1
|
Lee T, Horvat N, Gollub MJ, Garcia-Aguilar J, Kim TH. Prognostic value of lateral lymph node metastasis in pretreatment MRI for rectal cancer in patients undergoing neoadjuvant chemoradiation followed by surgical resection without lateral lymph node dissection: A systemic review and meta-analysis. Eur J Radiol 2024; 178:111601. [PMID: 38972182 DOI: 10.1016/j.ejrad.2024.111601] [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: 05/10/2024] [Revised: 06/25/2024] [Accepted: 07/02/2024] [Indexed: 07/09/2024]
Abstract
PURPOSE To systematically review and meta-analyze the prognostic significance of lateral lymph node metastasis (LLNM) on pretreatment MRI in patients with rectal cancer who undergo neoadjuvant chemoradiation followed by curative surgical resection without lateral lymph node dissection (LLND). METHODS We searched the MEDLINE and EMBASE databases until September 27, 2023, utilizing the following search terms: (rectal OR rectum OR colorectal) AND (lateral OR sidewall) AND (lymph OR node). The QUIPS tool was employed to evaluate methodological quality. We pooled the association between LLNM on pretreatment MRI and outcomes such as local recurrence, distant metastasis, disease-free survival, and overall survival using hazard ratio (HR) and odds ratio (OR) based on random effects model. RESULTS We included 9 studies, encompassing 3180 patients. LLNM on pretreatment MRI revealed a significant association with increased local recurrence rates (HR: 4.11; 95 % CI: [1.87, 9.02]) and elevated risks for both disease-free (HR: 1.70; 95 % CI: [1.42, 2.03]) and overall survival (HR: 1.76; 95 % CI: [1.44, 2.15]). As for distant metastasis, our analysis indicated a potential trend towards increased rates, though this did not reach statistical significance (HR: 1.67; 95 % CI: [0.85, 3.27]). CONCLUSIONS Our findings underscore the relationship between LLNM and increased local recurrence and compromised disease-free and overall survival. This emphasizes the potential limitations of relying solely on neoadjuvant chemoradiation and highlights the potential need to intensify treatment in select patients.
Collapse
Affiliation(s)
- Taehee Lee
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tae-Hyung Kim
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
2
|
Chaouch MA, Hussain MI, Carneiro da Costa A, Mazzotta A, Krimi B, Gouader A, Cotte E, Khan J, Oweira H. Robotic versus laparoscopic total mesorectal excision with lateral lymph node dissection for advanced rectal cancer: A systematic review and meta-analysis. PLoS One 2024; 19:e0304031. [PMID: 38809911 PMCID: PMC11135705 DOI: 10.1371/journal.pone.0304031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/05/2024] [Indexed: 05/31/2024] Open
Abstract
INTRODUCTION Lateral pelvic node dissection (LPND) poses significant technical challenges. Despite the advent of robotic surgery, determining the optimal minimally invasive approach remains a topic of debate. This study aimed to compare postoperative outcomes between robotic total mesorectal excision with LPND (R-LPND) and laparoscopic total mesorectal excision with LPND (L-LPND). METHODS This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 and AMSTAR 2 (Assessing the Methodological Quality of Systematic Reviews) guidelines. Utilizing the RevMan 5.3.5 statistical package from the Cochrane Collaboration, a random-effects model was employed. RESULTS Six eligible studies involving 652 patients (316 and 336 in the R-LPND and L-LPND groups, respectively) were retrieved. The robotic approach demonstrated favourable outcomes compared with the laparoscopic approach, manifesting in lower morbidity rates, reduced urinary complications, shorter hospital stays, and a higher number of harvested lateral pelvic lymph nodes. However, longer operative time was associated with the robotic approach. No significant differences were observed between the two groups regarding major complications, anastomotic leak, intra-abdominal infection, neurological complications, LPND time, overall recurrence, and local recurrence. CONCLUSIONS In summary, the robotic approach is a safe and feasible alternative for Total Mesorectal Excision (TME) with LPND in advanced rectal cancer. Notably, it is associated with lower morbidity, particularly a reduction in urinary complications, a shorter hospital stay and increased number of harvested lateral pelvic nodes. The trade-off for these benefits is a longer operative time.
