1
|
Li C, Luan J, Ji X, Wang X, Li J, Li X, Zhou Y. The influence of neoadjuvant chemoradiotherapy combined with lateral lymph nodes dissection or not on the local recurrence of low to intermediate-stage II/III rectal cancer. J Surg Oncol 2024; 129:273-283. [PMID: 37811551 DOI: 10.1002/jso.27471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Currently, the treatment options for stage II/III rectal cancer with preoperative lateral lymph nodes (LLN) enlargement are highly controversial between East and West, and the indications for diagnosing suspiciously positive enlarged LLN are inconsistent both nationally and internationally. Oriental scholars (especially Japanese) consider the LLN as a regional disease, they consider that prophylactic lateral lymph nodes dissection (LLND), regardless of whether the LLN is enlarged or not, is considered necessary if the tumor is found beneath the peritoneal reflex and invades the muscle layer. Western scholars regard LLN as distant metastases, recommending neoadjuvant chemoradiotherapy (nCRT) in conjunction with total rectal mesenteric resection (TME). In recent years, it has been found that neither of the two standard treatment regimens, East and West, significantly improved local control of tumors in patients with LLN enlargement. In contrast, nCRT combined with LLND significantly lowers the local recurrence (LR) rate. It has also been suggested that combination therapy regimens do not improve patient prognosis but increase treatment-related complications. Therefore, the suitable therapeutic option for rectal cancer with an enlarged LLN needs to be further explored. AIM Exploring appropriate treatment options for low to intermediate-stage II/III rectal cancer with LLN enlargement, as well as risk variables that may affect the LR in these patients with LLN enlarged. METHODS AND PATIENTS In this research, we retrospectively analyzed 110 patients with locally advanced mid-low (low boundary of tumor is no more than 10 cm from the anus) rectal cancer who were treated at Harbin Medical University Cancer Hospital arranged from 2017.1 to 2020.6. These patients had received nCRT and TME, and their initial rectal nuclear magnetic resonance imaging (MRI) revealed an enlarged LLN (short axis of LLN, SA ≥ 5 mm). Of these, 40 patients underwent LLND, thus, 110 patients were grouped into two groups: nCRT+TME (LLND-, n = 70) and nCRT+TME + LLND (LLND+, n = 40), and their 3 years prognoses were compared. RESULTS After a median follow-up of 49.0 months, the 3-year LR rate of the LLND- group was notably greater than the LLND+ group (22.8% vs. 7.5%, p = 0.04). However, there was no noteworthy difference in the 3-year progression-free survival (PFS, 70.5% vs. 77.5%, p > 0.05) rate or distant metastasis (DM) rate (20.0% vs. 17.5%, p > 0.05). Additionally, the LLND+ group experienced significantly more postoperative complications than the LLND- group (15.0% vs. 4.2%, p = 0.05). Subgroups analysis for the LLND- group revealed that patients with LLN short axis regression (ΔSA) > 35.9% after nCRT had significantly lower 3-year LR rate than patients with ΔSA ≤ 35.9% (9.1% vs. 35.1%, p = 0.01). Patients in the LLND- group with ΔSA > 35.9%, however, had comparable 3-year LR rate and DM rates to those in the LLND+ group. CONCLUSION LLN is an independent indicator for prognosis among people with low to intermediate-stage II/III malignant rectal tumors. Patients with poor SA regression (ΔSA ≤ 35.9%) after nCRT have a greater risk of positive LLN and a more substantial LR, and nCRT combined with LLND reduced the LR rate significantly, but considerably prolonged operative time, surgical bleeding, and postoperative complications. Patients with better SA regression (ΔSA > 35.9%), however, have a lower possibility of LR and might not need LLN clearance, in these cases, nCRT+TME is advised.
