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Yoo J, Han JY, Chang W, Hur BY, Kim JH, Choi Y, Kim SJ, Kim SH. Predicting lateral pelvic lymph node metastasis in rectal cancer patients using MRI radiomics: a multicenter retrospective study. Sci Rep 2025; 15:15071. [PMID: 40301516 PMCID: PMC12041232 DOI: 10.1038/s41598-025-99029-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2024] [Accepted: 04/16/2025] [Indexed: 05/01/2025] Open
Abstract
MRI has relatively low sensitivity and specificity in detecting lymph node metastases. This study aimed to develop and validate an MRI radiomics-based model for predicting lateral pelvic lymph node (LPLN) metastasis in rectal cancer patients who underwent LPLN dissection, and to compare its performance with that of radiologists. This multicenter retrospective study included 336 rectal cancer patients (199 men; mean age, 58.9 years ± 11.1 [standard deviation]) who underwent LPLN dissection. Patients were divided into development (n = 190) and validation (n = 146) cohorts. Radiomics features were extracted from MR images, and the Least Absolute Shrinkage and Selection Operator regression was used to construct radiomics and clinical-radiomics models. Model performance was compared with radiologists using receiver operating characteristic (ROC) analysis. Malignant LPLN was diagnosed in 32.4% of the development cohort (65/190) and 32.9% of the validation cohort (48/146) (P = 0.798). Seven radiomics features and two clinical features were selected. The radiomics and clinical-radiomics models demonstrated area under the curves (AUCs) of 0.819 and 0.830 in the development cohort and 0.821 and 0.829 in the validation cohort, respectively. The optimal cut-off (- 0.47) yielded sensitivities of 72.3% and 45.8% and specificities of 82.4% and 87.8% in the development and validation cohorts, respectively. Decision curve analysis indicated no additional net benefit from the clinical-radiomics model compared to the radiomics-only model. Radiologists' AUCs were significantly lower than that of the radiomics model (0.842) and improved with radiomics probability scores (0.734 vs. 0.801; 0.668 vs. 0.791). The MRI-based radiomics model significantly improves the prediction of LPLN metastasis in rectal cancer, outperforming conventional criteria used by radiologists.Trial registration: Retrospectively registered.
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Affiliation(s)
- Jeongin Yoo
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Jun Young Han
- College of Medicine, Seoul National University, Seoul, Korea
| | - Won Chang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Bo Yun Hur
- Department of Radiology, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Jae Hyun Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Yunhee Choi
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
| | - Soo Jin Kim
- Department of Radiology, National Cancer Center, Goyang, Korea
| | - Se Hyung Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, Korea.
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea.
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Xue X, Yang Y, Xu X, Cai M, Shen H. Clinical characteristics and predictive factors of pathological lateral pelvic lymph node metastasis in patients with rectal cancer. Mol Clin Oncol 2025; 22:25. [PMID: 39885866 PMCID: PMC11775861 DOI: 10.3892/mco.2025.2820] [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: 03/02/2024] [Accepted: 12/06/2024] [Indexed: 02/01/2025] Open
Abstract
In recent years, selective lateral lymph node dissection (LLND) has been performed more frequently. The present study aimed to explore the clinical characteristics and predictive factors of pathological lateral pelvic lymph node metastasis (LPLNM), which may be helpful for pre-treatment decisions. The present study included 64 patients with rectal cancer and clinically suspected LPLNM who underwent total mesorectal excision (TME) and LLND between February 2019 and April 2024. According to pathological outcomes, the patients were divided into the negative LPLN (n=40) and positive LPLN (n=24) groups. The primary endpoints were the overall pathological LPLNM positivity rate and different clinical characteristics between the two groups. The secondary endpoint was the identification of predictive factors of pathological LPLNM before surgery. Among the 64 patients, 24 (37.5%) had pathologically confirmed LPLNM, and pathological LPLNM was related to initial lymph node size. When initial LPLN size was <7 mm, the pathological LPLNM rate was 10.5%, whereas when LPLN size was between 7 and 10 mm, the rate was 34.6%, and when LPLN size was >10 mm, the rate was 68.4%. Initial LPLN size (≥7.1 mm, P=0.003) and cN stage (N1-2, P=0.005) were significantly associated with pathological LPLNM. In multivariate analysis of risk factors, initial LPN size (≥7.1 mm; hazard ratio=4.856, 95% confidence interval 1.158-20.359, P=0.031) was the only independent risk factor for pathological LPLNM. When the cut-off initial LPLN size was 7.1 mm, the sensitivity and specificity were 87.5 and 52.5%, respectively, and the area under the curve was 0.748 (P=0.0009). When both LPLN size ≥7.1 mm and cN1-2 were satisfied, the sensitivity was 66.7%, the specificity increased to 77.5%, and the positive and negative predictive values were 64.0 and 79.5%, respectively. In conclusion, initial LPLN size and cN stage were identified as significant clinical characteristics associated with pathological LPLNM. Patients with an initial LPLN size of ≥7.1 mm and with cN1-2 stage cancer could benefit from TME + LLND surgery.
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Affiliation(s)
- Xiajuan Xue
- Department of Colorectal Surgery, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Zhangzhou, Fujian 363000, P.R. China
| | - Yugang Yang
- Department of Colorectal Surgery, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Zhangzhou, Fujian 363000, P.R. China
| | - Xiaozhen Xu
- Gynecology Department, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Zhangzhou, Fujian 363000, P.R. China
| | - Mingzhi Cai
- Department of Colorectal Surgery, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Zhangzhou, Fujian 363000, P.R. China
| | - Huiqun Shen
- Department of Medical Oncology, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Zhangzhou, Fujian 363000, P.R. China
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Wang N, Li Y, Lu K, Wei K, Jia S, Fan S, Ren D, Fu Y, Liu Z. A combined diagnostic model including middle rectal artery visualization for predicting lateral lymph node metastasis in rectal cancer. Front Physiol 2025; 15:1444897. [PMID: 39839524 PMCID: PMC11747483 DOI: 10.3389/fphys.2024.1444897] [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: 06/06/2024] [Accepted: 12/18/2024] [Indexed: 01/23/2025] Open
Abstract
Purpose This study attempted to establish a combined diagnostic model encompassing visualization of the middle rectal artery (MRA) and other imaging features to improve the diagnostic efficiency of lateral lymph node (LLN) metastasis, which is crucial for clinical decision-making in rectal cancer. Method One hundred eleven patients receiving bilateral or unilateral lymph node dissection were enrolled, and 140 cases of LLN status on a certain unilateral pelvic sidewall were selected. Enhanced computed tomography (CT) was used to determine whether MRA was visible. Multivariable regression was used to establish a diagnostic model combining MRA visualization with other imaging features to predict LLN metastasis. Receiver operating characteristic (ROC) curve and area under the ROC curve (AUC) were used to test the diagnostic efficacy for LLN metastasis. Ten-fold cross-validation was completed to internally validate the diagnostic model. Results Of the 140 LLNs harvested from 111 patients, 76 were positive and 64 were negative for metastases, respectively. The diagnostic model combining the MRA visualization and lymph node short diameter showed a greater efficiency than a single scale (AUC = 0.945, 95% confidence interval = 0.893-0.976, P < 0.001). The mean cross-validated AUC was 0.869 (95% confidence interval = 0.835-0.903). Conclusion Our results establish a combined diagnostic model with the help of MRA visualization to yield a high diagnostic efficiency of LLN metastasis in rectal cancer.
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Affiliation(s)
- Ning Wang
- Department of Radiology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yiping Li
- Department of General Surgery (Coloproctology), The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Kun Lu
- Department of Anesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Kaikai Wei
- Department of Radiology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shize Jia
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Shuhong Fan
- Department of Radiology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Donglin Ren
- Department of General Surgery (Coloproctology), The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuanji Fu
- Department of General Surgery (Coloproctology), The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhimin Liu
- Department of General Surgery (Coloproctology), The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Nayak P, Saklani A, Kazi M, Kumar B, D'souza A, Baheti A, Kumar S, Agrawal A, Pansande N, Engineer R. Simultaneous integrated boost intensity-modulated radiation therapy targeting clinically involved extramesorectal lymph nodes in locally advanced rectal cancer: A retrospective study. Colorectal Dis 2025; 27:e17292. [PMID: 39844646 DOI: 10.1111/codi.17292] [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: 01/03/2024] [Revised: 07/25/2024] [Accepted: 08/23/2024] [Indexed: 01/24/2025]
Abstract
AIM Consensus is lacking regarding the management of extramesorectal lymph nodes (EMLN) in rectal cancer. Using simultaneous integrated boost intensity-modulated radiation therapy (SIB-IMRT), we targeted involved EMLN and reserved lateral pelvic lymph nodal dissection (LPLND) for nonresponders. The primary aim of this work was to determine the proportion of patients who avoided LPLND and to establish the pathological EMLN positivity rate. METHOD Consecutive patients with rectal cancer with suspicious EMLN [short axis dimension (SAD) ≥ 7 mm], receiving SIB-IMRT as part of neoadjuvant chemoradiotherapy and subsequently undergoing total mesorectal excision (TME) or watch-and-wait, were included. Our primary objective was to determine the proportion of patients with a good nodal response (EMLN SAD < 5 mm) who were spared LPLND. The 3-year locoregional relapse rate, distant metastasis-free survival (DMFS) and overall survival (OS) were also assessed. RESULTS Of the 61 patients studied, 38 (62.3%) responded well to SIB-IMRT. In this group, 32 patients underwent TME alone and six were observed as per watch-and-wait. The remaining 23 (37.7%) patients with persistent EMLN received TME with LPLND. On pathological evaluation, 7 (30.4%) patients had positive nodes while 16 (69.6%) were negative. At a median follow-up of 32 months (95% CI 23.3-40.7 months), 10 (16.4%) patients developed distant metastases while none had local or pelvic relapse. The resultant 3-year DMFS and OS for the whole cohort were 84.4% and 95.1%, respectively. Overall, 5/61 (8.2%) patients encountered radiation-induced toxicity of grade 3 or above and 8/55 (14.5%) patients had severe postoperative complications. CONCLUSION SIB-IMRT targeting EMLN followed by selective LPLND exhibits excellent oncological outcomes. While patients responding to SIB-IMRT safely avoid LPLND, the potential for increased morbidity in nonresponders must be considered.