Collapse
Affiliation(s)
- Mohamed Ali Chaouch
- Department of visceral and digestive surgery, Monastir University Hospital, Monastir, Tunisia
| | - Mohammad Iqbal Hussain
- Department of Robotic Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | | | - Alessandro Mazzotta
- Department of Surgery, M. G. Vannini Hospital, Istituto Figlie Di San Camillo, Rome, Italy
| | - Bassem Krimi
- Department of Surgery, Perpignan Hospital Center, Perpignan, France
| | - Amine Gouader
- Department of Surgery, Perpignan Hospital Center, Perpignan, France
| | - Eddy Cotte
- Department of Visceral Surgery, University Hospital of Lyon, University of Lyon, Lyon, France
| | - Jim Khan
- Department of Robotic Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | - Hani Oweira
- Department of Surgery, Universitäts Medizin Mannheim, Heidelberg University, Mannheim, Germany
| |
Collapse
|
3
|
Kim HJ, Choi GS, Park JS, Park SY, Song SH, Lee SM, Jeong MH, Cho SH. Long-term Complications of Laparoscopic or Robotic Lateral Pelvic Node Dissection After Preoperative Chemoradiotherapy for Locally Advanced Rectal Cancer. Dis Colon Rectum 2024; 67:505-513. [PMID: 38164944 DOI: 10.1097/dcr.0000000000003183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Patients with rectal cancer who underwent lateral pelvic node dissection might be at a higher risk of postoperative complications derived from technical complexity. However, little is known regarding the long-term complications after lateral pelvic node dissection. OBJECTIVES The study aimed to investigate the long-term complications of preoperative chemoradiotherapy, followed by total mesorectal excision with lateral pelvic node dissection for locally advanced rectal cancers. DESIGN A retrospective analysis of a prospectively collected database. SETTINGS This study was conducted in a tertiary cancer center. PATIENTS Patients with rectal cancer who underwent total mesorectal excision with lateral pelvic node dissection after preoperative chemoradiotherapy between 2011 and 2019 were analyzed. All operations were performed via a laparoscopic or robotic approach. MAIN OUTCOME MEASURES Long-term complications were defined as adverse events that persisted or newly appeared ≥90 days after surgery and could be related to the surgery. RESULTS A total of 164 patients underwent total mesorectal excision with lateral pelvic node dissection after preoperative chemoradiotherapy. Short-term and long-term complication rates were 36.0% and 36.6%, respectively. Lymphocele was the most common long-term complication (17.7% of patients), and 11.6% had anastomotic leakage with chronic sinus. Of the patients with long-term complications, 20.7% of patients needed readmission for treatment. Of the 29 patients with lymphocele, 13 (41.0%) experienced spontaneous absorption and 11 (37.9%) required surgical or percutaneous catheter drainage or antibiotics use. Multivariate analysis showed pathologic pelvic node metastases ( p = 0.008), and a higher number of unilateral harvested pelvic nodes ( p = 0.001) were significantly associated with long-term complications. At the last follow-up (median duration of 43 months), 15.9% of patients had unresolved complications. LIMITATIONS The retrospective design. CONCLUSIONS Patients undergoing lateral pelvic node dissection experienced a higher frequency of long-term complications, but half of them had asymptomatic lymphoceles, most of which resolved spontaneously. However, further efforts should be paid to reduce anticipated complications related to lateral pelvic node dissection. See Video Abstract . COMPLICACIONES A LARGO PLAZO DE LA DISECCIN DE LOS GANGLIOS LIFTICOS PLVICOS LATERALES LAPAROSCPICA O ROBTICA DESPUS DE LA QUIMIORRADIOTERAPIA PREOPERATORIA CONTRA EL CNCER DEL RECTO LOCALMENTE AVANZADO ANTECEDENTES:Los pacientes con cáncer del recto sometidos a disección ganglionar linfática pélvica lateral podrían tener mayor riesgo de complicaciones postoperatorias derivadas de la complejidad técnica. Sin embargo, se sabe poco sobre las complicaciones a largo plazo después de la disección de los ganglios linfáticos pélvicos laterales.OBJETIVOS:Investigar las complicaciones a largo plazo de la quimiorradioterapia preoperatoria, seguida de escisión mesorrectal total con disección de los ganglios linfáticos pélvicos laterales contra el cáncer de recto localmente avanzado.DISEÑO:Un análisis retrospectivo de una base de datos recopilada prospectivamente.AJUSTES:Este estudio se llevó a cabo en un centro oncológico terciario.PACIENTES:Se analizaron pacientes con cáncer de recto que se sometieron a escisión mesorrectal total con disección de ganglios linfáticos pélvicos laterales después de quimiorradioterapia preoperatoria entre 2011 y 2019. Todas las operaciones se realizaron mediante abordaje laparoscópico o robótico.PRINCIPALES MEDIDAS DE RESULTADO:Las complicaciones a largo plazo se definieron como eventos adversos que persistieron o aparecieron recientemente ≥ 90 días después de la cirugía y podrían estar relacionados con la cirugía.RESULTADOS:Un total de 164 pacientes se sometieron a escisión mesorrectal total con disección de los ganglios linfáticos pélvicos laterales después de quimiorradioterapia preoperatoria. Las tasas de complicaciones a corto y largo plazo fueron del 36,0% y 36,6%, respectivamente. El linfocele fue la complicación a largo plazo más común (17,7% de los pacientes) y el 11,6% tuvo fuga anastomótica con seno crónico. De los pacientes con complicaciones a largo plazo, el 20,7% de los pacientes necesitaron reingreso para recibir tratamiento. De 29 pacientes con linfocele, 13 (41,0%) experimentaron absorción espontánea y 11 (37,9%) requirieron drenaje quirúrgico o percutáneo con catéter o uso de antibióticos. El análisis multivariado mostró metástasis patológicas en los ganglios linfáticos pélvicos ( p = 0,008) y un mayor número de ganglios pélvicos extraídos unilateralmente ( p = 0,001) se asociaron significativamente con complicaciones a largo plazo. En el último seguimiento (mediana de 43 meses), el 15,9% de los pacientes tuvieron complicaciones no resueltas.LIMITACIÓN:El diseño retrospectivo.CONCLUSIONES:Los pacientes sometidos a disección de ganglios pélvicos linfáticos laterales experimentaron una mayor frecuencia de complicaciones a largo plazo, pero la mitad de ellos tuvieron linfoceles asintomáticos, la mayoría de los cuales se resolvieron espontáneamente. Sin embargo, se deben realizar mayores esfuerzos para reducir las complicaciones previstas relacionadas con la disección de los ganglios linfáticos pélvicos laterales. (Traducción-Dr. Aurian Garcia Gonzalez ).
