Langzeitüberleben nach laparoskopischer und offener Resektion des Kolon-Karzinoms – eine bevölkerungsbezogene Analyse

Hintergrund: Über 20 Jahre nach der Einführung von laparoskopischer Chirurgie für Kolon-Karzinome bevorzugen viele Chirurgen noch immer den offenen Operationszugang, obwohl verschiedene randomisierte Studien zu dem Schluss kamen, dass die Laparoskopie ein onkologisch sicheres Verfahren ist. Das geringe Vertrauen in die minimalinvasive Chirurgie ist möglicherweise Ergebnis eines Mangels an hochwertigen retrospektiven Arbeiten, die das Langzeitüberleben von Darmkrebspatienten nach laparoskopischen und offenen Routine-Eingriffen vergleichen. Patienten und Methoden: Diese bevölkerungsbezogene Kohortenstudie vergleicht in erster Linie Gesamtüberlebens- und rezidivfreie Überlebensraten nach laparoskopischen und offenen Kolon-Karzinom Resektionen. Die Daten dafür stammen aus einem deutschen klinischen Krebsregister, welches sämtliche Tumordiagnosen innerhalb eines 1,1 Millionen Einwohner umfassenden süddeutschen Regierungsbezirks erfasst. Insgesamt wurden etwa 2700 Patienten mit elektiver chirurgischer Resektion eines primären, nicht metastasierten Adenokarzinom des Kolons zwischen Januar 2004 und Dezember 2013 in die Auswertungen eingeschlossen. Zum Überlebenszeitvergleich wurde unter anderem auf Kaplan-Meier Analysen, relative Überlebensmodelle und multivariable logistische und Cox-Regressionsanalysen zurückgegriffen. Ergebnisse: Während des Beobachtungszeitraums nahm die Laparoskopierate zunächst von 6,9% auf 17,8% zu, um dann 2013 wieder auf ein Niveau von 13,2% zu sinken. Laparoskopisch operierte Patienten sind im Durchschnitt jünger, haben ein niedrigeres UICC-Stadium und erhalten häufiger eine adjuvante Chemotherapie. Die perioperative Mortalitäts-Rate ist nach minimalinvasiven Operationen geringer, wobei diesbezüglich in der multivariablen Analyse das Signifikanzniveau knapp verfehlt wird. Über alle eingeschlossenen Patienten gerechnet weisen die laparoskopischen Patienten im Vergleich zur offenen Gruppe signifikant höhere 5-Jahres-Gesamtüberlebens- und relative Überlebensraten auf (5-Jahres Gesamtüberlebensrate offen vs. laparoskopisch: 69,0 vs. 80,2%, p <0,001). Die Rezidivrate laparoskopischer Patienten ist marginal höher. Bei Betrachtung der rezidivfreien Überlebensraten minimiert sich dementsprechend der Vorteil der laparoskopisch Operierten und verfehlt das Signifikanzniveau knapp. Nach Adjustierung für eine Reihe wichtiger Confounder ist weiterhin ein signifikanter Überlebensvorteil der laparoskopischen Patienten in den Subgruppen der UICC-Stadium II Patienten sowie bei den 65- bis 77-jährigen zu beobachten. Schlussfolgerung: Gerade bei der im klinischen Alltag äußerst relevanten Subgruppe der Patienten mit mäßig fortgeschrittenem Tumoren im typischen Erkrankungsalter ist aus Sicht dieser Studie ein verstärkter Einsatz minimalinvasiver Operationstechniken anzustreben - die notwendige Expertise des Operateurs vorausgesetzt. Dennoch sind weitere bevölkerungsbezogene Beobachtungsstudien zum Thema nötig. Der auf repräsentativen klinischen Registern aufbauende Forschungsansatz des „real-time monitorings“ der „daily clinical practice“ profitiert stark von der Digitalisierung im Gesundheitssystem und dem Big-Data-Ansatz. - Eine Chance, die es zu nutzen gilt. Je mehr Patienten aus repräsentativen Settings unterschiedlicher Gesundheitssysteme weltweit untersucht werden, desto verlässlicher ist die Evidenz, die aus der Zusammenschau aller Ergebnisse entsteht

Influence of Laparoscopic Surgery on Cellular Immunity in Colorectal Cancer: A Systematic Review and Meta-Analysis

