Article

Understanding Optimal Colonic Cancer Surgery: Comparison of Japanese D3 Resection and European Complete Mesocolic Excision With Central Vascular Ligation

Leeds Institute of Molecular Medicine, Leeds, United Kingdom.
Journal of Clinical Oncology (Impact Factor: 18.43). 04/2012; 30(15):1763-9. DOI: 10.1200/JCO.2011.38.3992
Source: PubMed

ABSTRACT

Over recent years, patient outcomes after colon cancer resection have not improved to the same degree as for rectal cancer. Japanese D3 resection and European complete mesocolic excision (CME) with central vascular ligation (CVL) are both based on sound oncologic principles. Expert surgeons using both techniques report impressive outcomes as compared with standard surgery. We aimed to independently compare the physical appearances and quality of specimens resected using both techniques in major institutions in Japan and Germany.
A series of resections for primary colon cancer from one European and two Japanese centers were independently assessed in terms of the plane of surgery, physical characteristics, and lymph node yields.
Mesocolic plane resection rates from both series were high; however, Japanese D3 specimens were significantly shorter (162 v 324 mm, P < .001), resulting in a smaller amount of mesentery (8,309 v 17,957 mm(2), P < .001) and nodal yield (median, 18 v 32, P < .001). The distance from the high vascular tie to the bowel wall (100 v 99 mm, P = .605) was equivalent.
Both techniques showed high mesocolic plane resection rates and long distances between the high tie and the bowel wall. The extended longitudinal resection after CME with CVL increased the nodal yield but did not increase the number of tumor involved nodes. Both series were oncologically superior to recently reported series from other countries and confirm the wide variation in colonic cancer surgery and the need for further standardization and optimization following the approach undertaken in improving rectal cancer outcomes.

