Lymph node metastases in splenic flexure colon cancer: Is subtotal colectomy warranted?

BACKGROUND AND OBJECTIVES: Tumors of the splenic flexure (TSF) can be associated with metastatic lymph nodes (LN) along the left colic pedicle, but also along the superior mesenteric vessels. We aimed to detail the anatomical distribution of metastatic LNs in patients undergoing elective subtotal colectomy for TSF.

METHOD: Between 2000 and 2016, 65 patients were included. At pathological analysis, LNs were classified into two groups: locoregional LN (along the left colic artery) and distant LN (along the middle colic, right colic, and ileocolic arteries).

RESULTS: The median number of LNs examined was 20. Eighteen patients (27%) were pN+. Among them, six (33% of pN+ patients and 9% of the series) had at least one positive distant LN. All these patients had a positive distant LN along the right colic artery. These patients had a significantly advanced stage and more positive LNs than the others (stage III-IV: 100% vs 22%, P = 0.0009 and 6 [3-15] vs 0 [0-15], P < 0.0001, respectively). The presence of synchronous metastases was predictor of metastatic distant LNs (P = 0.042).

CONCLUSION: Elective subtotal colectomy for TSF allows to discover distant positive LNs in nearly 10% of patients. For those having TSF and synchronous metastatic disease enable to resection, subtotal colectomy should be recommended.