Collapse
Affiliation(s)
- Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Seung Ho Song
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung Min Lee
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Min Hye Jeong
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Seung Hyun Cho
- Department of Radiology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| |
Collapse
|
4
|
Ishizuka M, Shibuya N, Hachiya H, Nishi Y, Takayanagi M, Fujita J, Ihara K, Shiraki T, Matsumoto T, Mori S, Iso Y, Nakamura T, Aoki T, Irisawa A. Clinical influence of prophylactic lateral lymph node dissection on oncologic outcomes of patients with mid-low rectal cancer undergoing mesorectal excision: a meta-analysis. J Gastrointest Surg 2024; 28:548-558. [PMID: 38583909 DOI: 10.1016/j.gassur.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/06/2024] [Accepted: 01/13/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Although several recent meta-analyses have investigated the clinical influence of the addition of lateral lymph node dissection (LLND) on oncologic outcomes in patients with mid-low rectal cancer (RC) undergoing mesorectal excision (ME), most studies included in such meta-analyses were retrospectively designed. Therefore, this study aimed to explore the clinical influence of prophylactic LLND on oncologic outcomes in patients with mid-low RC undergoing ME. METHODS A comprehensive electronic search of the literature up to July 2022 was performed to identify studies that compared oncologic outcomes between patients with mid-low RC undergoing ME who underwent LLND and patients with mid-low RC undergoing ME who did not undergo LLND. A meta-analysis was performed using fixed-effects models and the generic inverse variance method to calculate hazard ratios (HRs) and 95% CIs, and heterogeneity was analyzed using I2 statistics. RESULTS A total of 6 studies, consisting of 3 randomized and 3 propensity score matching studies, were included in this meta-analysis. The results of the meta-analysis of 2 randomized studies demonstrated no significant effect of prophylactic LLND on improving oncologic outcomes concerning overall survival (OS) (HR, 1.22; 95% CI, 0.89-1.69; I2 = 0%; P = .22) and relapse-free survival (RFS) (HR, 1.03; 95% CI, 0.81-1.31; I2 = 28%; P = .83). CONCLUSION The results of this meta-analysis revealed no significant influence of prophylactic LLND on oncologic outcomes-OS and RFS-in patients with mid-low RC who underwent ME.
Collapse
Affiliation(s)
- Mitsuru Ishizuka
- Center for Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan; Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan.
| | - Norisuke Shibuya
- Center for Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan; Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Hiroyuki Hachiya
- Center for Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan; Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Yusuke Nishi
- Center for Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan; Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Masashi Takayanagi
- Center for Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Junki Fujita
- Center for Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Keisuke Ihara
- Center for Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Takayuki Shiraki
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Takatsugu Matsumoto
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Shozo Mori
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Yukihiro Iso
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Takatoshi Nakamura
- Center for Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Taku Aoki
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Atsushi Irisawa
- Center for Colorectal Surgery, Dokkyo Medical University, Tochigi, Japan
| |
Collapse
|
5
|
deLahunta D, Nalamati S. Management of Surgically Accessible Lymph Nodes Beyond Normal Resection Planes. Clin Colon Rectal Surg 2024; 37:71-79. [PMID: 38322601 PMCID: PMC10843887 DOI: 10.1055/s-0043-1761474] [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: 02/08/2024]
Abstract
This article discusses the management of isolated metastatic lymph nodes for colon and rectal cancer. There are traditionally significant differences in how certain regions of lymph nodes for colon and rectal cancer are managed in the East and West. This has led to the development of the lateral lymph node dissection for rectal cancer and extended lymphadenectomy techniques for colon cancer. This article will evaluate the literature on these techniques and what the surgical and oncological outcomes are at this time. In addition, colon and rectal cancers can occasionally have isolated distant lymph node metastases. These would traditionally be treated as systemic disease with chemotherapy. There is consideration though that these could be treated as similar to isolated liver or lung metastases which have been shown to be able to be treated surgically with good oncological results. The literature for these isolated distant lymph node metastases will be reviewed and treatment options available will be discussed.
Collapse
Affiliation(s)
- Daniel deLahunta
- Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Surya Nalamati
- Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
| |
Collapse
|
6
|
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
|
7
|
Garoufalia Z, Wexner SD. Indocyanine Green Fluorescence Guided Surgery in Colorectal Surgery. J Clin Med 2023; 12:jcm12020494. [PMID: 36675423 PMCID: PMC9865296 DOI: 10.3390/jcm12020494] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/04/2023] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Indocyanine green (ICG) imaging has been increasingly used for intraoperative guidance in colorectal surgery over the past decade. The aim of this study was to review and organize, according to different type of use, all available literature on ICG guided colorectal surgery and highlight areas in need of further research and discuss future perspectives. METHODS PubMed, Scopus, and Google Scholar databases were searched systematically through November 2022 for all available studies on fluorescence-guided surgery in colorectal surgery. RESULTS Available studies described ICG use in colorectal surgery for perfusion assessment, ureteral and urethral assessment, lymphatic mapping, and hepatic and peritoneal metastases assessment. Although the level of evidence is low, results are promising, especially in the role of ICG in reducing anastomotic leaks. CONCLUSIONS ICG imaging is a safe and relatively cheap imaging modality in colorectal surgery, especially for perfusion assessment. Work is underway regarding its use in lymphatic mapping, ureter identification, and the assessment of intraperitoneal metastatic disease.
