D3 lymph node dissection reduces recurrence after primary resection for elderly patients with colon cancer

Impact of D3 lymph node dissection on short-term and long-term outcomes in elderly patients with colon cancer

BACKGROUND

The oncologic impact of D3 lymph node dissection (LND) for colon cancer (CC) has been reported to be favorable. However, D3 LND is potentially more invasive than non-D3 LND, and whether it is beneficial for elderly patients with CC remains unclear. This study aimed to evaluate the perioperative safety and short- and long-term oncologic outcomes of D3 LND in elderly patients with CC.

METHODS

Subjects were 442 elderly patients aged ≥ 70 years who underwent curative surgery for pathologic stage (pStage) I-III CC between 2011 and 2022. Background clinical factors and short- and long-term outcomes were compared between patients who received D3 LND (D3 group; n = 363) and those who received non-D3 LND (non-D3 group; n = 79).

RESULTS

The D3 group had a significantly higher number of retrieved lymph nodes (median 20 vs. 12, p < 0.001) and a lower rate of postoperative complications (18% vs. 32%, p = 0.040) than the non-D3 group. In the overall cohort, overall survival (OS) did not differ between the two groups. Among pStage III patients, however, OS was significantly better (69.8% vs. 34.1%, p = 0.028), and RFS tended to be better (60.7% vs. 42.6%, p = 0.075) in the D3 group than in the non-D3 group. Multivariable analysis revealed that D3 LND was independently associated with better OS (HR 0.477; 95% CI 0.245-0.931, p = 0.030) and tended to be associated with better RFS (HR 0.588; 95% CI 0.329-1.051, p = 0.073).

CONCLUSION

D3 LND is safe and effective in improving the prognosis of elderly patients with pStage II/III CC.

The assessment of adjuvant chemotherapy benefits after D3 lymphadenectomy in patients with colon cancer: a propensity score matching study

PURPOSE

Adjuvant chemotherapy (AC) for stage III disease is recognized as a standard treatment and is routinely performed in patients with colon cancer (CC). However, the recommendation for AC is mainly based on studies performed in past environments, where D3 lymphadenectomy was not routinely performed.

METHODS

We retrospectively analyzed CC patients who underwent curative resection with D3 lymphadenectomy in Keio Surveillance Epidemiology and End Results (K-SEER) database. After patients were divided into AC and non-AC groups, propensity score matching (PSM) was performed to match the two groups.

RESULTS

After PSM, 84 patients were included in each group. There were no significant differences between the AC and non-AC groups in the 5-year cancer-specific survival (CSS; 88.01% vs. 81.46%, p = 0.295) and 5-year recurrence-free survival (RFS; 69.57 vs. 70.08%, p = 0.820), respectively. In the subgroup analysis, AC improved both the CSS [hazard ratio (HR)0.273; 95% confidence interval (CI) 0.094-0.797, p = 0.017] and RFS (HR 0.376; 95% CI 0.174-0.806, p = 0.012) only for tumors with N2 disease compared to non-AC.

CONCLUSION

The current indications for AC in patients with CC after D3 lymphadenectomy should be reconsidered. It is possible that AC is appropriate only for stage III CC patients with N2 disease.

Comparison of D2 vs D3 lymph node dissection for RIght COloN cancer (RICON): study protocol for an international multicenter open-label randomized controlled trial

BACKGROUND

Colon cancer is a global health concern, ranking fifth in both new diagnoses and deaths among tumors worldwide. Surgical intervention remains the primary treatment for localized cases, with a historical evolution marked by a focus on short-term outcomes. While Japan pioneered radical tumor removal with a systematic categorization of lymph nodes (D1, D2, D3), the dissemination of Japanese practices to the West was delayed until 90th of last century. Discrepancies between Japanese D3 dissection and the CME with CVL principle persist, with variations in longitudinal margins and recommended procedures. Non-randomized trials indicate the superiority of D3 over D2, but a consensus is lacking.

