noether theory, etc.
- Picard Groups of Moduli Problems - David Mumford.
- This paper is essentially the origin of algebraic stacks.
- The Structure of Algebraic Threefolds: An Introduction to Mori's Program - Janos Kollar
- This paper is an introduction to Mori's famous ``minimal model program, which is a far reaching program seeking to understand the birational geometry of higher dimensional varieties.
- Cayley-Bacharach Formulas - Qingchun Ren, Jürgen Richter-Gebert, Bernd Sturmfels.
- A classical result we all learn in a first semester of algebraic geometry is that 5 points in the plane (in general position) determine a unique plane conic. One can similarly show that 9 (general) points in the plane determine a unique plane cubic curve. This paper tries to answer the question: ``What is equation for this cubic curve?.
- On Varieties of Minimal Degree (A Centennial Approach) - David Eisenbud and Joe Harris.
- Suppose X is a projective variety embedded in projective space so that X is not contained in any hyperplane. By projecting from general points one can see that the degree of X is at least codim(X)+1. This paper discusses the classification of varieties that achieve this lower degree bound i.e. varieties of minimal degree. This topic is quite classical and the paper seems to contain a nice mixture of classical and modern geometry.
- The Gromov-Witten potential associated to a TCFT - Kevin J. Costello.
- This seems incredibly interesting, but fairing warning this paper has been described as highly technical, which considering it uses A-infinity algebras and the derived category of a Calabi-Yau seems like a reasonable description. (This paper may be covered in Caldararu's Spring 2017 topics course.)
Spring 2017
|Title (click to see abstract)
|February 14
|Moisés Herradón Cueto
|Fun with commutative groups
|February 21
|Moisés Herradón Cueto
|[math]\displaystyle{ \mathcal F }[/math]un with commutative groups
|February 28
|Dima Arinkin
|ODEs: algebraic vs analytic vs formal
|March 7
|Vladimir Sotirov
|Topology of Affine Schemes
|March 14
|David Wagner
|Derived Quot Schemes
|March 21
|Mao Li
|D modules in prime characteristic
|March 28
|Spring break
|April 4
|Rachel Davis
|Introduction to Grothendieck's dessins d'enfants
|April 11
|Brandon Boggess
|Néron models of elliptic curves
|April 18
|Soumya Sankar
|Modular forms over arbitrary rings
|April 25
|Solly Parenti
|The Theory of Heights and the Height of Theories
|May 2
|No talk today
|Keith Rush is giving a talk at the same time
February 14
|Moisés Herradón Cueto
|Title: Fun with commutative groups
My goal is to next week talk about Gerard Laumon's preprint Transformation de Fourier généralisée, which will encapsulate all the Fourier transforms I can name (which for me includes the Fourier transform for D-modules on affine space, the Mellin transform, the Fourier-Mukai transform for abelian varieties and the rare John Mahoney transform between modules on the punctured line and vector spaces with a Z-action) into one crazy package.
In order to achieve this altered mental state, we will have to rethink all our preconceptions, and rediscover algebraic groups, make sense of Cartier duality for them, define formal groups along the way, and see how duality of Abelian varieties relates to Cartier duality. If you come to the talk in an already in this altered mental state, then hopefully I'll do some examples that you've been too lazy to work out for yourself.
February 21
|[math]\displaystyle{ \mathcal F }[/math]un with commutative groups
|Title: [math]\displaystyle{ \mathcal F }[/math]un with commutative groups
I will talk about how last week's Cartier duality relates to duality for abelian varieties. Then we will see how this allows us to take certain complexes of groups which are self dual, going back to altered mental states which are now derived.
If we're going to Fourier transform something, it should be a sheaf, but what is even a sheaf on a complex of groups? Once we see what it should be, I will handwave what the Fourier transform is and give a bunch of concrete examples.