Collapse
|
8
|
Zhou S, Mei S, Feng B, Yang Y, Wang X, Wang Q, Liu Q. Mesorectal excision with or without lateral lymph node dissection for elderly patients with mid-low rectal cancer: safety and feasibility analysis. Jpn J Clin Oncol 2023; 53:26-34. [PMID: 36354102 DOI: 10.1093/jjco/hyac167] [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: 06/16/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The perioperative safety and survival benefits of lateral lymph node dissection in elderly patients have been less reported. This study aimed to compare short-term and survival outcomes of total mesorectal excision and total mesorectal excision + lateral lymph node dissection in elderly patients. METHODS A total of 444 elderly patients (≥65 years) with middle-low rectal cancer were enrolled in three institutions and divided into the total mesorectal excision + lateral lymph node dissection group (n = 110) and the total mesorectal excision group (n = 334). Eighty-three matched pairs were selected for evaluation after propensity matching. Data of 297 patients (age <65 years) with middle-low rectal cancer who underwent total mesorectal excision + lateral lymph node dissection were also collected and reviewed. Clinical and pathological features, postoperative outcomes and survival data were collected and analyzed. RESULTS Compared with the total mesorectal excision group, the operation time of patients in the total mesorectal excision + lateral lymph node dissection group was significantly longer (277.6 vs. 171.4 min, P < 0.001), and the estimated blood loss was significantly more (119.6 vs. 57.5 ml, P = 0.014). Although there was no significant difference in overall complications (24.1% vs. 14.4%, P = 0.115) and grade 3-5 complications (9.6% vs. 7.2%, P = 0.576) between the two groups, the incidence of urinary retention (10.8% vs. 2.4%, P = 0.029) was higher in the total mesorectal excision + lateral lymph node dissection group. Two groups of patients achieve a similar 3-year overall survival (92.8% vs. 85.4%, P = 0.195) and 3-year disease-free survival (81.5% vs. 73.0%, P = 0.625). In addition, we compared long-term outcomes in 110 elderly patients with total mesorectal excision + lateral lymph node dissection and 297 non-elderly patients with total mesorectal excision + lateral lymph node dissection, and the results showed that 3-year (89.2% vs. 80.9%, P = 0.546) and disease-free survival (76.4% vs. 70.4%, P = 0.346) were similar between elderly and non-elderly patients. CONCLUSIONS Although urinary retention is closely related to the implementation of lateral lymph node dissection in elderly patients, total mesorectal excision with lateral lymph node dissection could be performed safely with accepted overall and grade 3-5 postoperative complications in elderly patients with rectal cancer. Moreover, elderly patients with clinical lateral lymph node metastasis can also benefit from lateral lymph node dissection as well as younger patients. Prospective studies with large sample sizes are needed to verify our results further.
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
| | - Shiwen Mei
- 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
| | - Bo Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingchi Yang
- Department of General Surgery, Beijing Friendship Hospital, Beijing Key Laboratory of Cancer Invasion and Metastasis Research and National Clinical Research Center of Digestive Diseases, Capital Medical University, Beijing, China
| | - Xin Wang
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Quan Wang
- Department of Gastric and Colorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Qian Liu
- 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
|
9
|
Peparini N. Oncological outcome after lateral pelvic lymphadenectomy for low rectal carcinoma: not only an N-status matter. ANZ J Surg 2023; 93:54-58. [PMID: 36190012 DOI: 10.1111/ans.18067] [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: 07/12/2022] [Revised: 09/06/2022] [Accepted: 09/11/2022] [Indexed: 11/27/2022]
Abstract
Tumour deposits (TDs), novel pathological entities, should be considered when estimating the regional and systemic spread of rectal carcinoma and formulating treatment strategies. In fact, TDs may have more severe prognostic impact than lymph node positivity or the lymph node ratio. The assessment of the presence of TDs can be performed only through accurate postoperative pathological examination; however, the detection of TDs is not part of any of the procedures currently used to assess preoperative or intraoperative staging. This review aims to analyse and discuss the impact of TDs on the oncological outcome of patients who undergo surgery for advanced low rectal carcinoma. No prospective study has evaluated the impact of lateral pelvic TDs on oncological outcomes following total mesorectal excision with lateral pelvic lymphadenectomy. Although adequate total mesorectal excision allows for the excision of intramesorectal TDs, lateral pelvic lymph node dissection cannot guarantee the removal of lateral pelvic TDs; moreover, it remains to be determined whether surgical excision of lateral pelvic TDs can impact long-term outcomes. However, the identification of lateral pelvic TDs strengthens the 'staging effect' and limits the 'therapeutic effect' of lateral pelvic lymphadenectomy, supporting the rationale for the use of neoadjuvant chemoradiotherapy for rectal cancer. When evaluating the oncological outcomes after total mesorectal excision with lateral pelvic lymphadenectomy, the impact of lateral pelvic TDs should be considered.
Collapse
Affiliation(s)
- Nadia Peparini
- Distretto 3, Azienda Sanitaria Locale Roma 6, Ciampino (Rome), Italy
| |
Collapse
|
10
|
Takemasa I, Hamabe A, Miyo M, Akizuki E, Okuya K. Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment. Ann Gastroenterol Surg 2022; 7:198-215. [PMID: 36998300 PMCID: PMC10043777 DOI: 10.1002/ags3.12646] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 12/28/2022] Open
Abstract
In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.
