A comparison between the treatment of low rectal cancer in Japan and the Netherlands, focusing on the patterns of local recurrence. Ann Surg. 2009;249:229-235. [PMID: 19212175 DOI: 10.1097/sla.0b013e318190a664]

Neoadjuvant (Chemo)radiotherapy With Total Mesorectal Excision Only Is Not Sufficient to Prevent Lateral Local Recurrence in Enlarged Nodes: Results of the Multicenter Lateral Node Study of Patients With Low cT3/4 Rectal Cancer

PURPOSE

Improvements in magnetic resonance imaging (MRI), total mesorectal excision (TME) surgery, and the use of (chemo)radiotherapy ([C]RT) have improved local control of rectal cancer; however, we have been unable to eradicate local recurrence (LR). Even in the face of TME and negative resection margins (R0), a significant proportion of patients with enlarged lateral lymph nodes (LLNs) suffer from lateral LR (LLR). Japanese studies suggest that the addition of an LLN dissection (LLND) could reduce LLR. This multicenter pooled analysis aims to ascertain whether LLNs actually pose a problem and whether LLND results in fewer LLRs.

PATIENTS AND METHODS

Data from 1,216 consecutive patients with cT3/T4 rectal cancers up to 8 cm from the anal verge who underwent surgery in a 5-year period were collected. LLND was performed in 142 patients (12%). MRIs were re-evaluated with a standardized protocol to assess LLN features.

RESULTS

On pretreatment MRI, 703 patients (58%) had visible LLN, and 192 (16%) had a short axis of at least 7 mm. One hundred eight patients developed LR (5-year LR rate, 10.0%), of which 59 (54%) were LLRs (5-year LLR rate, 5.5%). After multivariable analyses, LLNs with a short axis of at least 7 mm resulted in a significantly higher risk of LLR (hazard ratio, 2.060; P = .045) compared with LLNs of less than 7 mm. In patients with LLNs at least 7 mm, (C)RT plus TME plus LLND resulted in a 5-year LLR of 5.7%, which was significantly lower than that in patients who underwent (C)RT plus TME (5-year LLR, 19.5%; P = .042).

CONCLUSION

LLR is still a significant problem after (C)RT plus TME in LLNs with a short axis at least 7 mm on pretreatment MRI. The addition of LLND results in a significantly lower LLR rate.

Neoadjuvant (Chemo)radiotherapy With Total Mesorectal Excision Only Is Not Sufficient to Prevent Lateral Local Recurrence in Enlarged Nodes: Results of the Multicenter Lateral Node Study of Patients With Low cT3/4 Rectal Cancer

PURPOSE

Improvements in magnetic resonance imaging (MRI), total mesorectal excision (TME) surgery, and the use of (chemo)radiotherapy ([C]RT) have improved local control of rectal cancer; however, we have been unable to eradicate local recurrence (LR). Even in the face of TME and negative resection margins (R0), a significant proportion of patients with enlarged lateral lymph nodes (LLNs) suffer from lateral LR (LLR). Japanese studies suggest that the addition of an LLN dissection (LLND) could reduce LLR. This multicenter pooled analysis aims to ascertain whether LLNs actually pose a problem and whether LLND results in fewer LLRs.

PATIENTS AND METHODS

Data from 1,216 consecutive patients with cT3/T4 rectal cancers up to 8 cm from the anal verge who underwent surgery in a 5-year period were collected. LLND was performed in 142 patients (12%). MRIs were re-evaluated with a standardized protocol to assess LLN features.

RESULTS

On pretreatment MRI, 703 patients (58%) had visible LLN, and 192 (16%) had a short axis of at least 7 mm. One hundred eight patients developed LR (5-year LR rate, 10.0%), of which 59 (54%) were LLRs (5-year LLR rate, 5.5%). After multivariable analyses, LLNs with a short axis of at least 7 mm resulted in a significantly higher risk of LLR (hazard ratio, 2.060; P = .045) compared with LLNs of less than 7 mm. In patients with LLNs at least 7 mm, (C)RT plus TME plus LLND resulted in a 5-year LLR of 5.7%, which was significantly lower than that in patients who underwent (C)RT plus TME (5-year LLR, 19.5%; P = .042).

CONCLUSION

LLR is still a significant problem after (C)RT plus TME in LLNs with a short axis at least 7 mm on pretreatment MRI. The addition of LLND results in a significantly lower LLR rate.

Local Cancer Recurrence: The Realities, Challenges, and Opportunities for New Therapies

Locoregional recurrence negatively impacts both long-term survival and quality of life for several malignancies. For appropriate-risk patients with an isolated, resectable, local recurrence, surgery represents the only potentially curative therapy. However, oncologic outcomes remain inferior for patients with locally recurrent disease even after macroscopically complete resection. Unfortunately, these operations are often extensive, with significant perioperative morbidity and mortality. This review highlights selected malignancies (mesothelioma, sarcoma, lung cancer, breast cancer, rectal cancer, and peritoneal surface malignancies) in which surgical resection is a key treatment modality and local recurrence plays a significant role in overall oncologic outcome with regard to survival and quality of life. For each type of cancer, the current, state-of-the-art treatment strategies and their outcomes are assessed. The need for additional therapeutic options is presented given the limitations of the current standard therapies. New and emerging treatment modalities, including polymer films and nanoparticles, are highlighted as potential future solutions for both prevention and treatment of locally recurrent cancers. Finally, the authors identify additional clinical and research opportunities and propose future research strategies based on the various patterns of local recurrence among the different cancers.

Lateral pelvic lymph node dissection and radiation treatment for rectal cancer: Mutually exclusive or mutually beneficial?

Lateral pelvic lymph nodes (LPLN) in mid-/low rectal cancer pose a theoretical and practical challenge for the clinician and the patient, with geographical differences in management based on historical competing priorities. Although there has been a tendency to think of neoadjuvant radiation versus intraoperative LPLN dissection as a binary choice, they should be more constructively seen as complementary options in the personalized management of patients with rectal cancer. Herein we propose one potential algorithm for using these treatment options in this way based on local preoperative staging and the current evidence available. We also outline future research priorities in this area with the aim of answering several residual questions that remain.

Critical and Challenging Issues in the Surgical Management of Low-Lying Rectal Cancer

Despite innovative advancements, the management of distally located rectal cancer (RC) remains a formidable endeavor. The critical location of the tumor predisposes it to a circumferential resection margin that tends to involve the sphincters and surrounding organs, pelvic lymph node metastasis, and anastomotic complications. In this regard, colorectal surgeons should be aware of issues beyond the performance of total mesorectal excision (TME). For decades, abdominoperineal resection had been the standard of care for low-lying RC; however, its association with high rates of tumor recurrence, tumor perforation, and poorer survival has stimulated the development of novel surgical techniques and modifications, such as extralevator abdominoperineal excision. Similarly, difficult dissections and poor visualization, especially in obese patients with low-lying tumors, have led to the development of transanal TME or the "bottom-to-up" approach. Additionally, while neoadjuvant chemoradiotherapy has allowed for the execution of more sphincter-saving procedures without oncologic compromise, functional outcomes remain an issue. Nevertheless, neoadjuvant treatment can lead to significant tumor regression and complete pathological response, permitting the utilization of organ-preserving strategies. At present, an East and West dualism pervades the management of lateral lymph node metastasis, thereby calling for a more global and united approach. Moreover, with the increasing importance of quality of life, a tailored, individualized treatment approach is of utmost importance when taking into account oncologic and anticipated functional outcomes.