METHODS

This prospective, international, multicenter, randomized controlled trial employs a two-arm, parallel-group, open-label design to rigorously compare the 5-year overall survival outcomes between D2 and D3 lymph node dissection in stage II-III right colon cancer. Building on prior studies, the trial aims to address existing knowledge gaps and provide a comprehensive evaluation of the outcomes associated with D3 dissection. The study population comprises patients with right colon cancer, ensuring a focused investigation into the specific context of this disease. The trial design emphasizes its global scope and collaboration across multiple centers, enhancing the generalizability of the findings.

DISCUSSION

This study's primary objective is to elucidate the potential superiority in 5-year overall survival benefits of D3 lymph node dissection compared to the conventional D2 approach in patients with stage II-III right colon cancer. By examining this specific subset of patients, the research aims to contribute valuable insights into optimizing surgical strategies for improved long-term outcomes. The trial's international and multicenter nature enhances its applicability across diverse populations. The outcomes of this study may inform future guidelines and contribute to the ongoing discourse surrounding the standardization of colon cancer surgery, particularly in the context of right colon cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03200834. Registered on June 27, 2017.

Management of Surgically Accessible Lymph Nodes Beyond Normal Resection Planes

This article discusses the management of isolated metastatic lymph nodes for colon and rectal cancer. There are traditionally significant differences in how certain regions of lymph nodes for colon and rectal cancer are managed in the East and West. This has led to the development of the lateral lymph node dissection for rectal cancer and extended lymphadenectomy techniques for colon cancer. This article will evaluate the literature on these techniques and what the surgical and oncological outcomes are at this time. In addition, colon and rectal cancers can occasionally have isolated distant lymph node metastases. These would traditionally be treated as systemic disease with chemotherapy. There is consideration though that these could be treated as similar to isolated liver or lung metastases which have been shown to be able to be treated surgically with good oncological results. The literature for these isolated distant lymph node metastases will be reviewed and treatment options available will be discussed.

Definition and reporting of lymphadenectomy and complete mesocolic excision for radical right colectomy: a systematic review

BACKGROUND

Several procedures have been proposed to reduce the rates of recurrence in patients with right-sided colon cancer. Different procedures for a radical right colectomy (RRC), including extended D3 lymphadenectomy, complete mesocolic excision and central vascular ligation have been associated with survival benefits by some authors, but results are inconsistent. The aim of this study was to assess the variability in definition and reporting of RRC, which might be responsible for significant differences in outcome evaluation.

METHODS

PRISMA-compliant systematic literature review to identify the definitions of RRC. Primary aims were to identify surgical steps and different nomenclature for RRC. Secondary aims were description of heterogeneity and overlap among different RRC techniques.

RESULTS

Ninety-nine articles satisfied inclusion criteria. Eight surgical steps were identified and recorded as specific to RRC: Central arterial ligation was described in 100% of the included studies; preservation of mesocolic integrity in 73% and dissection along the SMV plane in 67%. Other surgical steps were inconstantly reported. Six differently named techniques for RRC have been identified. There were 35 definitions for the 6 techniques and 40% of these were used to identify more than one technique.

CONCLUSIONS

The only universally adopted surgical step for RRC is central arterial ligation. There is great heterogeneity and consistent overlap among definitions of all RRC techniques. This is likely to jeopardise the interpretation of the outcomes of studies on the topic. Consistent use of definitions and reporting of procedures are needed to obtain reliable conclusions in future trials. PROSPERO CRD42021241650.

Long-term outcomes of D2 vs. D3 lymph node dissection for cT2N0M0 colorectal cancer: a multi‑institutional retrospective analysis

BACKGROUND

According to Japanese guidelines, D2 or D3 lymph node dissection (LND) is indicated for cT2N0M0 colorectal cancer (CRC). In this study, we retrospectively compared the long-term outcomes between D2 and D3 LND among patients with cT2N0M0 CRC.

METHODS

Our sample included 515 patients from the Japanese Study Group for Postoperative Follow-Up of Colorectal Cancer database, who underwent surgical resection for cT2N0M0 CRC between January 2009 and December 2012, 195 (37.9%) of whom underwent D2 LND and 320 (62.1%) D3 LND. The D2 and D3 groups were retrospectively compared in terms of long-term outcomes including overall survival (OS) and relapse-free survival (RFS). The prognostic factors for these outcomes were also evaluated.