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Affiliation(s)
- Prashant Nayak
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
- Homi Bhabha National Institute, DAE, Anushaktinagar, Mumbai, India
| | - Avanish Saklani
- Homi Bhabha National Institute, DAE, Anushaktinagar, Mumbai, India
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Mufaddal Kazi
- Homi Bhabha National Institute, DAE, Anushaktinagar, Mumbai, India
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Bharath Kumar
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
- Homi Bhabha National Institute, DAE, Anushaktinagar, Mumbai, India
| | - Ashwin D'souza
- Homi Bhabha National Institute, DAE, Anushaktinagar, Mumbai, India
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Akshay Baheti
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Centre, Mumbai, India
| | - Suman Kumar
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Centre, Mumbai, India
| | - Amiya Agrawal
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
- Homi Bhabha National Institute, DAE, Anushaktinagar, Mumbai, India
| | - Namrata Pansande
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
- Homi Bhabha National Institute, DAE, Anushaktinagar, Mumbai, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
- Homi Bhabha National Institute, DAE, Anushaktinagar, Mumbai, India
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Sun L, Meng C, Zhang Z, Luo Y, Yang Z, Yao H. Opportunities and challenges of indocyanine green in gastrointestinal cancers for intraoperative and nano-medicine application. Cancer Nanotechnol 2024; 15:12. [DOI: 10.1186/s12645-024-00251-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/24/2024] [Indexed: 01/12/2025] Open
Abstract
AbstractThe morbidity and mortality of gastrointestinal tumours remain high worldwide. Surgical resection is currently the most critical radical therapeutic schedule, while postoperative complications and sentinel lymph node (SLN) identification are closely related to the outcome. Indocyanine green (ICG)-mediated fluorescence imaging is increasingly being used in gastrointestinal surgery. It has been embraced by various surgical disciplines as a potential method to improve lymph node detection and enhance surgical field visualization. ICG can passively concentrate in SLN because of enhanced permeation and retention effects. After excitation by near-infrared light devices, SLN can display higher intensity fluorescence, helping visualization for better lymph node dissection. In addition, visual assessment of intestinal blood flow through ICG may reduce the incidence of anastomotic leakage. Although it has good clinical application, ICG-imaging still faces some problems, such as a higher false-negative rate, poorly targeted biodistribution, and lower fluorescence contrast, due to the lack of active tumour targeting. Thus, different ICG-coupled nanoparticles with inherent characteristics or functional modification-enhanced SLN identification features for gastrointestinal cancers bring benefit through active tumour targeting, superior tumour-background ratio, and high resolution. Nano-ICG combined with potential substances, including enhanced imaging contrast and/or combination therapy (chemotherapy, targeted therapy, immunotherapy, etc.), have been packaged and accumulated in the tumour area through active targeting for multimodal imaging and treatment. In this review, we outline the intraoperative application and possible future nanodirections of ICG in gastrointestinal cancer. The prospects and challenges of nano-ICG diagnostic and therapeutic methods in clinical applications are also discussed.
Graphical Abstract
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Chen LN, Jiang J, Jiang LM, Zhou HT, Li N, Lu NN, Gao YH, Liu SX, Wang WL, Wei LC, Li S, Cai Y, Li YH, Wang SL, Liu YP, Song YW, Fang H, Chen B, Li YX, Jin J, Tang Y. Post-hoc analysis of clinicopathological factors affecting lateral lymph node metastasis based on STELLAR study for rectal cancer. Radiother Oncol 2024; 200:110512. [PMID: 39216825 DOI: 10.1016/j.radonc.2024.110512] [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: 05/23/2024] [Revised: 08/11/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE In post-hoc analyses of phaseIII randomized controlled study(STELLAR), to analyzethe prognostic impact oflateral pelvic lymph node (LPLN)metastasis in locally advanced rectal cancer (LARC). METHODS LPLN metastasis was defined as a short diameter > 7 mm on magnetic resonance imaging (MRI).The studyincluded 591 patients with LARC.All patients received neoadjuvant (chemo)radiotherapy combined withradical resection. RESULTS Among 591 patients, 99 (16.8 %) were diagnosed with LPLN metastasis, mostly with unilateral metastasis (79.8 %), with internal iliac lymph node metastasis being more common (81.8 %).Significant differences were found among with and without LPLN metastasis in rectal segmentation (P=0.001),N disease (P<0.001), mesenteric LN metastasis or not (P=0.030). The median follow-up timewas 34.0 months, three-year disease-free survival (DFS),overall survival (OS), andmetastasis-free survival (MFS)were significantly lower in LPLN metastaticgroup than those in LPLN non-metastaticgroup (51.4 % vs. 68.2 %, P<0.001; 71.8 % vs. 84.2 %, P=0.006; 60.8 % vs. 80.1 %,P<0.001), respectively; while there were no significant differences in locoregional recurrence(11.4 % vs. 8.5 %, P=0.564). Multivariate analysis found that LPLN metastasis was an independent prognostic factor affecting DFS (P=0.005), OS (P=0.036),MFS (P=0.001).No significantly survival benefit was observed for the short-term radiotherapy based total neoadjuvant therapy compared to long-term concurrent chemoradiotherapy. CONCLUSIONS LPLN metastasis observed byMRI should be considered in LARC patients, especially in populations with lowrectal cancer, N2 disease, and mesenteric LN metastasis. LPLN metastasis diagnosed by MRI is a significant and independent risk factor and is associated with worse DFS, OS, MFS.
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Affiliation(s)
- Li-Ning Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China; State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Jiang
- State Key Laboratory of Molecular Oncology and Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Ming Jiang
- State Key Laboratory of Molecular Oncology and Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hai-Tao Zhou
- State Key Laboratory of Molecular Oncology and 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
| | - Ning Li
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning-Ning Lu
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan-Hong Gao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Shi-Xin Liu
- Department of Radiation Oncology, Jilin Provincial Cancer Hospital, Changchun, China
| | - Wen-Ling Wang
- Department of Oncology, Affifiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Li-Chun Wei
- Department of Radiation Oncology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Shuai Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Yong-Heng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Shu-Lian Wang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Wen Song
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Chen
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye-Xiong Li
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China; State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yuan Tang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Liu J, Jiang P, Zhang Z, Yang H, Zhou Y, Li P, Zeng Q, Zhang X, Sun Y. Survival analysis in rectal cancer patients after lateral lymph node dissection: Exploring the necessity of nCRT for suspected lateral lymph node metastasis. Curr Probl Surg 2024; 61:101525. [PMID: 39098341 DOI: 10.1016/j.cpsurg.2024.101525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 08/06/2024]
Affiliation(s)
- Jiafei Liu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, People's Republic of China; The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, People's Republic of China; Tianjin Institute of Coloproctology, Tianjin, People's Republic of China
| | - Peishi Jiang
- Nankai University, Tianjin, People's Republic of China
| | - Zhichun Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, People's Republic of China; The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, People's Republic of China; Tianjin Institute of Coloproctology, Tianjin, People's Republic of China; Nankai University, Tianjin, People's Republic of China
| | - Hongjie Yang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, People's Republic of China; The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, People's Republic of China; Tianjin Institute of Coloproctology, Tianjin, People's Republic of China; Nankai University, Tianjin, People's Republic of China
| | - Yuanda Zhou
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, People's Republic of China; The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, People's Republic of China; Tianjin Institute of Coloproctology, Tianjin, People's Republic of China
| | - Peng Li
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, People's Republic of China; The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, People's Republic of China; Tianjin Institute of Coloproctology, Tianjin, People's Republic of China
| | - Qingsheng Zeng
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, People's Republic of China; The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, People's Republic of China; Tianjin Institute of Coloproctology, Tianjin, People's Republic of China
| | - Xipeng Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, People's Republic of China; The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, People's Republic of China; Tianjin Institute of Coloproctology, Tianjin, People's Republic of China; Nankai University, Tianjin, People's Republic of China
| | - Yi Sun
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, People's Republic of China; The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, People's Republic of China; Tianjin Institute of Coloproctology, Tianjin, People's Republic of China; Nankai University, Tianjin, People's Republic of China.
