PMID: 11923601

Issn Print: 0003-4932

Publication Date: 2002/04/01


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The Effect of the Surgeon and the Pathologist on Patient Survival After Resection of Colon and Rectal Cancer

James W. Fleshman

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Excerpt

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.
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