Feasibility of Extended Dissection of Lateral Pelvic Lymph Nodes During Laparoscopic Total Mesorectal Excision in Patients with Locally Advanced Lower Rectal Cancer: A Single-Center Pilot Study After Neoadjuvant Chemotherapy

BACKGROUND The feasibility of additional dissection of the lateral pelvic lymph nodes (LPLNs) in patients undergoing total mesorectal excision (TME) combined with neoadjuvant chemotherapy (NAC) for locally advanced rectal cancer (LARC) is controversial. The use of laparoscopic surgery is also debated. In the present study, we evaluated the utility of laparoscopic dissection of LPLNs during TME for patients with LARC and metastatic LPLNs after NAC, based on our experience with 19 cases. MATERIAL AND METHODS Twenty-five patients with LARC with swollen LPLNs who underwent laparoscopic TME and LPLN dissection were enrolled in this pilot study. The patients were divided into 2 groups: those patients with NAC (n=19) and without NAC (n=6). Our NAC regimen involved 4 to 6 courses of FOLFOX plus panitumumab, cetuximab, or bevacizumab. RESULTS The operative duration was significantly longer in the NAC group than in the non-NAC group (648 vs. 558 minutes, respectively; P=0.022). The rate of major complications, defined as grade ≥3 according to the Clavien-Dindo classification, was similar between the 2 groups (15.8% vs. 33.3%, respectively; P=0.4016). No conversion to conventional laparotomy occurred in either group. In the NAC group, a histopathological complete response was obtained in 2 patients (10.5%), and a nearly complete response (Tis N0 M0) was observed in one patient (5.3%). Although the operation time was prolonged in the NAC group, the other perioperative factors showed no differences between the 2 groups. CONCLUSIONS Laparoscopic LPLN dissection is feasible in patients with LARC and clinically swollen LPLNs, even after NAC.

Laparoscopic treatment of rectal cancer and lateral pelvic lymph node dissection: are they obsolete?

Laparoscopic surgery for rectal cancer offers favorable short-term results without compromising long term oncological outcomes so far, according to the data from major trials. For this reason, it is currently considered as a standard option for rectal cancer surgery. The learning curve of laparoscopic rectal cancer surgery is generally longer compared to colon cancer. Appropriate standardization and training of laparoscopic rectal cancer surgery is required. Several RCTs suggested the potential negative effect on quality of resected specimen, which can increase local recurrence. The long-term outcomes - especially local recurrence rate - of these RCTs are awaited. Lateral pelvic lymph node dissection (LPLND) has a certain effect of reducing local recurrence of rectal cancer even after neoadjuvant radiotherapy. Since LPLND is associated with postoperative morbidity, we should carefully select the candidate to maximize the effect of LPLND and minimize the morbidity caused by LPLND. Recent advancements in imaging study such as CT and MRI enable us to find the suitable candidates for LPLND. The morbidity caused by LPLND could be reduced by minimally invasive surgeries such as laparoscopic surgery and robotic surgery. We have to improve oncological outcomes and reduce morbidity by the multidisciplinary strategy for rectal cancer including total mesorectal excision, neoadjuvant chemoradiotherapy and LPLND together with laparoscopic surgery.

Session 4: Shaping radiotherapy for rectal cancer: should this be personalized?

Preoperative radiotherapy continues to be widely used in patients with operable rectal cancer. However, the indications and goals for such treatment are evolving. Professor Marijnen reviews the historic and current evidence base for the use of preoperative neoadjuvant radiotherapy and the future challenges in tailoring the therapy according to the patients' needs and tumour stage.

Incidence and Predictive Model for Lateral Pelvic Lymph Node Metastasis in Lower Rectal Cancer

The lateral pelvic lymph node recurrence after curative resection in rectal cancer has been reported in more than 20% of cases and the lateral pelvic lymph node (LPLN) metastasis is an independent risk factor for local recurrence. A prospective cohort study with diagnosis of lower rectal cancer stages II and III performed to identify the factors with significant correlation with LPLN metastasis was categorised based on the number of positive factors and proposed a risk stratification model to uncover a possible benefit of LPLD in specific patient subgroups. Forty-three patients with lower rectal cancer underwent curative surgery, total mesorectal excision with bilateral lateral pelvic lymph node dissection. Pre-operative, female gender, raised serum CEA (> 5 ng/mL), cT4, enlarged mesorectal lymph nodes, borderline enlarged LPLN on MRI, lower location (< 5 cm from anal verge), large size (> 5 cm) and non-circumferential lesion were significant predictors for LPLN metastasis. Histopathological, higher tumour grade, higher pT and pN stage, and the presence of LVI were significant factors. On cox-proportional hazard model analysis, female gender, large tumour, cT4, enlarged mesorectal lymph nodes, borderline enlarged LPLN, pN1 and positive LVI were associated with significant hazard. In conclusion, a specific group of patients with lower rectal cancer of stages II and III might be have treated with LPND in spite of concurrent chemo-radiation to achieve satisfactory oncological outcome. The proposed stratification grouping is strongly guiding the patient for lateral pelvic lymph node dissection. Further study to prove the oncological advantage of LPND is warranted at large scale.

Standard versus extralevator abdominoperineal excision and oncologic outcomes for patients with distal rectal cancer: A meta-analysis

BACKGROUND

The role of extralevator abdominoperineal excision (ELAPE) for distal rectal cancer remains controversial, and the procedure is not widely accepted or practiced.

METHODS

An electronic search of Medline, EMBASE, Web of Science, and similar databases for articles in English was performed from the inception of the study until October 31, 2017. Two reviewers extracted information and independently assessed the quality of included studies by the methodological index for nonrandomized studies, then data were analyzed with Review Manager 5.3 software and Stata version 12.0 software.

RESULTS

Our meta-analysis included 17 studies with 3479 patients, of whom 1915 (55.0%) underwent ELAPE and 1564 (44.0%) underwent abdominoperineal excision (APE). Compared with patients undergoing APE, patients undergoing ELAPE had a significant reduced risk of no more than 3 years local recurrence (LR) (risk ratio [RR] = 0.27, 95% confidence interval [CI] = 0.08-0.94), 3-year mortality (odds ratio [OR] = 0.45, 95% CI = 0.20-0.97), intraoperative bowel perforation (IBP) involvement (RR = 0.48, 95% CI = 0.31-0.74), and circumferential resection margin (CRM) positivity (RR = 0.66, 95% CI = 0.43-1.00) at the threshold level.

CONCLUSIONS

The application of ELAPE is more effective in reducing the chance of 3 years LR, mortality, IBP involvement and CRM positivity than conventional APE, and worthy of being widely applied in surgical treatment of the distal rectal cancer.

Is There Any Reason to Still Consider Lateral Lymph Node Dissection in Rectal Cancer? Rationale and Technique

Nodal dissemination in locally advanced rectal cancer occurs mainly in two directions: upward and lateral. Lateral node involvement has been demonstrated; however, lateral lymph node dissection (LLND) is not routinely performed in Western countries and the focus is more on neoadjuvant treatment regimens. The main reasons for this are the high morbidity associated with the operation and the uncertain oncological benefit. There is, however, recent evidence that in selected cases, neoadjuvant treatment combined with total mesorectal excision only might not be sufficient. In this article, the historical developments in the East and the West, the current evidence regarding lateral nodal disease, and the surgical steps in the LLND are discussed.

Selective lateral pelvic lymph node dissection: a comparative study of the robotic versus laparoscopic approach

BACKGROUND

Lateral pelvic lymph node dissection (LPND) is a challenging procedure due to its technical difficulty and higher incidence of surgical morbidity. We compared short-term outcomes between laparoscopic and robotic LPND in patients with rectal cancer.

METHODS

Between May 2006 and December 2014, prospectively collected data from consecutive patients undergoing robotic or laparoscopic total mesorectal excision (TME) with LPND were retrospectively compared. Patients' demographics, perioperative outcomes, functional results, and initial oncologic outcomes were analyzed.

