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Complete mesocolic excision for colon cancer yielded better DFS than conventional surgery
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Patients with stage I to stage III colon adenocarcinoma who underwent complete mesocolic excision demonstrated longer DFS than those who underwent standard rectal surgery, according to results of a retrospective study conducted in Denmark.
Claus Anders Bertelsen, MD, of the department of surgery at Hillerød University Hospital in Denmark, and colleagues used the Danish Colorectal Cancer Group database to evaluate outcomes of 1,395 patients with stage I to stage III disease treated between June 1, 2008, and Dec. 31, 2011.
The analysis included 364 patients who underwent complete mesocolic excision (CME) — which allows the removal of the mesocolon and its lymphatic draining within embryological planes — at one center validated to perform the procedure. Researchers compared outcomes in that group with those of 1,031 controls who underwent conventional colon resection at one of three other hospitals.
Overall, researchers reported 4-year DFS of 85.8% (95% CI, 81.4-90.1) in the CME arm and 75.9% (95% CI, 72.2-79.7) in the control arm.
Results showed CME was associated with a 4-year DFS benefit among patients with stage I disease (100% vs. 89.8), stage II disease (91.9% vs. 77.9%) and stage III disease (73.5% vs. 67.5%).
Multivariable Cox regression analysis showed CME was a significant, independent predictive factor for improved DFS among all patients (HR=0.59; 95% CI, 0.42-0.83), those with stage II disease (HR=0.44; 95% CI, 0.23-0.86) and those with stage III disease (HR=0.64; 95% CI, 0.42-1).
After researchers performed propensity-score matching, they determined CME was associated with a significantly higher rate of 4-year DFS regardless of disease stage (85.8% vs. 73.4%; P=.0014).
“A higher mortality rate was reported in the CME group during the first 10.5 months postoperatively than in the non-CME group,” Bertelsen and colleagues wrote. “From a theoretical point of view, this could be related to the extended resection of the mesocolon. Central dissection could involve a risk of injury — eg, to the superior mesenteric vein and autonomous nerves.”
Additional larger population studies are needed to help better illustrate the potential short-term risks associated with CME, as well as to offer insights about the effects of a potential learning curve for surgeons, Bertelsen and colleagues wrote.
“We can no longer afford to ignore the variation in surgical quality for colonic cancer,” Phil Quirke, PhD, of the department of pathology and tumor biology at St. James University Hospital in Leeds, United Kingdom, and Nick West, PhD, of the department of pathology and tumor biology at Leeds Institute of Cancer and Pathology at the University of Leeds, wrote in an accompanying editorial. “As a first step, standard CME surgery should be routinely implemented worldwide with consistent high-quality pathological assessment and feedback.”
Strong consideration should be given to routine use of central vascular ligation, but a definitive trial is needed to prove that the benefit could be generalizable to practice in Western countries, Quirke and West wrote.
“The potential benefits of improved surgery … would be magnified in a screened population in which stage IV disease and emergency presentations are reduced and more patients are resectable,” Quirke and West wrote. “[This study has] generated strong evidence that improving colonic surgery offers the potential to improve survival to an equivalent or greater extent than adjuvant chemotherapy. This finding cannot be ignored and must be explored further.”
For more information:
Bertelsen CA. Lancet Oncol. 2014;doi:10.1016/S1470-2045(14)71168-4.
Quirke P. Lancet Oncol. 2014;doi:10.1016/S1470-2045(14)71223-9.
Disclosure: The researchers report no relevant financial disclosures. Quirke and West report no relevant financial disclosures.
Perspective
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Hermann Kessler, MD, PhD, FACS
Due to multiple improvements like the introduction of total mesorectal excision or multimodal therapeutical concepts, long-term results in rectal cancer surgery have surpassed outcome in colon cancer. Resection in colon cancer is frequently still viewed as a routine procedure not demanding special concerns. However, mainly by studies from Erlangen, it has been demonstrated that the principles of total mesorectal excision could also be applied in colon carcinoma surgery. The mesentery of the rectum does not stop at a level of 15 cm above the anal verge but is continuing as mesocolon. The corresponding concept of complete mesocolic excision is defined by dissection along and preservation of the genuine embryologically defined mesocolic planes and high vascular tie. All lymph nodes along the tumor supplying vessels are contained in the specimen which is removed as a package with the mesocolic fascia as an intact envelope. Bertelsen’s detailed analysis must be highly appreciated and is a key study in the effort to prove the known benefits of optimal rectal cancer surgery for colon cancer. It is the first population based study comparing CME with conventional colon cancer resection. Mathematical principles and quality control are introduced into surgery by photo documentation, measuring distances and lengths, a scale of mesocolic grading and internal and external pathology audit. It may be surprising that the positive effect of CME is especially obvious in stage I and II colon cancer. Must the intact removal of the mesocolon be seen separately from the role of central vascular ligation? For the first time, it is shown that high quality laparoscopic surgery of colon carcinoma is safely feasible as a routine, with no significant differences in outcome from open surgery. Still, carcinomas of the flexures and transverse colon have been spared for laparoscopy. Few questions remain open: how safely can laparoscopy be applied in these tumor locations? How long is the learning curve for open and laparoscopic CME technique? Does high vascular tie bear a higher risk of intra- and postoperative complications? These questions shouldn’t keep us from introducing complete mesocolic excision as surgical standard for colon cancer in combination with high quality pathological evaluation of the specimen.
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