Abstract
No one doubts that lymph node dissection in colon cancer is necessary, it is just the extent of that dissection that is still under debate. As the individual steps of an oncologic operation cannot be separated from each other, analysis of the significance of lymph node dissection alone is difficult. It has been proven that the T category is directly related to the number and central spread of lymph node metastases. Micrometastases and isolated tumor cells may be detected in lymph nodes by using special staining techniques; their presence may worsen prognosis significantly and approximate it to UICC stage III. The numbers of dissected lymph nodes and the ratio of involved versus dissected lymph nodes have been used as markers for quality of surgery and histopathological evaluation. Recent results underscore the importance of technique and extent of dissection. Dissection must be performed along the embryologic planes of the mesocolon and leave them intact. A high vascular tie with preservation of the central hypogastric nerves must be applied in order to achieve the best oncologic results while preserving quality of life. Extended lymphadenectomy is oncologically relevant only when it is combined with removal of the primary tumor with adequate longitudinal clearance, an intact complete mesocolon, and high vascular tie. It is part of a concept in which the tumor-bearing specimen is harvested as an enveloped package to minimize the risk of tumor cell spillage and local recurrence.
Similar content being viewed by others
References
West NP, Hohenberger W, Weber K et al (2010) Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol 28:272–278
Moynihan BG (1908) The surgical treatment of cancer of the sigmoid flexure and rectum with especial reference to the principles to be observed. Surg Gynecol Obstet 6:463
Dubecz A, Solymosi N, Schweigert M et al (2013) Time trends and disparities in lymphadenectomy for gastrointestinal cancer in the United States: a population-based analysis of 326, 243 patients. J Gastrointest Surg 17(4):611–618 discussion 618-619
Croner RS, Merkel S, Papadopoulos T et al (2009) Multivisceral resection for colon carcinoma. Dis Colon Rectum 52:1381–1386
Heald RJ (1988) The ‘holy plane’ of rectal surgery. J R Soc Med 81:503–508
Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1(8496):1479–1482
Hohenberger W, Weber K, Matzel K et al (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation—technical notes and outcome. Colorectal Dis 11:354–365
Quirke P, Durdey P, Dixon MF et al (1986) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet 2:996–999
Quirke P, Steele R, Monson J et al (2009) Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 373:821–828
West N (2010) Lymph node retrieval in colorectal cancer specimens: national standards are achievable, and low numbers are associated with reduced survival. Colorectal Dis 12:309–311
West NP, Morris EJ, Retime O et al (2008) Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol 9:857–865
Moertel CG, Fleming TR, Macdonald JS et al (1990) Levamisole and fluorouracil for adjuvant therapy of resected colon carcinoma. N Engl J Med 322:352–358
Påhlman L, Glimelius B (1990) Pre- or postoperative radiotherapy in rectal and rectosigmoid carcinoma. Report from a randomized multicenter trial. Ann Surg 211:187–195
Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740
Schmiegel W, Reinacher-Schick A, Arnold D et al (2008) Update S3-guideline “colorectal cancer” 2008. Z Gastroenterol 46:799–840
Hermanek P (2000) Lymph nodes and malignant tumors. Zentralbl Chir 125:790–795
Quirke P, Morris EJ (2007) Reporting colorectal cancer. Histopathology 50:103–112
Kaplan RN, Rafii S, Lyden D (2006) Preparing the “soil”: the premetastatic niche. Cancer Res 66(23):11089–11093
Oppenheimer SB (2006) Cellular basis of cancer metastasis: a review of fundamentals and new advances. Acta Histochem 108(5):327–334
