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• W2334856988 abstract "What more can we do as surgeons to improve the outcomes of our patients? This question should haunt each one of us on a daily basis. Improved patient care is never gained without maximum effort, intense scrutiny and optimization of communication. So what can we learn from the manuscripts presented by Prandi et al. from the Italian National Intergroup for Adjuvant Therapy on Colon Cancer (INTACC) and Birbeck et al. from Leeds, United Kingdom? I would propose that the surgeon and the pathologist have not as yet maximized their efforts to improve survival in patients with colorectal cancer. We can do more ourselves to rely less on the rescue efforts of the medical oncologist and direct therapy only to those patients who will really benefit from adjuvant chemotherapy.The INTACC report of 3,248 cases of stage II and III colon cancer accrued in 2 adjuvant therapy trials suggests that patients with stage II colon cancer who have fewer than 7 lymph nodes identified should receive chemotherapy. The risk of under-staging the cancer in these patients is such that a survival benefit may be achieved by adding chemotherapy to an otherwise surgically treated problem. The issue is not whether these patients will benefit from chemotherapy but why did they have only 7 lymph nodes (24% of patients) in their specimen? We are not given information regarding a standardized surgical technique, margins, vascular ligation, or mesenteric dissection, even though the authors say “treatment was carried out according to a uniform standard.” As a result we are unable to determine whether the improved survival noted in other stage II patients is due to an overall wider resection by the surgeon or whether the pathologist did a better lymph node dissection to achieve better staging. Prandi et al. are to be congratulated for their efforts to enlighten us regarding the affect of lymph node harvest but I hope we will take home a different message than to simply give chemotherapy if we surgeons fail to do our job.The first real attention paid to the importance of radial or circumferential margins in rectal cancer actually originated in Leeds. Therefore it is interesting to see the evolution of their work with radial margins in rectal cancer. Over 12 years they have followed 586 patients who have been staged using standardized pathology methodology by “bread loafing” the rectal and mesorectal specimen as a unit to determine circumferential margins. Conversely, a number of surgeons have submitted patients to the series and have only recently begun using a standardized surgical technique called Total Mesorectal Excision. Their conclusion suggests that clear circumferential margins (a surgeon specific factor) improves survival. Increased volume of patients and experience of the surgeon also improved survival. In fact, even experienced surgeons noted improved outcomes with the adoption of a standardized surgical technique (TME). This has been seen in other series from Sweden, Germany, and Norway referred to in their article. When surgeons perform a technically excellent procedure and pathologists, using standardized techniques, identify tumor at the circumferential margins, the Leeds group has shown a poor outcome. This most likely indicates a biological “bad actor” and a candidate for continued multi-modality therapy.These concepts of maximizing surgical and pathology techniques are not new. The debate over wide excision for colon cancer continues. In fact, until molecular markers become available to direct curative gene therapy it is likely to occupy the energy of many experts in the field. Recently, a publication from the University of Vienna concluded from a prospective observational study of 696 patients treated for Stage I-III colon cancer that “consistent, uniform radical surgery performed in specialized centers can offer tumor eradication for most patients with potentially curative resectable colon cancer.”1 Another report from the University of Tokyo on a series of 564 patients with curable colon cancer suggested that “high ligation may improve long term results in patients with aggressive nodal involvement,” but “less invasive low ligation should be considered” in patients with limited nodal involvement. This approach is certainly difficult without preoperative staging and would discount the role of lymphadenectomy for adequate staging suggested by Karamura et al. 2Sentinel lymph node mapping in colorectal cancer, in my opinion, is a method designed by surgeons to compensate for variability in the pathologist’s examination of the mesocolon to identify as many lymph nodes as needed to adequately stage the disease. It plays very little role in the selection of therapy. In fact, the conclusion of a recent article from Bethlehem, Pennsylvania suggests that sentinel lymph node mapping “may make it easier to identify lymph nodes most likely to contain metastatic disease.”3 Only 58% of patients in their small series had sentinel lymph nodes identified. Granted, the positive and negative predictive values were excellent (100% and 94%), but hardly useful when a bare majority of patients could benefit from the technique. This is a technique in progress. The current Cancer and Lymphoma Group B protocol for sentinel lymph node mapping in colon cancer should reveal the utility of the technique and the possibility of enhancing the benefit by microsectioning and polymerase chain reaction enhancement of DNA detection of cancer genes in nodes. There may be a practical role for this technique in a minimally invasive setting in the future.The consensus statement developed by the NCI “Guidelines 2000 for Colon and Rectal Surgery”4 states, “An appropriate lymph node resection should extend to the level of the origin of the primary feeding vessel. In all cases for cure, the lymph node resection should be radical and the lymph nodes should be removed en bloc,” and “for entry into colon adjuvant therapy trial in which lymph nodes are negative for disease, a minimum of 12 lymph nodes must be examined.”Obtaining clear margins during a resection for rectal cancer is not always possible due to the confines of the pelvis. Marked variability exists in the surgical management of rectal cancer in the United States. A review of 673 patients in 3 North Central Cancer Trial Group trials revealed “moderate surgeon variability was detected, and suboptimal surgical practices and reporting were identified in a high-risk population.”5 Hence the report of radial margins examined in only 32% of patients, fewer than 12 lymph nodes reported in 18% of patients and the conclusion that the “percentage of positive lymph nodes, not the number, was independently predictive of local recurrence.” Even in randomized controlled trials quality control of surgical technique and pathology processing of the specimen is poor.Several recent articles confirm the influence of involved circumferential margins on survival and local recurrence after resection of rectal cancer. An extreme example is seen in a series of 45 patients from M.D. Anderson, with locally advanced rectal cancer offered intraoperative radiotherapy or brachytherapy during radical resection. 6 The authors showed that “Patients with close or positive margins are at high risk of pelvic disease recurrence, even with IOR or interstitial brachytherapy boost.” These patients had received neoadjuvant chemoradiation and still had positive margins. While not an indicator of poor surgical technique in this instance, the circumferential spread of rectal cancer remains a force to be reckoned with and an indication of poor prognosis at this time. Pathologists and surgeons must be aware and respond appropriately. The “Guidelines 2000 for Colon and Rectal Surgery” recommend “Radial tumor-free margin should be described and must be histologically free of disease to be considered curative.”4Wexner, in a review of the literature regarding surgeon variables in rectal cancer surgery, 7 suggested that the following are surgeon related factors: 1) tumor free distal and lateral margins; 2) total mesorectal excision; and 3) sphincter sparing with a colonic J pouch reconstruction. He emphasized that surgeons should know their practice patterns, volumes of patients with rectal cancer diagnosis, and their own capabilities and results.What more can we do? Academic surgeons can commit to training residents and community surgeons to perform the appropriate en bloc cancer resection based on anatomic planes, primary vacular ligation, and clear radial margins. We can be relentless in our requests for adequate staging of colon and rectal cancer by our pathologist. It is time to face issues such as centers of excellence or specialty practice for the treatment of cancer regardless of the site. Our goal of “excellence” must be turned to action rather than empty words in order to fulfill our promise to provide outstanding care for our patients." @default.
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• W2334856988 title "The Effect of the Surgeon and the Pathologist on Patient Survival After Resection of Colon and Rectal Cancer" @default.
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