Neoadjuvant chemoradiotherapy followed by lateral pelvic lymph node dissection for rectal cancer patients: A retrospective study of its safety and indications

Tumor regression and safe distance of distal margin after neoadjuvant therapy for rectal cancer

Neoadjuvant therapy has been widely employed in the treatment of rectal cancer, demonstrating its utility in reducing tumor volume, downstaging tumors, and improving patient prognosis. It has become the standard preoperative treatment modality for locally advanced rectal cancer. However, the efficacy of neoadjuvant therapy varies significantly among patients, with notable differences in tumor regression outcomes. In some cases, patients exhibit substantial tumor regression, even achieving pathological complete response. The assessment of tumor regression outcomes holds crucial significance for determining surgical approaches and establishing safe margins. Nonetheless, current research on tumor regression patterns remains limited, and there is considerable controversy surrounding the determination of a safe margin after neoadjuvant therapy. In light of these factors, this study aims to summarize the primary patterns of tumor regression observed following neoadjuvant therapy for rectal cancer, categorizing them into three types: tumor shrinkage, tumor fragmentation, and mucinous lake formation. Furthermore, a comparison will be made between gross and microscopic tumor regression, highlighting the asynchronous nature of regression in the two contexts. Additionally, this study will analyze the safety of non-surgical treatment in patients who achieve complete clinical response, elucidating the necessity of surgical intervention. Lastly, the study will investigate the optimal range for safe surgical resection margins and explore the concept of a safe margin distance post-neoadjuvant therapy.

Optimization of treatment strategies based on preoperative imaging features and local recurrence areas for locally advanced lower rectal cancer after lateral pelvic lymph node dissection

Purpose

Local recurrence (LR) is the main cause of treatment failure in locally advanced lower rectal cancer (LALRC). This study evaluated the preoperative risk factors for LR in patients with LALRC to improve the therapeutic strategies.

Patients and Methods

LALRC patients who underwent total mesorectal excision (TME) with lateral pelvic lymph node (LPN) dissection (LPND) from January 2012 to December 2019 were reviewed. The log-rank test was used to assess local recurrence-free survival (LRFS), and multivariate Cox regression was used to identify the prognostic risk factors for LRFS. Follow-up imaging data were used to classify LR according to the location.

Results

Overall, 376 patients were enrolled, and 8.8% (n=33) of these patients developed LR after surgery. Multivariate analysis identified positive clinical circumferential resection margin (cCRM) as an independent prognostic factor for LRFS (HR: 4.94; 95% CI, 1.75-13.94; P=0.003). The most common sites for LR were the pelvic plexus and internal iliac area (PIA) (54.5%), followed by the central pelvic area (CPA) (39.4%) and obturator area (OA) (6.1%). Following a subgroup analysis, LR in the OA was not associated with positive cCRM. Patients treated with upfront surgery (n=35, 14.1%) had a lower cCRM positive rate when compared with patients treated with neoadjuvant chemoradiotherapy (nCRT) (n=12, 23.5%). However, the LR rate in the nCRT group was still lower (n=28, 36.4%) than that in the upfront surgery group (n=35, 14.%). Among patients with positive cCRM, the LR rate in patients with nCRT remained low (n=3, 10.7%).

Conclusion

Positive cCRM is an independent risk factor for LR after TME plus LPND in LALRC patients. LPND is effective and adequate for local control within the OA regardless of cCRM status. However, for LALRC patients with positive cCRM, nCRT should be considered before LPND to further reduce LR in the PIA and CPA.

Feasibility, Indications, and Prognostic Significance of Selective Lateral Pelvic Lymph Node Dissection After Preoperative Chemoradiotherapy in Middle/Low Rectal Cancer: Results of a Multicenter Lateral Node Study in China

BACKGROUND

Lateral pelvic lymph node dissection after preoperative chemoradiotherapy can decrease local recurrence to lateral compartments, thereby providing survival benefits.

