What is the management of a T3 N0 splenic flexure tumor?

From the Guidelines

The management of a T3 N0 splenic flexure tumor involves surgical resection as the primary treatment, typically through an extended left hemicolectomy, followed by adjuvant chemotherapy with a FOLFOX regimen or CAPOX for 6 months. Surgery should include complete mesocolic excision with central vascular ligation to ensure adequate lymph node harvest (at least 12 lymph nodes) 1. The choice of adjuvant chemotherapy is supported by the fact that fluoropyrimidine-based chemotherapy has shown to result in a statistically significant survival benefit for patients with stage II colon cancer, which includes T3 N0 M0 tumors 1. Although some studies suggest that observation may be considered for patients with T3N0M0 colon cancer without high-risk factors, with 53% of respondents choosing observation in one survey 1, the use of adjuvant chemotherapy is generally recommended for these patients to reduce the risk of recurrence. Preoperative evaluation should include complete colonoscopy, CT scans of chest/abdomen/pelvis, and baseline CEA level. Postoperatively, surveillance includes regular CEA testing every 3-6 months for 2 years then every 6 months for 3 more years, CT scans annually for 5 years, and colonoscopy at 1 year then every 3-5 years if normal. This approach is justified by the T3 status indicating invasion through the muscularis propria into pericolorectal tissues, which carries significant risk of recurrence despite the N0 (node-negative) status. Key considerations in the management of T3 N0 splenic flexure tumors include:

• Complete surgical resection with adequate lymph node harvest
• Adjuvant chemotherapy with FOLFOX or CAPOX regimens
• Regular postoperative surveillance with CEA testing, CT scans, and colonoscopy
• Preoperative evaluation with complete colonoscopy, CT scans, and baseline CEA level.

From the FDA Drug Label

The efficacy of oxaliplatin in combination with fluorouracil (FU)/leucovorin (LV) was evaluated in an international, multicenter, randomized (1:1) trial (The Multicenter International Study of Oxaliplatin/5-Fluorouracil/Leucovorin in the Adjuvant Treatment of Colon Cancer [MOSAIC], NCT00275210) in patients with stage II (Dukes’ B2) or III (Dukes’ C) colon cancer who had undergone complete resection of the primary tumor. Eligible patients were between 18 and 75 years of age, had histologically proven stage II (T3 to T4 N0 M0; Dukes’ B2) or III (any T N1-2 M0; Dukes’ C) colon carcinoma (with the inferior pole of the tumor above the peritoneal reflection, i.e., greater than or equal to 15 cm from the anal margin) and had undergone (within 7 weeks prior to randomization) complete resection of the primary tumor without gross or microscopic evidence of residual disease and carcino-embyrogenic antigen (CEA) less than 10 ng/mL

The management of a T3 N0 splenic flexure tumor may involve adjuvant chemotherapy with oxaliplatin in combination with fluorouracil/leucovorin, as this regimen has been shown to improve disease-free survival (DFS) in patients with stage II and III colon cancer, including those with T3 tumors 2.

• The recommended dosing regimen is oxaliplatin 85 mg/m2 on day 1, followed by leucovorin 200 mg/m2 and fluorouracil 400 mg/m2 bolus and 600 mg/m2 22-hour infusion on days 1 and 2, every 2 weeks for 12 cycles.
• However, it is essential to note that the improvement in DFS was not statistically significant in Stage II patients, and the decision to use adjuvant chemotherapy should be made on a case-by-case basis, considering factors such as the patient's overall health, tumor characteristics, and potential benefits and risks of treatment.

From the Research

Management of T3 N0 Splenic Flexure Tumor

The management of a T3 N0 splenic flexure tumor involves surgical resection, with the goal of removing the tumor and affected portion of the colon.

• The optimal surgical approach is still a matter of debate, with several options available, including:
  • Subtotal colectomy (STC)
  • Left hemicolectomy (LHC)
  • Segmental colon resection (SCR)
  • Extended right colectomy (ERC)
  • Left colectomy (LC)
  • Segmental left colectomy (SLC)

Surgical Approaches

• A study published in 2019 3 found that SCR is a safe and effective alternative for splenic flexure tumors, with no significant differences in operative results, hospital stay, pathological data, mortality, recurrence, or long-term survival outcomes compared to STC and LHC.
• A meta-analysis published in 2024 4 compared the outcomes of ERC, SC, and LC for splenic flexure colon cancer, and found that SC and LC may be more advantageous, with fewer postoperative complications and faster recovery.
• Another study published in 2021 5 found that SLC is a viable option for splenic flexure carcinomas, with no differences in overall survival (OS) or disease-free survival (DFS) compared to ERC and LC.

Lymph Node Dissection

• The extent of lymph node dissection is also a topic of debate, with some studies suggesting that more extensive dissection may not be necessary for splenic flexure tumors 6.
• A study published in 2001 6 found that left partial colectomy or partial resection of the transverse/descending colon without routine extended resection was not associated with a worse prognosis than colon cancers at other sites.

Outcome

• The choice of surgical approach may depend on various factors, including the location and size of the tumor, as well as the patient's overall health and preferences.
• A study published in 1987 7 found that the site of the tumor does not affect long-term survival, and that subtotal colectomy with ileosigmoid anastomosis may be a safe method of treating patients with an obstructed carcinoma at the splenic flexure.