RESULTS

Fifty and 35 patients underwent robotic or laparoscopic TME with LPND, respectively. Bilateral LPND was performed in 10 patients (20%) in the robotic group and 6 (17.1%) in the laparoscopic group. For unilateral pelvic dissection, the mean operative time was not significantly different between groups (robotic vs. laparoscopic group, 41.0 ± 15.8 min vs. 35.3 ± 13.4 min; P = 0.146), but the EBL was significantly lower in the robotic group (34.6 ± 21.9 mL vs. 50.6 ± 23.8 mL; P = 0.002). Two patients (4.0%) in the robotic group and 7 (20.0%) in the laparoscopic group underwent Foley catheter reinsertion for urinary retention postoperatively (P = 0.029). The mean number of harvested lateral pelvic lymph nodes (LPNs) was 6.6 (range 0-25) in the robotic group and 6.4 (range 1-14) in the laparoscopic group. Pathologic LPN metastatic rate was not different between groups (robotic vs. laparoscopic group, 28.0 vs. 41.2%; P = 0.243). During the median follow-up of 26.3 months, overall recurrence rate was not different between groups (robotic vs. laparoscopic group, 30.0 vs. 31.2%; P = 0.850). Three patients (6.0%) in the robotic group and 4 (11.4%) in the laparoscopic group developed local recurrence (P = 0.653).

CONCLUSIONS

Robotic TME with LPND is safe and feasible with favorable short-term surgical outcomes.

Preoperative chemoradiotherapy changes the size criterion for predicting lateral lymph node metastasis in lower rectal cancer

PURPOSE

The purpose of this study was to identify the size criteria of lateral lymph node metastasis in lower rectal cancer both in patients who underwent preoperative CRT and those who did not.

METHODS

This study enrolled 150 patients who underwent resection for primary lower rectal adenocarcinoma with lateral lymph node dissection between 2013 and 2015. Patients were divided into two groups: the CRT group, treated with preoperative chemoradiotherapy before surgery, and the non-CRT group, treated with surgery alone. The short-axis diameter of each dissected lateral lymph node was measured. Receiver-operating characteristic curves were generated to reveal the optimal cutoff values for determining lateral lymph node metastasis in both groups.

RESULTS

In the non-CRT group (n = 131), the ROC curve demonstrated that the optimal cutoff value for determining metastasis was 6.0 mm, with a sensitivity of 78.5% and specificity of 82.9%, and the AUC was 0.845. In comparison, in the CRT group (n = 19), the optimal cutoff value was 5.0 mm, with a sensitivity of 71.4% and specificity of 85.3% and an AUC of 0.836.

CONCLUSION

The cutoff size for determining lateral lymph node metastasis was smaller in the CRT group than in the non-CRT group.

Preoperative Chemoradiotherapy Might Improve the Prognosis of Patients with Locally Advanced Low Rectal Cancer and Lateral Pelvic Lymph Node Metastases

BACKGROUND

Preoperative chemoradiotherapy (CRT) is a standard treatment for locally advanced low rectal cancer (LALRC). However, the prognostic significance of CRT in patients with lateral lymph node metastasis (LLNM) is unknown. The present study aimed to examine the prognostic impact of preoperative CRT in patients with LALRC and LLNM.

METHODS

We retrospectively analyzed data for 73 patients with LALRC and LLNM who underwent total mesorectal excision and lateral lymph node dissection from 1985 to 2012. The patient population was divided into a CRT group (n = 30) who received preoperative CRT and a surgery alone group (n = 43) who were treated without CRT.

RESULTS

The 5-year overall survival (OS), 5-year relapse-free survival (RFS), and 5-year local recurrence (LR) rates were significantly better in the CRT group (78.2, 72.1, and 3.5 %, respectively) compared with the surgery alone group (41.1, 25.4, and 39.6 %, respectively). There were fewer total, mesorectal, and LLNMs in the CRT group compared with the surgery alone group. Multivariate analysis showed that surgery without CRT was an independent predictor of poorer OS (hazard ratio [HR] 3.513, p = 0.004), RFS (HR 2.696, p = 0.021), and LR rates (HR 11.094, p = 0.001). A total number of lymph node metastases ≥4 were also an independent predictor of poorer OS and RFS.

CONCLUSIONS

Preoperative CRT might have a significant prognostic impact on patients with LALRC with LLNM treated with total mesorectal excision and lateral lymph node dissection.

Prognostic impact of hospital volume on familial adenomatous polyposis: a nationwide multicenter study

PURPOSE

Many studies have shown that hospital volume is significantly associated with short- and long-term outcomes in various diseases, including cancer. However, there have been no reports discussing the relationship between hospital volume and familial adenomatous polyposis (FAP). This study aimed to clarify whether hospital volume affects short- and long-term outcomes in FAP patients.

METHODS

We established a retrospectively collected database of FAP patients who underwent initial surgical treatment at 23 Japanese institutions during 2000-2012. Factors associated with short- and long-term outcomes were analyzed.

RESULTS

The study cohort included 303 FAP patients. These patients were classified into tertile categories according to hospital volume: low (n = 31), middle (n = 72), and high volume (n = 200). The proportion of only adenoma/stage 0 was comparable among tertile categories. The adoption of operative procedure significantly differed among tertile categories; specifically, high-volume institutions preferred handsewn ileal pouch-anal anastomosis without diverting ileostomy (P < 0.001 and < 0.001, respectively). Nevertheless, the frequency of complications with Clavien-Dindo classification grade ≥ 3 was not significantly different among tertile categories. Functional results were acceptable in every category. Wexner scores were significantly lower in high-volume compared to low-volume institutions (P = 0.02). Multivariate analyses showed that UICC stage and hospital volume were significantly associated with overall survival (P = 0.04 and 0.03, respectively).

CONCLUSIONS

Hospital volume was significantly associated with short- and long-term outcomes in FAP patients.

Mesorectal Excision With or Without Lateral Lymph Node Dissection for Clinical Stage II/III Lower Rectal Cancer (JCOG0212): A Multicenter, Randomized Controlled, Noninferiority Trial

OBJECTIVE

The aim of the study was to confirm the noninferiority of mesorectal excision (ME) alone to ME with lateral lymph node dissection (LLND) in terms of efficacy.

BACKGROUND

Lateral pelvic lymph node metastasis is occasionally found in clinical stage II or III lower rectal cancer, and ME with LLND is the standard procedure in Japan. ME alone, however, is the international standard surgical procedure for rectal cancer.

METHODS

Eligibility criteria included histologically proven rectal cancer at clinical stage II/III; main lesion located in the rectum, with the lower margin below the peritoneal reflection; no lateral pelvic lymph node enlargement; Peformance Status of 0 or 1; and age 20 to 75 years. Patients were intraoperatively allocated to undergo ME with LLND or ME alone in a randomized manner. The primary endpoint was relapse-free survival, with a noninferiority margin for the hazard ratio of 1.34. Secondary endpoints included overall survival and local-recurrence-free survival. Analysis was by intention to treat.

RESULTS

In total, 701 patients were randomized to the ME with LLND (n = 351) and ME alone (n = 350) groups. The 5-year relapse-free survival in the ME with LLND and ME alone groups were 73.4% and 73.3%, respectively (hazard ratio: 1.07, 90.9% confidence interval 0.84-1.36), with a 1-sided P value for noninferiority of 0.0547. The 5-year overall survival, and 5-year local-recurrence-free survival in the ME with LLND and ME alone groups were 92.6% and 90.2%, and 87.7% and 82.4%, respectively. The numbers of patients with local recurrence were 26 (7.4%) and 44 (12.6%) in the ME with LLND and ME alone groups, respectively (P = 0.024).

CONCLUSIONS

The noninferiority of ME alone to ME with LLND was not confirmed in the intent-to-treat analysis. ME with LLND had a lower local recurrence, especially in the lateral pelvis, compared to ME alone.

Prognostic Impact of Intra-abdominal/Pelvic Inflammation After Radical Surgery for Locally Recurrent Rectal Cancer

BACKGROUND

The influence of postoperative infectious complications, such as anastomotic leakage, on survival has been reported for various cancers, including colorectal cancer. However, it remains unclear whether intra-abdominal/pelvic inflammation after radical surgery for locally recurrent rectal cancer is relevant to its prognosis.