Collapse
Affiliation(s)
- Ichiro Takemasa
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Atsushi Hamabe
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
- Department of Gastroenterological Surgery, Graduate School of MedicineOsaka UniversityOsakaJapan
| | - Masaaki Miyo
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Emi Akizuki
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Koichi Okuya
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| |
Collapse
|
11
|
Zhou J, Yuan X. Lateral Lymph Node Dissection Was Unnecessary for Low and Middle Rectal Cancer: a Systematic Review and Meta-analysis. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03632-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
12
|
Dai JY, Han ZJ, Wang JD, Liu BS, Liu JY, Wang YC. Short-term outcomes of near-infrared imaging using indocyanine green in laparoscopic lateral pelvic lymph node dissection for middle-lower rectal cancer: A propensity score-matched cohort analysis. Front Med (Lausanne) 2022; 9:1039928. [PMID: 36438036 PMCID: PMC9684625 DOI: 10.3389/fmed.2022.1039928] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/24/2022] [Indexed: 12/01/2023] Open
Abstract
Laparoscopic lateral pelvic lymph node dissection (LPND) is limited by complex neurovascular bundles in the narrow pelvic sidewall and various post-operative complications. Indocyanine green (ICG) has been applied to increase the number of harvested lymph nodes and reduce the injury of irrelevant vessels in patients with rectal cancer. However, few studies on the recurrence rate of ICG fluorescence imaging-guided laparoscopic LPND were reported. This retrospective study enrolled 50 middle- low rectal cancer patients who were treated by LPND. After propensity score matching, 20 patients were matched in each of the indocyanine green (ICG) guided imaging group (ICG group) and non-ICG guided imaging group (non-ICG group). The average follow-up time was 13.5 months (12-15 months). Our results showed that the total number of harvested lymph nodes in the ICG group was significantly higher than that in the non-ICG group (P < 0.05), and intraoperative blood loss and post-operative hospital stay times in the ICG group were less than those in the non-ICG group (P < 0.05). After 12 months of follow-up, no residual lymph node and local tumor recurrence were found for patients in the ICG group. Four patients in the non-ICG group detected residual lymph nodes at the 3-month visit. Our findings highlighted the importance of ICG fluorescence-guided imaging in LPND because it has unique advantages in improving the number of lymph node dissections, surgical accuracy, and decreasing the residual lymph nodes and local tumor recurrence. In addition, ICG fluorescence guidance technology can effectively shorten the operation time, and it is simple to operate, which is worth popularizing.
Collapse
Affiliation(s)
- Jin-Yu Dai
- Department of Enterochirurgia, Fengrun District People's Hospital, Tangshan, China
| | | | | | | | | | | |
Collapse
|
13
|
Zhou S, Tang J, Liang J, Lou Z, Fu W, Feng B, Yang Y, Xiao Y, Liu Q. Effective dissecting range and prognostic significance of lateral pelvic lymph node dissection for middle-low rectal cancer patients with lateral pelvic lymph node metastasis: Results of a large multicenter lateral node collaborative group in China. Front Oncol 2022; 12:916285. [PMID: 36033473 PMCID: PMC9413157 DOI: 10.3389/fonc.2022.916285] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background Lateral pelvic lymph node (LPN) metastasis causes increased lateral local recurrence and poor prognosis. We aimed to investigate the prognostic significance and effective range of dissection for the LPN dissection (LPND) in rectal cancer patients with LPN metastasis. Materials and methods Through this large, multicenter retrospective cohort study, we evaluated the therapeutic effect of LPND. From January 2012 to December 2019, 387 rectal cancer patients with clinical evidence of LPN metastasis who underwent total mesorectal excision with LPND were included in the study. According to pathological findings, they were divided into negative (n = 296) and positive (n = 91) LPN groups. Primary endpoints were 3-year overall survival (OS), recurrence-free survival (RFS), and local recurrence-free survival (LRFS). Results The OS, RFS, and LRFS in the positive group were significantly worse than those in the negative group; However, LPN metastases were not independent prognostic risk factors for LRFS (hazard ratio [HR]: 2.42; 95% confidence interval [CI], 0.77–7.64; P=0.132). Among patients with pathological LPN metastases, LPN metastases to the common and external iliac arteries were independent prognostic risk factors both for OS (HR: 4.74; 95% CI, 1.74–12.90; P=0.002) and RFS (HR: 2.70; 95% CI, 1.16–6.29; P=0.021). No significant difference was observed in the 3-year OS (72.3% vs. 70.2%, P=0.775) and RFS rates (60.9% vs. 52.6%, P=0.408) between patients with metastases to the obturator or internal iliac arteries and patients at N2b stage. Conclusions LPND may be effective in controlling local recurrence in patients with LPN metastasis but not systemic metastases. Patients with LPN metastasis limited to the internal iliac and obturator regions achieve a long-term survival benefit from LPND, and their prognoses may be comparable to those at the N2b stage. Further metastasis to the external iliac or common iliac region should be considered systemic disease, and LPND should be avoided. Clinical Trial Registration ClinicalTrials.gov, identifier NCT04850027.
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
| | - Jianqiang Tang
- 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
| | - Zheng Lou
- Department of Colorectal Surgery, The first affiliated hospital, Navy Medical University, Shanghai, China
| | - Wei Fu
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Bo Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingchi Yang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Cancer Invasion and Metastasis Research and National Clinical Research Center of Digestive Diseases, Beijing, China
| | - Yi Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Yi Xiao, ; Qian Liu,
| | - Qian Liu
- 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
- *Correspondence: Yi Xiao, ; Qian Liu,
| |
Collapse
|
14
|
Emile SH, Madbouly KM, Elfeki H, Shalaby M, Sakr A, Zuhdy M, Metwally IH, Abdelkhalek M. Multicenter validation of the PREDICT score for prediction of local recurrence after total mesorectal excision of rectal cancer. J Surg Oncol 2022; 126:772-780. [PMID: 35670070 DOI: 10.1002/jso.26978] [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: 04/25/2022] [Accepted: 05/28/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Total mesorectal excision (TME) is the gold standard treatment for rectal cancer. Although TME has managed to decrease the rates of local recurrence after rectal cancer resection, local recurrence is still recorded at varying rates. The present study aimed to validate the PREDICT score in the prediction of local recurrence of rectal cancer after TME with curative intent. METHODS This was a retrospective multicenter study on patients with nonmetastatic low or middle rectal cancer who underwent TME. The total PREDICT score was calculated for every patient and related to the onset of local recurrence. According to the final score, patients were allocated to one of three risk groups: low, moderate, and high, and the rates of local recurrence in each group were calculated and compared. RESULTS The present study included 262 patients (50.4% males) with a mean age of 47.1 years. The overall local recurrence rate was 12.6%. 29.4% of patients were in the low-risk group, 63.7% in the moderate-risk group, and 6.9% in the high-risk group. The local recurrence rate was 3.9% (95% confidence interval [CI]: 0.8-10.9) in the low-risk group, 13.2% (95% CI: 8.4-19.3) in the moderate risk group, and 44.4% (95% CI: 21.5-69.2) in the high-risk group (p < 0.0001). The sensitivity of the PREDICT score was 72.7%, the specificity was 88.1%, and the accuracy was 86.3%. CONCLUSIONS The PREDICT score had good diagnostic accuracy in the prediction of local recurrence after TME and a good discriminatory ability in the differentiation between patients at different risks to develop local recurrence.