Collapse
Affiliation(s)
- Chunying Li
- Department of Abdominal Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jinwei Luan
- Department of Abdominal Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xin Ji
- Department of Abdominal Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xinxin Wang
- Department of Radiology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jiaqi Li
- Department of Abdominal Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xianglan Li
- Department of Abdominal Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yang Zhou
- Department of Radiology, Harbin Medical University Cancer Hospital, Harbin, China
| |
Collapse
|
2
|
Zeng DX, Yang Z, Tan L, Ran MN, Liu ZL, Xiao JW. Risk factors for lateral pelvic lymph node metastasis in patients with lower rectal cancer: a systematic review and meta-analysis. Front Oncol 2023; 13:1219608. [PMID: 37746256 PMCID: PMC10512344 DOI: 10.3389/fonc.2023.1219608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/31/2023] [Indexed: 09/26/2023] Open
Abstract
Background and objective Lateral pelvic lymph node (LPLN) metastasis is one of the prominent reasons for local recurrence (LR) in patients with rectal cancer (RC). The evaluation criteria of lateral lymph node dissection (LLND) for patients in eastern (mainly in Japan) and western countries have been controversial. The aim of this study was to analyse the risk factors for LPLN metastasis in order to guide surgical methods. Methods We searched relevant databases (Embase (Ovid), Medline (Ovid), PubMed, Cochrane Library, and Web of Science) for articles published between 1 January 2000 and 05 October 2022 to evaluate the risk factors for LPLN metastasis in patients with RC in this meta-analysis. Results A total of 24 articles with 5843 patients were included in this study. The overall results showed that female sex, age <60 years, pretherapeutic CEA level >5 ng/ml, clinical T4 stage (cT4), clinical M1 stage (cM1), distance of the tumour from the anal verge (AV) <50 mm, tumour centre located below the peritoneal reflection (Rb), short axis (SA) of LPLN ≥8 mm before nCRT, short axis (SA) of LPLN ≥5 mm after nCRT, border irregularity of LPLN, tumour size ≥50 mm, pathological T3-4 stage (pT3-4), pathological N2 stage (pN2), mesorectal lymph node metastasis (MLNM), lymphatic invasion (LI), venous invasion (VI), CRM (+) and poor differentiation were significant risk factors for LPLN metastasis (P <0.05). Conclusion This study summarized almost all potential risk factors of LPLN metastasis and expected to provide effective treatment strategies for patients with LRC. According to the risk factors of lateral lymph node metastasis, we can adopt different comprehensive treatment strategies. High-risk patients can perform lateral lymph node dissection to effectively reduce local recurrence; In low-risk patients, we can avoid overtreatment, reduce complications and trauma caused by lateral lymph node dissection, and maximize patient survival and quality of life.
Collapse
Affiliation(s)
- De-xing Zeng
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Zhou Yang
- Department of Gastrointestinal Surgery, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Ling Tan
- Department of Urology, People’s Hospital Affiliated to Chongqing Three Gorges Medical College, Chongqing, China
| | - Meng-ni Ran
- Department of Pharmacy, Three Gorges Hospital Affiliated to Chongqing University, Chongqing, China
| | - Zi-lin Liu
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Jiang-wei Xiao
- Department of Gastrointestinal Surgery, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| |
Collapse
|
3
|
Mahendran B, Balasubramanya S, Sebastiani S, Smolarek S. Extended Lymphadenectomy in Locally Advanced Rectal Cancers: A Systematic Review. Ann Coloproctol 2021:ac.2021.00703.0100. [PMID: 34788526 PMCID: PMC8898625 DOI: 10.3393/ac.2021.00703.0100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/14/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose The surgical treatment of advanced low rectal cancer remains controversial. Extended lymphadenectomy (EL) is the preferred option in the East, especially in Japan, while neoadjuvant radiotherapy is the treatment of choice in the West. This review was undertaken to review available evidence supporting each of the therapies. Methods All studies looking at EL were included in this review. A comprehensive search was conducted as per PRISMA guidelines. Primary outcome was defined as 5-year overall survival, with secondary outcomes including 3-year overall survival, 3- and 5-year disease-free survival, length of operation, and number of complications. Results Thirty-one studies met the inclusion criteria. There was no significant publication bias. There was statistically significant difference in 5-year survival for patient who underwent EL (odds ratio, 1.34; 95 confidence interval, 0.09–0.5; P=0.006). There were no differences noted in secondary outcomes except for length of the operations. Conclusion There is evidence supporting EL in rectal cancer; however, it is difficult to interpret and not easily transferable to a Western population. Further research is necessary on this important topic.