OBJECTIVE

The safety of lateral pelvic lymph node dissection after preoperative chemoradiotherapy was investigated, and the surgical indications and survival benefits of lateral pelvic lymph node dissection were established on the basis of preoperative characteristics.

DESIGN

A multicenter retrospective study.

SETTINGS

Three hospitals in China.

PATIENTS

Four hundred nine patients with clinical evidence of lateral pelvic lymph node metastasis.

INTERVENTIONS

Patients who received lateral pelvic lymph node dissection were divided into 2 groups depending on whether they received chemoradiotherapy (n = 139) or not (n = 270).

MAIN OUTCOME MEASURES

The safety, indications, and survival benefits of lateral pelvic lymph node dissection after preoperative chemoradiotherapy were investigated.

RESULTS

The surgery times were significantly prolonged by preoperative chemoradiotherapy (291.3 vs 265.5 min; p = 0.021). Multivariate analysis demonstrated that poor/mucinous/signet-ring adenocarcinoma (OR = 4.42, 95% CI, 2.24-11.27; p = 0.031) and postchemoradiotherapy lateral pelvic lymph node short-axis diameter ≥7 mm (OR = 15.2, 95% CI, 5.89-53.01; p < 0.001) were independent predictive factors for lateral pelvic lymph node metastasis. Multivariate prognostic analysis showed that swollen lateral pelvic lymph nodes beyond the obturator or internal iliac as well as the involvement of 3 or more lateral pelvic lymph nodes were independent adverse prognostic factors.

LIMITATIONS

The retrospective nature of the study and the small sample size were the limitations of this study.

CONCLUSIONS

Preoperative chemoradiotherapy combined with lateral pelvic lymph node dissection is a practicable procedure with acceptable morbidity. Postchemoradiotherapy lateral pelvic lymph node short-axis diameter ≥7 mm and poor/signet/mucinous adenocarcinoma could be used for predicting lateral pelvic lymph node metastasis after chemoradiotherapy. However, lateral pelvic lymph node dissection should be carefully considered in patients with swollen lateral pelvic lymph nodes beyond the obturator or internal iliac region or involvement of multiple lateral pelvic lymph nodes. See Video Abstract at http://links.lww.com/DCR/C133 .

VIABILIDAD, INDICACIONES E IMPORTANCIA PRONSTICA DE LA DISECCIN SELECTIVA DE GANGLIOS LINFTICOS PLVICOS LATERALES DESPUS DE QUIMIORRADIOTERAPIA PREOPERATORIA EN CNCER DE RECTO MEDIO/INFERIOR RESULTADOS DE UN ESTUDIO MULTICNTRICO DE GANGLIOS LATERALES EN CHINA

