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Ozgur I, Gorgun E. Role of Lateral Pelvic Node Dissection in Rectal Cancer Surgery. Clin Colon Rectal Surg 2024; 37:222-228. [PMID: 38882936 PMCID: PMC11178386 DOI: 10.1055/s-0043-1770711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
The role of lateral pelvic lymph node dissection in the treatment of patients with locally advanced rectal cancer is a matter of controversy. Surgical practices in Korea and Japan have accepted this approach and are widely utilized; however, it is not routinely incorporated in the practice of countries in the Western hemisphere. This review will examine the role of lateral pelvic lymph node dissection.
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Affiliation(s)
- Ilker Ozgur
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Chua JYJ, Ngu JCY, Teo NZ. Current perspectives on the management of lateral pelvic lymph nodes in rectal cancer. World J Clin Oncol 2023; 14:584-592. [PMID: 38179407 PMCID: PMC10762530 DOI: 10.5306/wjco.v14.i12.584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/07/2023] [Accepted: 11/24/2023] [Indexed: 12/22/2023] Open
Abstract
Significant controversies exist with regards to the optimal management of lateral pelvic lymph nodes metastases (mLLN) in patients with low rectal cancer. The differing views held by Japanese and Western clinicians on the management of mLLN have been well documented. However, the adequacy of pelvic lymph node dissection (PLND) or neoadjuvant chemoradiation (NACRT) alone in addition to total mesorectal excision (TME) have recently come into question, due to the relatively high incidence of lateral local recurrences following PLND and TME, or NACRT and TME alone. Recently, a more selective approach to PLND has been suggested, involving a combination of neoadjuvant therapy, followed by PLND only to patients in whom the oncological benefit is likely to outweigh the risk of potential adverse events. A number of studies have attempted to retrospectively identify certain nodal characteristics on preoperative imaging, such as nodal size, appearance, and size reduction following neoadjuvant therapy. However, no consensus has been reached regarding the optimal criteria for a selective approach to PLND, partly due to the heterogeneity and retrospective nature of most of these studies. This review aims to provide an overview of recent evidence with regards to the diagnostic challenges, considerations for, and outcomes of the current management strategies for mLLN in rectal cancer patients.
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Affiliation(s)
- Jonathan Yu Jin Chua
- Department of General Surgery, Changi General Hospital, Singapore 529889, Singapore
| | - James Chi Yong Ngu
- Department of General Surgery, Changi General Hospital, Singapore 529889, Singapore
| | - Nan Zun Teo
- Department of General Surgery, Changi General Hospital, Singapore 529889, Singapore
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Zhang C, Cui M, Xing J, Yang H, Yao Z, Zhang N, Tan F, Liu M, Xu K, Su X. Effect of lateral lymph nodes without malignant characteristics on the prognosis of patients with rectal cancer. Future Oncol 2022; 18:3509-3518. [PMID: 36317561 DOI: 10.2217/fon-2022-0476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Lateral lymph node (LLN) metastasis is a poor prognostic factor for rectal cancer patients. However, the effect of LLNs without malignant characteristics on the prognosis of rectal cancer patients has been uncertain. Methods: Consecutive patients who underwent laparoscopic-assisted low anterior resection were included. Patients with MRI-detected LLNs, but without malignant characteristics, were compared with patients with no MRI-detected LLNs. Results: The local recurrence rate was higher in the LLN-present group than in the LLN-absent group (9.8% vs 2.5%; p = 0.056). The overall survival of patients with no MRI-detected LLNs was significantly better than that of patients with MRI-detected LLNs (p = 0.021). Conclusion: The presence of LLNs, even without malignant features, may lead to worse local control and overall survival.
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Affiliation(s)
- Chenghai Zhang
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Ming Cui
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Jiadi Xing
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Hong Yang
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Zhendan Yao
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Nan Zhang
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Fei Tan
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Maoxing Liu
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Kai Xu
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Xiangqian Su
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
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Abstract
The management of localized rectal cancer requires a multidisciplinary approach to optimize outcomes, reduce morbidity and prevent under or overtreatments. While early stages may obtain benefit of local resections without any additional therapies, locally advanced rectal cancer becomes a challenge defining the better sequential strategy of surgery, radiotherapy and chemotherapy. The latest results of international phase III studies have positioned the total neoadjuvant therapy as a potential new standard of care in high risk rectal cancers, however, the best schedule is still not well defined.