Laubert T, Habermann JK, Hemmelmann C et al (2012) Metachronous metastasis- and survival-analysis show prognostic importance of lymphadenectomy for colon carcinomas. BMC Gastroenterol 12:24
Bruch HP, Schwandner O, Schiedeck TH et al (1999) Actual standards and controversies on operative technique and lymph-node dissection in colorectal cancer. Langenbecks Arch Surg 384:167–175
Hermanek P, Mansmann U, Staimmer D et al (2000) The German experience. The surgeon as a prognostic factor in colon and rectl cancer surgery. Surg Oncol Clin N Am 9:33–49
Hermanek P, Wiebelt H, Staimmer D et al (1995) Prognostic factors of rectum carcinoma—experience of the German Multicentre Study SGCRC. German Study Group colo-rectal carcinoma. Tumori 81(3 Suppl):60–64
Kessler H, Hermanek P (1998) Outcomes in rectal cancer surgery are directly related to technical factors. Semin Colon Rectal Surg 9:247–253
Kessler H, Mansmann U, Hermanek P Jr, Riedl S, Staimmer D, Hermanek P for the Study Group Colo-Rectal Carcinoma (SGCRC) (1998) Semin Colon Rectal Surg 9(4):233–240
West NP, Sutton KM, Ingeholm P et al (2010) Improving the quality of colon cancer surgery through a surgical education program. Dis Colon Rectum 53:1594–1603
Kube R, Ptok H, Wolff S et al (2009) Quality of medical care in colorectal cancer in Germany. Onkologie 32:25–29
Haboubi N (2009) Colonic surgery for cancer: a new paradigm. Colorectal Dis 11:333–334
Chang GJ, Rodriguez-Bigas MA, Skibber JM et al (2007) Lymph node evaluation and survival after curative resection of colon cancer: systematic review. J Natl Cancer Inst 99:433–441
Le Voyer TE, Sigurdson ER, Hanlon AL et al (2003) Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 21:2912–2919
Rosenberg R, Engel J, Bruns C et al (2010) The prognostic value of lymph node ratio in a population-based collective of colorectal cancer patients. Ann Surg 251:1070–1078
Tsai HL, Lu CH, Hsieh JS et al (2007) The prognostic significance of total lymph node harvest in patients with T2–4N0M0 colorectal cancer. J Gastrointest Surg 11:660–665
Chok KS, Law WL (2007) Prognostic factors affecting survival and recurrence of patients with pT1 and pT2 colorectal cancer. World J Surg 31:1485–1490. doi:10.1007/s00268-007-9089-0
Chen SL, Bilchik AJ (2006) More extensive nodal dissection improves survival for stages I–III of colon cancer: a population-based study. Ann Surg 244:602–610
Johnson PM, Porter GA, Ricciardi R et al (2006) Increasing negative lymph node count is independently associated with improved long-term survival in stage IIIB and IIIC colon cancer. J Clin Oncol 24:3570–3575
Kotake K, Honjo S, Sugihara K et al (2012) Number of lymph nodes retrieved is an important determinant of survival of patients with stage II and stage III colorectal cancer. Jpn J Clin Oncol 42(1):29–35
Sjo OH, Merok MA, Svindland A et al (2012) Prognostic impact of lymph node harvest and lymph node ratio in patients with colon cancer. Dis Colon Rectum 55:307–315
Hashiguchi Y, Hase K, Ueno H et al (2010) Prognostic significance of the number of lymph nodes examined in colon cancer surgery: clinical application beyond simple measurement. Ann Surg 251:872–881
Peschaud F, Benoist S, Julié C et al (2008) The ratio of metastatic to examined lymph nodes is a powerful independent prognostic factor in rectal cancer. Ann Surg 248:1067–1073
Ceelen W, Van Nieuwenhove Y, Pattyn P (2010) Prognostic value of the lymph node ratio in stage III colorectal cancer: a systematic review. Ann Surg Oncol 17:2847–2855
Edler D, Ohrling K, Hallström M et al (2007) The number of analyzed lymph nodes–a prognostic factor in colorectal cancer. Acta Oncol 46:975–981
Storli K, Lindboe CF, Kristoffersen C et al (2010) Lymph node harvest in colon cancer specimens depends on tumour factors, patients and doctors, but foremost on specimen handling. APMIS 119:127–134
