Purpose Adjuvant chemotherapy for colon cancer with lymph node involvement (Stage III) has been the standard of care since the 1990s. Meanwhile, considerable evolvement of surgery combined with dedicated histopathological examinations may have led to stage migration. Furthermore, prognostic factors other than lymph node involvement have proven to affect overall survival. Thus, adjuvant chemotherapy in Stage III colon cancer should be reconsidered. The objective was to compare recurrence rates and survival in stage III colon cancer patients treated with or without adjuvant chemotherapy. Further, to assess the impact of extensive mesenterectomy, lymph node stage and vascular invasion on outcome. Methods Consecutive patients operated for Stage III colon carcinoma between 31 December 2005 and 31 December 2015 were identified in the pathological code register by matching colon (T67) and either adenocarcinoma (M81403) or mucinous adenocarcinoma (M84803), with lymph node (T08) and metastasis of adenocarcinoma (M81406 or M84806). Medical records of all identified patients were reviewed. Results Of 216 identified patients, 69 received no postoperative adjuvant chemotherapy (group NC), 69 insufficient adjuvant chemotherapy (FLV or < minimum recommended 6 cycles FLOX, group IC), and 78 sufficient adjuvant chemotherapy (≥ 6 cycles FLOX, group SC). When adjusted for age and comorbidity, 5-year overall survival did not differ statistically significant between groups (76% vs. 83% vs. 85%, respectively). Vascular invasion and a high lymph node ratio significantly reduced overall survival. Conclusion The findings imply that subgroups of Stage III colon cancer patients have good prognosis also without adjuvant chemotherapy. For definite conclusions about necessity of adjuvant chemotherapy, prospective trials are needed.
The past 15 years have resulted in dramatic changes in the treatment of colon cancer. The most significant development, since the work of Werner Hohenberger (1), lies in the fact that the Norwegian cancer registry demonstrates a steady improvement in 5year survival rates within this same period. What is most astonishing is the fact that the chemotherapy regimen has been stable within the whole period. The conclusion drawn therefore is: it is possible to achieve better long-term survival rates through "just performing better surgery". If correct, such a trend could in turn, lead to the decline of chemotherapy use in the treatment of colon cancer. Never the less, "just better surgery" does require a definition.When analyzed, the history of surgical education has focused on the surgeon, his apprentice, the surgical procedure and has seldom shown any interest in the individuality of or the variability in the patient. As has been successfully demonstrated through the work of Spasojevic (2) and Naesgaard (3) , this individuality and variability can and should lead to the individualization and personalization of surgery.Allow us to simplify the case. Drawing lines where the surgeon should divide the tissue will not be sufficient for all patients. Modern radiology allows for the preoperative awareness of the anatomy (through segmentation and 3D reconstruction (4)) that will in turn allow the surgeon to approach anatomical structures in a more responsible manner, from outside the lymphatic flow. Thus, the definition of "just better surgery" entails preoperative anatomical awareness than enables us to approach vessel origins (perform the lymphadenectomy) from outside the lymphatic flow (5). Personalized surgery should improve survival rates, reduce complications and the need for chemotherapy in most patients treated for localized colon cancer.
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