ANTECEDENTES:La disección de los ganglios linfáticos pélvicos laterales después de la quimiorradioterapia preoperatoria puede disminuir la recurrencia local en los compartimentos laterales, lo que brinda beneficios de supervivencia.OBJETIVO:Se investigó la seguridad de la disección de los ganglios linfáticos pélvicos laterales después de la quimiorradioterapia preoperatoria, y se establecieron las indicaciones quirúrgicas y los beneficios de supervivencia de la disección de los ganglios linfáticos pélvicos laterales en función de las características preoperatorias.DISEÑO:Estudio retrospectivo multicéntrico.ESCENARIO:Tres hospitales en China.PACIENTES:Cuatrocientos nueve pacientes con evidencia clínica de metástasis en los ganglios linfáticos pélvicos laterales.INTERVENCIONES:Los pacientes que recibieron disección de ganglios linfáticos pélvicos laterales se dividieron en dos grupos dependiendo de si recibieron quimiorradioterapia (n = 139) o no (n = 270).PRINCIPALES MEDIDAS DE RESULTADO:Se investigaron la seguridad, las indicaciones y los beneficios de supervivencia de la disección de los ganglios linfáticos pélvicos laterales después de la quimiorradioterapia preoperatoria.RESULTADOS:Los tiempos de cirugía se prolongaron significativamente con la quimiorradioterapia preoperatoria (291,3 vs 265,5 min, p = 0,021). El análisis multivariable demostró que el adenocarcinoma mal diferenciado/mucinoso/en anillo de sello (odds ratio = 4,42, intervalo de confianza del 95%, 2,24-11,27; p = 0,031) y el diámetro del eje corto de los ganglios linfáticos pélvicos laterales después de la quimiorradioterapia ≥7 mm (odds ratio = 15,2, intervalo de confianza del 95%, 5,89-53,01; p < 0,001) fueron factores predictivos independientes de metástasis en los ganglios linfáticos pélvicos laterales. El análisis pronóstico multivariable mostró que la inflamación de los ganglios linfáticos pélvicos laterales más allá del obturador o la ilíaca interna, así como la afectación de tres o más ganglios linfáticos pélvicos laterales, eran factores pronósticos adversos independientes.LIMITACIONES:La naturaleza retrospectiva del estudio y el pequeño tamaño de la muestra.CONCLUSIONES:La quimiorradioterapia preoperatoria combinada con la disección de los ganglios linfáticos pélvicos laterales es un procedimiento practicable con una morbilidad aceptable. Posterior a la quimiorradioterapia, el diámetro del eje corto de los ganglios linfáticos pélvicos laterales ≥7 mm y el adenocarcinoma pobre/en sello/mucinoso podrían usarse para predecir la metástasis en los ganglios linfáticos pélvicos laterales después de la quimiorradioterapia. Sin embargo, la disección de los ganglios linfáticos pélvicos laterales debe considerarse cuidadosamente en pacientes con ganglios linfáticos pélvicos laterales inflamados más allá del obturador o de la región ilíaca interna o compromiso de múltiples ganglios linfáticos pélvicos laterales. Consulte Video Resumen en http://links.lww.com/DCR/C133 . (Traducción-Dr. Felipe Bellolio ).

Can neoadjuvant chemoradiotherapy before lateral pelvic lymph node dissection improve local control and prognosis in rectal cancer patients with clinically suspected lateral lymph node metastasis? A multicenter lateral node study in China

AIMS

Selective lateral pelvic lymph node (LPN) dissection (LPND) following neoadjuvant chemoradiotherapy (nCRT) for rectal cancer is widely recognized. This study aimed to determine the effects of nCRT before LPND on local control and prognosis of rectal cancer patients.

MATERIALS AND METHODS

Data were retrieved from a prospective database for rectal cancer patients with clinical LPN metastasis receiving total mesorectal excision and LPND at three institutions between January 2012 and December 2019. Selection bias was minimized using propensity score matching (PSM) and short-term and clinical outcomes were compared.

RESULTS

Patients (n = 213) were enrolled and grouped as either nCRT (n = 97) or non-nCRT (n = 116). PSM was used to identify 83 matched pairs. In the matched cohort, nCRT patients had a longer operation duration (310.6 vs. 265.0 min, P = 0.001), lower pathological LPN metastasis rate (32.5% vs. 48.2%, P = 0.040), and fewer harvested lymph nodes (22 vs. 25, P = 0.018) compared to the non-nCRT group. However, after PSM, the two groups had similar estimated overall 3-year survival (79.5% vs. 80.7%, P = 0.922), 3-year disease-free survival (66.1% vs. 65.5, P = 0.820), and 3-year local recurrence-free survival (88.6% vs. 89.7%, P = 0.927). Distant metastasis was the predominant recurrence pattern in the overall (45/58, 77.6%) and matched (33/44, 75.0%) cohorts.

CONCLUSIONS

LPND without nCRT is effective and sufficient in preventing local recurrence in patients with LPN metastases. Future prospective randomized controlled studies are warranted to confirm these findings. Since systemic metastasis is the predominant recurrence pattern in patients with LPN metastasis post-LPND, improved perioperative systemic chemotherapy is needed to prevent micrometastasis.