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Sun Y, Lu Z, Yang H, Jiang P, Zhang Z, Liu J, Zhou Y, Li P, Zeng Q, Long Y, Li L, Du B, Zhang X. Prediction of lateral lymph node metastasis in rectal cancer patients based on MRI using clinical, deep transfer learning, radiomic, and fusion models. Front Oncol 2024; 14:1433190. [PMID: 39099685 PMCID: PMC11294238 DOI: 10.3389/fonc.2024.1433190] [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: 05/15/2024] [Accepted: 07/02/2024] [Indexed: 08/06/2024] Open
Abstract
Introduction Lateral lymph node (LLN) metastasis in rectal cancer significantly affects patient treatment and prognosis. This study aimed to comprehensively compare the performance of various predictive models in predicting LLN metastasis. Methods In this retrospective study, data from 152 rectal cancer patients who underwent lateral lymph node (LLN) dissection were collected. The cohort was divided into a training set (n=86) from Tianjin Union Medical Center (TUMC), and two testing cohorts: testing cohort (TUMC) (n=37) and testing cohort from Gansu Provincial Hospital (GSPH) (n=29). A clinical model was established using clinical data; deep transfer learning models and radiomics models were developed using MRI images of the primary tumor (PT) and largest short-axis LLN (LLLN), visible LLN (VLLN) areas, along with a fusion model that integrates features from both deep transfer learning and radiomics. The diagnostic value of these models for LLN metastasis was analyzed based on postoperative LLN pathology. Results Models based on LLLN image information generally outperformed those based on PT image information. Rradiomics models based on LLLN demonstrated improved robustness on external testing cohorts compared to those based on VLLN. Specifically, the radiomics model based on LLLN imaging achieved an AUC of 0.741 in the testing cohort (TUMC) and 0.713 in the testing cohort (GSPH) with the extra trees algorithm. Conclusion Data from LLLN is a more reliable basis for predicting LLN metastasis in rectal cancer patients with suspicious LLN metastasis than data from PT. Among models performing adequately on the internal test set, all showed declines on the external test set, with LLLN_Rad_Models being less affected by scanning parameters and data sources.
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Affiliation(s)
- Yi Sun
- Nankai University, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Tianjin Institute of Coloproctology, Tianjin, China
| | - Zhongxiang Lu
- The First Clinical College of Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu, China
| | - Hongjie Yang
- Nankai University, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Tianjin Institute of Coloproctology, Tianjin, China
| | | | - Zhichun Zhang
- Nankai University, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Tianjin Institute of Coloproctology, Tianjin, China
| | - Jiafei Liu
- Nankai University, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Tianjin Institute of Coloproctology, Tianjin, China
| | - Yuanda Zhou
- Nankai University, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Tianjin Institute of Coloproctology, Tianjin, China
| | - Peng Li
- Nankai University, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Tianjin Institute of Coloproctology, Tianjin, China
| | - Qingsheng Zeng
- Nankai University, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Tianjin Institute of Coloproctology, Tianjin, China
| | - Yu Long
- Nankai University, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Tianjin Institute of Coloproctology, Tianjin, China
| | - Laiyuan Li
- Gansu Provincial Hospital, Gansu Clinical Medical Research Center for Anorectal Diseases, Lanzhou, Gansu, China
| | - Binbin Du
- Gansu Provincial Hospital, Gansu Clinical Medical Research Center for Anorectal Diseases, Lanzhou, Gansu, China
| | - Xipeng Zhang
- Nankai University, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Tianjin Institute of Coloproctology, Tianjin, China
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9
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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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10
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Wang Y. MRI-Based Radiomics: A Promising Tool for Predicting Lateral Pelvic Lymph Node Metastasis in Locally Advanced Rectal Cancer. Acad Radiol 2024; 31:2773-2774. [PMID: 38879400 DOI: 10.1016/j.acra.2024.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 05/14/2024] [Accepted: 05/14/2024] [Indexed: 07/21/2024]
Affiliation(s)
- Yong Wang
- Department of Ultrasound, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China.
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11
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Zhao W, Xu H, Zhao R, Zhou S, Mei S, Wang Z, Zhao F, Xiao T, Huang F, Qiu W, Tang J, Liu Q. MRI-based Radiomics Model for Preoperative Prediction of Lateral Pelvic Lymph Node Metastasis in Locally Advanced Rectal Cancer. Acad Radiol 2024; 31:2753-2772. [PMID: 37643928 DOI: 10.1016/j.acra.2023.07.016] [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: 06/06/2023] [Revised: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 08/31/2023]
Abstract
RATIONALE AND OBJECTIVES To develop a magnetic resonance imaging (MRI)-based radiomics model for preoperative prediction of lateral pelvic lymph node (LPLN) metastasis (LPLNM) in patients with locally advanced rectal cancer MATERIALS AND METHODS: We retrospectively enrolled 263 patients with rectal cancer who underwent total mesorectal excision and LPLN dissection. Radiomics features from the primary lesion and LPLNs on baseline MRI images were utilized to construct a radiomics model, and their radiomics scores were combined to develop a radiomics scoring system. A clinical prediction model was developed using logistic regression. A hybrid predicting model was created through multivariable logistic regression analysis, integrating the radiomics score with significant clinical risk factors (baseline Carcinoembryonic Antigen (CEA), clinical circumferential resection margin status, and the short axis diameter of LPLN). This hybrid model was presented with a hybrid clinical-radiomics nomogram, and its calibration, discrimination, and clinical usefulness were assessed. RESULTS A total of 148 patients were included in the analysis and randomly divided into a training cohort (n = 104) and an independent internal testing cohort (n = 44). The hybrid clinical-radiomics model exhibited the highest discrimination, with an area under the receiver operating characteristic (AUC) of 0.843 [95% confidence interval (CI), 0.706-0.968] in the testing cohort compared to the clinical model [AUC (95% CI) = 0.772 (0.589-0.856)] and radiomics model [AUC (95% CI) = 0.731 (0.613-0.849)]. The hybrid prediction model also demonstrated good calibration, and decision curve analysis confirmed its clinical usefulness. CONCLUSION This study developed a hybrid MRI-based radiomics model that incorporates a combination of radiomics score and significant clinical risk factors. The proposed model holds promise for individualized preoperative prediction of LPLNM in patients with locally advanced rectal cancer. DATA AVAILABILITY STATEMENT The data presented in this study are available on request from the corresponding author.
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Affiliation(s)
- Wei Zhao
- 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, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (W.Z., S.Z., S.M., Z.W., F.Z., T.X., F.H., W.Q., J.T., Q.L.)
| | - Hui Xu
- School of Biomedical Engineering and Guangdong Provincial Key Laboratory of Medical Image Processing, Southern Medical University, Guangzhou, Guangdong, China (H.X.)
| | - Rui Zhao
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (R.Z.)
| | - 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, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (W.Z., S.Z., S.M., Z.W., F.Z., T.X., F.H., W.Q., J.T., Q.L.)
| | - 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, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (W.Z., S.Z., S.M., Z.W., F.Z., T.X., F.H., W.Q., J.T., Q.L.)
| | - Zhijie Wang
- 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, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (W.Z., S.Z., S.M., Z.W., F.Z., T.X., F.H., W.Q., J.T., Q.L.)
| | - Fuqiang Zhao
- 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, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (W.Z., S.Z., S.M., Z.W., F.Z., T.X., F.H., W.Q., J.T., Q.L.)
| | - Tixian Xiao
- 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, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (W.Z., S.Z., S.M., Z.W., F.Z., T.X., F.H., W.Q., J.T., Q.L.)
| | - Fei Huang
- 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, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (W.Z., S.Z., S.M., Z.W., F.Z., T.X., F.H., W.Q., J.T., Q.L.)
| | - Wenlong Qiu
- 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, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (W.Z., S.Z., S.M., Z.W., F.Z., T.X., F.H., W.Q., J.T., Q.L.)
| | - 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, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (W.Z., S.Z., S.M., Z.W., F.Z., T.X., F.H., W.Q., J.T., Q.L.)
| | - 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, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (W.Z., S.Z., S.M., Z.W., F.Z., T.X., F.H., W.Q., J.T., Q.L.).
