1
|
Anania G, Davies RJ, Arezzo A, Bagolini F, D’Andrea V, Graziosi L, Di Saverio S, Popivanov G, Cheruiyot I, Cirocchi R, Donini A. Rise and fall of total mesorectal excision with lateral pelvic lymphadenectomy for rectal cancer: an updated systematic review and meta-analysis of 11,366 patients. Int J Colorectal Dis 2021; 36:2321-2333. [PMID: 34125269 PMCID: PMC8505280 DOI: 10.1007/s00384-021-03946-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 02/04/2023]
Abstract
UNLABELLED The role of lateral lymph node dissection (LLND) during total mesorectal excision (TME) for rectal cancer is still controversial. Many reviews were published on prophylactic LLND in rectal cancer surgery, some biased by heterogeneity of overall associated treatments. The aim of this systematic review and meta-analysis is to perform a timeline analysis of different treatments associated to prophylactic LLND vs no-LLND during TME for rectal cancer. METHODS A literature search was performed in PubMed, SCOPUS and WOS for publications up to 1 September 2020. We considered RCTs and CCTs comparing oncologic and functional outcomes of TME with or without LLND in patients with rectal cancer. RESULTS Thirty-four included articles and 29 studies enrolled 11,606 patients. No difference in 5-year local recurrence (in every subgroup analysis including preoperative neoadjuvant chemoradiotherapy), 5-year distant and overall recurrence, 5-year overall survival and 5-year disease-free survival was found between LLND group and non LLND group. The analysis of post-operative functional outcomes reported hindered quality of life (urinary, evacuatory and sexual dysfunction) in LLND patients when compared to non LLND. CONCLUSION Our publication does not demonstrate that TME with LLND has any oncological advantage when compared to TME alone, showing that with the advent of neoadjuvant therapy, the advantage of LLND is lost. In this review, the most important bias is the heterogeneous characteristics of patients, cancer staging, different neoadjuvant therapy, different radiotherapy techniques and fractionation used in different studies. Higher rate of functional post-operative complications does not support routinely use of LLND.
Collapse
Affiliation(s)
- Gabriele Anania
- Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
| | - Richard Justin Davies
- Cambridge Colorectal Unit - Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126 Torino, Italy
| | - Francesco Bagolini
- Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
| | - Vito D’Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Luigina Graziosi
- Department of Surgery and Biomedical Sciences, University of Perugia, 06121 Perugia, Italy
| | - Salomone Di Saverio
- Department of General Surgery (S.D.S., G.I., E.Z., G.C.), University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Italy
| | - Georgi Popivanov
- Department of Surgery, Military Medical Academy, ul. “Sv. Georgi Sofiyski” 3, 1606 Sofia, Bulgaria
| | - Isaac Cheruiyot
- Department of Human Anatomy, University of Nairobi, Nairobi, Kenya
| | - Roberto Cirocchi
- Department of Surgery and Biomedical Sciences, University of Perugia, 06121 Perugia, Italy
| | - Annibale Donini
- Department of Surgery and Biomedical Sciences, University of Perugia, 06121 Perugia, Italy
| |
Collapse
|
2
|
Mahmoodzadeh H, Omranipour R, Borjian A, Borjian MA. Study of therapeutic results, lymph node ratio, short-term and long-term complications of lateral lymph node dissection in rectal cancer patients. Turk J Surg 2020; 36:224-228. [PMID: 33015568 DOI: 10.5578/turkjsurg.4593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/30/2019] [Indexed: 11/15/2022]
Abstract
Objectives This study aimed to assess disease free survival, lymph node ratio (LNR) and complication rate among advanced mid to low rectal cancer patients (stage 2-3) who underwent total mesorectal excision (TME) and lateral lymph node dissection (LLND) at the Iran Cancer Institute in 2016-2018. Material and Methods The study was carried out on 32 patients treated by curative surgery and lateral lymph node dissection at the Iran Cancer Institute from 2016 March to 2018 March. Chi-square test was used to assess the distribution of dichotomous clinical outcomes by sex. We also used Breslow test in Kaplan-Meier approach to estimate 1-year disease free survival and corresponding 95% confidence intervals (CI). Results Of the 279 dissected lymph nodes by TME, 42 nodes (in mesorectal) and of the 232 dissected lymph nodes by LLND, 7 nodes (in iliac, para-iliac and obturator) were positive for metastasis. Higher local recurrence was observed in men (three patients) compared to women (one patient) which was not statistically significant (p= 0.878). We also observed higher 1-year disease free survival rate in women (1-year disease free survival= 93.3%) compared to men (1-year disease free survival= 82.4%), which also was not statistically significant (p= 0.356). 1-year disease free survival rate in patient with negative lymph nodes was 95.5% while respective number in patients with positive lymph nodes was 70% (p= 0.047). Conclusion TME with LLND could prolong survival and reduce local recurrence in patients with advanced low rectal cancer. However, large-scale clinical trials are required to evaluate such procedure as a standard in Iran.