Optimization of therapeutic strategies for selective lateral lymph node dissection after neoadjuvant chemoradiotherapy in patients with rectal cancer with clinical suspected lateral lymph node metastasis

Background

Selective lateral lymph node (LLN) dissection with total mesorectal excision after neoadjuvant chemoradiotherapy (nCRT) is pointed out to reduce lateral compartment recurrence and to improve survival in patients with rectal cancer with LLN metastases. This study aimed to explore the safety, surgical indications, and survival outcomes of LLN dissection after nCRT.

Methods

This multicenter retrospective study included patients with rectal cancer with clinical evidence of LLN metastases (n = 466) treated across three hospitals in China. Patients who underwent total mesorectal excision and LLN dissection were grouped into nCRT (n = 155) and non-nCRT (n = 291), respectively. Propensity score matching was used to minimize selection bias.

Results

After matching, nCRT did not significantly increase the surgery duration, intraoperative blood loss or postoperative complications (P > 0.05). In a multivariate logistic regression analysis, poor/mucinous/signet adenocarcinoma (P = 0.042) and post-nCRT LLN short diameter ≥7 mm (P < 0.001) were independent risk factors for pathological LLN metastasis after nCRT. Overall survival (P < 0.001) and disease-free survival (P < 0.001) were significantly worse in patients with LLN metastasis, which was, however, not an independent risk factor for survival after eliminating confounders. Multivariate prognostic analysis of 40-patient subset with pathological LLN metastasis showed that distant metastasis, metastasis beyond the obturator or internal iliac region, and ≥2 LLN metastasis were independent predictors of poor overall survival.

Conclusions

Selective LLN dissection after nCRT is safe and feasible with acceptable perioperative outcomes. Patients with a post-nCRT LLN short diameter ≥7 mm or poor/mucinous/signet adenocarcinoma should receive supplementary LLN dissection after nCRT. However, patients with distant metastasis, metastasis beyond the obturator or internal iliac region, and involvement of ≥2 LLN may not benefit from LLN dissection, and LLN dissection should be carefully considered in such patients.

Feasibility and safety of lateral pelvic lymph node dissection for elderly patients with middle-low rectal cancer: results of a large multicenter lateral node collaborative group study in China

BACKGROUND

Lateral pelvic lymph node (LPN) dissection can improve local control in certain rectal cancer patients with LPN metastasis. However, the effects of this technically complex procedure on perioperative safety and long-term survival of elderly patients (≥ 70 years) remain unclear.

METHODS

Locally advanced middle-low rectal cancer patients diagnosed with LPN metastasis who underwent total mesorectal excision (TME) with LPN dissection at three institutions from January 2012 to December 2019 were included in this study. Additionally patients who had neoadjuvant chemoradiotherapy (nCRT) and those who did not were compared.

RESULTS

In total there were 407 patients, including 49 elderly and 358 non-elderly patients, of which 249 were male, with a median age of 58 years (range:18-85 years). In the whole cohort, operation time (280.7 vs. 292.0 min, p = 0.498) and estimated blood loss (100 vs. 100 ml, p = 0.384) were comparable in the elderly and non-elderly groups. There was no significant difference in the incidences of overall complications (24.5% vs. 19.8%, p = 0.448) and severe (Clavien-Dindo grade 3-5) surgical complications (8.2% vs. 7.5%, p = 0.778) between the two groups. However, the incidence of urinary retention (14.3% vs. 5.6%, p = 0.032) and intensive care unit admission (16.3% vs. 6.1%, p = 0.018) was significantly higher in the elderly group compared with those in the non-elderly group. The 3-year overall survival (88.7% vs. 82.1%, p = 0.516) and disease-free survival (81.2% vs. 70.7%, p = 0.352) were comparable between the two groups. Moreover, results in the nCRT cohort were comparable to those in the overall cohort.

CONCLUSIONS

Even with nCRT, TME combined with LPN dissection is safe and feasible for elderly patients, demonstrating low mortality and acceptable morbidity. Elderly and non-elderly patients with LPN metastasis who undergo LPN dissection can achieve comparable 3-year survival outcomes.

TRAIL REGISTRATION

ClinicalTrials.gov Identifier: NCT04850027.