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Fahy MR, Kelly ME, Nugent T, Hannan E, Winter DC. Lateral pelvic lymphadenectomy for low rectal cancer: a META-analysis of recurrence rates. Int J Colorectal Dis 2021; 36:551-558. [PMID: 33242114 DOI: 10.1007/s00384-020-03804-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Locoregional recurrence (LR) remains a problem for patients with lower rectal cancer despite standardized surgery and improved neoadjuvant treatment regimens. Lateral pelvic lymph node dissection (LPLND) has been routine practice for some time in the Orient/East, but other regions have concerns about morbidity. As perioperative care and surgical approaches are refined, this has been revisited for selected patients. The question as to whether LPLND improves oncological outcomes was explored here. METHODS A systematic review of patients who underwent TME with or without LPLND from 2000 to 2020 was performed. The primary endpoint was the rate of LR between the two groups. RESULTS Seven papers met the predefined search criteria in which 2000 patients underwent TME alone, while 1563 patients had TME and LPLND. The rate of LR was marginally higher with TME alone when compared with TME plus LPLND, but this result was not statistically significant (9.8 vs 9.4%, odds ratio 0.75, 95% CI 0.41-1.38, *p = 0.35). In addition, four studies reported on distant recurrence rates, with TME and LPLND showing a slight reduction in overall rates (27.3 vs 29.9%, respectively, OR 0.65, 95% CI 0.45-0.92, *p = 0.02). CONCLUSION The addition of LPLND to TME is not associated with a significantly lower risk of LR in patients who undergo surgery for lower rectal cancer.
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Affiliation(s)
- M R Fahy
- University College Dublin, Dublin, Ireland.
| | - M E Kelly
- University College Dublin, Dublin, Ireland
| | - T Nugent
- Trinity College Dublin, Dublin, Ireland
| | - E Hannan
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - D C Winter
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
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Elhusseini M, Aly EH. Lateral pelvic lymph node dissection in the management of locally advanced low rectal cancer: Summary of the current evidence. Surg Oncol 2020; 35:418-425. [PMID: 33038847 DOI: 10.1016/j.suronc.2020.09.021] [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: 06/11/2020] [Revised: 08/23/2020] [Accepted: 09/27/2020] [Indexed: 02/07/2023]
Abstract
Lateral pelvic lymph nodes (LPLN) are a major site for local recurrence following curative resection for low locally advanced rectal cancer. Ongoing advances in imaging techniques have improved predicting LPLN metastasis (LPLNM) during pre-operative staging. However, there is ongoing debate on optimal management of this subgroup of patients with variation between guidance of different societies. In Japan, LPLNM is considered as local disease and addressed by lateral pelvic node dissection (LPLND) in addition to total mesorectal excision (TME). However, in the west, LPLNM is considered as metastatic disease and those patients are offered neoadjuvant chemoradiotherapy (nCRT) followed by TME surgery. The potential surgical risks and morbidity associated with LPLND as well as the uncertainty of the oncological outcome have raised the concern that patients with locally advanced low rectal cancer with LPLNM could be over or under-treated. A comprehensive review of literature was performed, summarizing the current evidence on available modalities for predicting LPLNM, the role of LPLND in the management of advanced low rectal cancer and the available surgical approaches with their impact on surgical and oncological outcomes. LPLND is associated with increased operative time, blood loss and post-operative morbidity. The potential benefits for local disease control and survival still awaits high quality studies. There has been increasing number of reports of the use minimally invasive approaches in LPLND in an attempt to reduce post-operative complications. There is need for high quality evidence to define the role of LPLND in management of patients with advanced low rectal cancer.
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Affiliation(s)
- Mootaz Elhusseini
- University of Aberdeen, UK; Aberdeen Royal Infirmary, Department of Surgery, Surgical Admin Block, Yellow Zone, Level Foresterhill, Aberdeen, Scotland, AB25 2ZN, UK
| | - Emad H Aly
- University of Aberdeen, UK; Aberdeen Royal Infirmary, Department of Surgery, Surgical Admin Block, Yellow Zone, Level Foresterhill, Aberdeen, Scotland, AB25 2ZN, UK.
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