February 28
|Dima Arinkin
|Title: ODEs: algebraic vs analytic vs formal
Linear ordinary differential equations (or, as they are known geometrically, bundles with connections on Riemann surfaces) can be studied from many directions. In algebraic geometry, the goal is to classify equations rather than to solve them. The classification can be done in different settings: algebraic, analytic, or formal; each setting has its advantages and disadvantages. However, for one of the most important class of equations (equations with regular singularities aka Fuchsian equations) the three approaches agree, leading to a rich and beautiful picture.
In my talk, I will sketch the algebraic theory of differential equations, focusing on equations with regular singularities. (I do not expect to have time for irregular singularities.) The talk is related to my topics course on D-modules, but it does not rely on the topics course.
March 7
|Vladimir Sotirov
|Title: Topology of Affine Schemes
I will explain in what sense flat morphisms of (affine) schemes are the correct analogue of open maps of topological spaces, and then use that to explain how surjectivity in the sense of Zariski spectra corresponds to surjectivity of functors of points.
March 14
|David Wagner
|Title: Derived Quot Schemes
The titular paper of Ciocan-Fontanine & Kapranov constructs a "derived" version of Grothendieck's Quot scheme, whose degree zero truncation is the ordinary Quot scheme, and whose tangent space at each k-point consists higher Ext's. In this talk, we will talk about what is meant by "derived" in modern AG and why you might want a derived Quot scheme. In the remaining time, we will give a (hopefully transparent) description of how CF&K construct RQuot.
March 21
|Mao Li
|Title: D-modules in prime characteristic
The usual theory of D-modules concerns itself with sheaves and varieties over complex numbers. In this talk I'm going to consider its characteristic p analogue. The new feature is that the ring of differential operators has a large center. By using this extra information we can give a more precise description about the ring of differential operators, namely it has a canonical structure of an Azumaya algebra over the twisted cotangent bundle. This has lots of applications in algebraic geometry and representation theory.
April 4
|Rachel Davis
|Introduction to Grothendieck's dessins d'enfants
In 1978 Belyĭ first announced the following theorem: every algebraic curve defined over a fixed algebraic closure of the rationals can be represented as a covering of the projective line ramified over at most three points. Deligne then studied the fundamental group of the projective line minus three points. Grothendieck introduced combinatorial structures called dessins d'enfants. One consequence of Belyĭ's theorem is that the Galois action on the fundamental group of the projective line minus three points is faithful.
April 11
|Brandon Boggess
|Title: Néron models of elliptic curves
We will attempt to do algebraic geometry over the integers. Doing this for elliptic curves will lead us to the idea of Néron models, and we will see how to get our hands on these guys explicitly.
April 18
|Soumya Sankar
|Title: Modular forms over arbitrary rings
One way to understand moduli spaces of elliptic curves and related moduli problems better, is to study modular forms. With this in mind, I will define modular forms over arbitrary rings in the sense of Katz. I will also talk about p-adic modular forms in the sense of Serre and hopefully motivate the modern treatment of such modular forms.
April 25
|Solly Parenti
|Title: The Theory of Heights and the Height of Theories
I will talk about some of the different notions of height in arithmetic geometry, starting from the most naive, ending at some betterer ones.


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Friday, May 11, 2007
Piyajkolir Tarkari
Little S knows all about Mothers Day. By "about" I don't mean the history or the Hall Mark-ing of it but she knows there is a day like this when you are supposed to give your Mom cards etc. before you throw the usual tantrum. When she was 16 months, it was my first Mother's Day as a Mom and D took her to get me a card and Mom's Day gift. I got a funny card with a mirror and a dangly sparkly kind of bracelet in some abstract color which is not something I take to wearing. When I asked D why he got that thing, he said because S pointed it out!!! So last year I took it upon myself to get me something sensible crediting the money spent and joy of gift giving to D of course. The most precious thing though was the card little S made in school for Mother's day.
Since S is a 3 year old now with much more sense and I am a lover of good gifts, I was dreaming that maybe she will point out to the dazzling ruby and diamond bracelet or the Coach handbag at Macy's when D takes her to buy the Mom's Day gift instead of pointing to some arbitrary stuff .