Colorectal cancer (CRC) is the third most common cancer worldwide. The main treatment options are laparoscopic (LS) and open surgery (OS), which might differ in their impact on the cellular immunity so indispensable for anti-infectious and antitumor defense. MEDLINE, Embase, Web of Science (SCI-EXPANDED), the Cochrane Library, Google Scholar, ClinicalTrials.gov, and ICTRP (WHO) were systematically searched for randomized controlled trials (RCTs) comparing cellular immunity in CRC patients of any stage between minimally invasive and open surgical resections. A random effects-weighted inverse variance meta-analysis was performed for cell counts of natural killer (NK) cells, white blood cells (WBCs), lymphocytes, CD4+ T cells, and the CD4+/CD8+ ratio. The RoB2 tool was used to assess the risk of bias. The meta-analysis was prospectively registered in PROSPERO (CRD42021264324). A total of 14 trials including 974 participants were assessed. The LS groups showed more favorable outcomes in eight trials, with lower inflammation and less immunosuppression as indicated by higher innate and adaptive cell counts, higher NK cell activity, and higher HLA-DR expression rates compared to OS, with only one study reporting lower WBCs after OS. The meta-analysis yielded significantly higher NK cell counts at postoperative day (POD)4 (weighted mean difference (WMD) 30.80 cells/µL [19.68; 41.92], p < 0.00001) and POD6–8 (WMD 45.08 cells/µL [35.95; 54.21], p < 0.00001). Although further research is required, LS is possibly associated with less suppression of cellular immunity and lower inflammation, indicating better preservation of cellular immunity

Adherence to the Dutch Breast Cancer Guidelines for Surveillance in Breast Cancer Survivors:Real-World Data from a Pooled Multicenter Analysis

BACKGROUND: Regular follow-up after treatment for breast cancer is crucial to detect potential recurrences and second contralateral breast cancer in an early stage. However, information about follow-up patterns in the Netherlands is scarce. PATIENTS AND METHODS: Details concerning diagnostic procedures and policlinic visits in the first 5 years following a breast cancer diagnosis were gathered between 2009 and 2019 for 9916 patients from 4 large Dutch hospitals. This information was used to analyze the adherence of breast cancer surveillance to guidelines in the Netherlands. Multivariable logistic regression was used to relate the average number of a patient’s imaging procedures to their demographics, tumor–treatment characteristics, and individual locoregional recurrence risk (LRR), estimated by a risk-prediction tool, called INFLUENCE. RESULTS: The average number of policlinic contacts per patient decreased from 4.4 in the first to 2.0 in the fifth follow-up year. In each of the 5 follow-up years, the share of patients without imaging procedures was relatively high, ranging between 31.4% and 33.6%. Observed guidelines deviations were highly significant (P < .001). A higher age, lower UICC stage, and having undergone radio- or chemotherapy were significantly associated with a higher chance of receiving an imaging procedure. The estimated average LRR-risk was 3.5% in patients without any follow-up imaging compared with 2.3% in patients with the recommended number of 5 imagings. CONCLUSION: Compared to guidelines, more policlinic visits were made, although at inadequate intervals, and fewer imaging procedures were performed. The frequency of imaging procedures did not correlate with the patients’ individual risk profiles for LRR

Laparoscopic surgery for colon cancer

Background To evaluate a new procedure in daily clinical practice, it might not be sufficient to rely exclusively on the findings of randomized clinical trials (RCTs). This is the first systematic review providing a synthesis of the most important RCTs and relevant retrospective cohort studies on short- and long-term outcomes of laparoscopic surgery in colon cancer patients. Materials and methods In a literature search, more than 1800 relevant publications on the topic were identified. Relevant RCTs and representative high-quality retrospective studies were selected based on the widely accepted Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. Finally, 9 RCTs and 14 retrospective cohort studies were included. Results Laparoscopic surgery for colon cancer is associated with a slightly longer duration of surgery, but a variety of studies show an association with a lower rate of postoperative complications and a shorter duration of hospital stay. Particularly in older patients with more frequent comorbidities, laparoscopy seems to contribute to decreasing postoperative mortality. Concerning long-term oncologic outcomes, the laparoscopic and open techniques were shown to be at least equivalent. Conclusion The findings of the existing relevant RCTs on laparoscopic surgery for colon cancer are mostly confirmed by representative retrospective cohort studies based on real-world data; therefore, its further implementation into clinical practice can be recommended. intergrund Um die Eignung eines neuen Behandlungsverfahrens im klinischen Alltag zu überprüfen, sollte man sich nicht ausschließlich auf die Ergebnisse randomisierter Studien (RCTs) verlassen. Dies ist die erste Übersichtsarbeit zum Thema laparoskopische Tumorresektion beim Kolonkarzinom, welche neben RCTs repräsentative retrospektive Kohortenstudien zu Kurz- und Langzeitergebnissen berücksichtigt. Methoden In einer Literaturrecherche wurden über 1800 relevante Publikationen identifiziert. Eine Selektion der relevanten pro- und retrospektiven Studien zum Thema Laparoskopie beim Kolonkarzinom fand auf Grundlage der STROBE-Kriterien statt. Schließlich wurden 9 RCTs und 14 retrospektive Studien eingeschlossen. Ergebnisse Laparoskopische Chirurgie beim Kolonkarzinom ist zwar mit einer etwas längeren Operationsdauer, jedoch auch mit einer niedrigeren postoperativen Komplikationsrate und einer kürzeren Krankenhausverweildauer assoziiert. Vor allem ältere Patienten mit mehr Komorbiditäten scheinen von einer niedrigeren postoperativen Mortalität zu profitieren. Was das onkologische Langzeitergebnis betrifft, ist das laparoskopische dem offenen Verfahren mindestens ebenbürtig. Schlussfolgerung Die Ergebnisse der existierenden relevanten RCTs zur Laparoskopie beim Kolonkarzinom werden größtenteils von repräsentativen retrospektiven Kohortenstudien aus dem Klinikalltag bestätigt. Daher kann die weitere Implementierung der Laparoskopie in den Klinikalltag empfohlen werden