Collapse
Affiliation(s)
| | - Ramesh Omranipour
- Tehran University of Medical Science, Cancer Institute, Tehran, Iran
| | - Anahita Borjian
- Tehran University of Medical Science, Cancer Institute, Tehran, Iran
| | | |
Collapse
|
3
|
Masaki T, Matsuoka H, Kishiki T, Kojima K, Aso N, Beniya A, Tonari A, Takayama M, Abe N, Sunami E. Intraoperative radiotherapy for resectable advanced lower rectal cancer-final results of a randomized controlled trial (UMIN000021353). Langenbecks Arch Surg 2020; 405:247-254. [PMID: 32347365 DOI: 10.1007/s00423-020-01875-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/30/2020] [Indexed: 01/24/2023]
Abstract
AIM Pelvic autonomic nerve preservation (PANP) is useful to preserve voiding and sexual function after rectal cancer surgery. The aim of this study was to investigate the benefit of intraoperative radiotherapy (IORT) to have complete PANP without affecting oncological outcomes. METHODS Patients undergoing potentially curative resection of the rectum were included. They were randomized to intraoperative radiotherapy of the completely preserved bilateral pelvic nerve plexuses (IORT group) or the control group without IORT, but with limited nerve preservation. The primary endpoint was pelvic sidewall recurrence. Moreover, patients' clinicopathologic parameters, postoperative complications, voiding function, and other oncologic outcomes were compared. RESULTS From 79 patients, three were excluded from analysis, resulting in 38 patients in each group. Patients' demographic and pathological parameters were well balanced between the two groups. The trial was terminated prematurely in July 2017, because distant metastasis-free survivals were found to be significantly worse in the IORT group compared to the control group (odds ratio 2.554; 95% CI, 1.041 ~ 6.269; p = 0.041). Neither overall survival nor pelvic sidewall recurrence did differ between the two groups (overall survival: odds ratio 1.264; 95% CI, 0.523~3.051; p = 0.603/pelvic sidewall recurrence; odds ratio 1.350; 95% CI, 0.302~6.034; p = 0.694). Postoperative complications did not differ between the groups; however, the urinary function was significantly better in the IORT group in the short and long term. CONCLUSION With the aid of IORT, complete PANP can be done without increase of pelvic sidewall recurrence; however, IORT may increase the incidence of distant metastases. Therefore, IORT cannot be recommended as a standard therapy to compensate less radical resection for advanced lower rectal cancer.
Collapse
Affiliation(s)
- Tadahiko Masaki
- Department of Surgery, Kyorin University Hospital, 6-20-2, Shinkawa, Mitaka City, Tokyo, 181-8611, Japan.
| | - Hiroyoshi Matsuoka
- Department of Surgery, Kyorin University Hospital, 6-20-2, Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| | - Tomokazu Kishiki
- Department of Surgery, Kyorin University Hospital, 6-20-2, Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| | - Koichiro Kojima
- Department of Surgery, Kyorin University Hospital, 6-20-2, Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| | - Nobuyoshi Aso
- Department of Surgery, Kyorin University Hospital, 6-20-2, Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| | - Ayumi Beniya
- Department of Surgery, Kyorin University Hospital, 6-20-2, Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| | - Ayako Tonari
- Department of Radiation Oncology, Kyorin University Hospital, 6-20-2, Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| | - Makoto Takayama
- Department of Radiation Oncology, Kyorin University Hospital, 6-20-2, Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| | - Nobutsugu Abe
- Department of Surgery, Kyorin University Hospital, 6-20-2, Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| | - Eiji Sunami
- Department of Surgery, Kyorin University Hospital, 6-20-2, Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| |
Collapse
|
4
|
Oronsky B, Reid T, Larson C, Knox SJ. Locally advanced rectal cancer: The past, present, and future. Semin Oncol 2020; 47:85-92. [PMID: 32147127 DOI: 10.1053/j.seminoncol.2020.02.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 01/29/2020] [Accepted: 02/03/2020] [Indexed: 12/20/2022]
Abstract
From a series of clinical trials in the last several decades, current treatment paradigms for locally advanced rectal cancer include: (1) preoperative long-course radiotherapy (RT) combined with radiosensitizing chemotherapy; (2) preoperative short-course RT alone followed by adjuvant postoperative chemotherapy; and (3) total neoadjuvant therapy with induction chemotherapy followed by chemoradiotherapy. Other strategies under active investigation in both institutional and cooperative trials include neoadjuvant chemotherapy alone without RT in select patients, total neoadjuvant therapy, watchful waiting after a clinical complete response as an alternative to surgical resection, and the use of different chemotherapeutic and targeted agents. The focus of this review is on established and novel therapeutic strategies for locally advanced rectal cancer.