Robotic versus laparoscopic approach for minimally invasive lateral pelvic lymph node dissection of advanced lower rectal cancer: a retrospective study comparing short-term outcomes

PURPOSE

The importance of lateral pelvic lymph node dissection (LLND) for advanced low rectal cancer is gradually being recognized in Europe and the USA, where some patients were affected by uncontrolled lateral pelvic lymph node (LLNs) metastasis, even after total mesorectal excision (TME) with neoadjuvant chemoradiotherapy (CRT). The purpose of this study was thus to compare robotic LLND (R-LLND) with laparoscopic (L-LLND) to clarify the safety and advantages of R-LLND.

METHODS

Sixty patients were included in this single-institution retrospective study between January 2013 and July 2022. We compared the short-term outcomes of 27 patients who underwent R-LLND and 33 patients who underwent L-LLND.

RESULTS

En bloc LLND was performed in significantly more patients in the R-LLND than in the L-LLND group (48.1% vs. 15.2%; p = 0.006). The numbers of LLNs on the distal side of the internal iliac region (LN 263D) harvested were significantly higher in the R-LLND than in the L-LLND group (2 [0-9] vs. 1 [0-6]; p = 0.023). The total operative time was significantly longer in the R-LLND than in the L-LLND group (587 [460-876] vs. 544 [398-859]; p = 0.003); however, the LLND time was not significantly different between groups (p = 0.718). Postoperative complications were not significantly different between the two groups.

CONCLUSION

The present study clarified the safety and technical feasibility of R-LLND with respect to L-LLND. Our findings suggest that the robotic approach offers a key advantage, allowing significantly more LLNs to be harvested from the distal side of the internal iliac region (LN 263D). Prospective clinical trials examining the oncological superiority of R-LLND are thus necessary in the near future.

Mesorectal excision with or without lateral lymph node dissection for elderly patients with mid-low rectal cancer: safety and feasibility analysis

OBJECTIVE

The perioperative safety and survival benefits of lateral lymph node dissection in elderly patients have been less reported. This study aimed to compare short-term and survival outcomes of total mesorectal excision and total mesorectal excision + lateral lymph node dissection in elderly patients.

METHODS

A total of 444 elderly patients (≥65 years) with middle-low rectal cancer were enrolled in three institutions and divided into the total mesorectal excision + lateral lymph node dissection group (n = 110) and the total mesorectal excision group (n = 334). Eighty-three matched pairs were selected for evaluation after propensity matching. Data of 297 patients (age <65 years) with middle-low rectal cancer who underwent total mesorectal excision + lateral lymph node dissection were also collected and reviewed. Clinical and pathological features, postoperative outcomes and survival data were collected and analyzed.

RESULTS

Compared with the total mesorectal excision group, the operation time of patients in the total mesorectal excision + lateral lymph node dissection group was significantly longer (277.6 vs. 171.4 min, P < 0.001), and the estimated blood loss was significantly more (119.6 vs. 57.5 ml, P = 0.014). Although there was no significant difference in overall complications (24.1% vs. 14.4%, P = 0.115) and grade 3-5 complications (9.6% vs. 7.2%, P = 0.576) between the two groups, the incidence of urinary retention (10.8% vs. 2.4%, P = 0.029) was higher in the total mesorectal excision + lateral lymph node dissection group. Two groups of patients achieve a similar 3-year overall survival (92.8% vs. 85.4%, P = 0.195) and 3-year disease-free survival (81.5% vs. 73.0%, P = 0.625). In addition, we compared long-term outcomes in 110 elderly patients with total mesorectal excision + lateral lymph node dissection and 297 non-elderly patients with total mesorectal excision + lateral lymph node dissection, and the results showed that 3-year (89.2% vs. 80.9%, P = 0.546) and disease-free survival (76.4% vs. 70.4%, P = 0.346) were similar between elderly and non-elderly patients.

