Optimizing lymphadenectomy in laparoscopic surgery for colon cancer

Abstract

Complete tumor resection (R0) for stages I to III, if feasible, has been essential as the basis of multimodal treatment of solid cancer [1–5]. However, the adequate extent of lymph node dissection for solid tumors, including colorectal cancer (CRC), has not been established to date [6–14]. Over recent decades there have been two main treatment trends. The first trend considers an appropriate lymphadenectomy to be an important part of an R0 resection. The main argument is that local and nodal control is important not only for recurrence-free survival but also for overall survival. Such lymphadenectomy requires resection and examination of at least 12 lymph nodes CRC [6]. The National Quality Forum has endorsed the examination of at least 12 lymph nodes for patients undergoing colon cancer surgery as a means of improving staging and survival. Using data from the National Cancer Data Base, researchers have shown that patient survival increases when 12 or more nodes are examined [6]. The second trend contends that the number of lymph nodes harvested does not have an impact on survival. In a retrospective cohort study using the national Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database (1995–2005), the data for 30,625 U.S. patients undergoing colectomy for nonmetastatic colon cancer were analyzed. Emphasis was given to whether more or less than 12 lymph nodes were examined. Wong et al. [7] concluded that the number of lymph nodes hospitals examine after colectomy for colon cancer is not associated with staging, use of adjuvant chemotherapy, or patient survival. These too large retrospective contrasting studies reemphasize that well-designed, randomized, phase III, controlled trials are important in the approach to the truth. Until high-quality evidence becomes available, a R0 resection, including the resection of metastatic lymph nodes, via surgical endoscopy appears to be a rational approach to the prevention of nodal recurrence. Can laparoscopic surgery result in such a quality R0 surgery with adequate lymphadenectomy? To highlight this issue, El-Gazzaz et al. [15] report in a recent issue of Surgical Endoscopy the number of lymph nodes harvested after laparoscopic and open colorectal cancer resections. Of the 729 patients who underwent surgical resection with curative intent between 1996 and 2007, 243 patients had laparoscopic surgery, and 486 had open surgery. The number of nodes harvested did not differ significantly between laparoscopic and open surgery. In this retrospective study, the mean number of lymph nodes retrieved and examined was high: 24.8 ± 20.6 per patient. The lymph nodes obtained were twice the number recently recommended, reflecting the quality of laparoscopic surgery. Although no conclusion can be drawn from the study whether this appropriate lymphadenectomy may provide a survival benefit, it reflects a rational approach accepted by most surgeons. Laparoscopic colectomy has become the standard of care for colon cancer patients with potentially curable disease (stages I to III). To achieve optimal R0 resection, metastatic lymph nodes also should be removed. Given that preoperative or operative nodal staging is inaccurate in distinguishing node-positive from node-negative disease, a standardized lymphadenectomy determined by more than 12 lymph nodes harvested appears to be beneficial for patients with node-positive colon cancer. This surgical approach is adequate for local and nodal control C. Hottenrott (&) St. Elisabethenkrankenhaus, Chirurgische Klinik, Frankfurt, Germany e-mail: info@gastricbreastcancer.com