OBJECTIVE

The purpose of this study was to evaluate factors associated with survival after radical surgery for locally recurrent rectal cancer.

DESIGN

The prospectively collected data of patients were retrospectively evaluated.

SETTINGS

This study was conducted at a single-institution tertiary care cancer center.

PATIENTS

Between 1983 and 2012, patients who underwent radical surgery for locally recurrent rectal cancer with curative intent at the National Cancer Center Hospital were reviewed.

MAIN OUTCOME MEASURES

Factors associated with overall and relapse-free survival were evaluated.

RESULTS

During the study period, a total of 180 patients were eligible for analyses. Median blood loss and operation time for locally recurrent rectal cancer were 2022 mL and 634 minutes. Five-year overall and 3-year relapse-free survival rates were 38.6% and 26.7%. Age (p = 0.002), initial tumor stage (p = 0.03), pain associated with locally recurrent rectal cancer (p = 0.03), CEA level (p = 0.004), resection margin (p < 0.001), intra-abdominal/pelvic inflammation (p < 0.001), and surgery period (p = 0.045) were independent prognostic factors associated with overall survival, whereas CEA level (p = 0.01), resection margin (p = 0.002), and intra-abdominal/pelvic inflammation (p = 0.001) were associated with relapse-free survival. Intra-abdominal/pelvic inflammation was observed in 45 patients (25.0%). A large amount of perioperative blood loss was the only factor associated with the occurrence of intra-abdominal/pelvic inflammation (p = 0.007).

LIMITATIONS

This study was limited by its retrospective nature and heterogeneous population.

CONCLUSIONS

Intra-abdominal/pelvic inflammation after radical surgery for locally recurrent rectal cancer is associated with poor prognosis. See Video Abstract at http://journals.lww.com/dcrjournal/Pages/videogallery.aspx.

What To Do With Lateral Nodal Disease in Low Locally Advanced Rectal Cancer? A Call for Further Reflection and Research

BACKGROUND

There remains a lack of international consensus on the appropriate management of lateral nodal disease. Although the East manages this more aggressively with lateral lymph node dissections, the West aims to eradicate small-volume disease with neoadjuvant chemoradiotherapy and lateral nodal disease is not considered for routine surgical treatment. However, recent studies have shown that, despite neoadjuvant treatment, a significant number of patients with lateral nodal disease develop local recurrence in the lateral compartment after total mesorectal excision.

OBJECTIVE

The aim of this study is to assess the role of the pretreatment features of lateral nodes on MRI in regard to local recurrence.

DESIGN

All patients operated on for low locally advanced rectal cancer over a 5-year period were evaluated retrospectively.

SETTINGS

This study was conducted at a single expert center.

PATIENTS

The MRIs of a total of 313 patients were reviewed, and only those with rectal cancers up to 8 cm from the anorectal junction, measured on MRI, were selected. This left 185 patients; of these, 58 patients had clinical T1 or T2 tumors as assessed on MRI, identifying 127 patients who had cT3/T4 tumors that were included in this study.

MAIN OUTCOME MEASURES

The primary outcomes measured were lateral local recurrence and multivariate analyses.

RESULTS

The lateral local recurrence rate was significantly higher (33.3% 4-year rate) in patients with nodes larger than 10 mm than in patients with smaller nodes (10.1%, p = 0.03), despite patients being irradiated in the lateral compartment.

LIMITATIONS

Because this is a relatively uncommon disease, patient numbers are low, and a multicenter study is needed to further address lateral nodal disease in low rectal cancer.

CONCLUSIONS

Chemoradiotherapy with total mesorectal excision might not be sufficient in a selected group of patients. Further research is needed about which pretreatment features of the lateral nodes predict local recurrence and what is needed to prevent these from developing. See Video Abstract at http://links.lww.com/DCR/A338.

Potential impact of lateral lymph node dissection (LLND) for low rectal cancer on prognoses and local control: A comparison of 2 high-volume centers in Japan that employ different policies concerning LLND

BACKGROUND

Controversy remains around whether the addition of lateral lymph node dissection to total mesorectal excision offers benefits in terms of survival or local control to patients with low rectal cancer. This study aimed to examine the impact of lateral lymph node dissection in the treatment of low rectal cancer on prognosis and local control and to identify patients who might benefit from lateral lymph node dissection at 2 high-volume centers in Japan that employ different policies with regard to adopting lateral lymph node dissection.

METHODS

We reviewed outcomes from a total of 1,191 consecutive patients with low rectal cancer (rectal cancer distal to the peritoneal reflection) who underwent total mesorectal excision plus lateral lymph node dissection at 2 high-volume centers (the National Cancer Center and Aichi Cancer Center) in Japan. To assess the therapeutic outcomes of the respective node dissections, we applied an index calculated by multiplying the incidence by the 5-year overall survival of patients with metastasis in the respective lateral node stations. Multivariate analyses were performed to determine independent risk factors for local recurrence and prognostic factors.

RESULTS

Outcomes according to the presence or absence of lateral nodal metastases showed long-term survival with lateral dissection, even in patients with lateral nodal metastases (5-year overall survival: 53.1% at the National Cancer Center vs 45.2% at Aichi Cancer Center), while stage I to III patients with no lateral nodal metastases had very good prognoses at both centers (5-year overall survival: 81.7% at the National Cancer Center vs 81.0% at Aichi Cancer Center). According to the index of estimated benefit from lateral lymph node dissection, dissection of the distal internal iliac nodes and obturator nodes yielded the greatest therapeutic benefit in patients at both centers. Compared to patients with bilateral lateral lymph node dissection, the relative risk for local recurrence was 2.0 for those with unilateral lateral lymph node dissection.

CONCLUSION

Lateral lymph node dissection outcomes observed at the 2 high-volume centers in Japan demonstrate high reproducibility with good results in terms of prognosis. Differences in policies concerning the adoption of lateral lymph node dissection affected local recurrence rate.

The important risk factor for lateral pelvic lymph node metastasis of lower rectal cancer is node-positive status on magnetic resonance imaging: study of the Lymph Node Committee of Japanese Society for Cancer of the Colon and Rectum

PURPOSE

This study seeks to evaluate lateral pelvic lymph node (LPLN) and perirectal lymph node (PRLN) status on magnetic resonance imaging (MRI) as potential risk factors for lymph node metastasis.

METHODS

The subjects were 394 patients with lower rectal cancer who underwent MRI prior to mesorectal excision (combined with lateral pelvic lymph node dissection in 272 patients) at 6 institutes. No patients received neoadjuvant therapy. Cases were classified as cN(+) and cN(-) based on the short axis of the largest lymph node ≥5 and <5 mm, respectively. LPLN and PRLN status and other clinicopathologic factors were analyzed by multivariate logistic regression. The importance of identified risk factors for lymph node metastasis was examined using the area under the curve (AUC).

RESULTS

Independent risk factors for right LPLN metastasis included histopathological grade (G3 + G4), pPRLN(+), M1, cLPLN(+) [odds ratio (OR) 10.73, 95 % confidence interval (CI) 4.59-27.1], and those for left LPLN metastasis were age (<64), histopathological grade (G3 + G4), pPRLN(+), and cLPLN(+) (OR 24.53, 95 % CI 9.16-77.7). ORs for cLPLN(+) were highest. The AUCs for right and left cLPLN status of 0.7484 (95 % CI 0.6672-0.8153) and 0.7904 (95 % CI 0.7088-0.8538), respectively, were significantly higher than those for other risk factors. In contrast, the ORs for cPRLN(+) and cPRLN status of 2.46 (95 % CI 1.47-4.18) and 0.6396 (95 % CI 0.5917-0.6848) were not much higher than for other factors.

CONCLUSIONS

An LPLN-positive status with a short axis ≥5 mm on MRI is an important predictor of LPLN metastasis, but PRLN status is not a strong predictor of PRLN metastasis.