CONCLUSIONS

Although urinary retention is closely related to the implementation of lateral lymph node dissection in elderly patients, total mesorectal excision with lateral lymph node dissection could be performed safely with accepted overall and grade 3-5 postoperative complications in elderly patients with rectal cancer. Moreover, elderly patients with clinical lateral lymph node metastasis can also benefit from lateral lymph node dissection as well as younger patients. Prospective studies with large sample sizes are needed to verify our results further.

Establishing and validating predictive nomograms for lateral pelvic lymph node metastasis in patients with rectal cancer based on radiologic factors and clinicopathologic characteristics

INTRODUCTION

It is critical to accurately predict the occurrence of lateral pelvic lymph node (LPN) metastasis. Currently, verified predictive tools are unavailable. This study aims to establish nomograms for predicting LPN metastasis in patients with rectal cancer who received or did not receive neoadjuvant chemoradiotherapy (nCRT).

MATERIALS AND METHODS

We carried out a retrospective study of patients with rectal cancer and clinical LPN metastasis who underwent total mesorectal excision (TME) and LPN dissection (LPND) from January 2012 to December 2019 at 3 institutions. We collected and evaluated their clinicopathologic and radiologic features, and constructed nomograms based on the multivariable logistic regression models.

RESULTS

A total of 472 eligible patients were enrolled into the non-nCRT cohort (n = 312) and the nCRT cohort (n = 160). We established nomograms using variables from the multivariable logistic regression models in both cohorts. In the non-nCRT cohort, the variables included LPN short diameter, cT stage, cN stage, histologic grade, and malignant features, and the C-index was 0.930 in the training cohort and 0.913 in the validation cohort. In the nCRT cohort, the variables included post-nCRT LPN short diameter, ycT stage, ycN stage, histologic grade, and post-nCRT malignant features, and the C-index was 0.836 in the training dataset and 0.827 in the validation dataset. The nomograms in both cohorts were moderately calibrated and well-validated.

CONCLUSIONS

We established nomograms for patients with rectal cancer that accurately predict LPN metastasis. The performance of the nomograms in both cohorts was high and well-validated.

Short- and long-term outcomes of laparoscopic versus open selective lateral pelvic lymph node dissection for locally advanced middle-low rectal cancer: Results of a multicentre lateral node study in China

AIM

Lateral pelvic lymph node dissection (LPND) is a technically challenging procedure, and the safety and feasibility of laparoscopic LPND remains undetermined. Here, we compared the short- and long-term survival outcomes of laparoscopic LPND with those of open LPND.

METHODS

From January 2012 to December 2019, locally advanced middle-low rectal cancer patients with clinical evidence of lateral pelvic lymph node metastasis (LPNM) who underwent total mesorectal excision with LPND at three institutions were included. Propensity score matching was used to minimize selection bias. The short-term and oncological outcomes of open and laparoscopic LPND were compared.

RESULTS

Overall, 384 patients were enrolled into the study including 277 and 107 patients who underwent laparoscopic and open LPND, respectively. After matching, patients were stratified into laparoscopic (n = 100) and open (n = 100) LPND groups. Patients in the laparoscopic LPND group had a shorter operation time (255 vs. 300 min, p = 0.001), less intraoperative blood loss (50 vs. 300 ml, p < 0.001), lower incidence of postoperative complications (32.0% vs. 15.0%, p = 0.005), shorter postoperative hospital stay (8 vs. 14 days, p < 0.001), and excision of more lateral pelvic lymph nodes (9 vs. 7, p = 0.025) than those in the open LPND group. The 3-year overall survival (p = 0.581) and 3-year disease-free survival (p = 0.745) rates were similar between the groups, and LPNM was an independent predictor of survival.

CONCLUSION

Laparoscopic LPND is technically safe and feasible with favourable short-term results and similar oncological outcomes as open surgery in selected patients.

Predictive value of a serum tumor biomarkers scoring system for clinical stage II/III rectal cancer with neoadjuvant chemoradiotherapy

BACKGROUND

Multiple classes of molecular biomarkers have been studied as potential predictors for rectal cancer (RC) response. Carcinoembryonic antigen (CEA) is the most widely used blood-based marker of RC and has proven to be an effective predictive marker. Cancer antigen 19-9 (CA19-9) is another tumor biomarker used for RC diagnosis and postoperative monitoring, as well as monitoring of the therapeutic effect. Using a panel of tumor markers for RC outcome prediction is a practical approach.

