Dr. Werner Hohenberger, Chirurgische Universitatsklinik Erlangen

1. Universitätsklinikum Erlangen
Friedrich-Alexander-Universität
Erlangen-Nürnberg
Standardization
of CME for
Transverse Colon Cancer
.
Werner Hohenberger
University Hospital Erlangen

2. Universitätsklinikum Erlangen
Transverse Colon Cancer
About 15 % of all colon cancers
Prognosis probably worst regarding
all colorectal cancers

3. Universitätsklinikum Erlangen
Transverse Colon Cancer
Three dimensional lymphatic spread
Embryology and anatomy of
upper abdomen complex
Detailled knowlegde needed

4. Universitätsklinikum Erlangen
Oncologic Surgery
Locoregional Recurrence due to Failures
Reasons
Inadequate lymph node dissection
Tumor dissemination

5. Universitätsklinikum Erlangen
Lymph Node Metastases
Principles
Follows regular routes
pericolic to central nodes at supplying artery
Skip lesions rare (5 % at the most)
Lymph node stations defined by supplying arteries
Bi- to three-dimensional spread possible
Mode of spread:
regional nodes
extraregional nodes
- invasion of adjacent organ
- distant spread

6. Universitätsklinikum Erlangen
Oncologic Surgery
Locoregional Recurrence due to Failures
Reasons
Lymph nodes potentially involved left behind
Tumor dissemination due to
breaching/destroying planes
cutting through tumor
inadequate margin of clearance
shaving tumor invasion off fixt structures

7. Universitätsklinikum Erlangen
Colon Cancer
Locoregional Recurrence

8. Universitätsklinikum Erlangen
Courtesy of Th. Wedel/Kiel

9. Universitätsklinikum ErlangenCourtesy of Th. Wedel/Kiel

10. Universitätsklinikum Erlangen

11. Universitätsklinikum Erlangen

12. Universitätsklinikum Erlangen

13. Universitätsklinikum Erlangen
right gastro-epiploic art.
branch to
hepatic flexure
Surgical anatomy
Opening of gastrocolic lig.
Colon anatomy: embryology, lymphatic drainage, mesocolon
transverse
mesocolon
transverse colon
stomach
gastrocolic lig.
Courtesy of Prof. Thilo Wedel

14. Universitätsklinikum Erlangen
Small arteries from middle colic a.
o transverse pancreatic a. inside the pancreas

15. Universitätsklinikum Erlangen

16. Universitätsklinikum Erlangen
Transverse Colon Cancer
Gastroepiploic Lymph Node Metastases
CA. Bertelsen 2014
98 cases
gastroepiploic l. n. found n = 86
median number n = 4 (0-16)
mesocolic l.n. metastases n = 34
gastroepipl. l.n. mets. n = 4 / 34 (12 %)
n = 4/ 98 ( 4 %)

17. Universitätsklinikum Erlangen
Transverse Colon Cancer
Lymph Node Involvement
right p. and hepatic flexure (n=16)
middle part (n=26)
left p. and splenic flexure (n= 4)
Stage
III
n= 6 n=1 -
gastro- infra-
epiploic pancr.
n=11 n=2 n=5
n= 1 - -
Transverse colon
Chirurg. Univ.-Klinik Erlangen 2009-2012; n=45 (Int J Colorectal Dis 2015)

18. Universitätsklinikum Erlangen

19. Universitätsklinikum Erlangen

20. Universitätsklinikum Erlangen
Cancer of the Transverse Colon
Optimized Lymph-Node Dissection

21. Cancer of transverse colon and right flexure –
extended right hemicolectomy

22. Midtransversum colon cancer –
resection transverse colon including flexures

23. Cancer splenic flexure

24. Universitätsklinikum Erlangen
Colon Cancer Surgery
Splenic flexure cancer
Special Aspects
„borderline localisation“ :
„rectal“ vs. supine position
right or left sided approach?
(„10 cm and arcade principle“!)
in most cases: left side concept better

25. Universitätsklinikum Erlangen
Colon Cancer Surgery
Splenic flexure cancer
Oncologic demands
Four lymph node stations to be dissected
middle colic a.
left asc. colonic a.
left pancreas (branches to transverse
pancreatic a.
right gastroepiploic a.

26. Universitätsklinikum Erlangen

27. Universitätsklinikum Erlangen

28. Universitätsklinikum Erlangen

29. Universitätsklinikum Erlangen
Surgery for
Transverse Colon Cancer
least standardized procedure
complex lymphatic spread
gastroepiplopic arcade and
pancreatic lymph nodes
usually not dissected
extend of dissection depending
on exact site of tumor