So yesterday I told S with a lot of enthu – "You know Mothers Day is this month"
She said – "Oh when is it?" (In Bengali she said "Kobe re?" with the right inflection)
So I showed her the calendar and the day and asked her – "What do you want to do on the day?"
She flung her small soft arms around me and said "I want to hug you" !!!
Holding her tightly the commercialized Mom in me said " What else ?"
She said " It will be your holiday so you won't have work and I want to sit in your lap all day"
I was ashamed, yeah downright ashamed. While I was thinking of gifts all this tiny creature wanted was to love me and be with me. Amidst all the days work its true that I don't always get time to be just with her. So even when I am physically around and it may seem I am spending time with her, I am multitasking and feeding her while chopping veggies or sneaking a peek at the blogs while talking to her. I don't really just sit with her for long. Even if I do for a little while I am prone to say " Chal chal anek kaj ache" (Let's get going I have lots to do). Soon she will grow up and this is not what she will want from me. So as long as she asks for it maybe I should set aside my chores and just sit and enjoy and smell the freshness of her innocence. (Ok it may not work out as beautiful as it sounds because this 3 year old is an active imp and before long you may see me panting and gasping for air, a far cry from "smelling innocence" but at least I should make an effort)
I was never a fan of Valentines Day, but I liked Mothers Day since even being far I would send my Mother small gifts which I thought showed my love for her and it also meant "one more occasion" to get some loot for myself. But maybe even all my Mom wanted was just to be with me (or maybe she preferred the gifts which were more useful than the adult me , I never asked)
So between my Mother and my little daughter was I the one caught in the Hall Mark warp, totally discounting the actual essence of the day and concentrating on the screaming Mothers Day Sale banners instead.
To change my attitude this year I asked D to not get me a gift for Mother's Day, instead if the weather is good we will pack a lunch and have a "picnic" somewhere and enjoy the day as it comes
(D if you are reading this, you can give me gift on all other occasions, do not take this to your benefit. I am thinking of the child here remember !!!)
Happy Mother's Day to my Ma who has always been a good friend, has helped me through all my growing years including my studies, stood by me when I wanted to take up job in another city, stood by me in most of my life's decisions and done for me a lot more that I can ever imagine doing for her. I really feel bad that being far I am not really able to do for her as I should have as a grown up daughter in their day to day life. But she doesn't complain and neither expects anything from me. Hope to be a similar mother for S to be happy in her happiness and not expect much....
Happy Mothers Day to myself and to all Moms out there
(This post shared with Desi Momz Club)
Piyajkoli Or Scallion/Green Onion/Spring Onion is used to make this very simple typically Bengali dish. Tempered with Kalo Jeera/kalonji, a very common spice used for tempering in Bengali cooking, and Green Chillies this is one of the quick dry dishes you would make on a week day to go with chapati at dinner or packed with roti for next days lunch.Me the Rice lover, loves it with White Rice too. The shrimps add a festive touch to this and since I love shrimps I almost always add shrimps to this dish.
This goes to Nupur for "A - Z of Indian Vegetables" for this week's P -- Piyajkoli'r Tarkari a dry dish made with Scallion, Potatoes and Shrimp
Read more...
What You Need
Scallion or Green Onion (known as piyajkoli in Bengali) ~ 4 bunches chopped small (as shown in pic)
Potatoes ~ 3 medium sized peeled and cubed as shown in pic
Green Chillies ~ 4-5 slit
Shrimp ~ ½ cup. I used frozen medium shrimp. You can use fresh smaller shrimps or even salad shrimps
Kalo Jeera/Kalonji/ Nigella Seeds ~ 1 tsp
Turmeric Powder ~ ½ tsp
Red Chilli Powder ~ 1/2 tsp or according to tatse. I do not add this usually
How I Did It
Defrost shrimp if frozen else wash and clean. Sprinkle little turmeric powder and salt on the shrimp and leave it aside for 15-20 minutes
Wash and chop the scallions and potatoes
Heat Oil in a Kadhai/Frying Pan
Lightly fry the shrimp till they are golden. Remove them and keep aside
In the same oil sauté the potato cubes till they acquire a hint of golden. Remove and keep aside
In the same oil (liitle more oil needs to be added by this point) add kalo jeera/kalonji and green chillies for tempering
Add the chopped scallion and sauté
Lightly fry till the scallion wilts.