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    • "We demonstrate that patients with low CD8i infiltration in the biopsy are at high risk of transmurally invasive primary tumors with lymphovascular invasion, spread to local lymph nodes and formation of tumor deposits in the pericolic tissue. In colon cancer, extensive lymph node removal by resection in the mesocolonic plane should be advocated to reduce the relative risk of tumor recurrence and improve long term survival for these patients [27-29]. In rectal cancer, pre-operative staging has profound therapeutic implications. "
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    ABSTRACT: Background and aims: Reliable prognostic markers based on biopsy specimens of colorectal cancer (CRC) are currently missing. We hypothesize that assessment of T-cell infiltration in biopsies of CRC may predict patient survival and TNM-stage before surgery. Pre-operative biopsies and matched resection specimens from 130 CRC patients treated from 2002-2011 were included in this study. Whole tissue sections of biopsy material and primary tumors were immunostained for pancytokeratin and CD8 or CD45RO. Stromal (s) and intraepithelial (i) T-cell infiltrates were analyzed for prediction of patient survival as well as clinical and pathological TNM-stage of the primary tumor. CD8 T-cell infiltration in the preoperative biopsy was significantly associated with favorable overall survival (CD8i p = 0.0026; CD8s p = 0.0053) in patients with primary CRC independently of TNM-stage and postoperative therapy (HR [CD8i] = 0.55 (95%CI: 0.36-0.82), p = 0.0038; HR [CD8s] = 0.72 (95%CI: 0.57-0.9), p = 0.0049). High numbers of CD8i in the biopsy predicted earlier pT-stage (p < 0.0001) as well as absence of nodal metastasis (p = 0.0015), tumor deposits (p = 0.0117), lymphatic (p = 0.008) and venous invasion (p = 0.0433) in the primary tumor. Infiltration by CD45ROs cells was independently associated with longer survival (HR = 0.76 (95%CI: 0.61-0.96), p = 0.0231) and predicted absence of venous invasion (p = 0.0025). CD8 counts were positively correlated between biopsies and the primary tumor (r = 0.42; p < 0.0001) and were reproducible between observers (ICC [CD8i] = 0.95, ICC [CD8s] = 0.75). For CD45RO, reproducibility was poor to moderate (ICC [CD45i] = 0.16, ICC [CD45s] = 0.49) and correlation with immune infiltration in the primary tumor was fair and non-significant (r[CD45s] = 0.16; p = 0.2864). For both markers, no significant relationship was observed with radiographic T-stage, N-stage or M-stage, indicating that assessment of T-cells in biopsy material can add additional information to clinical staging in the pre-operative setting. T-cell infiltration in pre-operative biopsy specimens of CRC is an independent favorable prognostic factor and strongly correlates with absence of nodal metastasis in the resection specimen. Quantification of CD8i is highly reproducible and allows superior prediction of clinicopathological features as compared to CD45RO. The assessment of CD8i infiltration in biopsies is recommended for prospective investigation.
    Full-text · Article · Mar 2014 · Journal of Translational Medicine
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    • "More than 12 lymph nodes were dissected in all cases except 3. The mean length of the resected specimen was also acceptable, with adequate tumor-free distal and proximal surgical margins. Oncologic resection with meticulous mesocolic dissection and optimal lymph node clearance may improve oncologic outcomes [9, 10]. The embryologic tissue planes must be respected to minimize the likelihood of cancer recurrence, and true central ligation of the lymphatic drainage maximizes regional lymph node harvest [11]. "
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    ABSTRACT: Single-site laparoscopic colectomy (SLC) is an emerging concept that, compared with conventional multiport laparoscopic colectomy (MLC), yields reduced postoperative pain and improved cosmesis. Complete mesocolic excision (CME) is a novel concept for colon cancer surgery that provides improved oncologic outcomes; however, there are no reports of SLC with CME. We conducted a prospective case-control study to evaluate the feasibility and safety of SLC with CME for colon cancer. Prospectively collected data of patients with stage I-III colon cancer who underwent SLC (n = 150) or MLC (n = 150) between June 2008 and March 2012 were analyzed. Patients who underwent SLC were, in terms of clinical characteristics and tumor location, matched as closely as possible with those undergoing MLC. Within each group, patients were classified as having right-sided (n = 69 in each group) or left-sided (n = 81 in each group) colon cancer, and short-term outcomes were compared between the two procedures overall and per side. Overall perioperative outcomes, including operation time, blood loss, number of lymph nodes harvested, length of the resected specimen, and complications, were similar between the two procedures, whereas postoperative pain was significantly lower with SLC. Operation time for right-sided SLC was significantly shortened. SLC with CME was completed successfully in 94 % (65/69) of right-sided cases and in 88 % (71/81) of left-sided cases. Conversion rates were 1.4 % (1/69) and 1.1 % (1/81), respectively. The umbilical scars were nearly invisible 3 months after the procedure, and most patients reported being quite satisfied with the cosmetic outcomes. SLC with CME for colon cancer is feasible when performed by experienced surgeons in selected patients. Excellent cosmesis and reduced postoperative pain as well as oncologic clearance can be expected. A large-scale, prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over MLC with CME.
    Full-text · Article · Nov 2013 · Surgical Endoscopy
    • "CME includes more mesentery than the more common standard D2 resection[1,2]. In order to document such a radical approach, the length and area of the excised mesentery may be measured or the number of lymph nodes retrieved may act as a surrogate measure of radical surgery[3]. The survival benefit of a large lymph node harvest has been shown in several reports[1,4,5]. "
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    ABSTRACT: Background: Complete mesocolic excision (CME) and a high (apical) vascular tie may improve oncologic outcome after surgery for colon cancer. Our primary aim was to emulate a previous national result of 73.8% overall survival (OS) with both the open and laparoscopic techniques. Methods: A prospective study of radical colon cancer was initiated in a Norwegian community teaching hospital in 2007 and comprised a consecutive group of 251 patients with TNM stages I-III that had surgery according to the CME principle. Oncological outcome was assessed as OS, disease-free survival (DFS) and cancer-specific survival (CSS), as well as time to recurrence (TTR), using Cox regression analysis. Results: In-hospital mortality was 3.6%, 2.3% for laparoscopic surgery and 4.9% for open management. Significantly more patients in the open CME group developed complications in the short term (p < 0.001). Twelve or more lymph nodes were retrieved from 82.9% (208/251) of the specimens. Overall 3-year OS was 84.5%, DFS 77.4%, CSS 91.5% and TTR 86.8%. The surgical approach was not a significant predictor for any of the survival parameters. Conclusions: There was no survival difference between open and laparoscopic CME colonic resections, and the present OS improved from a previous OS from 2000.
    No preview · Article · Sep 2013 · Digestive surgery
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