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Laparoscopic Colectomy for Colon Cancer

Survival advantages were associated with laparoscopic versus open colectomy in patients with advanced disease.

In a prior single-center, randomized study, short-term outcomes (median follow-up, 43 months) after laparoscopy-assisted colectomy (LAC) — in terms of cancer-related survival, tumor recurrence, and morbidity — were superior to those after open colectomy (OC) in patients with nonmetastatic–colon cancer (Lancet 2002; 359:2224). To examine the longer-term results of this trial (median follow-up, 95 months), investigators in Spain evaluated 219 nonmetastatic–colon cancer patients assigned to LAC or OC, all of whom underwent similar adjuvant chemotherapy and postoperative surveillance.

Among all patients, overall survival (OS) was higher in the LAC group compared with the OC group, although the difference was not statistically significant (64% vs. 49%; P=0.06). However, among patients with stage III colon cancer, the LAC group experienced significantly longer OS (P=0.048), cancer-related survival (P=0.02), and recurrence-free survival (P=0.048) than did the OC group; among patients with stage I or II tumors, no significant differences were noted between the two surgical groups for survival or recurrence. LAC was independently associated with lower risk for death from any cause (hazard ratio, 0.59; P=0.04), cancer-related death (HR, 0.44; P=0.03), or tumor relapse (HR, 0.47; P=0.03). The authors concluded that LAC is more effective than OC in the treatment of colon cancer.

Comment: LAC for nonmalignant bowel problems offers the advantages of less pain and earlier return of bowel function; but for cancer surgery, LAC raises safety concerns. An obvious question is why would any survival advantage be associated with one surgical procedure over another? One theory is that the lower psychological stress associated with LAC versus OC might play a role. Experimental evidence in animal models has shown an inverse relation between resistance to cancer and response to the stress of surgery (Surgery 1987; 102:71). Other research has shown that elevated serum vascular endothelial growth factor levels — a pro-angiogenic state that hypothetically could promote metastasis — occurs in patients who undergo OC versus LAC (Ann Surg 2006; 244:792). Yet another explanation for a survival advantage in patients receiving LAC rather than OC is related to the reduced degree of tumor manipulation and subsequent release of tumor cells into the circulation (Clin Cancer Res 1998; 4:343).

The current findings are controversial in that the significant survival advantage in patients with stage III colon cancer receiving LAC could be due to chance alone. A recently published meta-analysis of randomized trials involving more than 1500 patients with stage I, II, or III colon cancer treated with LAC or OC showed no disease-free or overall survival disadvantage at 3 years for either method of resection (Arch Surg 2007; 142:298). The take-home message from the present study, with its median follow-up of nearly 8 years, is that the evidence showing LAC to be safe for colon cancer patients is mounting.

— Henry Mark Kuerer, MD, PhD, FACS

Published in Journal Watch Oncology and Hematology August 5, 2008

Citation(s):

Lacy AM et al. The long-term results of a randomized clinical trial of laparoscopy-assisted versus open surgery for colon cancer. Ann Surg 2008 Jul; 248:1.

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