Collapse
Affiliation(s)
| | - Tony Reid
- Department of Medical Oncology, UC San Diego School of Medicine, San Diego, CA
| | | | - Susan J Knox
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA.
| |
Collapse
|
5
|
Hartvigson PE, Apisarnthanarax S, Schaub S, Cohen S, Bernier G, Koh WJ, Kim EY. Radiation Therapy Dose Escalation to Clinically Involved Pelvic Sidewall Lymph Nodes in Locally Advanced Rectal Cancer. Adv Radiat Oncol 2019; 4:478-486. [PMID: 31360803 PMCID: PMC6639784 DOI: 10.1016/j.adro.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/24/2019] [Accepted: 03/20/2019] [Indexed: 12/20/2022] Open
Abstract
Purpose Lateral pelvic sidewall lymph nodes (PSW LN) may be involved in up to 24% of locoregionally advanced rectal cancers. PSW LN are not resected in total mesorectal excision (TME), and no standard of care regarding the management of PSW LN exists in the United States. We assessed our institutional experience of preoperative radiation therapy (RT) boost to clinically involved PSW LN that were not planned for resection. Methods and materials Data from all patients with rectal adenocarcinoma treated between 2006 and 2018 were reviewed to identify those who received a cumulative dose of >50.4 Gy to suspicious PSW LN during neoadjuvant chemoradiation therapy (nCRT). Demographic, cancer characteristic, treatment, and toxicity data were derived from the chart. Results Of a total of 261 patients, 12 patients met the inclusion criteria. The median age was 47.5 years, and 83% of patients were men. All patients had T3/4 disease, 17% of patients had N1b disease and the remainder had N2 disease, and 33% had M1 disease (all ≤2 metastases). Seventy-five percent of patients had moderately or poorly differentiated histology. The mean distance from the anal verge was 4.85 cm (range, 2-8.9 cm), and 58% had ≥2 PSW LN with an average short axis diameter of 1.11 cm (range, 0.4-3.2 cm). Boost doses ranged from 53.48 Gy to 60.2 Gy in 27 to 30 fractions (1.8-2.15 Gy/fraction). The median follow-up time was 18 months. One patient who received concurrent capecitabine and irinotecan had grade 3 perineal dermatitis and anemia during nCRT. The median hospitalization time for TME was 6.5 days. Within 90 days of TME, 1 patient required surgical exploration for perineal wound breakdown, and another required a blood transfusion for anemia. At the time of the last follow up, 75% of patients were alive. Local control at 12 months was 90%. Conclusions RT dose escalation to nonresected PSW LN during nCRT was well tolerated with a low risk of acute toxicity and perioperative complications and has a high rate of local control at 12 months. RT boost warrants further study in patients with clinically involved nonresected PSW LN.