Add the lightly sauted potatoes and mix well
Add ¼ tsp of turmeric powder, salt and sprinkle a little water if necessary. Add Red Chilli Powder if you wish
Cover and cook till done. Don't cover and let it burn, since there is very little water you need to stir this often.Don't worry doesn't take long
Add the fried shrimps and mix well. Cook for a couple of minutes and you are done
This will be a dry dish and enjoy with Chapati or White Rice as a part of your everyday meal
Note: As one of my readers mentioned, instead of frying the potatoes as a separete step you can add the potatoes after tempering the oil with Kalonji and Green Chillies. Saute the potatoes and add the chopped scallions and cover and cook as the next steps indicate.
Remember to wash your bunch of scallions well when you bring them in fresh and for storing and chopping information check here
Trivia:The words scallion and shallot are related and can be traced back to the Greek askolonion as described by the Greek writer Theophrastus
43 comments:
This sounds simple enough for a novice like me to try...will let u know how it turns out once i have tried it....Meanwhile, have a great Mother's day.....Hallmark or no Hallmark!!! :)ReplyDelete
Sandeepa, silly me, but my eyes are misting.....Lil' S indeed has grown up, from getting those shiny bracelets to hugs.....hugs, something one can't have enough of.....sorry, if i sound mumbling here. something in your post touched me.....hugs to you both :).ReplyDelete
Lovely recipe. I am gonna' make it tomorrow. i bought some spring onions today!
Great piece, beautiful photos! Soon, it'll be the li'l one asking you for the diamonds and the Pradas!ReplyDelete
That gesture would have made you so proud!!!! :) Its wonderfully written! :)ReplyDelete
Loved the recipies as well! :) Nice and simple
Funny and touching at the same time. Happy Mother's Day to you! Give S a Hug for me. May it be diamonds this year.ReplyDelete
Dish looks super simple but tasty. Adding shrimp to vegetables does not come naturally to me but the whole family loves shrimp, will give this a try.
- AnonymousMay 12, 2007 8:47 AM
Lovely write up on Mother's Day, San! It was touching to read about what little S wanted to do on Mother's Day. Out of the mouths of babes come the most profound things sometimes! What a sweet little angel she is! Alright, an angelic imp! :)ReplyDelete
The recipe is so simple and looks delicious!
Happy Mother's Day, San! Hugs to you and little S!
Have fun Sandeepa,Diamonds are little too much but a hug and a kiss and a card is always welcome,right?:))ReplyDelete
Dish is simple and looks delish,I will have to skip the Shrimps.Thanks.
lil S is such asweet heart , My lil one also seeks attention in which ever way possible for her ,
enjoy the day with her .
i love the dish without shrimp ...
hugs and smiles
Sandeepa, whenever I read about li'l S(whom i want to meet very badly)I always feel that she is quite matured and intelligent for her age, I dont see kids at her age with so much of intelligence, asking for hugs and time with her mom as a gift !...no, no I'm not casting an eye on her...just sharing my observation thru ur writings....MY HUGS to li'l S and the big S :) Beautiful notes !ReplyDelete
And one more thing I noticed about the cooking is, shrimp is so part of your cooking, isn't it?
Hope you get to go for a picnic and enjoy the Mother's Day !
ohhh Sandeepa, little S is absolutely an angel... a clever one at that.... Another beautiful post from you... I liked the subtext for D after you declared you don't want a gift for mother's day :DReplyDelete
Have a fun picnic with your beautiful family , Happy Mother's Day to you!
