standardization of cme for transverse colon cancer
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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