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12
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Özdemir Ü, Gündoğdu E, Yakar M, Canaz F, Ulaş M, Özer İ. Lateral lymph node involvement presents another challenge in rectum cancer in the age of neoadjuvant chemoradiotherapy + total mesorectal excision: an evaluation of survival outcomes. Langenbecks Arch Surg 2023; 408:356. [PMID: 37702958 DOI: 10.1007/s00423-023-03101-1] [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: 05/28/2023] [Accepted: 09/07/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE In the last decades, total mesorectal excision (TME) and neoadjuvant chemoradiotherapy (nCRT) have produced an undeniable improvement in the treatment of rectal cancer. However, local recurrence is still an important problem, and the effect of lateral lymph node (LLN) involvement on local recurrence is a controversial issue. The aim of this study was to investigate the effects of LLN status on local recurrence and survival in rectal cancers treated with nCRT + TME. METHODS Clinical features, pre- and post-nCRT lateral pelvic region imaging, long-term local recurrence, and the survival outcomes of 114 patients who underwent nCRT + TME for rectal cancer were evaluated. RESULTS On MRI before nCRT, 20 (17.5%) patients had lateral lymph nodes (LLN+), and 94 (82.5%) patients had no lymph nodes in the lateral pelvic compartments (LLN-). Local recurrences at 1 year in LLN+ and LLN- patients were 3 (15.8%) and 2 (2.3%), respectively (p=0.039). Five-year local recurrence-free survival rates and the mean duration of recurrence-free survival in LLN+ and LLN- patients were 56.2%, 42.6 months, and 87.3% 66.9 months, respectively (p=0.001). Disease-free survival and overall survival were shorter in LLN+ patients, but the difference was not statistically significant (p=0.096 and p=0.46, respectively). In the multivariate analysis, LLN involvement was determined to be an independent risk factor for local recurrence-free survival (Hazard Ratio 4.54, p=0.003). CONCLUSION Lateral lymph node involvement causes local recurrence to remain high after nCRT + TME. LLN status should be considered in treatment planning. Further studies are needed to define precise criteria for LLN involvement and the effect of LLND on local recurrence and survival.
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Affiliation(s)
- Ümit Özdemir
- Department of General Surgery, Section of Gastroenterological Surgery, Ankara Etlik City Hospital, Ankara, Turkey.
| | - Elif Gündoğdu
- Department of Radiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Melek Yakar
- Department of Radiation Oncology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Funda Canaz
- Department of Pathology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Murat Ulaş
- Department of General Surgery, Section of Gastroenterological Surgery, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - İlter Özer
- Department of General Surgery, Section of Gastroenterological Surgery, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
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13
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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.
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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
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14
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Watanabe J, Ohya H, Sakai J, Suwa Y, Goto K, Nakagawa K, Ozawa M, Ishibe A, Suwa H, Kunisaki C, Endo I. Long-term outcomes of indocyanine green fluorescence imaging-guided laparoscopic lateral pelvic lymph node dissection for clinical stage II/III middle-lower rectal cancer: a propensity score-matched cohort study. Tech Coloproctol 2023; 27:759-767. [PMID: 36773172 DOI: 10.1007/s10151-023-02761-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 01/25/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND We previously reported that indocyanine green fluorescence imaging (ICG-FI)-guided laparoscopic lateral pelvic lymph node dissection (LPLND) was able to increase the total number of harvested lateral pelvic lymph nodes without impairing functional preservation. However, the long-term outcomes of ICG-FI-guided laparoscopic LPLND have not been evaluated. The aim of the present study was to compare the long-term outcomes of ICG-FI-guided laparoscopic LPLND to conventional laparoscopic LPLND without ICG-FI. METHODS This was a retrospective, multi-institutional study with propensity score matching. The study population included consecutive patients with middle-low rectal cancer (clinical stage II to III) who underwent laparoscopic LPLND between January 2013 and February 2018. The main evaluation items in this study were the 3-year overall survival, relapse-free survival (RFS), local recurrence rate, and lateral local recurrence (LLR) rate. RESULTS A total of 172 patients with middle-lower rectal cancer who had undergone laparoscopic LPLND were included in this study. After propensity score matching, 58 patients were matched in each of the ICG-FI and non-ICG-FI groups. There were no substantial differences in the baseline characteristics between the two groups. The ICG-FI group and non-ICG-FI group included 40 and 38 women and had a median age of 65 (IQR 60-72) and 66 (IQR 60-73) years, respectively. The median follow-up for all patients was 63.7 (IQR 51.3-76.8) months. The estimated respective 3-year overall survival, RFS, and local recurrence rates were 93.1%, 70.7%, and 5.2% in the ICG-FI group and 85.9%, 71.7%, and 12.8% in the non-ICG-FI group (p = 0.201, 0.653, 0.391). The 3-year cumulative LLR rate was 0% in the ICG-FI group and 9.3% in the non-ICG-FI group (p = 0.048). CONCLUSIONS This study revealed that laparoscopic LPLND combined with ICG-FI was able to decrease the LLR rate. It appears that ICG-FI could contribute to improving the quality of laparoscopic LPLND and strengthening local control of the lateral pelvis. TRIALS REGISTRATION This study was registered with the Japanese Clinical Trials Registry as UMIN000041372 ( http://www.umin.ac.jp/ctr/index.htm ).
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Affiliation(s)
- J Watanabe
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan.
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - H Ohya
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - J Sakai
- Department of Surgery, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Y Suwa
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - K Goto
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - K Nakagawa
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - M Ozawa
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - A Ishibe
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - H Suwa
- Department of Surgery, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - C Kunisaki
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - I Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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15
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Zhou S, Mei S, Feng B, Yang Y, Wang X, Wang Q, Liu Q. Feasibility and safety of lateral pelvic lymph node dissection for elderly patients with middle-low rectal cancer: results of a large multicenter lateral node collaborative group study in China. Tech Coloproctol 2023; 27:655-664. [PMID: 36515808 DOI: 10.1007/s10151-022-02746-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Lateral pelvic lymph node (LPN) dissection can improve local control in certain rectal cancer patients with LPN metastasis. However, the effects of this technically complex procedure on perioperative safety and long-term survival of elderly patients (≥ 70 years) remain unclear. METHODS Locally advanced middle-low rectal cancer patients diagnosed with LPN metastasis who underwent total mesorectal excision (TME) with LPN dissection at three institutions from January 2012 to December 2019 were included in this study. Additionally patients who had neoadjuvant chemoradiotherapy (nCRT) and those who did not were compared. RESULTS In total there were 407 patients, including 49 elderly and 358 non-elderly patients, of which 249 were male, with a median age of 58 years (range:18-85 years). In the whole cohort, operation time (280.7 vs. 292.0 min, p = 0.498) and estimated blood loss (100 vs. 100 ml, p = 0.384) were comparable in the elderly and non-elderly groups. There was no significant difference in the incidences of overall complications (24.5% vs. 19.8%, p = 0.448) and severe (Clavien-Dindo grade 3-5) surgical complications (8.2% vs. 7.5%, p = 0.778) between the two groups. However, the incidence of urinary retention (14.3% vs. 5.6%, p = 0.032) and intensive care unit admission (16.3% vs. 6.1%, p = 0.018) was significantly higher in the elderly group compared with those in the non-elderly group. The 3-year overall survival (88.7% vs. 82.1%, p = 0.516) and disease-free survival (81.2% vs. 70.7%, p = 0.352) were comparable between the two groups. Moreover, results in the nCRT cohort were comparable to those in the overall cohort. CONCLUSIONS Even with nCRT, TME combined with LPN dissection is safe and feasible for elderly patients, demonstrating low mortality and acceptable morbidity. Elderly and non-elderly patients with LPN metastasis who undergo LPN dissection can achieve comparable 3-year survival outcomes. TRAIL REGISTRATION ClinicalTrials.gov Identifier: NCT04850027.
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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, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, 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, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Bo Feng
- Department of Gastrointestinal Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Yingchi Yang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, 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, 1 Xinmin Dajie, Chaoyang District, Changchun, 130012, 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, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
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Zhao W, Wang ZJ, Mei SW, Chen JN, Zhou SC, Zhao FQ, Xiao TX, Huang F, Liu Q. Fascia- vs vessel-oriented lateral lymph node dissection for rectal cancer: Short-term outcomes and prognosis in a single-center experience. World J Gastrointest Surg 2023; 15:1080-1092. [PMID: 37405106 PMCID: PMC10315111 DOI: 10.4240/wjgs.v15.i6.1080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/02/2023] [Accepted: 04/23/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND For the management of lateral lymph node (LLN) metastasis in patients with rectal cancer, selective LLN dissection (LLND) is gradually being accepted by Chinese scholars. Theoretically, fascia-oriented LLND allows radical tumor resection and protects of organ function. However, there is a lack of studies comparing the efficacy of fascia-oriented and traditional vessel-oriented LLND. Through a preliminary study with a small sample size, we found that fascia-oriented LLND was associated with a lower incidence of postoperative urinary and male sexual dysfunction and a higher number of examined LLNs. In this study, we increased the sample size and refined the postoperative functional outcomes.
AIM To compare the effects of fascia- and vessel-oriented LLND regarding short-term outcomes and prognosis.
METHODS We conducted a retrospective cohort study on data from 196 patients with rectal cancer who underwent total mesorectal excision and LLND from July 2014 to August 2021. The short-term outcomes included perioperative outcomes and postoperative functional outcomes. The prognosis was measured based on overall survival (OS) and progression-free survival (PFS).