Collapse
Affiliation(s)
- Sameh H Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Khaled M Madbouly
- Department of Surgery, Section of Colon & Rectal Surgery, University of Alexandria, Egypt
| | - Hossam Elfeki
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Mostafa Shalaby
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Ahmad Sakr
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Mohammad Zuhdy
- Department of Surgical Oncology, Oncology Center Mansoura University (OCMU), Mansoura University, Mansoura, Egypt
| | - Islam H Metwally
- Department of Surgical Oncology, Oncology Center Mansoura University (OCMU), Mansoura University, Mansoura, Egypt
| | - Mohamed Abdelkhalek
- Department of Surgical Oncology, Oncology Center Mansoura University (OCMU), Mansoura University, Mansoura, Egypt
| |
Collapse
|
15
|
Meldolesi E, Chiloiro G, Giannini R, Menghi R, Persiani R, Corvari B, Coco C, Manfrida S, Ratto C, De Luca V, Sofo L, Reina S, Crucitti A, Masiello V, Dinapoli N, Valentini V, Gambacorta MA. The Role of Simultaneous Integrated Boost in Locally Advanced Rectal Cancer Patients with Positive Lateral Pelvic Lymph Nodes. Cancers (Basel) 2022; 14:cancers14071643. [PMID: 35406415 PMCID: PMC8996944 DOI: 10.3390/cancers14071643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/04/2022] [Accepted: 03/15/2022] [Indexed: 11/30/2022] Open
Abstract
Aims: Between 11 to 14% of patients with locally advanced rectal cancer (LARC) have positive lateral pelvic lymph nodes (LPLN) at diagnosis, related to a worse prognosis with a 5-year survival rate between 30 to 40%. The best treatment choice for this group of patients is still a challenge. The optimal radiotherapy (RT) dose for LPLN patients has been investigated. Methods: We retrospectively collected data from LARC patients with LPLN at the primary staging MRI, treated in our center from March 2003 to December 2020. Patients underwent a neoadjuvant concomitant chemo-radiotherapy (CRT) treatment on the primary tumor (T), mesorectum, and pelvic nodes, associated with a fluoride-based chemotherapy. The total reached dose was 45 Gy at 1.8 Gy/fr on the elective sites and 55 Gy at 2.2 Gy/fr on the disease and mesorectum. Patients were divided in two groups based on whether they received a simultaneous integrated RT boost on the LPLN or not. Overall Survival (OS), Disease Free Survival (DFS), Metastasis Free Survival (MFS), and Local Control (LC) were evaluated in the whole group and then compared between the two groups. Results: A total of 176 patients were evaluated: 82 were included in the RT boost group and 94 in the non-RT boost group. The median follow-up period was 57.8 months. All the clinical endpoint (OS, DFS, MFS, LC), resulted were affected by the simultaneous integrated boost on LPLN with a survival rate of 84.7%, 79.5%, 84.1%, and 92%, respectively, in the entire population. From the comparison of the two groups, there was a statistical significance towards the RT boost group with a p < 0.006, 0.030, 0.042, 0.026, respectively. Conclusions: Concomitant radiotherapy boost on positive LPLN has shown to be beneficial on the survival outcomes (OS, DFS, MFR, and LC) in patients with LARC and LPLN. This analysis demonstrates that a higher dose of radiotherapy on positive pelvic lymph nodes led not only to a higher local control but also to a better survival rate. These results, if validated by future prospective studies, can bring a valid alternative to the surgery dissection without the important side effects and permanent disabilities observed during the years.
Collapse
Affiliation(s)
- Elisa Meldolesi
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
| | - Giuditta Chiloiro
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
| | - Roberta Giannini
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
- Correspondence:
| | - Roberta Menghi
- Digestive Surgery Unit, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (R.M.); (R.P.); (C.C.); (C.R.); (L.S.); (A.C.)
| | - Roberto Persiani
- Digestive Surgery Unit, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (R.M.); (R.P.); (C.C.); (C.R.); (L.S.); (A.C.)
| | - Barbara Corvari
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
| | - Claudio Coco
- Digestive Surgery Unit, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (R.M.); (R.P.); (C.C.); (C.R.); (L.S.); (A.C.)
| | - Stefania Manfrida
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
| | - Carlo Ratto
- Digestive Surgery Unit, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (R.M.); (R.P.); (C.C.); (C.R.); (L.S.); (A.C.)
| | - Viola De Luca
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
| | - Luigi Sofo
- Digestive Surgery Unit, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (R.M.); (R.P.); (C.C.); (C.R.); (L.S.); (A.C.)
| | - Sara Reina
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
| | - Antonio Crucitti
- Digestive Surgery Unit, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (R.M.); (R.P.); (C.C.); (C.R.); (L.S.); (A.C.)