What a delightful post! I love how your blog is becoming a collection of vignettes from your little girl's childhood...little moments that are too precious to be forgotten.ReplyDelete
Such a touching post on Mothers and mothering. I am moved...ReplyDelete
As to the dish, I use green onions almost daily. I love the combo you used: green onions, shrimp and potatoes.
Yeah it indeed is simple and very typical like a Bong quick sabzi
Thank you, you are such a sweet person
Please please no!!! if she asks, I know what to say now ;-)
She is still small you know
Happy Mothers Day to you too. No diamonds for sure :)
I am a shrimp lover try tossing it in everything but because D has a higher cholesterol, he avoids them
Thanks and Happy Mother Day to you too with lovely M
Yeah, a kiss a small gift a hug a kiss everything will do :) S already gave me a card she made at school and Monday I will go for a Mothers Day Tea at her school gain
At this age kids want a lot of attention, you are right. My ma also does not add shrimp
Thanks and S is a sweet kid indeed. But she does not ask for hugs etc. when I ask "What she wants as a gift?" (intelligent, right ?) Though even then she aks for small things like an Yo-yo last year. You know kids are innocent at this age
And shrimp -- same as I told Indo
Yeah you know I don't want him to take it to heart ;-)
You are right. I wanted a separete blog but that's too much of a effort so I try combining when ever appropriate
Try it, its a very simple and a pretty quick dish
Sandepa, isn't it amazing how kids tend to spring surprises when you least expect them to...you don't think they will observe certain things...hugs to you and your little one and spend the day in a special way...ReplyDelete
Sandeepa, little S seems to have the real spirit of Mother's Day. That is so sweet. Have a wonderful Mother's Day. Piyarkolir tarkari shrimp diye... yummy.ReplyDelete
- AnonymousMay 13, 2007 12:54 PM
sandeepa, happy mother's day!! that is so touching. little S is a cutie. when i asked today what my little 'M' is going to give me? she told me that 'i am present'. at 3 they are the most innocent in the world.ReplyDelete
i have never heard of this dish. looks very authentic. my mom makes a kerala thoran with spring onions.
i felt the exact same thing when i sent her a bouquet this year. Now all I want is to BE there with her on this wonderful day. Though am not a mom I can truly relate to what u feel. But do u think we would have been able to realise this but for our children. My mom always used to say "U vl understand when u get a child".. Guess u got to understand that.. BTW, I had trouble spelling the name (Piya.. what) for a while :DReplyDelete
Wow, everything lil one talks with innocence and love makes everything beautiful around us. My hugs for both u and "s". minus shrimp, will be my platter:). Nice picture and happy mothers day.ReplyDelete
- AnonymousMay 13, 2007 6:57 PM
That has been such a touching story. I agree that sometimes there is a guilt to leave your child in child care and missing on her little silly beautiful acts..At work you think of them and at home you think of all the chores...It has been so sweet of little S to remind all of us "All what is needed is Love and care". She is a little Angel...ReplyDelete
Happy Mothers day to you dear Sandeepa. Wishing you loads of fun on your picnic..
- AnonymousMay 13, 2007 8:05 PM
great post...really lovely...great recipe as always...I am learning all about regional names and dishes...its great...thanks for sharingReplyDelete
sandeepa, its so cute and very nice writeup! the dish looks good ofcourse will skip the shrimps:)ReplyDelete
oh sandeepa.... girl.. u made me so emotinal and i am right here in my office with tears in my eyes.... beautiful post... and a big hug to little S and big S:) hope u had good time with one another:) i am lost for words!!! donno what else to day...ReplyDelete
oh!!! just forgot to thank u for ur concern sandeepa:) my ankle is much better now. its healed 90% :)ReplyDelete
Sandeepa - tomar comment dekhlam. muffin-e 2 tbspoon butter diye chilam. post update kore diyechi.ReplyDelete
Hi....Ur dish is simple and elegant...i love it...Nice pictures...ReplyDelete
lovely Post . you must be so proud of your lil darling. She has made your day.ReplyDelete
BTW loved your recipe too. good one for "p"
Sunita, Mandira, Reena, Shivapriya, sushma, DilipJi, Roopa, Supriya, SharmiReplyDelete
Thanks all of you. I did have a great relaxing time yesterday and today was a Mothers Day Tea at S's daycare/pre-school which I thoroughly enjoyed
Thanks to all of you dear friends
Thanks I am going to make it this week
Does it remind you of "Piya , Piya " ;-)
hope you had a great day with your darling daughter, sandeepa. what a sweetheart she is.ReplyDelete
Hugs, hugs and more of the tight hugs was our way of spending the Mother's Day too. Hugs to Lil S for growing up fast. On the Pneyajkoli front, my mouth is watering, as I am yet to visit the good old Chittaranjan Park this month, the Bengali hub for fish, Bong veggies, spices, sweets, pickles, bori, aamshatwo, magazines....... in Delhi NCR. As a variation you can try not frying both pneyajkoli and alu separately and use a saute, cover, stir process. It comes as less soggy.Once done add fried shrimps/ kucho chingri as you want.
