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Anatomical and temporal patterns of lymph node metastasis in colorectal cancer (Chapter 9)

Boekbijdrage - Hoofdstuk

The pathophysiology of metastatic spread in colon cancer (CC) is complex, heterogeneous, and incompletely understood. Traditionally, metastatic spread has been interpreted as a stepwise process, involving orderly progression from the primary tumor to nearby lymph nodes (LNs), henceforth to more distant LNs, and ultimately to distant organs such as the liver. If this behavior is real, efforts to maximize lymphadenectomy may result in removal of the last cancer-invaded node, prevent further seeding, and result in cure. However, recent data suggest that this traditional paradigm does not hold in most CC patients. Phylogenetic and autopsy studies support the notion that metastatic spread occurs early in the course of the disease and that lymphatic and systemic spread occur independently from each other. Data from studies that have mapped the anatomical location of LN metastases in stage III CC suggest that in a sizeable proportion of patients, the pattern of metastatic spread appears to be random, without any orderly progression from central to distal locations. In addition, clinical studies comparing standard surgery with more extensive procedures [high ligation of the inferior mesenteric artery, complete mesocolic excision (CME), D3 dissection, and para-aortic or extra-mesenteric node dissection] show that while these techniques increase LN count, they exacerbate postoperative morbidity and have, at present, not demonstrated to result in a lower risk of local recurrence and metastatic disease or improved survival. However, several randomized trials comparing standard surgery with CME are ongoing, and the results are awaited. In addition, the molecular and (epi)genetic mechanisms that drive lymphatic metastasis in CC should be further elucidated in larger datasets. When combined with novel intraoperative imaging techniques to identify LNs and lymphatic pathways, these efforts may ultimately result in a precision surgical approach that allows to tailor the extent of surgery to the biology of the cancer.
Boek: The lymphatic system in colorectal cancer : basic concepts, pathology, imaging and treatment perspectives
Pagina's: 131 - 151
Jaar van publicatie:2022
Toegankelijkheid:Closed