| | - Valeria Masiello
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
| | - Nicola Dinapoli
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
| | - Vincenzo Valentini
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
| | - Maria Antonietta Gambacorta
- Department of Radiology, Radiation Oncology and Hematology, Catholic University of the Sacred Heart, Agostino Gemelli University Hospital Foundation IRCCS, 00168 Roma, Italy; (E.M.); (G.C.); (B.C.); (S.M.); (V.D.L.); (S.R.); (V.M.); (N.D.); (V.V.); (M.A.G.)
| |
Collapse
|
16
|
Cribb BI, Kong J, McCormick J, Warrier SK, Heriot AG. Functional outcomes after lateral pelvic lymph node dissection for rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:583-595. [PMID: 34846550 DOI: 10.1007/s00384-021-04073-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Lateral pelvic lymph node dissection (LPLND) may improve oncological outcomes for select patients with rectal cancer, though functional outcomes may be adversely impacted. The aim of this study is to assess the functional outcomes associated with LPLND for rectal cancer and compare these outcomes with standard surgical resection. METHODS A systematic search was undertaken to identify relevant studies reporting on urinary dysfunction (UD), sexual dysfunction (SD), and defecatory dysfunction (DD) for patients who underwent LPLND for rectal cancer. Studies comparing functional outcomes in patients who underwent surgery with and without LPLND were assessed. In addition, a comparison of functional outcomes in patients who underwent LPLND before and after the year 2000 was performed. RESULTS Twenty-one studies of predominantly non-randomised observational data were included. Ten were comparative studies. Male SD was worse in patients who underwent LPLND compared with those who did not (RR 1.68 (95% CI 1.41-1.99, P < 0.001)). No difference was observed for the rate of UD between treatment groups. The rates of UD and male SD in patients who underwent LPLND after the year 2000 were significantly lower than those who underwent LPLND before the year 2000 ((UD) RR = 4.5, p value = 0.0034; male SD RR = 28.7, p value < 0.001). CONCLUSION Lateral pelvic lymph node dissection is associated with worse male sexual dysfunction compared to standard surgical resection. However, the rates of urine dysfunction and male sexual dysfunction are better in contemporary cohorts which may reflect improved surgical technique and autonomic nerve preservation.
Collapse
Affiliation(s)
- Benjamin I Cribb
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia.,Epworth Healthcare, Melbourne, VIC, Australia
| | - Joseph Kong
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia.,Epworth Healthcare, Melbourne, VIC, Australia
| | - Jacob McCormick
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia.,Epworth Healthcare, Melbourne, VIC, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Satish K Warrier
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia.,Epworth Healthcare, Melbourne, VIC, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Alexander G Heriot
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia.,Epworth Healthcare, Melbourne, VIC, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
17
|
Varela C, Kim NK. Surgical Treatment of Low-Lying Rectal Cancer: Updates. Ann Coloproctol 2021; 37:395-424. [PMID: 34961303 PMCID: PMC8717072 DOI: 10.3393/ac.2021.00927.0132] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023] Open
Abstract
Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.
Collapse
Affiliation(s)
- Cristopher Varela
- Coloproctology Unit, Department of General Surgery, Hospital Dr. Domingo Luciani, Caracas, Venezuela
| | - Nam Kyu Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
18
|
Kim MC, Oh JH. Lateral Pelvic Lymph Node Dissection After Neoadjuvant Chemoradiotherapy in Patients With Rectal Cancer: A Single-Center Experience and Literature Review. Ann Coloproctol 2021; 37:382-394. [PMID: 34961302 PMCID: PMC8717070 DOI: 10.3393/ac.2021.00913.0130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/24/2021] [Indexed: 12/14/2022] Open
Abstract
Purpose We aimed to evaluate the surgicopathological outcomes of lateral pelvic lymph node dissection (LPLD) and long-term oncological outcomes of selective LPLD after neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer and compare them to those of total mesorectal excision (TME) alone based on pretreatment magnetic resonance imaging (MRI). Methods We compared the TME-alone group (2001–2009, n=102) with the TME with LPLD group (2011–2016, n=69), both groups having lateral lymph nodes (LLNs) of ≥5 mm in short axis diameter. The surgicopathological outcomes were analyzed retrospectively. Oncological outcomes were analyzed using the Kaplan-Meier method. Results The rates of overall postoperative 30-day morbidity (42.0% vs. 26.5%, P=0.095) and urinary retention (13.7% vs. 10.1%, P=0.484) were not significantly different between the LPLD and TME-alone groups, respectively. Pathologically proven LLN metastasis was identified in 24 (34.8%) LPLD cases after nCRT. The LPLD group showed a lower 5-year local recurrence (LR) rate (27.9% vs. 4.6%, P<0.001) and better recurrence-free survival (RFS) (59.6% vs. 78.2%, P=0.008) than those of the TME-alone group, while the 5-year overall survival was not significantly different between the 2 groups (76.2% vs. 86.5%, P=0.094). Conclusion This study suggests that LPLD is a safe and feasible procedure. The oncological outcomes suggest that selective LPLD improves LR and RFS in patients with clinically suspicious LLNs on pretreatment MRI. Considering that lateral nodal disease is not common, a multicenter large-scale study is necessary.