A Phase II/III randomized controlled trial comparing perioperative versus postoperative chemotherapy with mFOLFOX6 for lower rectal cancer with suspected lateral pelvic node metastasis: Japan Clinical Oncology Group Study JCOG1310 (PRECIOUS study)

A randomized phase II/III trial was started in May 2015 comparing perioperative versus postoperative chemotherapy with modified infusional fluorouracil and folinic acid with oxaliplatin for lower rectal cancer patients with suspected lateral pelvic node metastasis. The standard arm is total mesorectal excision or tumor-specific mesorectal excision with lateral pelvic node dissection (LND) followed by postoperative chemotherapy (modified infusional fluorouracil and folinic acid with oxaliplatin; 12 cycles). The experimental (perioperative chemotherapy) arm is six courses of modified infusional fluorouracil and folinic acid with oxaliplatin before and six courses after total mesorectal excision with lateral pelvic node dissection. The aim of this trial is to confirm the superiority of perioperative chemotherapy. A total of 330 patients will be enrolled over 7 years. The primary endpoint in Phase II part is proportion of R0 resection and that in Phase III part is overall survival. Secondary endpoints are progression-free survival, local progression-free survival, etc. This trial has been registered in the UMIN Clinical Trials Registry as UMIN000017603 [http://www.umin.ac.jp/ctr/index-j.htm].

Meta-analysis of application of lateral lymph node dissection for low rectal cancer in China

AIM: To assess the value of the application of lateral lymph node dissection (LLND) for low rectal cancer in China.

METHODS: By meta-analysis we made a comprehensive analysis of the application of LLND for low rectal cancer based on 11 articles published in China between January 2005 and September 2015.

RESULTS: Operative time was significantly longer in the LLND group than in the non-LLND (NLLND) group [weighted mean difference (WMD) = 47.79 min, P < 0.00001]. Intra-operative blood loss was significantly greater in the LLND group than in the NLLND group (WMD = 27.84, P < 0.0001). Five-year survival rate was significantly higher in the LLND group than in the NLLND group (59.38% vs 51.3%, P = 0.02). Three-year survival rate was also significantly higher in the LLND group than in the NLLND group (81.6% vs 63.5%, P < 0.00001). Local recurrence rate for the NLLND group (16.9%) was significantly higher than that of the LLND group (8.4%) (P = 0.0003). Local recurrence rate showed no statistical difference between the LLND group and the NLLND group for stage I or IIA low rectal cancer, but was significantly lower in the LLND group than in the NLLND group for stage Ⅲ rectal cancer (14.5% vs 22.1%, P = 0.01).

CONCLUSION: Lateral lymph node dissection in Chinese patients with low rectal cancer can effectively prolong the 5-year survival rate and 3-year survival rate, decrease the local recurrence rate (especially in stage Ⅲ low rectal cancer) and improve the patient's prognosis, but it increases the operative time and the amount of bleeding.

Clinical Significance of Extramural Tumor Deposits in the Lateral Pelvic Lymph Node Area in Low Rectal Cancer: A Retrospective Study at Two Institutions

Background

The presence of extramural tumor deposits without lymph node structure (EX) is an important prognostic factor for patients with colorectal cancer. However, the clinical significance of EX in the lateral pelvic lymph node area (LP-EX) remains unclear. This study aimed to determine the prognostic implications of LP-EX for patients with low rectal cancer.

Methods

This retrospective study involved 172 consecutive patients with stage 2 or 3 low rectal cancer who underwent curative surgery including lateral pelvic lymph node (LPLN) dissection. The patients were classified into the following three groups according to the metastatic status of the LPLN area: patients without metastasis (no-LP-M group), patients with lymph node metastasis (LP-LNM group), and patients with EX (LP-EX group). Potential prognostic factors of overall survival (OS) and relapse-free survival (RFS) were identified in uni- and multivariate analyses.

Results

Classification assigned 131 patients (76 %) to the no-LP-M group, 27 patients (16 %) to the LP-LNM group, and 14 patients (8 %) to the LP-EX group. The 5-year OS rate was 80.3 % in the no-LP-M group, 61.1 % in the LP-LNM group, and 34.9 % in the LP-EX group (P < 0.001). The corresponding 5-year RFS rates were 62.2, 33.8, and 14.3 %, respectively (P < 0.001). A multivariate Cox proportional hazards regression analysis showed that the presence of LP-EX was an independent prognostic factor for OS (P = 0.006) and RFS (P = 0.001).

Conclusions

The LP-EX classification is a useful pathologic parameter that can be used to stratify patients with metastasis in the LPLN area.

A prospective feasibility study to evaluate neoadjuvant-synchronous S-1 with radiotherapy for locally advanced rectal cancer: A multicentre phase II trial

Treatment results of locally advanced rectal cancer without preoperative chemoradiotherapy (CRT) in Japan do not differ from those of Western countries. Preoperative CRT with new anticancer agents may decrease local recurrence rate and prevent distant metastases, thus improving survival. We conducted a trial to evaluate feasibility of neoadjuvant CRT using S-1 in patients with locally advanced rectal cancer. A multi-institutional (17 specialized centres), interventional, phase II trial was conducted from April 2009 to August 2011. Patients fulfilling the following requirements before neoadjuvant CRT were included: histologically proven rectal carcinoma; tumour in the upper or lower rectum; cancer classified as T3-4 N0-3 M0. Neoadjuvant CRT with S-1 (80 mg/m²/day on days 1-5, 8-12, 22-26, and 29-33) and irradiation (total 45 Gy/25 fr, 1.8 Gy/day, on days 1-5, 8-12, 15-19, 22-26, and 29-33) was performed. Total mesorectal excision with D3 lymphadenectomy was performed during weeks 4 and 8 after completion of neoadjuvant CRT. The primary endpoint was completion rate of neoadjuvant CRT. Secondary endpoints were response rate to neoadjuvant CRT, short-term clinical outcomes, curative resection rate, and pathologic response (grade 2/3). Of the 37 patients included, 86.5% completed neoadjuvant CRT (95% CI, 75.5-97.5%), and 10.8% (4) experienced an adverse event (grade 3/4). Response rate (RECIST 1.0) was 56.8% (95% CI, 40.8-72.7%), and pathologic response rate was 48.6% (95% CI, 32.5-64.8%). This study demonstrated that neoadjuvant-synchronous S-1+radiotherapy for locally advanced rectal cancer was feasible in terms of pathologic response and adverse events. Registration number: UMIN-CTR, No. C003396.

Treating patients with advanced rectal cancer and lateral pelvic lymph nodes with preoperative chemoradiotherapy based on pretreatment imaging

Preoperative chemoradiotherapy (CRT) and lateral pelvic lymph node (LPLN) dissection (LPLD) based on pretreatment imaging are performed to improve oncological outcomes at our institution. However, the advantage of LPLD following preoperative CRT in advanced rectal cancer remains unclear. The objective of the present study was to assess the validity of this approach. Thirty-two patients with advanced rectal cancer were included in the study. All patients were treated with preoperative CRT and curative operation. Of these, 16 patients who were treated between August 2005 and June 2008 underwent LPLD on both sides (LPLD group). Sixteen patients who were treated between July 2008 and January 2013 underwent LPLD only on the side with suspected LPLN metastasis determined by pretreatment imaging; in cases without LPLN metastasis, only total mesorectal excision was performed (limited-LPLD group). The overall survival and relapse-free survival between the LPLD and the limited-LPLD groups were compared. Preoperative CRT was able to lower clinical lymph node status in 50% of the cases. In addition, pathological lymph node status did not exceed the pretreatment clinical lymph node status stage in the LPLD group. There were no differences in the overall survival and relapse-free survival between the two groups (P=0.729 and P=0.874, respectively). We conclude that multi-imaging studies have a very low risk of overlooking pathologically positive LPLN metastases. Therefore, limited LPLD is a feasible strategy for patients with advanced rectal cancer and suspicious LPLN metastases based on pretreatment imaging.