RESULTS A total of 105 patients were included in the final analysis and were divided into fascia- and vessel-oriented groups that included 41 and 64 patients, respectively. Regarding the short-term outcomes, the median number of examined LLNs was significantly higher in the fascia-oriented group than in the vessel-oriented group. There were no significant differences in the other short-term outcomes. The incidence of postoperative urinary and male sexual dysfunction was significantly lower in the fascia-oriented group than in the vessel-oriented group. In addition, there was no significant difference in the incidence of postoperative lower limb dysfunction between the two groups. In terms of prognosis, there was no significant difference in PFS or OS between the two groups.
CONCLUSION It is safe and feasible to perform fascia-oriented LLND. Compared with vessel-oriented LLND, fascia-oriented LLND allows the examination of more LLNs and may better protect postoperative urinary function and male sexual function.
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Affiliation(s)
- Wei Zhao
- 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 100021, China
| | - Zhi-Jie Wang
- 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 100021, China
| | - Shi-Wen 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 100021, China
| | - Jia-Nan Chen
- 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 100021, China
| | - Si-Cheng 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 100021, China
| | - Fu-Qiang Zhao
- 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 100021, China
| | - Ti-Xian Xiao
- 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 100021, China
| | - Fei Huang
- 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 100021, 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 100021, China
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17
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Chang G, Halabi WJ, Ali F. Management of lateral pelvic lymph nodes in rectal cancer. J Surg Oncol 2023; 127:1264-1270. [PMID: 37222691 DOI: 10.1002/jso.27317] [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: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 05/25/2023]
Abstract
Lateral pelvic lymph node (LPLN) involvement occurs in 10%-25% of rectal cancer cases. Total mesorectal excision (TME) with routine LPLN dissection (LPLND) is predominantly applied in Japan whereas TME with neoadjuvant treatment are used in the West. LPLND is a morbid procedure and minimally invasive techniques may help reduce its morbidity. Selective lateral pelvic node dissection with TME following neoadjuvant treatment achieves acceptable disease-free and overall survival.
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Affiliation(s)
- Gloria Chang
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Wissam J Halabi
- Department of Surgery, Enloe Medical Center, Chico, California, USA
| | - Fadwa Ali
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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18
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Kim JS, Kim J, Baek SJ, Park H, Kwak JM, Kim SH. Laparoscopic Extraperitoneal Approach for Lateral Pelvic Node Dissection in Rectal Cancer: Techniques and Short-Term Outcomes. Surg Innov 2023; 30:13-19. [PMID: 35232305 DOI: 10.1177/15533506221076193] [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: 11/15/2022]
Abstract
BACKGROUND Lateral pelvic lymph node dissection has been performed selectively in rectal cancer cases; however, it involves highly skilled techniques because of the complex adjacent anatomical structures. MATERIALS AND METHODS Laparoscopic EP-LPND was performed in Korea University Anam Hospital from June 2018, and short-term surgical outcomes were analyzed from June to December 2018. Among the patients with histologically diagnosed rectal adenocarcinoma, patients who were suspected Lateral pelvic lymph node metastasis at magnetic resonance imaging were selected for this procedure. RESULTS Seven patients underwent laparoscopic extraperitoneal approach for lateral pelvic lymph node dissection in the study period. The mean number of retrieved lymph node was 4.57, and metastatic lymph nodes were identified in 3 patients (42.8%). All of the lymph nodes with suspected metastasis preoperatively were removed in postoperative images. There was no immediate postoperative complication beyond the moderate grade associated with lateral pelvic lymph node dissection. The median follow-up was 9 months, and there were no local recurrence nor complications related to sexual and voiding functions. CONCLUSIONS The laparoscopic extraperitoneal approach might be an efficient way to perform lateral pelvic lymph node dissection using the same principles as the conventional method without violation of the peritoneum.
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Affiliation(s)
- Ji-Seon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
| | - Jin Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
| | - Se-Jin Baek
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
| | - Hyunmi Park
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
| | - Jung-Myun Kwak
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
| | - Seon-Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
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19
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Yoo GS, Park HC, Yu JI. Clinical implication and management of rectal cancer with clinically suspicious lateral pelvic lymph node metastasis: A radiation oncologist's perspective. Front Oncol 2022; 12:960527. [PMID: 36568216 PMCID: PMC9768025 DOI: 10.3389/fonc.2022.960527] [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: 06/24/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022] Open
Abstract
Rectal cancer is the eighth most common malignancy worldwide. With the introduction of total mesorectal excision (TME) and neoadjuvant chemoradiation (NCRT), intrapelvic local control has been remarkably improved. However, lateral pelvic recurrence remains problematic, especially in patients with clinically suspicious lateral pelvic lymph node (LPLN). LPLN dissection has been applied for the management of LPLN metastasis, mainly in Japan and other Eastern countries, while the role of NCRT is more emphasized and LPLN dissection is performed in very limited cases in Western countries. However, the optimal management strategy for patients with rectal cancer with suspicious LPLN metastasis has not been determined. Herein, we review the latest studies on the optimal management of LPLN metastasis to suggest the most appropriate treatment policies according to current evidence and discuss future research directions.
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Affiliation(s)
| | | | - Jeong Il Yu
- *Correspondence: Jeong Il Yu, ; Hee Chul Park,
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20
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Tang J, Zhou S, Zhao W, Lou Z, Liang J, Feng B, Yang Y, Wang X, Liu Q. Short- and long-term outcomes of laparoscopic versus open selective lateral pelvic lymph node dissection for locally advanced middle-low rectal cancer: Results of a multicentre lateral node study in China. Colorectal Dis 2022; 24:1325-1334. [PMID: 35713974 DOI: 10.1111/codi.16223] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/07/2022] [Accepted: 06/11/2022] [Indexed: 02/08/2023]
Abstract
AIM Lateral pelvic lymph node dissection (LPND) is a technically challenging procedure, and the safety and feasibility of laparoscopic LPND remains undetermined. Here, we compared the short- and long-term survival outcomes of laparoscopic LPND with those of open LPND. METHODS From January 2012 to December 2019, locally advanced middle-low rectal cancer patients with clinical evidence of lateral pelvic lymph node metastasis (LPNM) who underwent total mesorectal excision with LPND at three institutions were included. Propensity score matching was used to minimize selection bias. The short-term and oncological outcomes of open and laparoscopic LPND were compared. RESULTS Overall, 384 patients were enrolled into the study including 277 and 107 patients who underwent laparoscopic and open LPND, respectively. After matching, patients were stratified into laparoscopic (n = 100) and open (n = 100) LPND groups. Patients in the laparoscopic LPND group had a shorter operation time (255 vs. 300 min, p = 0.001), less intraoperative blood loss (50 vs. 300 ml, p < 0.001), lower incidence of postoperative complications (32.0% vs. 15.0%, p = 0.005), shorter postoperative hospital stay (8 vs. 14 days, p < 0.001), and excision of more lateral pelvic lymph nodes (9 vs. 7, p = 0.025) than those in the open LPND group. The 3-year overall survival (p = 0.581) and 3-year disease-free survival (p = 0.745) rates were similar between the groups, and LPNM was an independent predictor of survival. CONCLUSION Laparoscopic LPND is technically safe and feasible with favourable short-term results and similar oncological outcomes as open surgery in selected patients.
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Affiliation(s)
- 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.,Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Hebei Cancer Hospital, Chinese Academy of Medical Sciences, Langfang, China
| | - 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
| | - Wei Zhao
- 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, Changhai Hospital, Nava Military Medical University, Shanghai, 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
| | - Bo Feng
- Department of Gastrointestinal Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Yingchi Yang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Xin Wang
- Department of General Surgery, Peking University First Hospital, Beijing, 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
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21
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Peacock O, Manisundaram N, Dibrito SR, Kim Y, Hu CY, Bednarski BK, Konishi T, Stanietzky N, Vikram R, Kaur H, Taggart MW, Dasari A, Holliday EB, You YN, Chang GJ. Magnetic Resonance Imaging Directed Surgical Decision Making for Lateral Pelvic Lymph Node Dissection in Rectal Cancer After Total Neoadjuvant Therapy (TNT). Ann Surg 2022; 276:654-664. [PMID: 35837891 PMCID: PMC9463102 DOI: 10.1097/sla.0000000000005589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Lateral pelvic lymph node (LPLN) metastases are an important cause of preventable local failure in rectal cancer. The aim of this study was to evaluate clinical and oncological outcomes following magnetic resonance imaging (MRI)-directed surgical selection for lateral pelvic lymph node dissection (LPLND) after total neoadjuvant therapy (TNT). METHODS A retrospective consecutive cohort analysis was performed of rectal cancer patients with enlarged LPLN on pretreatment MRI. Patients were categorized as LPLND or non-LPLND. The main outcomes were lateral local recurrence rate, perioperative and oncological outcomes and factors associated with decision making for LPLND. RESULTS A total of 158 patients with enlarged pretreatment LPLN and treated with TNT were identified. Median follow-up was 20 months (interquartile range 10-32). After multidisciplinary review, 88 patients (56.0%) underwent LPLND. Mean age was 53 (SD±12) years, and 54 (34.2%) were female. Total operative time (509 vs 429 minutes; P =0.003) was greater in the LPLND group, but median blood loss ( P =0.70) or rates of major morbidity (19.3% vs 17.0%) did not differ. LPLNs were pathologically positive in 34.1%. The 3-year lateral local recurrence rates (3.4% vs 4.6%; P =0.85) did not differ between groups. Patients with LPLNs demonstrating pretreatment heterogeneity and irregular margin (odds ratio, 3.82; 95% confidence interval: 1.65-8.82) or with short-axis ≥5 mm post-TNT (odds ratio 2.69; 95% confidence interval: 1.19-6.08) were more likely to undergo LPLND. CONCLUSIONS For rectal cancer patients with evidence of LPLN metastasis, the appropriate selection of patients for LPLND can be facilitated by a multidisciplinary MRI-directed approach with no significant difference in perioperative or oncologic outcomes.
