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JANUARY 2015    A Monthly Review of Articles of Interest for the Clinical Community

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<This Month's Clinical Focus: GI>

 

  Complete Mesocolic Surgery Improves Outcomes in Colon Cancer

In colorectal cancers, surgery represents a potentially curative outcome for patients with stage I-III disease. A surgical technique that involves complete removal of mesenteric layers is now a gold standard in rectal cancer surgery, but although it has also led to improved outcomes in colon surgery, its uptake among colon surgeons is slow. But experts now argue that the new technique should be taken up as a standard procedure worldwide.

In rectal cancer, it is has been argued that, from a surgical point of view, the advent of total mesorectal excision (TME), pioneered by Heald (J R Soc Med. 1988;81:503–8), has contributed significantly to improving outcomes for patients with rectal cancer — with local recurrence rates down to 4% from 30% to 40%. Today, the procedure is considered a gold standard in rectal cancer surgery.

Procedures implemented in rectal cancers slowly find their way into colon cancer practices. The operative word is slowly. Analogous to TME in rectal cancer, some colon cancer surgeons have been recommending a similar approach for surgical resection of colon cancers in what is described as complete mesocolic excision (CME), which includes central vascular ligation (CVL) and dissection in the mesocolic plane.

SurgeryTheater

Recently, a Danish study published online December 2014 in Lancet Oncology showed that 4-year disease-free survival (DFS) was significantly higher for patients with stage I-III colon cancer who underwent CME with CVL surgery compared with conventional surgery in Denmark.

Reporting on behalf of the Danish Colorectal Cancer Group (DCCG), Claus Anders Bertelsen, MD, consulting surgeon, Hillerød University Hospital, Denmark, and his colleagues suggest that "the improved outcomes after CME are likely to be related to resection in the mesocolic plane and to high ligation of the tumour-supplying vessels."

They also state: "Although further studies are needed to clarify the potential risks of CME, we suggest that an increased focus should be put on implementation of CME surgery."

"Bertelsen and colleagues have 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," write Phil Quirke, MD, and Nick West, MD, in an accompanying commentary (Lancet Oncol. Published online December 31, 2014). Dr Quirke is from the Section of Pathology and Tumour Biology, St James's University Hospital, Leeds, and Dr West is from the Section of Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, United Kingdom.

The Danish Study

In the Danish study, Dr Bertelsen and colleagues retrospectively analyzed data for patients who underwent elective surgical resection for stage I-III colon adenocarcinoma in the Capital Region of Denmark.

CME surgery is offered only at a single institution, the Hillerød Hospital; conventional colon resection is offered at three hospitals. Patient data were extracted from the DCCG and medical charts.

Of the 1395 patients eligible for this analysis, 364 patients underwent CME surgery, and 1031 patients underwent conventional surgery.

Significantly Higher DFS for CME Surgery

For all patients in the study, 4-year DFS was significantly higher after CME: 85.8% vs 75.9% for conventional surgery (P = .001). Four-year DFS was as follows for patients across each stage compared with conventional surgery:

•For patients with stage I disease: 100% after CME vs 89.8%
•For patients with stage II disease: 91.9% after CME vs 77.9%
•For patients with stage III disease: 73.5% after CME vs 67.5%

CME was a predictive factor for lower disease recurrence or a higher DFS for patients with stage I, II, and III disease.
Although similar data were reported in another small study and in two single-center studies with historical controls, critics have indicated that only randomized trials may set the debate at rest.

In their discussion, Dr Bertelsen and colleagues write: "Randomised controlled trials comparing CME with non-CME surgery would be difficult to undertake because the preferences of CME surgeons would be entrenched and a usable definition of how they should undertake conventional resections would be difficult."

When asked about a randomized clinical study, Dr Bertelsen indicated that this will probably never occur. "Surgeons trained in CME will never go back to doing conventional surgery," he said. 

Source:  Alexander M. Castellino, PhD   READ THE FULL ARTICLE at: http://www.medscape.com/viewarticle/838573#vp_1
 



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