Collapse
Affiliation(s)
- Pehr E Hartvigson
- Department of Radiation Oncology, Seattle, Washington.,Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon
| | | | | | | | - Greta Bernier
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Wui-Jin Koh
- National Comprehensive Cancer Network, Plymouth Meeting, Pennsylvania
| | - Edward Y Kim
- Department of Radiation Oncology, Seattle, Washington
| |
Collapse
|
6
|
Impact of Lateral Pelvic Lymph Node Dissection on the Survival of Patients with T3 and T4 Low Rectal Cancer. World J Surg 2017; 40:1492-9. [PMID: 26908236 DOI: 10.1007/s00268-016-3444-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The aim of this study was to clarify the survival benefit of lateral pelvic lymph node dissection (LPLND) for patients with pathological T3 and T4 (pT3/T4) low rectal cancer. METHODS We evaluated the impact of LPLND on survival for pT3/T4 low rectal cancer patients. The primary endpoint of the study was overall survival (OS). The large-scale database of the Japanese Society for Cancer of the Colon and Rectum registration system was accessed and the data were analyzed using a propensity score matching method based on the likelihood of receiving LPLND. Using seven covariates, the propensity scores were calculated with multivariate logistic regression. A total of 499 propensity score-matched pairs of patients were selected from the entire cohort of 1,840 patients who had received curative resection for pT3/T4 low rectal cancer between 1995 and 2004. RESULTS In the matched cohort, the 5-year OS of the patients who had and had not undergone LPLND were 68.9 and 62.0 %, respectively (p = 0.013; hazard ratio [HR], 0.755; 95 % confidence interval [CI], 0.604-0.944). The 5-year OS of the patients with node-negative disease who had and had not received LPLND differed statistically significantly (5-year OS were 82.1 and 71.4 %, respectively. p = 0.006; HR, 0.579; 95 % CI 0.389-0.862). However, those with node-positive disease did not differ significantly (5-year OS were 55.5 and 53.8 %, respectively. p = 0.415; HR 0.893; 95 % CI 0.681-1.172). CONCLUSIONS The impact of LPLND on OS for patients with node-negative pT3/T4 low rectal cancer was suggested in this retrospective cohort study. To determine true benefits and harms of LPLND, further prospective studies may be warranted.
Collapse
|
7
|
Park JS, Sakai Y, Simon NSM, Law WL, Kim HR, Oh JH, Shan HCY, Kwak SG, Choi GS. Long-Term Survival and Local Relapse Following Surgery Without Radiotherapy for Locally Advanced Upper Rectal Cancer: An International Multi-Institutional Study. Medicine (Baltimore) 2016; 95:e2990. [PMID: 27258487 PMCID: PMC4900695 DOI: 10.1097/md.0000000000002990] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Controversy remains regarding whether preoperative chemoradiation protocol should be applied uniformly to all rectal cancer patients regardless of tumor height. This pooled analysis was designed to evaluate whether preoperative chemoradiation can be safely omitted in higher rectal cancer.An international consortium of 7 institutions was established. A review of the database that was collected from January 2004 to May 2008 identified a series of 2102 patients with stage II/III rectal or sigmoid cancer (control arm) without concurrent chemoradiation. Data regarding patient demographics, recurrence pattern, and oncological outcomes were analyzed. The primary end point was the 5-year local recurrence rate.The local relapse rate of the sigmoid colon cancer (SC) and upper rectal cancer (UR) cohorts was significantly lower than that of the mid/low rectal cancer group (M-LR), with 5-year estimates of 2.5% for the SC group, 3.5% for the UR group, and 11.1% for the M-LR group, respectively. A multivariate analysis showed that tumor depth, nodal metastasis, venous invasion, and lower tumor level were strongly associated with local recurrence. The cumulative incidence rate of local failure was 90.6%, 92.5%, and 94.4% for tumors located within 5, 7, and 9 cm from the anal verge, respectively.Routine use of preoperative chemoradiation for stage II/III rectal tumors located more than 8 to 9 cm above the anal verge would be excessive. The integration of a more individualized approach focused on systemic control is warranted to improve survival in patients with upper rectal cancer.
Collapse
Affiliation(s)
- Jun Seok Park
- From the Colorectal Cancer Center (JSP, G-SC), Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea; Department of Surgery (YS), Kyoto University Hospital, Kyoto, Japan; Department of Surgery (NGSMS), The Chinese University of Hong Kong, Sha Tin, Hong Kong; Division of Colorectal Surgery (WLL), The University of Hong Kong, Pok Fu Lam, Hong Kong; Department of Surgery (HRK), Chonnam National University Hwasun Hospital and Medical School, Gwangju, Korea; Center for Colorectal Cancer (JHO), National Cancer Center Hospital, Goyang city, Korea; Department of surgery (HCYS), Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong; and Department of Medical Statistics (SGK), School of Medicine, Catholic University of Daegu, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
What Is the Role of Lateral Lymph Node Excision in Patients with Locally Advanced Rectal Cancer Who Received Preoperative Chemoradiotherapy? CURRENT COLORECTAL CANCER REPORTS 2014. [DOI: 10.1007/s11888-014-0212-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
9
|
Oh HK, Kang SB, Lee SM, Lee SY, Ihn MH, Kim DW, Park JH, Kim YH, Lee KH, Kim JS, Kim JW, Kim JH, Chang TY, Park SC, Sohn DK, Oh JH, Park JW, Ryoo SB, Jeong SY, Park KJ. 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. Ann Surg Oncol 2014; 21:2280-7. [PMID: 24604580 DOI: 10.1245/s10434-014-3559-z] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Indexed: 12/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Heung-Kwon Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Charran O, Muhleman M, Shah S, Tubbs RS, Loukas M. Ligaments of the Rectum: Anatomical and Surgical Considerations. Am Surg 2014. [DOI: 10.1177/000313481408000323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The ligaments of the rectum have been the subject of controversy for decades. Not only have their contents and components been a source of contention, but also the very existence of these ligaments has been called into question. This article explores the anatomical features of these ligaments with implications for surgical treatment of rectal prolapse, rectal cancer, and resection of the rectum and mesorectum. A theory about the evolution of the lateral rectal ligaments and the mesorectum in humans and higher mammals is also presented.