Færden AE, Sjo OH, Bukholm IR et al (2011) Lymph node micrometastases and isolated tumor cells influence survival in stage I and II colon cancer. Dis Colon Rectum 54(2):200–206
Merrie AEH, Phillips LV, Yun K et al (2001) Skip metastases in colon cancer: assessment by lymph node mapping using molecular detection. Surgery 129:684–691
Söndenaa K, West N, Sugihara K et al (2013) The rationale behind complete mesocolic excision (CME) and a high (apical) vascular tie for colon cancer in open and laparoscopic access surgery (submitted)
Morris EJA, Maughan NJ, Forman D et al (2007) Who to treat with adjuvant therapy in Dukes B/stage II colorectal cancer? The need for high quality pathology. Gut 56:1419–1425
Japanese Society for Cancer of the Colon and Rectum (2009) Japanese classification of colorectal carcinoma (2nd english edn). Kanehara & Co, Tokyo
Kobayashi H, Ueno H, Hashiguchi Y et al (2006) Distribution of lymph node metastasis is a prognostic index in patients with stage III colon cancer. Surgery 139:516–522
Hogan NM, Winter DC (2013) A nodal positivity constant: new perspectives in lymph node evaluation and colorectal cancer. World J Surg 37(4):878–882. doi:10.1007/s00268-012-1891-7
Hida J, Okuno K, Yasutomi M et al (2005) Number versus distribution in classifying regional lymph node metastases from colon cancer. J Am Coll Surg 201:217–222
Toyota S, Ohta H, Anazawa S (1995) Rationale for extent of lymph node dissection for right colon cancer. Dis Colon Rectum 38:705–711
Goligher JC (1984) Incidence and pathology of carcinoma of the colon and rectum. In: Goligher JC (ed) Surgery of the anus, rectum and colon. 5. Aufl. Balliére Tindall, London, p 445
Jinnai D (1983) General rules for clinical and pathological studies on cancer of the colon, rectum and anus. Jpn J Surg 13:557–573
Tan KY, Kawamura YJ, Mizokami K et al (2010) Distribution of the first metastatic lymph node in colon cancer and its clinical significance. Colorectal Dis 12:44–47
Hashiguchi Y, Hase K, Ueno H et al (2011) Optimal margins and lymphadenectomy in colonic cancer surgery. Br J Surg 98:1171–1178
Ovebro K, Rokke O (2010) Extended lymph node dissection in colorectal cancer surgery. Reliability and reproducibility in assessments of operative reports. Int J Colorectal Dis 25:213–222
Robinson CN, Chen GJ, Balentine CJ et al (2011) Minimally invasive surgery is underutilized for colon cancer. Ann Surg Oncol 18:1412–1418
Turnbull RB Jr (1975) Current concepts in cancer. Cancer of the GI tract: colon, rectum, anus. The no-touch isolation technique of resection. JAMA 231:1181–1182
Spasojevic M, Stimec BV, Gronvold LB et al (2011) The anatomical and surgical consequences of right colectomy for cancer. Dis Colon Rectum 54:1503–1509
Bernhoff R, Holm T, Sjövall A et al (2012) Increased lymph node harvest in patients operated on for right-sided colon cancer: a population-based study. Colorectal Dis 14:691–696
Park IJ, Choi GS, Kang BM et al (2009) Lymph node metastasis patterns in right-sided colon cancers: is segmental resection of these tumors oncologically safe? Ann Surg Oncol 16:1501–1506
Quirke P (2008) Prospective assessment of the quality of surgery in the MRC CLASICC trial evidence for variation in the plane of surgery in colon cancer, local recurrence and survival. www.ncri.org.uk/ncriconference/2008abstracts/abstracts/B115.htm. Accessed 20 Sept 2011
Yada H, Sawai K, Taniguchi H et al (1997) Analysis of vascular anatomy and lymph node metastases warrants radical segmental bowel resection for colon cancer. World J Surg 21:109–115
Maingot R (1974) Abdominal operations. Cop, New York
Hohenberger W, Lux P, Merkel S et al (2011) Lymph node dissection for carcinomas of the lower gastrointestinal tract. What is evidence-based? Chirurg 82:1096–1105