Data archive of: Impact of laparoscopic versus open surgery on humoral immunity in patients with colorectal cancer: a systematic review and meta-analysis

Supplementary data containing the supplementary tables S1-S4, Figures of the main text as well as supplementary figures, the PRISMA-S and PRISMA 2020 checklists to complement the manuscript

Long-term oncologic outcomes after laparoscopic vs. open colon cancer resection: a high-quality population-based analysis in a Southern German district

Over 20 years after the introduction of laparoscopic surgery for colon cancer, many surgeons still prefer the open approach. Whereas randomized controlled trials (RCTs) have proven the oncologic safety of laparoscopy, long-term data depicting daily clinical routine are scarce. This population-based cohort study compares 5-year overall, relative, and recurrence-free survival rates after laparoscopic and open colon carcinoma surgery. Data derive from an independent German cancer registry encompassing all tumor patients within a political district of 1.1 million inhabitants. The final analysis included 2669 patients with major elective resection of primary non-metastatic colonic adenocarcinoma between January 1, 2004 and December 31, 2013. Survival rates were compared using Kaplan-Meier analyses, relative survival models, and multivariate Cox regression. Sensitivity analysis quantified selection bias. The proportion of laparoscopic procedures increased from 9.7 to 25.8% in 2011 and dropped again to 15.8% at the end of observation period. Laparoscopy patients were younger, had a lower tumor stage, and were more likely to receive postoperative chemotherapy. Overall, relative, and recurrence-free survival was significantly superior or equivalent in Kaplan-Meier analysis (5-year overall survival rate open vs. laparoscopic: 69.0 vs. 80.2%, p < 0.001). The superiority of laparoscopy mostly remained stable after adjusting for confounders, although significance was only reached in T1-3 patients without lymph node metastases (overall survival: hazard ratio (HR) 0.654; 95% confidence interval (CI) 0.446-0.958; p = 0.029). Laparoscopy is a safe and promising alternative to the open approach in daily clinic practice. These favorable outcomes require future confirmation by high-quality studies outside the setting of RTCs

Langzeitüberleben von Patienten mit Kolon- und Rektumkarzinomen: Ein Vergleich von Darmkrebszentren und nicht zertifizierten Krankenhäusern

Aim of the study Hospitals specializing in the treatment of colorectal carcinoma with high quality standards can apply for certification as colorectal cancer centers. The aim of this study was to clarify if there is a substantial difference between certified and non-certified hospitals in terms of long-term survival of patients. Methods This is a population-based retrospective cohort study using the data of a clinical cancer registry (Tumorzentrum Regensburg) which covers a southern German region of approximately 1.1 million inhabitants. 4302 patients with colorectal carcinoma who underwent radically surgery between 2004 and 2013 were divided into 4 groups for comparing certified and non-certified centers as well as the situation before and after certification. 3-year overall survival is displayed using Kaplan-Meier analysis, multivariate cox regression and relative survival models. Sensitivity analysis for missing data was conducted. Results The estimated 3-year survival rates of patients treated at certified compared to non-certified centers were 71.6 % and 63.6 %, respectively. Even after adjusting for possible confounders, treatment at certified centers was associated with significant survival benefits for patients (HR = 0.808, CI: 0.665-0.982). Comparison of colorectal cancer centers before and after certification showed almost identical 3-year survival rates. Cox regression analysis also showed no substantial difference between the two (HR = 0.964, CI: 0.848-1.096). Conclusion Patients with colorectal cancer treated in certified compared to non-certified centers show long-term survival benefits. Patients of certified colorectal cancer centers show long-term survival benefits compared to those treated at non-certified centers. Early and successful implementation of high quality standards could explain why survival rates before and after certification do not differ