Die komplette mesokolische Exzision beim rechtsseitigen Kolonkarzinom – welche Rolle spielen die zentralen Lymphknoten?

Zusammenfassung

Hintergrund: Die komplette mesokolische Exzision (CME) mit zentraler vaskulärer Ligatur (CVL) bei rechtsseitigen Kolonkarzinomen ist möglicherweise der Standardhemikolektomie hinsichtlich des onkologischen Ergebnisses überlegen. Dies wird derzeit in der multizentrischen Resektatstudie von den Autoren untersucht. Im Rahmen der monozentrischen Pilotphase dieser Studie haben wir die Häufigkeit zentraler Lymphknotenmetastasen standardisiert analysiert. Patienten: Bei 51 Patienten wurde bei einem rechtsseitigen Kolonkarzinom (cT1–3, cM0) eine CME mit CVL durchgeführt. Am unfixierten Resektat wurde am zentralen Absetzungsrand ein 4 cm langes Segment der Vasa ileocolica markiert, das bei der Standardhemikolektomie wahrscheinlich belassen worden wäre. Die Lymphknoten in diesem Segment wurden gesondert aufgearbeitet. Ergebnisse: In den CME-Präparaten konnten durchschnittlich 52,6 (Streubreite: 27–171) Lymphknoten (LK) entfernt und auch histologisch nachgewiesen werden. Davon befanden sich durchschnittlich 35,0 % (Streubreite: 13,1–65,6 %) im zentralen Anteil des Präparats – also innerhalb des 4 cm langen Segments. Der Anteil an LK-positiven Patienten betrug 25,5 % (13/51). Der Anteil positiver LK betrug 1,97 % (53/2686). Bei 3/51 (5,8 %) der Patienten waren die zentralen LK befallen. Bei einem Patienten war dies die einzige Lokalisation positiver LKs. Das endgültige UICC-Stadium wurde durch die befallenen zentralen LKs bei 2/3 Patienten beeinflusst (Stage migration: UICC IIB nach IIIB, UICC IIIB nach IIIC). Schlussfolgerung: Die CME mit CVL erhöht bei rechtsseitigen Kolonkarzinomen die Wahrscheinlichkeit, regionäre Lymphknotenmetastasen komplett zu entfernen und führt damit zu einem präziseren Tumorstaging. Eine Verbesserung des Langzeitüberlebens durch die CME erscheint daher naheliegend, muss aber in der multizentrischen Resektatstudie überprüft werden.

Abstract

Background: Complete mesocolic excision (CME) and central vascular ligation (CVL) for right-sided colon cancer may be superior to standard hemicolectomy in terms of oncological results. This hypothesis is currently being investigated in a large multicentre trial conducted by the authors of this paper (Resektatstudie). Because CVL in right-sided hemicolectomy is technically rather demanding the incidence of central node involvement is of special interest. Therefore, during the single centre pilot phase of our multicentre trial we have analysed the incidence of central lymph node metastasis in CME specimens. Patients: In 51 patients with right-sided colon adenocarcinoma (cT1–3, cM0) an open CME with CVL was performed. In the fresh specimen the central four centimetres of the ileocolic vessels that would have been presumably left in place during a standard hemicolectomy were marked with a suture. The lymph nodes in this segment were separately analysed. Results: In the CME specimen the mean lymph node count was 52.6 (range: 27–171). 35.0 % (range: 13.1–65.6 %) of the nodes were located in the central 4 cm segment. The proportion of patients with positive nodes was 25.5 % (13/51). Of all nodes 1.97 % (53/2686) were metastatic. In 3/51 (5.8 %) patients the central nodes were involved. In one patient the central nodes were the only metastatic site. UICC stage was influenced in two of the three patients who had central involvement (stage migration: UICC IIB to IIIB, UICC IIIB to IIIC). Conclusion: CME with CVL in right-sided colon adenocarcinoma increases the probability of complete removal of the local lymph node drainage and thus local metastatic lymph nodes. Considering this result an improvement of long-term survival by the CME procedure seems conceivable but needs to be confirmed by the current multicentre trial.

Schlüsselwörter

Abdominalchirurgie - kolorektales Karzinom - CME - Hemikolektomie rechts - Lymphadenektomie - mesokolische Faszie

Key words

abdominal surgery - colorectal cancer - CME - right-sided hemicolectomy - lymphadenectomy - mesocolic fascia

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