Collapse
Affiliation(s)
- Balaji Mahendran
- Department of Colorectal Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Supriya Balasubramanya
- Department of Colorectal Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Simone Sebastiani
- Department of Colorectal Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Sebastian Smolarek
- Department of Colorectal Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| |
Collapse
|
4
|
Inoue H, Sasaki K, Nozawa H, Kawai K, Murono K, Emoto S, Iida Y, Ishii H, Yokoyama Y, Anzai H, Sonoda H, Ozaki K, Yamauchi S, Sugihara K, Ishihara S. Therapeutic significance of D3 dissection for low rectal cancer: a comparison of dissections between the lateral pelvic lymph nodes and the lymph nodes along the root of the inferior mesenteric artery in a multicenter retrospective cohort study. Int J Colorectal Dis 2021; 36:1263-1270. [PMID: 33537876 DOI: 10.1007/s00384-021-03858-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE D3 dissection is the standard treatment modality for locally advanced low rectal cancer in Japan. The benefit of lateral pelvic lymph node (LPLN) dissection (LPLND) and lymph nodes along the root of inferior mesenteric artery (253 LN) dissection (253 LND) for low rectal cancer has often been studied separately, and few studies have investigated their benefit in the same cohort. This study aimed to clarify the therapeutic significance of dissection of the LPLN in comparison to that of dissection of the 253 LN for low rectal cancer. METHODS We retrospectively evaluated 3508 patients with treatment-naïve stage I-III low rectal cancer who underwent mesorectal excision between 1997 and 2012. They were identified from the Japanese Study Group for Postoperative Follow-Up of Colorectal Cancer database. The rates of metastasis, survival, and therapeutic value index (5-year overall survival (OS) rate multiplied by metastatic rate for lymph node metastasis) were compared between LPLN and 253 LN. RESULTS The rates of LPLN metastasis and 253 LN metastasis were 17.9% and 1.5%, respectively. The 5-year OS was significantly different between patients with and without LPLN metastasis (55.0% vs 85.5%, P < 0.0001) and between patients with and without 253 LN metastasis (36.2% vs 83.3%, P < 0.0001). The therapeutic value indexes of LPLN and 253 LN were 9.85 and 0.54, respectively. CONCLUSIONS LPLND may have more therapeutic value than 253 LND for patients with treatment-naïve low rectal cancer, although both the patients with LPLN metastasis and those with 253 LN metastasis remained to have poor prognosis.
Collapse
Affiliation(s)
- Hiroaki Inoue
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yuuki Iida
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroaki Ishii
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yuichiro Yokoyama
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroyuki Anzai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hirofumi Sonoda
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kousuke Ozaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shinichi Yamauchi
- Department of Surgical Oncology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenichi Sugihara
- Department of Surgical Oncology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| |
Collapse
|
5
|
Zhou S, Jiang Y, Pei W, Zhou H, Liang J, Zhou Z. Neoadjuvant chemoradiotherapy followed by lateral pelvic lymph node dissection for rectal cancer patients: A retrospective study of its safety and indications. J Surg Oncol 2021; 124:354-360. [PMID: 33882149 DOI: 10.1002/jso.26509] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/18/2021] [Accepted: 04/11/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES There is no consensus on the safety and indications of lateral pelvic lymph node dissection (LPND) for patients with clinical lateral pelvic node metastasis (LPNM) after neoadjuvant chemoradiotherapy (nCRT). METHODS We retrospectively analyzed 151 patients who underwent total mesorectal excision (TME) + LPND and divided them into two groups: nCRT group (n = 73) and non-nCRT group (n = 78). RESULTS Thirty-one (20.5%) patients had LPNM by pathology. The operative time was significantly longer in the nCRT group (291.9 vs. 237.0 min, p < 0.001); however, the two groups had comparable intraoperative blood loss (87.3 vs. 78.9 ml, p = 0.607) and morbidity (19.2% vs. 15.7%, p = 0.537). Additionally, in the nCRT group, multivariate logistic regression analysis showed that poor/mucinous/signet adenocarcinoma (odds ratio [OR] = 6.65, 95% confidence interval [CI] = 1.03-43.03, p = 0.047) and post-nCRT LPN size ≥7 mm (OR = 26.67, 95% CI = 2.87-247.91, p = 0.004) were independent risk factors for pathological LPNM. CONCLUSION nCRT before TME + LPND is safe and feasible with a comparably low mortality and acceptable morbidity. Poor/mucinous/signet adenocarcinoma and post-nCRT LPN size ≥7 mm were independent predictive factors of pathological LPNM after nCRT for rectal cancer patients with clinical LPNM, and patients with these characteristics should consider LPND after nCRT.