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Affiliation(s)
- Oliver Peacock
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Naveen Manisundaram
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Sandra R Dibrito
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Youngwan Kim
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Chung-Yuan Hu
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Brian K Bednarski
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Nir Stanietzky
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Raghunandan Vikram
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Harmeet Kaur
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Melissa W Taggart
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Arvind Dasari
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Y Nancy You
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - George J Chang
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
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22
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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: 0.7] [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.
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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,
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23
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Near-Infrared Imaging Using Indocyanine Green for Laparoscopic Lateral Pelvic Lymph Node Dissection for Clinical Stage II/III Middle-Lower Rectal Cancer: A Propensity Score-Matched Cohort Study. Dis Colon Rectum 2022; 65:885-893. [PMID: 34840301 DOI: 10.1097/dcr.0000000000002156] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The examination of the efficacy of near-infrared imaging using indocyanine green in laparoscopic lateral pelvic lymph node dissection remains insufficient. OBJECTIVE The aim of this study was to examine whether near-infrared imaging contributed to an increase in the total number of harvested lateral pelvic lymph nodes in laparoscopic lateral pelvic lymph node dissection. DESIGN This was a retrospective, multi-institutional study with propensity score matching. SETTINGS We conducted this study within the framework of the Yokohama Clinical Oncology Group in Japan. PATIENTS The study population included consecutive patients with middle-low rectal cancer (clinical stage II to III) who underwent laparoscopic lateral pelvic lymph node dissection between January 2013 and February 2018. MAIN OUTCOME MEASURES The total number of harvested lateral pelvic lymph nodes was compared in laparoscopic lateral pelvic lymph node dissection with and without near-infrared imaging. RESULTS A total of 172 eligible patients were included; 84 of these patients underwent laparoscopic surgery with near-infrared imaging. After propensity score matching, 58 patients were matched in each of the near-infrared and the non-near-infrared groups. The operation time in the near-infrared group was significantly longer than that in the non-near-infrared group (426 vs 369 min), and the amount of intraoperative blood loss in the near-infrared group was significantly smaller than that in the non-near-infrared group (13 vs 110 mL). The total number of harvested lateral pelvic lymph nodes in the near-infrared group was significantly higher than that in the non-near-infrared group (14 vs 9). There were no significant differences in the postoperative complication rates of the 2 groups. LIMITATIONS The limitations of the present study include its retrospective design. CONCLUSIONS This study revealed that laparoscopic lateral pelvic lymph node dissection combined with near-infrared imaging could increase the total number of harvested lateral pelvic lymph nodes without impairing functional preservation. See Video Abstract at http://links.lww.com/DCR/B800.This study was registered with the Japanese Clinical Trials Registry as UMIN000041372 (http://www.umin.ac.jp/ctr/index.htm).IMÁGENES CASI-INFRARROJAS UTILIZANDO VERDE DE INDOCIANINA EN LA DISECCIÓN LAPAROSCÓPICA DE GANGLIOS LINFÁTICOS PÉLVICOS LATERALES EN CASOS DE CÁNCER DE RECTO MEDIO-INFERIOR DE ESTADIO CLÍNICO II / III: ESTUDIO DE COHORTES CON PUNTUACIÓN DE PROPENSIÓNANTECEDENTES:El examen de la eficacia de las imágenes casi-infrarrojas utilizando le verde de indocianina en la disección laparoscópica de los ganglios linfáticos pélvicos laterales sigue siendo insuficiente.OBJETIVO:El objetivo de este estudio fue examinar si las imágenes casi-infrarrojas contribuyeron a un aumento en el número total de ganglios linfáticos pélvicos laterales recolectados durante su disección laparoscópica.DISEÑO:Estudio retrospectivo, multi-institucional con emparejamiento por puntuación de propensión.AJUSTES:Estudio realizado dentro el marco establecido por el Grupo de Oncología Clínica de Yokohama, Japón.PACIENTES:La población estudiada incluyó pacientes consecutivos con cáncer de recto medio-bajo (estadio clínico II a III) que se sometieron a una disección laparoscópica de los ganglios linfáticos pélvicos laterales entre enero de 2013 y febrero de 2018.PRINCIPALES RESULTADOS MEDIDAS:El número total de ganglios linfáticos pélvicos laterales extraídos se comparó en la disección laparoscópica de ganglios linfáticos pélvicos laterales con y sin imágenes casi-infrarrojas.RESULTADOS:Se incluyeron un total de 172 pacientes elegibles; 84 de estos pacientes se sometieron a cirugía laparoscópica con imágenes casi-infrarrojas. Después del emparejamiento por puntuación de propensión, 58 pacientes fueron emparejados en cada uno de los grupos de luz casi-infrarroja y los sin luz. El tiempo de operación en el grupo de luz casi-infrarroja fue significativamente más largo que en el grupo sin luz (426 frente a 369 min), y la cantidad de pérdida de sangre intraoperatoria en el grupo de luz casi-infrarroja fue significativamente menor que en el grupo sin luz (13 frente a 110 ml). El número total de ganglios linfáticos pélvicos laterales recolectados en el grupo de luz casi-infrarroja fue significativamente mayor que en el grupo sin luz (14 frente a 9). No hubo diferencias significativas en las tasas de complicaciones posoperatorias de los dos grupos.LIMITACIONES:Las limitaciones del presente estudio incluyen su diseño retrospectivo.CONCLUSIONES:Este estudio reveló que la disección laparoscópica de los ganglios linfáticos pélvicos laterales combinada con imágenes casi-infrarrojas podría aumentar el número total de ganglios linfáticos pélvicos laterales recolectados sin afectar la preservación funcional. Consulte Video Resumen en http://links.lww.com/DCR/B800. (Traducción-Dr. Xavier Delgadillo)Este estudio se registró en el Registro de Ensayos Clínicos de Japón como UMIN000041372 (http://www.umin.ac.jp/ctr/index.htm).
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24
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Lim HK, Kim M, Park JW, Ryoo SB, Park KJ, Oh HK, Kim DW, Kang SB, Lee DW, Park SC, Oh JH, Jeong SY. Laparoscopic versus open lateral pelvic lymph node dissection in locally advanced rectal cancer: multicentre retrospective cohort study. BJS Open 2022; 6:zrac068. [PMID: 35694967 PMCID: PMC9189607 DOI: 10.1093/bjsopen/zrac068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/05/2022] [Accepted: 04/12/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Lateral pelvic lymph node dissection (LPLND) is an option in the treatment of rectal cancer and may reduce local recurrence/improve disease-free survival. Advancements in minimally invasive technology have improved the ability to identify anatomy and neurovascular structures that may help in LPLND. The aim of this retrospective study was to evaluate the technical feasibility and oncological safety of laparoscopic LPLND compared with the open LPLND. METHOD Between July 2010 and July 2019, patients from three tertiary referral hospitals who underwent LPLND with total mesorectal excision for primary rectal cancer were included. Baseline patient characteristics, perioperative outcomes, pathologic results, recurrence, and survival were compared between the laparoscopic and open groups. RESULTS There were 126 and 70 patients in the laparoscopic and open groups respectively. The laparoscopic group had less estimated blood loss (100 ml versus 300 ml, P < 0.001) and lower transfusion rate (0.8 per cent versus 10.0 per cent; P = 0.003) but longer operating times (318 min versus 270 min, P = 0.004). The laparoscopic group had fewer wound infections (1.6 per cent versus 10.0 per cent, P = 0.011) and neuropathy (0 per cent versus 4.3 per cent, P = 0.044). Lateral pelvic recurrence rate was 7.6 per cent in the laparoscopic group and 19.6 per cent in the open group (P = 0.053). Recurrence-free survival (72.2 per cent versus 63.5 per cent; P = 0.190) and overall survival (93.3 per cent versus 85.0 per cent; P = 0.118) were not significantly different. CONCLUSION Laparoscopic LPLND was associated with improved perioperative outcomes and non-inferior oncological outcomes.
