The role of the lymph nodes in colon cancer
Summary
Metastatic spread of colon cancer to intermediate lymphnodes is found, depending on tumor stage, in up to 44 % of patients and to central lymph nodes in about 10 %. The incidence of skip metastases is estimated not to exceed 5 %. Tumorous involvement of pericolic lymph nodes occurs almost only within a 10 cm distance from the primary. There is only one prospective randomized controlled trial available comparing hemicolectomy versus radical segmental colectomy in patients with left colonic cancer. In this limited study there was no statistical difference regarding survival, mortality and morbidity between the two groups. However, several large retrospective studies are in favor of extended colon resection with radical clearance of lymphatic tissue. In 198 patients with colon cancer excluding rectal cancer in a 6-year period we performed 151 radical (76 %) and 47 segmental (24 %) colonic resections. The median length of the specimens in an unstretched and formalin-fixed state was 39 cm and 19 cm, respectively. The mean number of investigated lymph nodes was 16 and 12, respectively. 40 % of our patients showed lymph node metastases. In-hospital mortality was 4/198 patients (2 %) and surgical morbidity occurred in 29/198 patients (15 %). We recommend radical colonic resections in all potentially curable patients with colonic cancer.
Zusammenfassung
Beim Kolonkarzinom sind die intermediären Lymphknoten stadienabhängig in bis zu 44 %, die zentralen Lymphknoten in rund 10 % der Patienten metastatisch befallen. Das Vorliegen von Skip-Metastasen wird auf 5 % aller Patienten mit Kolonkarzinom geschätzt. Die perikolische lymphogene Tumorausbreitung übersteigt nur selten eine Distanz von 10 cm nach proximal bzw. distal vom Primärtumor. Die Treffsicherheit der präoperativen bildgebenden Verfahren bzw. intraoperativen Inspektion und Palpation bezüglich Lymphknotenmetastasierung ist gering. In der bis heute einzigen randomisierten Studie bei Patienten mit linksseitigem Kolonkarzinom führte die Hemikolektomie links zu keinem verlängerten Überleben im Vergleich zu einer radikalen Kolonsegmentresektion, jedoch auch zu keiner erhöhten Operationsmortalität oder Morbidität. Mehrere retrospektive Analysen dagegen lassen die ausgedehnte Kolonresektion unter radikaler Mitentfernung der lymphatischen Abflußwege und unter zentraler Gefäßligatur favorisieren. Über einen Zeitraum von 6 Jahren führten wir im eigenen Krankengut von 198 Patienten mit Kolonkarzinom (exklusive Rektumkarzinom) 151mal eine radikale (76 %) und 47mal eine segmentäre Kolonresektion durch. Die mediane Resektatlänge war in ungestrecktem und Formalin-fixiertem Zustand 39 cm bzw. 19 cm. Die durchschnittliche Anzahl untersuchter Lymphknoten betrug 16 bzw. 12. In 40 % unserer Patienten wurden Lymphknotenmetastasen entdeckt. Die Krankenhausletalität belief sich auf 4/198 (2 %) Patienten. 29 von 198 (15 %) Patienten erlitten chirurgische Komplikationen, wovon eine Anastomoseninsuffizienz (0,6 %). Aufgrund der pathophysiologischen Gegebenheiten sowie der aktuell zur Verfügung stehenden Daten aus der Literatur kann zumindest für Patienten mit Kolonkarzinom ohne wesentliche Komorbidität eine Resektion von mindestens 25 cm Kolon mit radikaler Entfernung des lymphatischen Abflußgebietes und zentraler Gefäßligatur empfohlen, nicht aber gefordert werden.
Key words
Colon - neoplasms - lymph nodes - micrometastasis - resection - review
Schlüsselwörter
Kolon - Neoplasma - Lymphknoten - Resektion - Mikrometastasen - Übersicht
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