Collapse
Affiliation(s)
- Ordessia Charran
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies
| | - Mitchel Muhleman
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies
| | - Sameer Shah
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies
| | - R. Shane Tubbs
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama
| | - Marios Loukas
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies
| |
Collapse
|
11
|
Kim TG, Park W, Choi DH, Park HC, Kim SH, Cho YB, Yun SH, Kim HC, Lee WY, Lee J, Park JO, Park YS, Lim HY, Kang WK, Chun HK. Factors associated with lateral pelvic recurrence after curative resection following neoadjuvant chemoradiotherapy in rectal cancer patients. Int J Colorectal Dis 2014; 29:193-200. [PMID: 24322736 DOI: 10.1007/s00384-013-1797-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to determine the risk factors for lateral pelvic recurrence (LPR) in rectal cancer patients treated with neoadjuvant chemoradiotherapy (CRT) and curative surgery. METHODS Four hundred forty-three patients treated with neoadjuvant CRT and curative surgery from October 1999 through June 2009 were analyzed. All patients underwent total mesorectal resection without lateral pelvic lymph node (LPLN) dissection. Recurrence patterns and lateral pelvic recurrence-free survival (LPFS) were evaluated relative to clinicopathologic parameters including pelvic LN status. RESULTS Median follow-up was 52 months, with locoregional recurrence in 53 patients (11.9 %). Of the 53 patients, 28 (52.8 %) developed LPR, of which eight had both central and lateral PR. Multivariate analysis showed a significant relationship between LPFS and the number of lateral pelvic LN (p = 0.010) as well as the ratio of the number of positive LN/number of dissected LN (p = 0.038). The relationship between LPFS and LPLN size had a marginal trend (p = 0.085). Logistic regression analysis showed positive relationships between LPR probability and the number of LPLN (odds ratio [OR] 1.507; 95 % confidence interval [CI] 1.177-1.929; p = 0.001) as well as LPLN size (OR 1.124; CI 1.029-1.227, p = 0.009). CONCLUSIONS LPLN ≥ 2 and a ratio of the number of positive LN/number of dissected LN > 0.3 were prognostic of poor LPFS. The prediction curve of LPR according to the number and size of LPLN could be useful for determining the benefit of additional lateral pelvic treatment.
Collapse
Affiliation(s)
- Tae Gyu Kim
- Department of Radiation Oncology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
The role of lateral lymph node dissection in the management of lower rectal cancer. Langenbecks Arch Surg 2011; 397:353-61. [PMID: 22105772 DOI: 10.1007/s00423-011-0864-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Accepted: 10/10/2011] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Lateral lymph node involvement is a problem encountered in patients with low rectal cancers. This has been documented in both anatomical and pathological studies. Currently, the vast majority of centers have concentrated on the use of chemoradiation to obtain better local control and manage these nodes indirectly. In Japan, extended nodal dissection for the control of pelvic nodal disease has seen further advancement. This paper discusses the key issues involved in the management of pelvic lateral nodes in low rectal cancers. METHODS A review of available literature and critical appraisal of the entity of lateral nodes in low rectal cancers, the treatment options, and oncological and functional results were performed. RESULTS There are good data showing that the entity of pelvic lateral nodes in low rectal cancers should not be ignored. Recent data have emerged showing that radiotherapy is associated with significant long-term functional side effects. Refinement of the technique, lateral node dissection, has led to good local control as well as good functional outcomes. CONCLUSION In this context, there needs to be a reevaluation of the role of chemoradiation as the sole treatment for lateral nodal disease in centers outside of Japan. Individualization of the treatment of rectal cancer may require all centers to be able to offer both modalities.