Laparoscopic lateral pelvic lymph node dissection is achievable and offers advantages as a minimally invasive surgery over the open approach

BACKGROUND

Laparoscopic lateral pelvic lymph node dissection (LPLD) is a minimally invasive alternative to open surgical therapy for advanced low rectal cancer patients. This study assessed potential risk factors for lateral pelvic lymph node metastasis (LPLM) and evaluated the feasibility and oncological safety of laparoscopic LPLD compared with the conventional open approach.

METHODS

We retrospectively reviewed the clinical records of 90 patients with advanced low rectal cancer who underwent LPLD following total mesorectal excision at Kyushu University Hospital between January 2001 and July 2014. We compared the clinicopathological features between the patients with and without LPLM and the surgical outcomes between patients who underwent laparoscopic LPLD (LL) and open LPLD (OL).

RESULTS

Fourteen (15.6 %) patients had LPLM. Univariate analysis revealed that undifferentiated cancer, positive lymphatic invasion, >50 % circumferential cancer extent, mesorectal lymph node metastases (MLM), and distant metastasis were associated with LPLM. In the multivariate analysis, MLM was the only independent risk factor for LPLM. Forty-six (51.1 %) patients underwent LL, and 44 (48.9 %) patients underwent OL. The mean surgical duration was longer in the LL group than in the OL group (641.0 vs. 312.0 min, P < 0.001). The LL group also had less hemorrhage (252.0 vs. 815.0 mL, P < 0.001) and a shorter hospital stay (22.9 vs. 29.1 days, P = 0.04) than the OL group. The mean number of harvested lateral pelvic lymph nodes was larger in the LL group than in the OL group (19.5 vs. 15.8, P < 0.05). The morbidity rate and overall survival (3-year OS: 94.7 vs. 82.9 %, P = 0.25) did not differ between the two groups.

CONCLUSIONS

Patients with advanced low rectal cancer presenting MLM are good candidates for LPLD. Laparoscopic LPLD enables retrieval of more lymph nodes and may be acceptable for the treatment of advanced low rectal cancer.

Practice Guideline for the Surveillance of Patients After Curative Treatment of Colon and Rectal Cancer

Current evidence suggests improved rates of curative secondary treatment following identification of recurrence among patients who participate in a surveillance program after initial curative resection of colon or rectal cancer. The newer data show that surveillance CEA, chest and liver imaging,and colonoscopy can also improve survival through early diagnosis of recurrence; thus, these modalities are now included in the current guideline. Although the optimum strategy of surveillance for office visits, CEA, chest and liver imaging, and colonoscopy is not yet defined, routine surveillance does improve the detection of recurrence that can be resected with curative intent. Recommended surveillance schedules are shown in Table 4. However, the factors to be considered when recommending surveillance include underlying risk for recurrence, patient comorbidity, and the ability to tolerate major surgery to resect recurrent disease or palliative chemotherapy, performance status, physiologic age, preference, and compliance. The success of surveillance for early detection of curable recurrence will depend on patient and provider involvement to adhere to the surveillance schedule and avoid unnecessary examination. It should be noted that, after curative resection of colorectal cancer, patients are still at risk for other common malignancies(lung, breast, cervix, prostate) for which standard screening recommendations should be observed and measures to maintain general health (risk reduction for cardiovascular disease, eg, cessation of smoking, control of blood pressure and diabetes mellitus, balanced diet, regular exercise and sleep, and flu vaccines) should be recommended.

Optimizing the selection of patients with low rectal cancer for intersphincteric resection by evaluating vertical invasion to the levator and external sphincter

AIM

The indications for intersphincteric (ISR) anterior resection are not clearly defined. The aim of this study was to evaluate vertical extension of T2 or T3 low rectal cancer treated by rectal amputation to optimize patient selection for ISR.

METHOD

The abdominoperineal excision specimens of T2 or T3 low rectal cancer from 53 patients treated between 1992 and 2004 were retrospectively reviewed. Vertical invasion was quantified by measuring the shortest distance between the tumour and the striated muscle (T-SM), assuming that this represented the surgical margin that would have be achieved had an ISR been performed.

RESULTS

Involvement of the dentate line (DL) and intramural distal spread were independent risk factors for T-SM ≤ 2 mm. The T-SM was less when the inferior border of the tumour was on the distal side of the DL (r = 0.572, P < 0.001). The probability of involvement of the DL, intramural distal spread or either one of these being associated with T-SM ≤ 2 mm was 43, 46 and 43%, respectively. All patients without both intramural distal spread and involvement of the DL had T-SM > 2.

CONCLUSION

We recommend that ISR should only be performed for patients with T2 or T3 low rectal cancer in whom the lowest edge of the tumour is above the DL and there is no intramural distal spread. Such patients are relatively unlikely to have a T-SM ≤ 2 mm.

Neoadjuvant capecitabine, bevacizumab and radiotherapy for locally advanced rectal cancer: results of a single-institute Phase I study

The aim of this Phase I clinical trial was to assess the feasibility and safety of capecitabine-based preoperative chemoradiotherapy (CRT) combined with bevacizumab and to determine the optimal capecitabine dose for Japanese patients with locally advanced rectal cancer. Patients with cT3/T4 rectal cancer were eligible. Bevacizumab was administered at 5 mg/kg intravenously on Days 1, 15 and 29. Capecitabine was administered on weekdays concurrently with pelvic radiotherapy at a daily dose of 1.8 Gy, totally to 50.4 Gy. Capecitabine was initiated at 825 mg/m(2) twice daily at Dose Level 1, with a planned escalation to 900 mg/m(2) twice daily at Dose Level 2. Within 6.1-10.3 (median, 9.4) weeks after the completion of the CRT, surgery was performed. Three patients were enrolled at each dose level. Regarding the CRT-related acute toxicities, all of the adverse events were limited to Grade 1. There was no Grade 2 or greater toxicity. No patient needed attenuation or interruption of bevacizumab, capecitabine or radiation. All of the patients received the scheduled dose of CRT. All of the patients underwent R0 resection. Two (33.3%) of the six patients had a pathological complete response, and five (83.3%) patients experienced downstaging. In total, three patients (50%) developed postoperative complications. One patient developed an intrapelvic abscess and healed with incisional drainage. The other two patients healed following conservative treatment. This regimen was safely performed as preoperative CRT for Japanese patients with locally advanced rectal cancer. The recommended capecitabine dose is 900 mg/m(2) twice daily.

Laparoscopic salvage surgery for locally recurrent rectal cancer

BACKGROUND

Surgical treatment for locally recurrent rectal cancer is challenging, and the value of laparoscopic surgery in such cases is unknown. The purpose of this study was to compare the feasibility of laparoscopic surgery with that of open surgery for locally recurrent rectal cancer.

METHODS

Thirty patients with local rectal cancer recurrence at the anastomotic site or lateral pelvic lymph nodes were evaluated. Perioperative outcomes were compared between the laparoscopic (n = 13) and open (n = 17) groups.

RESULTS

The median operation time was significantly longer (381 vs. 241 min) but the median estimated blood loss tended to be smaller (110 vs. 450 mL) in the laparoscopic than in the open group. There was only one converted case (7.7%). The R0 resection rate (100 vs. 94%) and postoperative complications (31 vs. 24%) were not significantly different between the two groups. The median times to flatus (1 vs. 2 days), first stool (2 vs. 5 days), and oral intake (2 vs. 5 days) were significantly shorter in the laparoscopic than in the open group.

CONCLUSION

Laparoscopic surgery for locally recurrent rectal cancer has short-term benefits over open surgery and has potential as a treatment option for locally recurrent rectal cancer.

A phase I trial of preoperative S-1 in combination with oxaliplatin and pelvic radiation for lower rectal cancer with T4 and lateral pelvic lymph node metastasis

BACKGROUND

The purpose of this phase I study of the dose escalation of oxaliplatin in combination with oral S-1 and pelvic radiation preoperatively for poor-risk lower rectal cancer was to determine the dose-limiting toxicity (DLT) and recommended dose of oxaliplatin.