Hey, belated Mothers day wishes to you!!! I'm sure you had a wonderful time... You have a lovely blog!! This dish looks really good!! Its appetizing even for a veggie like me!! :))ReplyDelete
Happy Belated mother's day sandeepa ...too good on the write up man .....i have spring onions with me today ...i am going to try it with shrimp..bec i am pure veg person ...thks a lot ..a small hug to ur cute little one ....ReplyDelete
- AnonymousMay 15, 2007 12:09 PM
you have put down my thoughts in writing so beautifully. At this age they ask for nothing more than our time, and unfortunately, we tend to multi-task at any given time of the day. Oh well,
BTW...just spotted an error. At her 16 months, it must have been your 2nd mother's day as a mom:)
Thanks :)
Bong WM
You are right about the piyajkoli. I do it your way most of the time but I always thought that saved time and did not realize that keeps it more crunchy
Ramya and deepa
At 4/5 months it was indeed my first Mothers Day but since S was too small and not involved in the card giving I consider the 16 months as the real one
hey this is a nice dish with spring onion, i see you do not add any kind of masala pwd :) will try it without the shrimp.ReplyDelete
- AnonymousMay 15, 2007 10:54 PM
hello SandeepaReplyDelete
lovely recipe.thanks for sharing. i started blogging recently. u can visit my blog at www.spiceweb.blogspot.com
I don't know how I missed this blog!! Beautiful writing...loved it!ReplyDelete
Will be checking in here often :)
Your child is sooo sweet Sandeepa! What a sweet gift for Mothers Day!! A hug to lil S for that!!ReplyDelete
Spring onions and shrimp...hmm, I'll think abt that!
Sandeepa, you took me straight to my mom-in-law's kitchen with the smell of your piyajkolir tarkari! Very good blog. I wanted to become a member of DMC. What do I do? Belated Happy Mother's Day!ReplyDelete
ur daughter is a cutie.. maybe she read ur valentines's post and decided that her mom doesn't like commercialised gifts.have fun!ReplyDelete
- AnonymousMay 17, 2007 6:59 PM
Hi Sandeepa, I'm late in coming to this one, but what a lovely, touching post. I often have the same feeling about my own kids, even at their older ages. Always hurrying from this to that, when what they want the most even now is my *time*. Hope you had a lovely picnic for Mother's Day :)ReplyDelete
Many of the typical Bengali dry sabzis do not use any masala powder other than the spice for tempering. On the same lines we make a Cauliflower-Potato dr sabzi too, minus shrimps
Shall check your blog soon
Thanks for dropping by
Jyothsna and Sogno
Don't give her any more ideas :)
And I though things will get better here after
Hey Sandeepa, as i promised, am here to convey my thanx...I tried the piyajkolir tarkari and it turned out yum!!! hope u have been doing well..waiting for ur new post!!! :)ReplyDelete
wanted to say a hi and inform u that this weekend, I tried out red thai curry (with shrimps) from your blog and it turned out really nice...thank u :)ReplyDelete