Collapse
Affiliation(s)
- Sicheng Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yujuan Jiang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Pei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haitao Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianwei Liang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhixiang Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
6
|
Emile SH, Elfeki H, Shalaby M, Sakr A, Kim NK. Outcome of lateral pelvic lymph node dissection with total mesorectal excision in treatment of rectal cancer: A systematic review and meta-analysis. Surgery 2020; 169:1005-1015. [PMID: 33317903 DOI: 10.1016/j.surg.2020.11.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Total mesorectal excision is the gold standard treatment of mid- and low-lying rectal cancer. Lateral pelvic lymph node dissection has been suggested as an approach to decrease recurrence and improve survival. Our meta-analysis presented here aimed to review the current outcomes of lateral pelvic lymph node dissection and total mesorectal excision in comparison with total mesorectal excision alone. METHODS A systematic literature search querying electronic databases was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We reviewed articles that reported the outcomes of lateral pelvic lymph node dissection combined with total mesorectal excision in comparison with total mesorectal excision alone. The main outcome measures were local recurrence, distant metastasis, overall and disease free-survival, and complications. RESULTS This systematic review included 29 studies of 10,646 patients. Of those patients, 39.4% underwent total mesorectal excision with lateral pelvic lymph node dissection. The median operation time for the lateral pelvic lymph node dissection + total mesorectal excision was significantly longer than total mesorectal excision alone (360 minutes versus 294.7 minutes, P = .02). Lateral pelvic lymph node dissection + total mesorectal excision was associated with higher odds of overall complications (odds ratio = 1.48, 95% confidence interval: 1.18-1.87, P < .001) and urinary dysfunction (odds ratio = 2.1, 95% confidence interval: 1.21-3.67, P = .008) than total mesorectal excision alone. Both groups had similar rates of male sexual dysfunction (odds ratio = 1.62, 95% confidence interval: 0.94-2.79, P = .08), anastomotic leakage (odds ratio = 1.15, 95% confidence interval: 0.69-1.93, P = .59), local recurrence (hazard ratio = 0.96, 95% confidence interval: 0.75-1.25, P = .79), distant metastasis (hazard ratio = 0.96, 95% confidence interval: 0.76-1.2, P = .72), overall survival (hazard ratio = 1.056, 95% confidence interval: 0.98-1.13, P = .13), and disease-free survival (hazard ratio = 1.02, 95% confidence interval: 0.97-1.07, P = .37). CONCLUSION Lateral pelvic lymph node dissection was not associated with a significant reduction of recurrence rates or improvement in survival as compared with total mesorectal excision alone; however, LPLND was associated with longer operation time and increased complication rate.