AIM

To assess the predictive effect of pre-neoadjuvant chemoradiotherapy (NCRT) CEA and CA19-9 levels on the prognosis of stage II/III RC patients.

METHODS

CEA and CA19-9 levels were evaluated 1 wk before NCRT. According to the receiver operating characteristic curve analysis, the optimal cut-off point of CEA and CA19-9 levels for the prognosis were 3.55 and 19.01, respectively. The novel serum tumor biomarker (NSTB) scores were as follows: score 0: Pre-NCRT CEA < 3.55 and CA19-9 < 19.01; score 2: Pre-NCRT CEA > 3.55 and CA19-9 > 19.01; score 1: Other situations. Pathological information was recorded according to histopathological reports after the operation.

RESULTS

In the univariate analysis, pre-NCRT CEA < 3.55 [P = 0.025 for overall survival (OS), P = 0.019 for disease-free survival (DFS)], pre-NCRT CA19-9 < 19.01 (P = 0.014 for OS, P = 0.009 for DFS), a lower NSTB score (0-1 vs 2, P = 0.009 for OS, P = 0.005 for DFS) could predict a better prognosis. However, in the multivariate analysis, only a lower NSTB score (0-1 vs 2; for OS, HR = 0.485, 95%CI: 0.251-0.940, P = 0.032; for DFS, HR = 0.453, 95%CI: 0.234-0.877, P = 0.019) and higher pathological grade, node and metastasis stage (0-I vs II-III; for OS, HR = 0.363, 95%CI: 0.158-0.837, P = 0.017; for DFS, HR = 0.342, 95%CI: 0.149-0.786, P = 0.012) were independent predictive factors.

CONCLUSION

The combination of post-NCRT CEA and CA19-9 was a predictive factor for clinical stage II/III RC patients receiving NCRT, and the combined index had a stronger predictive effect.

Effective dissecting range and prognostic significance of lateral pelvic lymph node dissection for middle-low rectal cancer patients with lateral pelvic lymph node metastasis: Results of a large multicenter lateral node collaborative group in China

Background

Lateral pelvic lymph node (LPN) metastasis causes increased lateral local recurrence and poor prognosis. We aimed to investigate the prognostic significance and effective range of dissection for the LPN dissection (LPND) in rectal cancer patients with LPN metastasis.

Materials and methods

Through this large, multicenter retrospective cohort study, we evaluated the therapeutic effect of LPND. From January 2012 to December 2019, 387 rectal cancer patients with clinical evidence of LPN metastasis who underwent total mesorectal excision with LPND were included in the study. According to pathological findings, they were divided into negative (n = 296) and positive (n = 91) LPN groups. Primary endpoints were 3-year overall survival (OS), recurrence-free survival (RFS), and local recurrence-free survival (LRFS).

Results

The OS, RFS, and LRFS in the positive group were significantly worse than those in the negative group; However, LPN metastases were not independent prognostic risk factors for LRFS (hazard ratio [HR]: 2.42; 95% confidence interval [CI], 0.77–7.64; P=0.132). Among patients with pathological LPN metastases, LPN metastases to the common and external iliac arteries were independent prognostic risk factors both for OS (HR: 4.74; 95% CI, 1.74–12.90; P=0.002) and RFS (HR: 2.70; 95% CI, 1.16–6.29; P=0.021). No significant difference was observed in the 3-year OS (72.3% vs. 70.2%, P=0.775) and RFS rates (60.9% vs. 52.6%, P=0.408) between patients with metastases to the obturator or internal iliac arteries and patients at N2b stage.

