standardization of cme for transverse colon cancer

Universitätsklinikum ErlangenFriedrich-Alexander-UniversitätErlangen-Nürnberg

Standardization of CME for

Transverse Colon Cancer

. Werner Hohenberger

University Hospital Erlangen

Universitätsklinikum Erlangen

Transverse Colon Cancer

About 15 % of all colon cancers

Prognosis probably worst regardingall colorectal cancers

Universitätsklinikum Erlangen

Transverse Colon Cancer

Three dimensional lymphatic spread

Embryology and anatomy of upper abdomen complex

Detailled knowlegde needed

Universitätsklinikum Erlangen

Oncologic SurgeryLocoregional Recurrence due to Failures

Reasons

Inadequate lymph node dissection

Tumor dissemination

Universitätsklinikum Erlangen

Lymph Node MetastasesPrinciples

Follows regular routes pericolic to central nodes at supplying artery Skip lesions rare (5 % at the most) Lymph node stations defined by supplying arteries Bi- to three-dimensional spread possible Mode of spread: regional nodes extraregional nodes - invasion of adjacent organ - distant spread

Universitätsklinikum Erlangen

Oncologic SurgeryLocoregional Recurrence due to Failures

Reasons

Lymph nodes potentially involved left behind

Tumor dissemination due to breaching/destroying planes cutting through tumor inadequate margin of clearance shaving tumor invasion off fixt structures

Universitätsklinikum Erlangen

Colon CancerLocoregional Recurrence

Universitätsklinikum ErlangenCourtesy of Th. Wedel/Kiel

Universitätsklinikum Erlangen Courtesy of Th. Wedel/Kiel

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

right gastro-epiploic art.

branch to hepatic flexure

Surgical anatomy

Opening of gastrocolic lig.

Colon anatomy: embryology, lymphatic drainage, mesocolon

transverse mesocolon

transverse colon

stomach

gastrocolic lig.

Courtesy of Prof. Thilo Wedel

Universitätsklinikum Erlangen

Small arteries from middle colic a. to transverse pancreatic a. inside the pancreas

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

Transverse Colon CancerGastroepiploic Lymph Node Metastases

CA. Bertelsen 2014

98 cases

gastroepiploic l. n. found n = 86median number n = 4 (0-16)mesocolic l.n. metastases n = 34gastroepipl. l.n. mets. n = 4 / 34 (12 %) n = 4/ 98 ( 4 %)

Universitätsklinikum Erlangen

Transverse Colon CancerLymph Node Involvement

right p. and hepatic flexure (n=16)

middle part (n=26)

left p. and splenic flexure (n= 4)

Stage III

n= 6 n=1 -

gastro- infra- epiploic pancr.

n=11 n=2 n=5

n= 1 - -

Transverse colon

Chirurg. Univ.-Klinik Erlangen 2009-2012; n=45 (Int J Colorectal Dis 2015)

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

Cancer of the Transverse ColonOptimized Lymph-Node Dissection

Cancer of transverse colon and right flexure – extended right hemicolectomy

Midtransversum colon cancer – resection transverse colon including flexures

Cancer splenic flexure

Universitätsklinikum Erlangen

Colon Cancer SurgerySplenic flexure cancer

Special Aspects

„borderline localisation“ : „rectal“ vs. supine position right or left sided approach? („10 cm and arcade principle“!)

in most cases: left side concept better

Universitätsklinikum Erlangen

Colon Cancer SurgerySplenic flexure cancerOncologic demands

Four lymph node stations to be dissected

middle colic a. left asc. colonic a. left pancreas (branches to transverse pancreatic a. right gastroepiploic a.

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

Universitätsklinikum Erlangen

Surgery forTransverse Colon Cancer

least standardized procedurecomplex lymphatic spread

gastroepiplopic arcade and pancreatic lymph nodes usually not dissected extend of dissection depending on exact site of tumor