Collapse
Affiliation(s)
- Sameh Hany Emile
- Department of General surgery, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Egypt.
| | - Hossam Elfeki
- Department of General surgery, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Mostafa Shalaby
- Department of General surgery, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Ahmad Sakr
- Department of General surgery, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Egypt
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
7
|
Peacock O, Chang GJ. The Landmark Series: Management of Lateral Lymph Nodes in Locally Advanced Rectal Cancer. Ann Surg Oncol 2020; 27:2723-2731. [PMID: 32519144 DOI: 10.1245/s10434-020-08639-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Indexed: 12/12/2022]
Abstract
There has historically been a significant divide in the approach to the management of lateral pelvic lymph nodes in patients with rectal cancer. These differing paradigms have developed based upon competing priorities. In the West, the circumferential resection margin has been the main focus because it is a strong predictor of local recurrence, distal recurrence, and survival. This approach was supplemented by radiation and chemotherapy to treat the lateral pelvic lymph nodes and micrometastatic disease. In the East, lateral pelvic lymph nodes are considered to be locoregional; thus, surgical treatment has traditionally included routine dissection of this compartment for low rectal cancers without the use of neoadjuvant chemoradiotherapy. However, neither approach has adequately addressed the important issue of lateral compartment recurrence in patients with clinically evident lateral pelvic lymph node metastasis. The aims of the review were to present the recent key studies and evolution of lateral pelvic lymph node management in locally advanced rectal cancer and secondly to propose a management strategy for the lateral compartment based on the current evidence.
Collapse
Affiliation(s)
- Oliver Peacock
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George J Chang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
8
|
Abstract
BACKGROUND Despite the use of neoadjuvant chemoradiation and total mesorectal excision for rectal cancer, lateral pelvic lymph node recurrence is still an important problem. OBJECTIVE This study aimed to determine the indication for lateral pelvic lymph node dissection in post neoadjuvant chemoradiation rectal cancer. DESIGN This is a retrospective analysis of a prospectively collected institutional database. SETTINGS This study was conducted at a tertiary care cancer center from January 2006 through December 2017. PATIENTS Patients who had rectal cancer with suspected lateral pelvic lymph node metastasis, who underwent total mesorectal excision with lateral pelvic lymph node dissection, were included. MAIN OUTCOME MEASURES The primary outcome measured was pathologic lateral pelvic lymph node positivity. INTERVENTIONS The associations between lateral pelvic lymph node size on post-neoadjuvant chemoradiation imaging and pathologic lateral pelvic lymph node positivity and recurrence outcomes were evaluated. RESULTS A total of 64 patients were analyzed. The mean lateral pelvic lymph node size before and after neoadjuvant chemoradiation was 12.6 ± 9.5 mm and 8.5 ± 5.4 mm. The minimum size of positive lateral pelvic lymph node was 5 mm on post neoadjuvant chemoradiation imaging. Among 13 (20.3%) patients who had a <5 mm lateral pelvic lymph node after neoadjuvant chemoradiation, none were pathologically positive. Among 51 (79.7%) patients who had a ≥5 mm lateral pelvic lymph node after neoadjuvant chemoradiation, 33 patients (64.7%) were pathologically positive. Five-year overall survival and disease-specific survival were higher in the histologic lateral pelvic lymph node negative group than in the lateral pelvic lymph node positive group (overall survival 79.6% vs 61.8%, p = 0.122; disease-specific survival 84.5% vs 66.2%, p= 0.088). After a median 39 months of follow-up, there were no patients in the <5 mm group who died of cancer. There were no lateral compartment recurrences in the entire cohort. LIMITATIONS