Conclusions

LPND may be effective in controlling local recurrence in patients with LPN metastasis but not systemic metastases. Patients with LPN metastasis limited to the internal iliac and obturator regions achieve a long-term survival benefit from LPND, and their prognoses may be comparable to those at the N2b stage. Further metastasis to the external iliac or common iliac region should be considered systemic disease, and LPND should be avoided.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT04850027.

Risk factors and prognostic significance of postoperative complications following lateral pelvic lymph node dissection for rectal cancer: results of the multicenter lateral node study in China

OBJECTIVE

Total mesorectal excision (TME) plus lateral pelvic lymph node (LPN) dissection (LPND) is a technically complex and challenging procedure with higher morbidity than TME alone. We aimed to investigate the risk factors for postoperative complications after TME + LPND, and the impact of complications on patient prognosis.

METHODS

A total of 387 rectal cancer patients with clinical LPN metastasis (LPNM) who underwent TME + LPND at three institutions affiliated with the Chinese Lateral Node Collaborative Group were included. Logistic regression models were used to identify the risk factors for post-surgical complications, and the log-rank test was used to compare the prognosis. Severe complications were described as grade III-V.

RESULTS

The incidence rates of overall complications and severe complications after TME + LPND were 15.2% (59/387) and 7.8% (30/387), respectively. Multivariate analysis showed that a duration of operation ≥260 min was an independent risk factor for both overall (odds ratio [OR] = 3.03, 95% confidence interval [CI] = 1.57-5.85, P = 0.001) and severe postoperative complications (OR = 2.67, 95% CI = 1.06-6.73, P = 0.037). The development of overall postoperative complications (P = 0.114) and severe postoperative complications (P = 0.298) had no significant impact on the overall survival. However, patients with overall complications (P = 0.015) or severe complications (P = 0.031) with a postoperative hospital stay >30 days had significantly an overall worse survival.

CONCLUSION

A surgical duration of ≥260 min is a significant risk factor for both overall and severe postoperative complications after TME + LPND for middle-low rectal cancer. Furthermore, the development of overall complications or severe complications that require a postoperative hospital stay >30 days significantly worsens the prognosis.

Prognostic significance of lateral pelvic lymph node dissection for middle-low rectal cancer patients with lateral pelvic lymph node metastasis: a propensity score matching study

Background

There is still controversy regarding the clinical value and significance of lateral pelvic lymph node (LPN) dissection (LPND). The present study aimed to investigate whether the addition of LPND to total mesorectal excision (TME) confers survival benefits in rectal cancer patients with clinical lateral pelvic node metastasis (LPNM).

Methods

From January 2015 to January 2021, a total of 141 rectal cancer patients with clinical evidence of LPNM who underwent TME + LPND were retrospectively analysed and divided into the LPNM group (n = 29) and the non-LPNM group (n = 112). The LPNM group was further subdivided into a high-risk LPNM group (n = 14) and a low-risk LPNM group (n = 15). Propensity score matching (PSM) was performed to minimize selection bias. The primary outcomes of this study were 3-year overall survival (OS) and disease-free survival (DFS).

Results

Of the 141 patients undergoing LPND, the local recurrence rate of patients with LPNM was significantly higher than that of patients without LPNM both before (27.6% vs. 4.5%, P = 0.001) and after (27.6% vs. 3.4%, P = 0.025) PSM. Multivariate analysis revealed that LPNM was an independent risk factor for not only OS (HR: 3.06; 95% CI, 1.15–8.17; P = 0.025) but also DFS (HR: 2.39; 95% CI, 1.18–4.87; P = 0.016) in patients with LPNM after TME + LPND. When the LPNM group was further subdivided, multivariate logistic regression analysis showed that OS and DFS were significantly better in the low-risk group (obturator/internal iliac artery region and < 2 positive LPNs).

Conclusion

Even after LPND, LPNM patients have a poor prognosis. Moreover, LPNM is an independent poor prognostic factor affecting OS and DFS after TME + LPND. However, LPND appears to confer survival benefits to specific patients with single LPN involvement in the obturator region or internal iliac vessel region. Furthermore, LPND may have no indication in stage IV patients and should be selected carefully.