Collapse
|
13
|
Review of histopathological and molecular prognostic features in colorectal cancer. Cancers (Basel) 2011; 3:2767-810. [PMID: 24212832 PMCID: PMC3757442 DOI: 10.3390/cancers3022767] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 06/14/2011] [Accepted: 06/15/2011] [Indexed: 02/06/2023] Open
Abstract
Prediction of prognosis in colorectal cancer is vital for the choice of therapeutic options. Histopathological factors remain paramount in this respect. Factors such as tumor size, histological type and subtype, presence of signet ring morphology and the degree of differentiation as well as the presence of lymphovascular invasion and lymph node involvement are well known factors that influence outcome. Our understanding of these factors has improved in the past few years with factors such as tumor budding, lymphocytic infiltration being recognized as important. Likewise the prognostic significance of resection margins, particularly circumferential margins has been appreciated in the last two decades. A number of molecular and genetic markers such as KRAS, BRAF and microsatellite instability are also important and correlate with histological features in some patients. This review summarizes our current understanding of the main histopathological factors that affect prognosis of colorectal cancer.
Collapse
|
14
|
de Wilt JHW, Vermaas M, Ferenschild FTJ, Verhoef C. Management of locally advanced primary and recurrent rectal cancer. Clin Colon Rectal Surg 2010; 20:255-63. [PMID: 20011207 DOI: 10.1055/s-2007-984870] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Treatment for patients with locally advanced and recurrent rectal cancer differs significantly from patients with rectal cancer restricted to the mesorectum. Adequate preoperative imaging of the pelvis is therefore important to identify those patients who are candidates for multimodality treatment, including preoperative chemoradiation protocols, intraoperative radiotherapy, and extended surgical resections. Much effort should be made to select patients with these advanced tumors for treatment in specialized referral centers. This has been shown to reduce morbidity and mortality and improve long-term survival rates. In this article, we review the best treatment options for patients with locally advanced and recurrent rectal cancer. We also emphasize the necessity of a multidisciplinary team, including a radiologist, radiation oncologist, urologist, surgical oncologist, plastic surgeon, and gynecologist in the diagnosis and treatment of patients with these pelvic tumors.
Collapse
Affiliation(s)
- Johannes H W de Wilt
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
| | | | | | | |
Collapse
|
15
|
Improving prediction of lateral node spread in low rectal cancers—multivariate analysis of clinicopathological factors in 1,046 cases. Langenbecks Arch Surg 2010; 395:545-9. [DOI: 10.1007/s00423-010-0642-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 03/22/2010] [Indexed: 12/20/2022]
|
16
|
Hermanek P, Merkel S, Fietkau R, Rödel C, Hohenberger W. Regional lymph node metastasis and locoregional recurrence of rectal carcinoma in the era of TME [corrected] surgery. Implications for treatment decisions. Int J Colorectal Dis 2010; 25:359-68. [PMID: 20012295 DOI: 10.1007/s00384-009-0864-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS For rectal carcinoma treated according to the concept of total mesorectal excision (TME surgery), the independent influence of regional lymph node metastasis on the locoregional recurrence risk is still in discussion. A reliable assessment of this risk is important for an individualised selective indication for neoadjuvant radio-/radiochemotherapy. METHODS Analysis of literature, especially of the last 20 years, and consideration of pathological and oncological basic research. Multivariate analysis of data of the Erlangen Registry of Colorectal Carcinoma. RESULTS The clinical assessment of the pretherapeutic regional lymph node status by the present available imaging methods is still unreliable. The analysis of the association between pretherapeutic regional lymph node status and locoregional recurrence risk has to be based on follow-up data of patients treated by primary surgery and has to be distinguished between patients treated by conventional and optimised quality-assured TME surgery, respectively. Data from Erlangen show an increase of the local recurrence risk for patients with at least four involved regional lymph nodes. CONCLUSIONS For patients with at least four involved regional lymph nodes, a neoadjuvant radiochemotherapy may be indicated. However, today, the pretherapeutic diagnosis is uncertain and results in overtherapy in 40%. Thus, in case of positive lymph node findings by imaging methods, the benefits and risk of neoadjuvant therapy in such situations should always be discussed with the patient in the sense of informed consent and shared decision.