Collapse
Affiliation(s)
- Min Chul Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| |
Collapse
|
19
|
Ogawa S, Itabashi M, Inoue Y, Ohki T, Bamba Y, Koshino K, Nakagawa R, Tani K, Aihara H, Kondo H, Yamaguchi S, Yamamoto M. Lateral pelvic lymph nodes for rectal cancer: A review of diagnosis and management. World J Gastrointest Oncol 2021; 13:1412-1424. [PMID: 34721774 PMCID: PMC8529924 DOI: 10.4251/wjgo.v13.i10.1412] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/21/2021] [Accepted: 08/24/2021] [Indexed: 02/06/2023] Open
Abstract
The current status and future prospects for diagnosis and treatment of lateral pelvic lymph node (LPLN) metastasis of rectal cancer are described in this review. Magnetic resonance imaging (MRI) is recommended for the diagnosis of LPLN metastasis. A LPLN-positive status on MRI is a strong risk factor for metastasis, and evaluation by MRI is important for deciding treatment strategy. LPLN dissection (LPLD) has an advantage of reducing recurrence in the lateral pelvis but also has a disadvantage of complications; therefore, LPLD may not be appropriate for cases that are less likely to have LPLN metastasis. Radiation therapy (RT) and chemoradiation therapy (CRT) have limited effects in cases with suspected LPLN metastasis, but a combination of preoperative CRT and LPLD may improve the treatment outcome. Thus, RT and CRT plus selective LPLD may be a rational strategy to omit unnecessary LPLD and produce a favorable treatment outcome.
Collapse
Affiliation(s)
- Shimpei Ogawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Michio Itabashi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Yuji Inoue
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Takeshi Ohki
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Yoshiko Bamba
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Kurodo Koshino
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Ryosuke Nakagawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Kimitaka Tani
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Hisako Aihara
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Hiroka Kondo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Shigeki Yamaguchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| |
Collapse
|
20
|
Franceschilli M, Di Carlo S, Vinci D, Sensi B, Siragusa L, Bellato V, Caronna R, Rossi P, Cavallaro G, Guida A, Sibio S. Complete mesocolic excision and central vascular ligation in colorectal cancer in the era of minimally invasive surgery. World J Clin Cases 2021; 9:7297-7305. [PMID: 34616795 PMCID: PMC8464444 DOI: 10.12998/wjcc.v9.i25.7297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/14/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
Since the 19th century, appropriate lymphadenectomy has been considered a cornerstone of oncologic surgery and one of the most important prognostic factors. This approach can be applied to any surgery for gastrointestinal cancer. During surgery for colon and rectal cancer, an adequate portion of the mesentery is removed together with the segment of bowel affected by the disease. The adequate number of lymph nodes to be removed is standardized and reported by several guidelines. It is mandatory to determine the appropriate extent of lymphadenectomy and to balance its oncological benefits with the increased morbidity associated with its execution in cancer patients. Our review focuses on the concept of “complete mesenteric excision (CME) with central vascular ligation (CVL),” a radical lymphadenectomy for colorectal cancer that has gained increasing interest in recent years. The aim of this study was to evaluate the evolution of this approach over the years, its potential oncologic benefits and potential risks, and the improvements offered by laparoscopic techniques. Theoretical advantages of CME are improved local-relapse rates due to complete removal of the intact mesocolic fascia and improved distance recurrence rates due to ligation of vessels at their origin (CVL) which guarantees removal of a larger number of lymph nodes. The development and worldwide diffusion of laparoscopic techniques minimized postoperative trauma in oncologic surgery, providing the same oncologic results as open surgery. This has been widely applied to colorectal cancer surgery; however, CME entails a technical complexity that can limit its wide minimally-invasive application. This review analyzes results of these procedures in terms of oncological outcomes, technical feasibility and complexity, especially within the context of minimally invasive surgery.
Collapse
Affiliation(s)
- Marzia Franceschilli
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Sara Di Carlo
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Danilo Vinci
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Bruno Sensi
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Leandro Siragusa
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Vittoria Bellato
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Roberto Caronna
- Department of Surgical Sciences, Unit of Pancreatic and Biliary Surgery, Sapienza University of Rome, Rome 00161, Italy
| | - Piero Rossi
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Giuseppe Cavallaro
- Department of Surgery P Valdoni, Unit of Oncologic and Minimally Invasive Surgery, Sapienza University of Rome, Rome 00161, Italy
| | - Andrea Guida
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Simone Sibio
- Department of Surgery P Valdoni, Unit of Oncologic and Minimally Invasive Surgery, Sapienza University of Rome, Rome 00161, Italy
| |
Collapse
|
21
|
Comment on "Is the Never-Ending Story Still Unsolved? Beyond the Long Debate About Lateral Pelvic Lymph Node Dissection in Rectal Cancer". Dis Colon Rectum 2021; 64:e528-e529. [PMID: 34117175 DOI: 10.1097/dcr.0000000000002183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
22
|
Franceschilli M, Vinci D, Di Carlo S, Sensi B, Siragusa L, Guida A, Rossi P, Bellato V, Caronna R, Sibio S. Central vascular ligation and mesentery based abdominal surgery. Discov Oncol 2021; 12:24. [PMID: 35201479 PMCID: PMC8777547 DOI: 10.1007/s12672-021-00419-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022] Open
Abstract
In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.
Collapse
Affiliation(s)
- M Franceschilli
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - D Vinci
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy.
| | - S Di Carlo
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - B Sensi
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - L Siragusa
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - A Guida
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - P Rossi
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - V Bellato
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - R Caronna
- Department of Surgery Pietro Valdoni Unit of Oncologic and Minimally Invasive Surgery, Rome, Italy
- Department of Surgical Science, Sapienza University of Rome, Rome, Italy
| | - S Sibio
- Department of Surgery Pietro Valdoni Unit of Oncologic and Minimally Invasive Surgery, Rome, Italy
- Department of Surgical Science, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
23
|
Kong JCH, Chang GJ. Apples and oranges: The evidence regarding lateral pelvic lymph node dissection for rectal cancer. Surgery 2021; 169:1003-1004. [PMID: 33745734 DOI: 10.1016/j.surg.2021.02.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/10/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Joseph C H Kong
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George J Chang
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
| |
Collapse
|