Kim JC, Lee KH, Yu CS et al (2004) The clinicopathological significance of inferior mesenteric lymph node metastasis in colorectal cancer. Eur J Surg Oncol 30:271–279
Lange MM, Buunen M, van de Velde CJ et al (2008) Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie. A review. Dis Colon Rectum 51:1139–1145
Titu LV, Tweedle E, Rooney PS (2008) High tie of the inferior mesenteric artery in curative surgery for left colonic and rectal cancers: a systematic review. Dig Surg 25:148–157
West NP, Hohenberger W, Finan PJ et al (2009) Mesocolic plane surgery: an old but forgotten technique? Colorectal Dis 11:988–989
Bertelsen CA, Bols B, Ingeholm P et al (2011) Can the quality of colonic surgery be improved by standardization of surgical technique with complete mesocolic excision? Colorectal Dis 13:1123–1129
Hogan AM, Winter DC (2009) Complete mesocolic excision—a marker of surgical quality? J Gastrointest Surg 13:1889–1891
Weber K, Merkel S, Perrakis A et al (2013) Is there a disadvantage to radical lymph node dissection in colon cancer? Int J Colorectal Dis 28(2):217–226
Caplin S, Cerottini JP, Bosman FT et al (1998) For patients with Dukes’ B (TNM stage II) colorectal carcinoma, examination of six or fewer lymph nodes is related to poor prognosis. Cancer 83:666–672
Ratto C, Sofo L, Ippoliti M et al (1999) Accurate lymph-node detection in colorectal specimens resected for cancer is of prognostic significance. Dis Colon Rectum 42:143–154 discussion 154-158
Cianchi F, Palomba A, Boddi V et al (2002) Lymph node recovery from colorectal tumor specimens: recommendation for a minimum number of lymph nodes to be examined. World J Surg 26:384–389. doi:10.1007/s00268-001-0236-8
Wong JH, Bowles BJ, Bueno R et al (2002) Impact of the number of negative nodes on disease-free survival in colorectal cancer patients. Dis Colon Rectum 45:1341–1348
Prandi M, Lionetto R, Bini A et al (2002) Prognostic evaluation of stage B colon cancer patients is improved by an adequate lymphadenectomy: results of a secondary analysis of a large scale adjuvant trial. Ann Surg 235:458–463
Goldstein NS (2002) Lymph node recoveries from 2427 pT3 colorectal resection specimens spanning 45 years: recommendations for a minimum number of recovered lymph nodes based on predictive probabilities. Am J Surg Pathol 26:179–189
Law CH, Wright FC, Rapanos T et al (2003) Impact of lymph node retrieval and pathological ultra-staging on the prognosis of stage II colon cancer. J Surg Oncol 84:120–126
Berberoglu U (2004) Prognostic significance of total lymph node number in patients with T1–4N0M0 colorectal cancer. Hepatogastroenterology 51:1689–1693
Yoshimatsu K, Ishibashi K, Umehara A et al (2005) How many lymph nodes should be examined in Dukes’ B colorectal cancer? Determination on the basis of cumulative survival rate. Hepatogastroenterology 52:1703–1706
Gumus M, Yumuk PF, Atalay G et al (2005) What is the optimal number of lymph nodes to be dissected in colorectal cancer surgery? Tumori 91:168–172
Sarli L, Bader G, Iusco D et al (2005) Number of lymph nodes examined and prognosis of TNM stage II colorectal cancer. Eur J Cancer 41:272–279
Mammen JM, James LE, Molloy M et al (2007) The relationship of lymph node dissection and colon cancer survival in the veterans affairs central cancer registry. Am J Surg 194:349–354
Tsikitis VL, Larson DL, Wolff BG et al (2009) Survival in stage III colon cancer is independent of the total number of lymph nodes retrieved. J Am Coll Surg 208:42–47
Vather R, Sammour T, Kahokehr A et al (2009) Lymph node evaluation and long-term survival in stage II and stage III colon cancer: a national study. Ann Surg Oncol 16:585–593
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Kessler, H., Hohenberger, W. Extended Lymphadenectomy in Colon Cancer is Crucial. World J Surg 37, 1789–1798 (2013). https://doi.org/10.1007/s00268-013-2130-6
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-013-2130-6