Collapse
Affiliation(s)
- Paul Hermanek
- Department of Surgery, University Hospital, Krankenhausstr. 12, 91054, Erlangen, Germany
| | | | | | | | | |
Collapse
|
17
|
|
18
|
Wu ZY, Wan J, Li JH, Zhao G, Yao Y, Du JL, Liu QF, Peng L, Wang ZD, Huang ZM, Lin HH. Prognostic value of lateral lymph node metastasis for advanced low rectal cancer. World J Gastroenterol 2008; 13:6048-52. [PMID: 18023098 PMCID: PMC4250889 DOI: 10.3748/wjg.v13.45.6048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the risk factors for lateral lymph node metastasis in patients with advanced low rectal cancer, in order to make the effective selection of patients who could benefit from lateral lymph node dissection, as well as the relationship of lateral lymph node metastasis with local recurrence and survival of patients with advanced low rectal cancer. METHODS A total of 96 consecutive patients who underwent curative surgery with lateral pelvic lymphadenectomy for advanced lower rectal cancer were retrospectively analyzed. The relation of lateral lymph node metastasis with clinicopathologic characteristics, local recurrence and survival of patients was identified. RESULTS Lateral lymph node metastasis was observed in 14.6% (14/96) of patients with advanced low rectal cancer. Lateral lymph node metastasis was detected in 10 (25.0%) of 40 patients with tumor diameter >or= 5 cm and in 4 (7.1%) of 56 patients with tumor diameter < 5 cm. The difference between the two groups was statistically significant (c2 = 5.973, P = 0.015). Lateral lymph node metastasis was more frequent in patients with 4/4 diameter of tumor infiltration (7 of 10 cases, 70.0%), compared with patients with 3/4, 2/4 and 1/4 diameter of tumor infiltration (3 of 25 cases, 12.0%; 3 of 45 cases, 6.7%; 1 of 16 cases, 6.3%) (c2 = 27.944, P = 0.0001). The lateral lymph node metastasis rate was 30.0% (9 of 30 cases), 9.1% (4 of 44 cases) and 4.5% (1 of 22 cases) for poorly, moderately and well-differentiated carcinoma, respectively. The difference between the three groups was statistically significant (c2 = 8.569, P = 0.014). Local recurrence was 18.8% (18 of 96 cases), 64.3% (9 of 14 cases), and 11.0% (9 of 82 cases) in patients with advanced low rectal cancer, in those with and without lateral lymph node metastasis, respectively. The difference between the two groups was statistically significant (c2 = 22.308, P = 0.0001). Kaplan-Meier survival analysis showed significant improvements in median survival (80.9 +/- 2.1 m, 95% CI: 76.7-85.1 m vs 38 +/- 6.7 m, 95% CI: 24.8-51.2 m) of patients without lateral lymph node metastasis compared with those with lateral lymph node metastasis (log-rank, P = 0.0001). CONCLUSION Tumor diameter, infiltration and differentiation are significant risk factors for lateral lymph node metastasis. Lateral pelvic lymphadenectomy should be performed following surgery for patients with tumor diameter >or= 5 cm. Lateral lymph node metastasis is an important predictor for local recurrence and survival in patients with advanced low rectal cancer.
Collapse
Affiliation(s)
- Ze-Yu Wu
- Department of General Surgery, Guangdong Provincial People's Hospital, Guangzhou 510080, Guangdong Province, China
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Yano H, Moran BJ. The incidence of lateral pelvic side-wall nodal involvement in low rectal cancer may be similar in Japan and the West. Br J Surg 2008; 95:33-49. [PMID: 18165939 DOI: 10.1002/bjs.6061] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is an East-West divide with regard to the frequency, significance and management of lateral pelvic side-wall nodes associated with low rectal cancer. In Japan, removal of nodes is considered essential in curative treatment of selected patients. In the West, involved nodes are generally considered as metastatic disease. There may be international differences in rectal cancer behaviour. METHODS A review of relevant studies was undertaken using PubMed, Cochrane Library and personal archives of references; further cross-referencing was conducted. Historical developments, relevant anatomy and reports on lateral pelvic lymphadenectomy (LPLD) were identified. Outcomes following LPLD were assessed. RESULTS The low rectum has lateral lymphatic drainage. Enhanced pelvic imaging techniques suggest that some patients with low rectal cancer have lateral pelvic lymph node involvement. However, there is no universal agreement on the definition of either the rectum or low rectal cancer. Selective use of LPLD has led to good outcomes in Japan. An alternative strategy might be neoadjuvant therapy for involved lateral nodes. CONCLUSION Pelvic imaging and correlation with pathological findings are crucial in the assessment of lateral pelvic side-wall nodes. East and West should combine their experience of preoperative staging, surgical treatment and pathological assessment of low rectal cancer.