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Affiliation(s)
- Han-Ki Lim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
| | - Minjung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Republic of Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Republic of Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Republic of Korea
| | - Dong Woon Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
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25
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Chen Z, Sasaki K, Murono K, Kawai K, Nozawa H, Kobayashi H, Ishihara S, Sugihara K. Oncologic Status of Obturator Lymph Node Metastases in Locally Advanced Low Rectal Cancer: A Japanese Multi-Institutional Study of 3487 Patients. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11372-z. [PMID: 35243595 DOI: 10.1245/s10434-022-11372-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/10/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND The American Joint Committee on Cancer tumor-node-metastasis staging system for rectal cancer defines lateral pelvic lymph nodes (LPLNs) only in the internal iliac region as regional. However, the Japanese Society for Cancer of the Colon and Rectum (JSCCR) staging system, also considers obturator lymph nodes (LNs) as regional. This retrospective cohort study evaluated the oncologic status of obturator LNs in low rectal cancer. METHODS The study identified 3487 patients with pT3-T4 low rectal cancer who had undergone curative resections without preoperative radiotherapy or chemotherapy between 2003 and 2011 in the JSCCR database and divided them into six groups. Overall survival (OS) and recurrence-free survival (RFS) were analyzed by groups. RESULTS Histologic LPLN metastases were identified in 8% (279/3487) of all the patients and in 18.2% (279/1530) of the patients who underwent lateral pelvic node dissection. The 5-year OS and RFS rates of the obturator-LPLN group (P = 0.095) were worse than those of the internal-LPLN group (P = 0.075), but the difference was not significant. The OS of the obturator-LPLN group was similar to that of the resectable liver metastasis group (P = 0.731), and the RFS of the obturator-LPLN group was significantly better than that of the other-LPLN group (P = 0.016). CONCLUSION The prognosis for obturator LN metastases in low rectal cancer was not significantly worse than for internal iliac LN metastases, defined as regional by the current American Joint Committee on Cancer staging system, and the oncologic status of obturator LNs warrants more studies.
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Affiliation(s)
- Zhifen Chen
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kazuhito Sasaki
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Koji Murono
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kazushige Kawai
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Hioaki Nozawa
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Hirotoshi Kobayashi
- Department of Surgery, Teikyo University, Mizonokuchi Hospital, Kawasaki-city, Kanagawa, Japan
| | - Soichiro Ishihara
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan.
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Shiraishi T, Sasaki T, Tsukada Y, Ikeda K, Nishizawa Y, Ito M. Radiologic Factors and Areas of Local Recurrence in Locally Advanced Lower Rectal Cancer After Lateral Pelvic Lymph Node Dissection. Dis Colon Rectum 2021; 64:1479-1487. [PMID: 34657076 DOI: 10.1097/dcr.0000000000001921] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Identifying preoperative risk factors of local recurrence and patterns of treatment failure resulting after rectal cancer management is important for planning treatment strategies and improving the results of multidisciplinary care. OBJECTIVE The purpose of this study was to analyze the associations between the preoperative factors and local recurrence and to investigate the local recurrence areas in patients with locally advanced lower rectal cancer who underwent lateral pelvic lymph node dissection. DESIGN The study used a retrospective cohort design. SETTINGS It was conducted at a single institution. PATIENTS Overall 469 patients with locally advanced lower rectal adenocarcinoma located below the peritoneal reflex who received curative resection with lateral pelvic lymph node dissection during 2010 to 2018 were included. MAIN OUTCOME MEASURES Independent risk factors for local recurrence were assessed using multivariate Cox regression. Local recurrence was classified into 3 areas using follow-up images. RESULTS A total of 286 patients underwent upfront surgery, 132 patients received neoadjuvant chemotherapy followed by surgery, and 51 patients received preoperative chemoradiotherapy followed by surgery. Eighty-six patients (18.3%) were extramural venous invasion positive, and 113 patients (24.1%) were circumferential resection margin positive. The median follow-up period was 46 months. Local recurrence showed significant association with extramural venous invasion positive (HR = 2.596 (95% CI, 1.321-5.102); p = 0.006) or circumferential resection margin positive (HR = 2.298 (95% CI, 1.158-4.560); p = 0.017). The incidence of local recurrence was observed in 51 patients (10.8%), with the pelvic plexus and internal iliac area being the most frequent (6.6%), followed by the central pelvis area (3.8%), and was markedly low in the obturator area (0.4%). LIMITATIONS This was a retrospective, single-institution design. CONCLUSIONS Extramural venous invasion status and circumferential resection margin status were associated with a high local recurrence rate in patients who underwent lateral pelvic lymph node dissection. In addition, local recurrence in the obturator area was low compared with that in other areas. See Video Abstract at http://links.lww.com/DCR/B683. FACTORES RADIOLGICOS Y REAS DE RECURRENCIA LOCAL EN EL CNCER DE RECTO INFERIOR LOCALMENTE AVANZADO DESPUS DE LA DISECCIN GANGLIONAR PLVICA LATERAL ANTECEDENTES:El identificar los factores de riesgo preoperatorios para recurrencia local y los patrones de fracaso del tratamiento que resultan del manejo del cáncer de recto es importante para planificar las estrategias de tratamiento y mejorar los resultados de la atención multidisciplinaria.OBJETIVO:Analizar las asociaciones entre los factores preoperatorios y la recidiva local, e investigar las áreas de recidiva local en pacientes con cáncer de recto inferior localmente avanzado que se sometieron a disección de ganglios linfáticos pélvicos laterales.DISEÑO:Un diseño de cohorte retrospectivo.ENTORNO CLÍNICO:Una sola institución.PACIENTES:Un total de 469 pacientes con adenocarcinoma rectal inferior localmente avanzado ubicado debajo del reflejo peritoneal que recibieron resección curativa con disección de ganglios linfáticos pélvicos laterales durante 2010-2018.PRINCIPALES MEDIDAS DE RESULTADO:Los factores de riesgo independientes de recurrencia local se evaluaron mediante regresión de Cox multivariante. La recurrencia local se clasificó en 3 áreas utilizando imágenes de seguimiento.RESULTADOS:Doscientos ochenta y seis pacientes se sometieron a cirugía inicial, 132 pacientes recibieron quimioterapia neoadyuvante seguida de cirugía y 51 pacientes recibieron quimiorradioterapia preoperatoria seguida de cirugía. Ochenta y seis pacientes (18,3%) fueron positivos para invasión venosa extramural y 113 pacientes (24,1%) fueron positivos para el margen de resección circunferencial. La mediana del período de seguimiento fue de 46 meses. La recidiva local mostró una asociación significativa con la invasión venosa extramural positiva (cociente de riesgo: 2,596; intervalo de confianza del 95%: 1,321-5,102; p = 0,006) o el margen de resección circunferencial positivo (cociente de riesgo: 2,298; intervalo de confianza del 95%: 1,158-4,560; p = 0,017). La incidencia de recidiva local se observó en 51 pacientes (10,8%), siendo el plexo pélvico y el área ilíaca interna los más frecuentes (6,6%), seguidos del área pélvica central (3,8%), y fue marcadamente baja en el área del obtudador (0.4%).LIMITACIONES:Un diseño retrospectivo de una sola institución.CONCLUSIONES:El estado de invasión venosa extramural o el estado del margen de resección circunferencial se asociaron con una alta tasa de recurrencia local en pacientes que se sometieron a disección de ganglios linfáticos pélvicos laterales. Además, la recurrencia local en el área del obturador fue baja en comparación con la de otras áreas. Consulte Video Resumen en http://links.lww.com/DCR/B683.