Being a single-center retrospective study may limit generalizability. CONCLUSIONS Post-neoadjuvant chemoradiation lateral pelvic lymph node size ≥5 mm was strongly associated with pathologic positivity. No patients with size <5 mm had pathologically positive lymph nodes. Following lateral pelvic lymph node dissection, no patients with a positive lateral pelvic lymph node developed lateral compartment recurrence. Therefore, patients who have rectal cancer with clinical evidence of lateral pelvic lymph node metastasis and post-neoadjuvant chemoradiation lateral pelvic lymph node size ≥5 mm should be considered for lateral pelvic lymph node dissection at the time of total mesorectal excision. See Video Abstract at http://links.lww.com/DCR/B3. ¿QUIéN DEBE RECIBIR LINFADENECTOMíA PéLVICA LATERAL DESPUéS DE LA QUIMIORRADIACIóN NEOADYUVANTE?: A pesar del uso de quimiorradiación neoadyuvante y la escisión total de mesorectao para el cáncer de recto, la recurrencia en los ganglios linfáticos pélvicos laterales sigue siendo un problema importante. OBJETIVO Determinar la indicación para la disección de los ganglios linfáticos pélvicos laterales en el cáncer rectal post quimiorradiación neoadyuvante. DISEÑO:: Análisis retrospectivo de la base de datos institucional prospectivamente recopilada. ESCENARIO Centro de cáncer de atención terciaria, de enero de 2006 hasta diciembre de 2017. PACIENTES Pacientes con cáncer de recto con sospecha de metástasis en los ganglios linfáticos pélvicos laterales, que se sometieron a escisión total mesorectal con disección de los ganglios linfáticos pélvicos laterales. PRINCIPALES MEDIDAS DE RESULTADOS Positividad de ganglios linfáticos pélvicos laterales en histopatología. INTERVENCIONES Se evaluaron las asociaciones entre el tamaño de los ganglios linfáticos pélvicos laterales en imagenología postquimiorradiación neoadyuvante y la positividad y recurrencia en los ganglios linfáticos pélvicos laterales en histopatología. RESULTADOS Se analizaron un total de 64 pacientes. La media del tamaño de los ganglios linfáticos pélvicos laterales antes y después de la quimiorradiación neoadyuvante fue de 12.6 ± 9.5 mm y 8.5 ± 5.4 mm, respectivamente. El tamaño mínimo de los ganglios linfáticos pélvicos laterales positivos fue de 5 mm en las imágenes postquimiorradiación neoadyuvante. Entre 13 (20.3%) pacientes que tenían <5 mm de ganglio linfático lateral pélvico después de la quimiorradiación neoadyuvante; ninguno fue positivo en histopatología. Entre 51 (79.7%) pacientes con ganglio linfático pélvico lateral ≥ 5 mm después de la quimiorradiación neoadyuvante; 33 pacientes (64.7%) fueron positivos en histopatología. La supervivencia general a 5 años y la supervivencia específica de la enfermedad fueron mayores en el grupo histológico de ganglio linfático pélvico lateral negativo que en el grupo de ganglio linfático pélvico lateral positivo (Supervivencia general 79.6% vs 61.8%, p = 0.122; Supervivencia específica de la enfermedad 84.5% vs 66.2%, p = 0.088). Después de una mediana de seguimiento de 39 meses, no hubo pacientes en el grupo de <5 mm que hayan fallecido por cáncer. No hubo recurrencias en el compartimento lateral en toda la cohorte. LIMITACIONES Al ser un estudio retrospectivo en un solo centro puede limitar la generalización. CONCLUSIONES El tamaño de los ganglios linfáticos pélvicos laterales postquimiorradiación neoadyuvante ≥ 5 mm se asoció fuertemente con la positividad histopatológica. Ningún paciente con tamaño <5 mm tuvo ganglios linfáticos histopatológicamente positivos. Después de la disección de los ganglios linfáticos pélvicos laterales, ningún paciente con ganglios linfáticos pélvicos laterales positivos desarrolló recurrencia del compartimiento lateral. Por lo tanto, los pacientes con cáncer rectal con evidencia clínica de metástasis en los ganglios linfáticos pélvicos laterales y tamaño de ganglios linfáticos pélvicos laterales postquimiorradiación neoadyuvante ≥ 5 mm deben considerarse para disección de los ganglios linfáticos pélvicos laterales en el momento de la escisión total de mesorrecto. Vea el Abstract en video en http://links.lww.com/DCR/B3.