Collapse
Affiliation(s)
- H Yano
- Colorectal Research Unit, Basingstoke and North Hampshire Foundation Trust, Basingstoke, UK
| | | |
Collapse
|
20
|
Intraoperative radiotherapy for oncological and function-preserving surgery in patients with advanced lower rectal cancer. Langenbecks Arch Surg 2008; 393:173-80. [DOI: 10.1007/s00423-007-0260-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2007] [Accepted: 11/27/2007] [Indexed: 12/18/2022]
|
21
|
Abstract
AIM: To evaluate the risk factors for lateral lymph node metastasis in patients with advanced low rectal cancer, in order to make the effective selection of patients who could benefit from lateral lymph node dissection, as well as the relationship of lateral lymph node metastasis with local recurrence and survival of patients with advanced low rectal cancer.
METHODS: A total of 96 consecutive patients who underwent curative surgery with lateral pelvic lymphadenectomy for advanced lower rectal cancer were retrospectively analyzed. The relation of lateral lymph node metastasis with clinicopathologic characteristics, local recurrence and survival of patients was identified.
RESULTS: Lateral lymph node metastasis was observed in 14.6% (14/96) of patients with advanced low rectal cancer. Lateral lymph node metastasis was detected in 10 (25.0%) of 40 patients with tumor diameter ≥ 5 cm and in 4 (7.1%) of 56 patients with tumor diameter < 5 cm. The difference between the two groups was statistically significant (χ2 = 5.973, P = 0.015). Lateral lymph node metastasis was more frequent in patients with 4/4 diameter of tumor infiltration (7 of 10 cases, 70.0%), compared with patients with 3/4, 2/4 and 1/4 diameter of tumor infiltration (3 of 25 cases, 12.0%; 3 of 45 cases, 6.7%; 1 of 16 cases, 6.3%) (χ2 = 27.944, P = 0.0001). The lateral lymph node metastasis rate was 30.0% (9 of 30 cases), 9.1% (4 of 44 cases) and 4.5% (1 of 22 cases) for poorly, moderately and well-differentiated carcinoma, respectively. The difference between the three groups was statistically significant (χ2 = 8.569, P = 0.014). Local recurrence was 18.8% (18 of 96 cases), 64.3% (9 of 14 cases), and 11.0% (9 of 82 cases) in patients with advanced low rectal cancer, in those with and without lateral lymph node metastasis, respectively. The difference between the two groups was statistically significant (χ2 = 22.308, P = 0.0001). Kaplan-Meier survival analysis showed significant improvements in median survival (80.9 ± 2.1 m, 95% CI: 76.7-85.1 m vs 38 ± 6.7 m, 95% CI: 24.8-51.2 m) of patients without lateral lymph node metastasis compared with those with lateral lymph node metastasis (log-rank, P = 0.0001).
CONCLUSION: Tumor diameter, infiltration and differentiation are significant risk factors for lateral lymph node metastasis. Lateral pelvic lymphadenectomy should be performed following surgery for patients with tumor diameter ≥ 5 cm. Lateral lymph node metastasis is an important predictor for local recurrence and survival in patients with advanced low rectal cancer.
Collapse
|
22
|
MRI staging. COLORECTAL CANCER 2007. [DOI: 10.1017/cbo9780511902468.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
23
|
Mortenson MM, Khatri VP, Bennett JJ, Petrelli NJ. Total mesorectal excision and pelvic node dissection for rectal cancer: an appraisal. Surg Oncol Clin N Am 2007; 16:177-97. [PMID: 17336243 DOI: 10.1016/j.soc.2006.10.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Total mesorectal excision has revolutionized the surgical treatment of rectal cancer since its introduction in the 1980s. The rationale, technique, and outcomes of total mesorectal excision in rectal cancer are explored. Lateral pelvic lymph node dissection is used by the Japanese in selected patients and has remained a controversial approach in the management of rectal cancer. The technique, controversies, and outcomes are summarized.
Collapse
Affiliation(s)
- Melinda M Mortenson
- Department of Surgery, Division of Surgical Oncology, University of California, Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817, USA
| | | | | | | |
Collapse
|