Doubt Cast on Traditional Pattern of Cancer Metastases Interview with:
Benjamin Weixler, MD
Department of Surgery
University Hospital Basel, Basel, Switzerland and
Leiden University Medical Center, Leiden, the Netherlands What is the background for this study? What are the main findings?

Response: For most patients with lymph node negative colon cancer (stage I and II) surgery is regarded to be the curative treatment. Despite the curative attempt up to thirty percent of these patients will develop disease recurrence, most likely due to missed micro-metastatic disease at initial tumor staging. Pathological standard processing with hematoxylin and eosin (H&E) entails a considerable risk of missing micro-metastatic deposits in the lymph nodes. Mounting evidence indicates that micro-metastatic tumor deposits in the lymph nodes as well as in the bone marrow might be associated with an increased risk of disease recurrence and death in node negative patients. With our study we wanted to examine the correlation between the occurrence of micro-metastatic deposits in the lymph nodes and the bone marrow as well as their prognostic significance.

As a main finding, the study provides compelling evidence that tumor cell dissemination to the lymph nodes and to the bone marrow are independent events in patients with colon cancer. Most importantly did the study demonstrate that micro-metastatic deposits in the lymph nodes as well as in the bone marrow are independent negative prognostic factors regarding  disease-free and overall survival. The combined occurrence is associated with significantly worse prognosis compared to either one of them. What should clinicians and patients take away from your report?

Response: Our study demonstrates that hematogenic and lymphogenic tumor cell dissemination are of equal importance already at early colon cancer stages. The traditional idea of sequential metastatic spread should be doubted. The results of our study also raise the question if standard lymph node dissection and evaluation are sufficiently accurate to identify patients at risk of disease recurrence. The very essence of our results may be that standard lymph node dissection with H&E staining only plays a subordinate role and that more meticulous techniques, like sentinel lymph node mapping, bone marrow aspiration and/or semiautomatic mRNA amplification, will be of bigger importance for the detection of the tumors real metastatic potential and for individual patient treatment. What recommendations do you have for future research as a result of this study?

Response: Future research should address the question if lymph node negative colon cancer patients (stage I and II) harboring micro-metastatic deposits in the lymph nodes and/or in the bone marrow might benefit from adjuvant chemotherapy. We recommend to intensify pathological staging in future clinical colon cancer trials by the implementation of preoperative bone marrow aspiration and intraoperative sentinel lymph node mapping. 

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Weixler B, Viehl CT, Warschkow R, Guller U, Ramser M, Sauter G, Zuber M. Comparative Analysis of Tumor Cell Dissemination to the Sentinel Lymph Nodes and to the Bone Marrow in Patients With Nonmetastasized Colon CancerA Prospective Multicenter Study. JAMA Surg. Published online June 07, 2017. doi:10.1001/jamasurg.2017.1514

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Last Updated on August 2, 2017 by Marie Benz MD FAAD