RESULTS

The D2 group had significantly older patients and higher proportion of men than the D3 group. The rates of OS (5-year OS; 94.8% in the D3 group vs. 93.4% in the D2 group, p = 0.38) and RFS (5-year RFS; 89.3% in the D3 group vs. 89.1% in the D2 group, p = 0.91) were comparable for both groups. On multivariate analysis, age ≥ 80 years was significantly associated with poor OS. The extent of LND was not associated with either OS or RFS. Long-term outcomes were similar between the two groups, independent of tumor location.

CONCLUSION

The long-term outcomes did not differ between the D2 and D3 groups and the extent of LND was not associated with prognosis for cT2N0M0 CRC. Therefore, D2 LND may be sufficient for cT2N0N0 CRC treatment.

Complete mesocolic excision versus conventional surgery for colon cancer: A systematic review and meta-analysis

AIM

Complete mesocolic excision (CME) lacks consistent data advocating operative superiority compared to conventional surgery for colon cancer. We performed a systematic review and meta-analysis, analysing population characteristics and perioperative, pathological and oncological outcomes.

METHODS

D3 extended lymphadenectomy dissection was considered comparable to CME, and D2 and D1 dissection to be comparable to conventional surgery. Outcomes reviewed included lymph node yield, R1 resection, overall complications, overall survival and disease-free survival.

RESULTS

In all, 3039 citations were identified; 148 studies underwent full-text reviews and 31 matched inclusion criteria: total cohort 26 640 patients (13 830 CME/D3 vs. 12 810 conventional). Overall 3- and 5-year survival was higher in the CME/D3 group compared with conventional surgery: relative risk (RR) 0.69 (95% CI 0.51-0.93, P = 0.016) and RR 0.78 (95% CI 0.64-0.95, P = 0.011) respectively. Five-year disease-free survival also demonstrated CME/D3 superiority (RR 0.67, 95% CI 0.52-0.86, P < 0.001), with similar findings at 1 and 3 years. There were no statistically significant differences between the CME/D3 and conventional group in overall complications (RR 1.06, 95% CI 0.97-1.14, P = 0.483) or anastomotic leak (RR 1.02, 95% CI 0.81-1.29, P = 0.647).

CONCLUSIONS

Meta-analysis suggests CME/D3 may have a better overall and disease-free survival compared to conventional surgery, with no difference in perioperative complications. Quality of evidence regarding survival is low, and randomized control trials are required to strengthen the evidence base.

Comparing complete mesocolic excision versus conventional colectomy for colon cancer: A systematic review and meta-analysis

Conventional colectomy, and the Japanese Society for Cancer of the Colon and Rectum (JSCCR) D2 Lymphadenectomy (LND2), are currently considered standard of care for surgical management of colon cancer. Colectomy with complete mesocolic excision (CME) and JSCCR D3 Lymphadenectomy (LND3) are more radical alternative approaches and provide a greater degree of lymph nodal clearance. However, controversy exists over the long-term benefits of CME/LND3 over non-CME colectomies (NCME)/LND2. In this study, we performed a systematic review and meta-analysis to compare the surgical, pathological, and oncological outcomes of CME/LND3 with NCME/LND2. Embase, Medline and CENTRAL databases were searched from inception until May 15, 2020, in accordance with PRISMA guidelines. Studies were included if they compared curative intent CME/LND3 with NCME/LND2. Weighted mean differences (WMD) and odds ratios (OR) were estimated for continuous and dichotomous outcomes respectively. Out of 1310 unique citations, 106 underwent full-text review, and 30 were included for analysis. In total, 21,695 patients underwent resection for colon cancer. 11,625 received CME/LND3, and 10,070 underwent NCME/LND2. No significant differences were found in post-operative morbidity and mortality. Both overall and disease-free survival favored CME/LND3 (5-year OS: OR = 1.29; 95% CI 1.02 to 1.64, p = 0.03; 5-year DFS: OR = 1.61; 95% CI 1.14 to 2.28; p = 0.007). This is the first systematic review and meta-analysis to demonstrate that CME/LND3 has superior long-term survival outcomes compared to NCME/LND2.