Collapse
|
9
|
Dev K, Veerenderkumar KV, Krishnamurthy S. Incidence and Predictive Model for Lateral Pelvic Lymph Node Metastasis in Lower Rectal Cancer. Indian J Surg Oncol 2018; 9:150-156. [PMID: 29887692 DOI: 10.1007/s13193-017-0719-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 12/12/2017] [Indexed: 01/22/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Kapil Dev
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, India
| | - K V Veerenderkumar
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, India
| | | |
Collapse
|
10
|
Yang D, Quan W, Wu J, Ji X, Dai Y, Xiao W, Chew H, Sun Z, Li D. The value of red blood cell distribution width in diagnosis of patients with colorectal cancer. Clin Chim Acta 2018; 479:98-102. [PMID: 29407693 DOI: 10.1016/j.cca.2018.01.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/16/2017] [Accepted: 01/16/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Red blood cell distribution width (RDW) is a parameter of standard full blood count tests that reflects the size variability of erythrocytes In recent studies, RDW levels have been associated with ischemic heart disease, acute and chronic heart failure, hypertension, and inflammatory bowel disease. However, it is unclear whether RDW is associated with colorectal cancer. METHODS Eighty-five patients were diagnosed with colorectal cancer. Fifty-four other patients each diagnosed with colon polyps during the same period served as the control group. The patients were classified according to the seventh edition of the AJCC Cancer Staging Manual of 2009 into groups of different cancer stages, and simultaneously divided into groups with or without metastasis. The multigroup metering data was tested by a non-parametric Kruskal-Wallis H test, and the two subsets of patients formed above were compared using a Mann-Whitney U test. The association between continuous variables was assessed by Spearman correlation analysis while the association between RDW and colorectal cancer metastasis was estimated by receiver operating characteristic (ROC) curve analysis. RESULTS Increased RDW was observed in patients with colorectal cancer. The RDW was significantly different for each subgroup of colorectal cancer as follows: stage III + IV > stage III, T3 + T4 > T1 + T2, N1 + N2 > N0, and M1 > M0 (P < 0.05). The area under the receiver-operating characteristic curve of the RDW in the diagnosis of colorectal cancer metastasis was 0.721 (95% confidence interval of 0.612-0.831). CONCLUSIONS The value of RDW is closely related to colorectal cancer metastasis.
Collapse
Affiliation(s)
- Dianyu Yang
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China
| | - Wenqiang Quan
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China
| | - Junlu Wu
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China
| | - Xiaoyi Ji
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China
| | - Yan Dai
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China
| | - Weidong Xiao
- Sol Sherry Thrombosis Research Center, Temple University, 19140 Philadelphia, PA, USA
| | - Helen Chew
- Sol Sherry Thrombosis Research Center, Temple University, 19140 Philadelphia, PA, USA
| | - Zujun Sun
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China.
| | - Dong Li
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, 200065 Shanghai, China.
| |
Collapse
|
11
|
Preoperative chemoradiotherapy changes the size criterion for predicting lateral lymph node metastasis in lower rectal cancer. Int J Colorectal Dis 2017; 32:1631-1637. [PMID: 28762190 DOI: 10.1007/s00384-017-2873-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 02/07/2023]
Abstract
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.
Collapse
|
12
|
Glynne-Jones R, Wyrwicz L, Tiret E, Brown G, Rödel C, Cervantes A, Arnold D. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28:iv22-iv40. [PMID: 28881920 DOI: 10.1093/annonc/mdx224] [Citation(s) in RCA: 966] [Impact Index Per Article: 138.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- R Glynne-Jones
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Northwood, London, UK
| | - L Wyrwicz
- Department of Gastrointestinal Cancer, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - E Tiret
- Department of Surgery, Sorbonne Universités, UPMC Univ Paris 06, Paris
- APHP, Hôpital Saint-Antoine, Paris, France
| | - G Brown
- Department of Radiology, The Imperial College and Royal Marsden Hospital, Sutton, Surrey, UK
| | - C Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
| | - A Cervantes
- CIBERONC, Medical Oncology Department, INCLIVA University of Valencia, Valencia, Spain
| | - D Arnold
- Instituto CUF de Oncologia (I.C.O.), Lisbon, Portugal
| |
Collapse
|