METHODS

Patients with cT4 and lateral pelvic lymph node metastasis, and without distant metastasis (cM0), were treated with weekly oxaliplatin, oral S-1 40 mg/m(2) twice daily for 5 days a week, and radiation. A total of 5 weekly doses of oxaliplatin were planned. RT was administered to a total dose of 50.4 Gy in 28 fractions.

RESULTS

We enrolled 11 patients between December 2009 and January 2012. DLTs were observed at dose level 1 (50 mg/m(2)) in two patients, one of whom experienced grade 3 aspartate aminotransferase elevation and a grade 3 alanine aminotransferase increase, and the other developed grade 4 hypokalemia and a grade 3 alanine aminotransferase increase. Five patients at dose level 2 (60 mg/m(2)) showed no DLTs. The hematological toxicities in all patients were mild and reversible. One patient showed distant metastasis after chemoradiation. Ten of the 11 patients achieved R0 resection by mesorectal resection and lateral lymph node dissection; three of the 10 underwent combined resection of the other organs.

CONCLUSION

This phase I trial of preoperative S-1 in combination with oxaliplatin and radiation for lower rectal cancer with T4 and lateral pelvic lymph node metastasis revealed that the recommended dose of oxaliplatin was 60 mg/m(2) weekly.

Clinical feasibility of laparoscopic lateral pelvic lymph node dissection following total mesorectal excision for advanced rectal cancer

PURPOSE

To evaluate the technical feasibility, safety and oncological outcomes of laparoscopic lateral pelvic lymph node dissection in patients with advanced low rectal cancer.

METHODS

Laparoscopic lateral pelvic lymph node dissection was performed in 18 patients from November 2009 to September 2012. The data regarding the patient demographics, surgical outcomes and short-term oncological outcomes were analyzed.

RESULTS

In all 18 patients, the procedures were completed without conversion to open surgery. The mean length of the operation was 603.7 min (473-746 min). The mean number of harvested lateral pelvic lymph nodes was 16.9 (7-27), and five patients (27.8 %) had lymph node metastases. The postoperative mortality and morbidity rates were 0 and 16.7 %, respectively. Three patients developed Grade 2 urinary retention. No local recurrence had developed after a mean follow-up period of 23.6 months.

CONCLUSION

Laparoscopic lateral pelvic lymph node dissection is technically feasible, safe and oncologically acceptable within the limitations of the short-term follow-up period.

Lateral lymph node dissection for lower rectal cancer

The mainstay of surgical therapy for rectal cancer is colectomy (including lesions) with lymph node dissection. The lymphatic spread of rectal cancer can proceed in two directions: medially toward the origin of the inferior mesenteric artery or laterally toward the pelvis aslong the internal iliac artery. To prevent postoperative recurrence, lymph nodes situated along these two axes should be adequately dissected, leaving no residual cancer cells. In Japan, the standard procedure for advanced lower rectal cancer is mesorectal excision and lateral lymph node dissection with autonomic nerve preservation. In Europe and North America, lateral lymph node dissection used to be performed, but it led to increased blood loss, complications, and dysfunction, with no improvement in survival. Lateral lymph node dissection is thus no longer performed. Instead, multidisciplinary therapy combining mesorectal excision with preoperative chemoradiotherapy is now the standard treatment for advanced rectal cancer. Although lateral lymph node dissection decreases the rate of local recurrence similar to preoperative chemoradiotherapy, whether it contributes to improved survival remains unclear. In addition, it is unlikely that prophylactic lateral lymph node dissection is required in all patients with rectal cancer. Definition of the indications for lateral lymph node dissection is thus an important concern.

Neoadjuvant chemoradiotherapy affects the indications for lateral pelvic node dissection in mid/low rectal cancer with clinically suspected lateral node involvement: a multicenter retrospective cohort study

BACKGROUND

Although lateral pelvic node dissection (LPND) is recommended for rectal cancer with clinically metastatic lateral pelvic lymph nodes (LPNs), LPNs may respond to neoadjuvant chemoradiotherapy (nCRT). Our aim was to determine the optimal indication for LPND after nCRT for mid/low rectal cancer.

METHODS

Of 2,263 patients with clinical stage II/III mid/low rectal cancer who were managed at three tertiary referral hospitals, 66 patients underwent curative surgery including LPND after nCRT were included in this study. Risk factors for LPN metastasis were retrospectively analyzed and oncologic outcomes determined according to LPN response to nCRT.

RESULTS

Persistent LPNs greater than 5 mm on post-nCRT magnetic resonance imaging were significantly associated with residual tumor metastasis, unlike responsive LPN after nCRT (short-axis diameter ≤ 5 mm) (pathologically, 61.1 % [22 of 36] vs. 0 % [0 of 30], P < 0.001). Multivariable analysis revealed post-nCRT LPN size as a significant and independent risk factor for LPN metastasis (odds ratio 2.390; 95 % confidence interval 1.104-4.069). Over a median follow-up of 39.3 months, the recurrence rate was lower in patients with responsive nodes than in patients with persistent nodes (20 % [6 of 30] vs. 47.2 % [17 of 36], P = 0.012). The 5-year overall survival and 5-year disease-free survival rates were lower in patients with persistent LPN than in patients with responsive LPN (44.6 % vs. 77.1 %, P = 0.034; 33.7 % vs. 72.5 %, P = 0.011, respectively).

CONCLUSIONS

In mid/low rectal cancer with clinically metastatic LPNs, the decision to perform LPND should be based on the LPN response to nCRT.

Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis

PURPOSE

The oncological superiority, i.e., lower circumferential resection margin (CRM) involvement, lower intraoperative perforation (IOP), and local recurrence (LR) rates, of extralevator abdominoperineal resection (EAPR) over conventional abdominoperineal resection (APR) for rectal cancer is inconclusive. This meta-analysis systematically compared the rates of CRM involvement, IOP, and LR of rectal cancer patients treated by EAPR and APR, respectively.

METHODS

An electronic literature search of MEDLINE, EMBASE, and Cochrane Library through May 2013 was performed by two investigators independently to identify studies evaluating the CRM involvement, IOP, and LR rates of EAPR and APR, and search results were cross-checked to reach a consensus. Data was extracted accordingly. A Mantel-Haenszel random effects model was used to calculate the odds ratio (OR) with 95 % confidence intervals (95 % CI).

RESULTS

Six studies with a total of 881 patients were included. Meta-analysis of CRM involvement and IOP data from all six studies demonstrated significant lower CRM involvement (OR, 0.36; 95%CI, 0.23-0.58; P < 0.0001) and IOP (OR, 0.31; 95%CI, 0.12-0.80; P = 0.02) rates of EAPR. Data from four studies also showed that EAPR was associated with a lower LR rate than APR (OR, 0.27; 95%CI, 0.08-0.95; P = 0.04). No differences of between-study heterogeneity or publication bias were seen in any of the meta-analyses.

CONCLUSIONS

Extralevator abdominoperineal resection could achieve better CRM involvement outcome and lower IOP and LR rates, demonstrating an oncological superiority over conventional abdominoperineal resection.

Distal dissection in total mesorectal excision, and preoperative chemoradiotherapy and lateral lymph node dissection for rectal cancer

The local recurrence rate after total mesorectal excision (TME) appears to be markedly lower than that after conventional operations. We reviewed all relevant articles identified from the MEDLINE databases and clarified the rationale for TME. It is clear that distal intramural spread is rare. Even when present, such spread is not likely to extend beyond 2 cm. Data with attention to mesorectal cancer deposits suggest that mesorectal clearance of at least 4-5 cm distal to the tumor should be sufficient. TME should be performed for most tumors of the mid- and lower rectum. This does not mean that the gut tube needs to be divided at the same level in every case. Dissection of the distal mesorectum off the gut tube can be performed, so the distal line of division of the bowel wall can be made at a minimum of 2 cm below the tumor if such a maneuver would ensure that the sphincters are preserved. In cases with cancer in the upper third of the rectum, the mesorectum and gut tube can safely be divided 5 cm below the tumor without jeopardizing the recurrence rates. Our findings indicate that TME is an essential treatment approach for rectal cancer, and lateral lymph node dissection and preoperative chemoradiotherapy are additional therapies that should be considered for advanced rectal cancer.

