Choosing the volume of resection for transverse colon cancer: preliminary results

AIM: to justify the extent of resection for transverse colon cancer based on the lymphatic drainage.

PATIENTS AND METHODS: since October 2023, a prospective observational study has been initiated. As of January 2026, 42 patients with carcinoma of the transverse colon have been included. All patients underwent extended right hemicolectomy with omentectomy and D3 lymph node dissection. To evaluate the pathways of lymphatic drainage, intraoperative fluorescent lymphography (IFL) with peritumoral injection of indocyanine green (ICG) was performed. Lymph nodes of removed specimens were meticulously dissected from the mesentery in accordance with the Japanese Classification of Regional Lymph Nodes of the Colon. The study involved a correlative analysis of the fluorescent lymphography findings and the results of the morphological examination of the surgical specimen. The evaluated parameters included intraoperative metrics, postoperative complications, and the diagnostic accuracy of fluorescent lymphography.

RESULTS: postoperative complications occurred in 19 (45.2%) patients, with Grade I and II complications (according to the Clavien-Dindo classification) accounting for 16 (38.1%) cases. The rate of severe complications (Grade III-IV) was 7,1% (3/19). Successful IFL was performed in 34 (80.9%) patients. Multi-directional lymphatic drainage developed in 14 cases (41.2%): in two directions in 13 patients (38.2%) and in three directions in 1 (2.9%) case. In addition to lymph nodes along the middle colic artery, drainage was visualized towards lymph nodes in the mesentery of the right colon in 9 (26.5%) patients and towards the greater omentum in another 9 (26.5%) patients. Lymph node metastasis was detected in 14 patients (33.3%), including one case (2.4%) of metastasis in a 202 station lymph node (according to the Japanese classification).ICG-based fluorescent lymphography demonstrated high specificity of 0.95 (95% CI: 0.93–0.97) in identifying lymph nodes without metastases. However, the sensitivity of the method for detecting metastatic nodes was low at 0.15 (95% CI: 0.08–0.25). The positive predictive value (PPV) was 0.38 (95% CI: 0.24–0.54), while the negative predictive value (NPV) was high at 0.86 (95% CI: 0.83–0.89) regarding the absence of metastases in non-fluorescent lymph nodes.

CONCLUSION: the data obtained demonstrate significant variability in lymphatic drainage in transverse colon cancer, including pathways to the mesentery of the right colon and the greater omentum. Extended right hemicolectomy with omentectomy appears to be a justified extent of surgery, ensuring the removal of potential metastatic basins, and shows an acceptable safety profile. ICG-based fluorescent lymphography enables the intraoperative mapping of lymphatic drainage pathways. Further research is necessary to determine whether this technique can serve as a tool for personalizing the extent of resection.

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