Neo-adjuvant radiotherapy in rectal cancer

In rectal cancer treatment, attention has focused on the local primary tumour and the regional tumour cell deposits to diminish the risk of a loco-regional recurrence. Several large randomized trials have also shown that combinations of surgery, radiotherapy and chemotherapy have markedly reduced the risk of a loco-regional recurrence, but this has not yet had any major influence on overall survival. The best results have been achieved when the radiotherapy has been given preoperatively. Preoperative radiotherapy improves loco-regional control even when surgery has been optimized to improve lateral clearance, i.e., when a total mesorectal excision has been performed. The relative reduction is then 50%-70%. The value of radiotherapy has not been tested in combination with more extensive surgery including lateral lymph node clearance, as practised in some Asian countries. Many details about how the radiotherapy is performed are still open for discussion, and practice varies between countries. A highly fractionated radiation schedule (5 Gy × 5), proven efficacious in many trials, has gained much popularity in some countries, whereas a conventionally fractionated regimen (1.8-2.0 Gy × 25-28), often combined with chemotherapy, is used in other countries. The additional therapy adds morbidity to the morbidity that surgery causes, and should therefore be administered only when the risk of loco-regional recurrence is sufficiently high. The best integration of the weakest modality, to date the drugs (conventional cytotoxics and biologicals) is not known. A new generation of trials exploring the best sequence of treatments is required. Furthermore, there is a great need to develop predictors of response, so that treatment can be further individualized and not solely based upon clinical factors and anatomic imaging.

Clinical implication of additional selective lateral lymph node excision in patients with locally advanced rectal cancer who underwent preoperative chemoradiotherapy

PURPOSE

To identify the indication and prognostic significance of lateral lymph node (LLN) excision in locally advanced rectal cancer patients underwent preoperative chemoradiotherapy.

METHODS

Included were 67 consecutive patients with suspicious LLN metastasis who underwent chemoradiotherapy and surgery including selective LLN excision (82 excisions). The excisions were grouped according to the presence of LLN metastasis and compared in terms of the clinicopathological findings and oncological results. The correlation between the largest short-axis diameter of LLN measured by imaging and metastasis rates was explored.

RESULTS

LLN metastases were identified in 32 excisions (40.0 %). The calculated short-axis LLN diameter predicting metastasis was 11.7 mm (before chemoradiotherapy) and 11.4 mm (before surgery). LLN metastasis was observed more frequently in the low rectum (p = 0.031) and associated with higher CEA levels (p = 0.048). The 3-year overall survival rates for patients with and without LLN metastasis were 60.3 % and 90.3 % (p = 0.048), while the 3-year disease-free survival rates were 31.4 % and 70.5 % (p = 0.009). The hazard ratio of LLN metastasis for recurrence was 2.938 (95 % CI = 1.258-6.863).

CONCLUSIONS

LLN metastasis in rectal cancer patients underwent chemoradiotherapy was a distinct poor prognostic factor. Selective LLN excision based on imaging studies may have a role for such patients.

Post-chemoradiation anastomotic recurrence in locally advanced rectal cancer: no increased risk associated with distal margin

BACKGROUND AND PURPOSE

Anastomotic recurrence after radical sphincter-preserving surgery preceded by neoadjuvant therapy in locally advanced rectal cancer is an uncommon event that merits further assessment. The aim of this study is to analyze the effect of preoperative chemoradiation on the risk of anastomotic recurrence. Based on the initial extension of the tumor, we analyzed whether the distal surgical section was calculated through the virtual initial extension of the rectal tumor.

PATIENTS AND METHODS

Eligible patients with locally advanced rectal cancer were offered preoperative chemoradiation, sphincter sparing surgery and intraoperative radiation therapy boost.

RESULTS

180 patients were treated with anterior resection (40 %), low anterior resection (45.6 %) and ultra-low anterior resection (14.4 %). With a median follow-up of 41.1 months (0.36-143 months), anastomotic recurrence was diagnosed in 9 patients (5 %). There was no statistical correlation with downstaging (T or N), downsizing effects, or with distance from the lower limit of the residual lesion to the distal margin. Virtual intratumoral surgical section was speculated in 44 patients (3 developed anastomotic recurrence; 6.8 vs 4.8 %, p = 0.482).

CONCLUSION

Anastomotic recurrence in patients with rectal cancer treated with neoadjuvant chemoradiation is an infrequent event. Virtual intratumoral surgical sections followed by anastomosis do not contribute to an excessive risk of recurrence. Our findings encourage the development of policies for preservation of the ano-rectal complex in rectal cancer patients.

Selective lateral pelvic lymph node dissection in patients with advanced low rectal cancer treated with preoperative chemoradiotherapy based on pretreatment imaging

BACKGROUND

The significance of lateral pelvic lymph node (LPLN) metastasis in advanced low rectal cancer treated with preoperative chemoradiotherapy (CRT) remains unclear. The objective of this study was to evaluate the outcomes of selective LPLN dissection (LPLD) based on the pretreatment imaging in patients with advanced low rectal cancer treated with preoperative CRT.

METHODS

We reviewed 127 consecutive patients with clinical stage II-III low rectal cancer below the peritoneal reflection who underwent preoperative CRT and curative resection. LPLD was performed in patients with suspected LPLN metastasis based on MDCT or MRI before CRT (LPLD group, N = 38), and only total mesorectal excision (TME) was performed in patients without suspected LPLN metastasis (TME group, N = 89). Clinical characteristics and the oncological outcome were compared between groups.

RESULTS

The median tumor-to-anal verge distance was 40 mm in both groups. The median maximum long-axis LPLN diameter before CRT was 0 mm in the TME group and 10.5 mm in the LPLD group. Pathological LPLN metastasis was confirmed in 25 patients (66 %) in the LPLD group. Local recurrence at LPLN developed in 3 patients (3.4 %) in the TME group and in none (0 %) of the LPLD group. Multivariate analysis showed that only ypN was an independent prognostic factor for relapse-free survival (RFS), but LPLN metastasis was not associated with poor RFS.

CONCLUSIONS

The incidence of LPLN metastasis is high even after preoperative CRT, and LPLD might improve local control and survival of patients with LPLN metastasis in advanced low rectal cancer treated with preoperative CRT.

Initial clinical experience with robotic lateral pelvic lymph node dissection for advanced rectal cancer

Purpose

This study was conducted to evaluate the technical feasibility and safety of robotic extended lateral pelvic lymph node dissection (LPLD) in patients with advanced low rectal cancer.

Methods

A review of a prospectively-collected database at Kyungpook National University Medical Center from January 2011 to November revealed a series of 8 consecutive robotic LPLD cases with a preoperative diagnosis of lateral node metastasis. Data regarding patient demographics, operating time, perioperative blood loss, surgical morbidity, lateral lymph node status, and functional outcome were analyzed.

Results

In all eight patients, the procedures were completed without conversion to open surgery. The mean operative time of extended pelvic node dissection was 38 minutes (range, 20 to 51 minutes), the mean number of lateral lymph nodes harvested was 4.1 (range, 1 to 13), and 3 patients (38%) were found to have lymph node metastases. Postoperative mortality and morbidity were 0% and 25%, respectively, but, there was no LPLD-related morbidity. The mean hospital stay was 7.5 days (range, 5 to 12 days).

Conclusion

Robotic LPLD is safe and feasible, with the advantage of being a minimally invasive approach. Further large-scale studies comparing robotic and conventional surgery with long-term follow-up evaluation are needed to confirm these findings.