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Affiliation(s)
- Takuya Shiraishi
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
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The Addition of Preoperative Radiation Is Insufficient for Lateral Pelvic Control in a Subgroup of Patients With Low Locally Advanced Rectal Cancer: A Post Hoc Study of a Randomized Controlled Trial. Dis Colon Rectum 2021; 64:1321-1330. [PMID: 33990500 DOI: 10.1097/dcr.0000000000001935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The local recurrence of rectal cancer has been improved by total mesorectal excision following neoadjuvant chemoradiotherapy. However, in patients with low locally advanced rectal cancer, lateral pelvic recurrence remains to be addressed. OBJECTIVE This study aimed to determine the efficiency of neoadjuvant radiotherapy in addressing lateral pelvic recurrence and which subgroup of patients might be optimal to receive lateral lymph node dissection. DESIGN The MRI/CT images were reassessed for lateral lymph node status. The lateral lymph nodes with short axis ≥5 mm and ≥4 mm were considered positive in pretreatment and restaging MRI/CT. SETTING This was a post hoc analysis of a prospective randomized controlled trial (FOWARC, NCT01211210). PATIENTS A total of 495 patients with stage II or III rectal adenocarcinoma were included in the original trial. According to the excluding criteria, the finally included population consists of 253 patients; of these, 195 patients received neoadjuvant chemoradiotherapy and 94 received chemotherapy alone. MAIN OUTCOMES AND MEASURES The primary outcome was the 5-year lateral pelvic recurrence rate. RESULTS Compared with patients receiving chemotherapy alone, patients receiving additional radiotherapy had a marginal significance of lower lateral pelvic recurrence rate (6.6% vs 13.0%; p = 0.051). In the subset with pretreatment positive lateral lymph nodes, patients had a lateral pelvic recurrence rate of 22.6% and 45.1% after neoadjuvant chemoradiotherapy and chemotherapy alone. Of note, 34.9% of the pretreatment positive lateral lymph nodes were persistent after neoadjuvant chemoradiotherapy, culminating in a lateral pelvic recurrence rate of 63.3%. LIMITATIONS This is a post hoc analysis, and only the patients from the leading center were included, which limited the sample size. In addition, the lateral lymph node dissection was not performed in this cohort. CONCLUSIONS The addition of radiotherapy in neoadjuvant regimens could not address lateral pelvic recurrence adequately. Some subgroups of patients might need additional dissection. See Video Abstract at http://links.lww.com/DCR/B613. LA INCLUSION DE LA RADIOTERAPIA PREOPERATORIA ES INSUFICIIENTE EN EL CONTROL PLVICO LATERAL EN UN SUBGRUPO DE PACIENTES CON CNCER DE RECTO INFERIOR LOCALMENTE AVANZADO UN ESTUDIO POSTHOC CONTROLADO Y RANDOMIZADO ANTECEDENTES:La recurrencia local del cancer de recto ha disminuido al efectuar una excision mesorrectal total seguida de quimioradioterapia neoadyuvante. No obstante, en pacientes con cancer de tercio inferior de recto avanzado localmente, aún está por controlarse la recurrencia pélvicaOBJETIVOS:Determinar la eficacia de la radioterapia neoadyuvante en el control de la recurrencia pélvica lateral y en que subgrupo de pacientes sería conveniente efecutar una excisión lateral de las cadenas ganglionares.DISEÑO:Se reevaluaron las imágenes tomográficas y de resonancia magnética del status de las cadenas ganglionares linfáticas laterales. Los ganglios linfáticos laterales con un eje-corto > 5 mm y ≥ 4 mm se consideraron como positivos previo al tratamiento y reestadificados con RM y TAC respectivamente.ESCENARIO:Es un análisis post hoc de un studio prospectivo randomizado controlado (FOWARC, NCT01211210).PACIENTESSe incluyeron un total de 495 pacientes en estdio II o III con adenomcarcinoma rectal en el estudio original. De acuerdo a los criterios de exclusión, la población final incluida consistió en 253 pacientes; de estos, 195 recibieron quimioradioterapia neoadyuvante y 94 quimioterapia sola.EVALUACION DE LOS RESULTADOS PRINCIPALES:El parámetro mas importante fue la tasa de recurrencia pélvica lateral a cinco años.RESULTADOS:En comparación con los pacientes que recibieron quimioterapia sola, aquellos que además fueron sometidos a radioterapia adicional presentaron un margen significativo de menor tasa de recurrencia pélvica lateral (6.6% vs. 13.0%; p=0.051). En el grupo de pacientes con ganglios linfáticos laterales positivos, los enfermos presentaron una tasa de recurrencia pélvica lateral de 22.6% y 45.1% después de quimioradiaterapia neoadyuvante en comparación con quimioterapia sola respectivamente. Cabe mencionar que el 34.9% de los pacientes con ganglios linfáticos laterales positivos antes del tratamiento persistieron después de la quimioradioterapia neoadyuvante, reportándose finalmente una recurrencia pélvica lateral de un 63.3%.LIMITACIONES:Se trata de un análisis posthoc y solo los pacientes del hospital fueron incluidos, lo que limita el tamaño de la muestra. Además, no se efectuó la disección de los ganglios linfáticos laterales en este grupo.CONCLUSIONES:La radioterapia en los esquemas de neoadyuvancia no logran controlar la recurrencia pélvica lateral en forma adecuada. Algunos subgrupos de pacientes podría requerir de disección adicional. Consulte Video Resumen en http://links.lww.com/DCR/B613.
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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: 2.5] [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.
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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
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Morohashi H, Sakamoto Y, Miura T, Ichinohe D, Umemura K, Akaishi T, Sato K, Kuwata D, Yamazaki K, Wakiya T, Hakamada K. Effective dissection for rectal cancer with lateral lymph node metastasis based on prognostic factors and recurrence type. Int J Colorectal Dis 2021; 36:1251-1261. [PMID: 33527145 PMCID: PMC8119260 DOI: 10.1007/s00384-021-03870-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE There are no reports showing the significance and effective range of dissection for patients with lateral lymph node metastasis (LLNM). This study aimed to investigate the indications for lateral lymph node dissection (LLND) in patients with LLNM based on prognostic factors and recurrence types. METHODS We reviewed 379 patients with advanced rectal cancer who were treated with total mesorectal excision plus LLND. We analyzed background factors and survival times of patients who had LLNM to determine prognostic factors and recurrence types. RESULTS Pathological LLNM occurred in 44 (11.6%). Among patients with LLNM, the predictors of poor prognoses, according to univariate analysis, were > 3 node metastases, the presence of node metastasis on both sides, and spreading beyond the internal iliac lymph nodes. Moreover, LLNM beyond the internal iliac region was found to be an independent prognostic risk factor. Twenty-eight of the 44 patients with lateral lymph node metastasis (64%) relapsed, 22 of whom had distant metastases and 11 of whom experienced local recurrences. Among the latter group, nine (20%) and two (5%) had recurrences in the central and lateral pelvis, respectively. CONCLUSION The therapeutic benefit of resection was high, especially in patients with ≤ 3 positive lateral lymph nodes, one-sided bilateral lymph node areas, and positive nodes localized near the internal iliac artery.
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Affiliation(s)
- Hajime Morohashi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan.
| | - Yoshiyuki Sakamoto
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan
| | - Takuya Miura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan
| | - Daichi Ichinohe
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan
| | - Kotaro Umemura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan
| | - Takanobu Akaishi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan
| | - Kentaro Sato
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan
| | - Daisuke Kuwata
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan
| | - Keisuke Yamazaki
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan
| | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Zaifu-cho 5, Hirosaki-shi, 036-8562, Japan
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Cribb B, Kong J, McCormick J, Warrier S, Heriot A. Lateral pelvic lymph node dissection for rectal cancer: unfinished business? ANZ J Surg 2021; 90:1228-1229. [PMID: 33448565 DOI: 10.1111/ans.15761] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/27/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Benjamin Cribb
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - Joseph Kong
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jacob McCormick
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - Satish Warrier
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
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Indications and oncological outcomes of selective dissection for clinically suspected lateral lymph node metastasis in patients with rectal cancer based on pretreatment imaging. Tech Coloproctol 2021; 25:425-437. [PMID: 33585985 DOI: 10.1007/s10151-020-02386-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 11/26/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of this study was to identify the indications and oncological outcomes of selective lateral lymph node dissection (sLLND) in rectal cancer patients. METHODS A retrospective study was conducted on consecutive patients with rectal cancer who had standard total mesorectal excision and sLLND at our institution. Clinicopathological characteristics and oncological outcomes were analyzed. We performed subgroup analysis and multivariate analysis based on patients with or without preoperative chemoradiotherapy to identify the related risk factors. RESULTS A total of 77 consecutive patients with TME and sLLND were included. Twenty-two (28.6%) patients with pathological positive lateral lymph nodes metastasis (LLNM) were identified. Forty-seven (61%) patients accepted neoadjuvant chemoradiotherapy (nCRT). The pretreatment maximum short-axis diameters of LLN (≥ 8 mm) were the independent risk factors for LLNM among patients with LLN ≥ 5 mm. Lymph node metastasis were significantly higher in patients with pretreatment LLN ≥ 8 mm than in patients with LLN 5-8 mm (63% vs. 10%, p < 0.001). The receiver operating curve analysis suggested that the optimal cutoff value of LLN short-axis diameter for predicting LLNM was 8 mm. At a median follow-up of 42 months (range 6-140 months) 3 (3.9%) patients with lateral pelvic recurrence were observed. The 3-year cumulative overall survival in patients with LLNM and patients without LLNM was 76.7% and 89.8%, respectively (p = 0.01). The 3-year cumulative disease-free survival was 53.6% in patients with LLNM and 88.3% in patients without LLNM (p = 0.008). CONCLUSION Patients with LLNM had a worse prognosis. The pretreatment maximum short-axis diameter of LLN (≥ 8 mm) should be considered as an indication for sLLND.
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Kim YI, Jang JK, Park IJ, Park SH, Kim JB, Park JH, Kim TW, Ro JS, Lim SB, Yu CS, Kim JC. Lateral lymph node and its association with distant recurrence in rectal cancer: A clue of systemic disease. Surg Oncol 2020; 35:174-181. [DOI: 10.1016/j.suronc.2020.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/08/2020] [Accepted: 08/16/2020] [Indexed: 12/12/2022]
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Peacock O, Limvorapitak T, Bednarski BK, Kaur H, Taggart MW, Dasari A, Holliday EB, Minsky BD, You YN, Chang GJ. Robotic lateral pelvic lymph node dissection after chemoradiation for rectal cancer: a Western perspective. Colorectal Dis 2020; 22:2049-2056. [PMID: 32892473 DOI: 10.1111/codi.15350] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/06/2020] [Accepted: 08/25/2020] [Indexed: 12/15/2022]
Abstract
AIM There are limited outcome data for lateral pelvic lymph node dissection (LPLND) following neoadjuvant chemoradiotherapy (nCRT), particularly in the West. Our aim was to evaluate the short-term perioperative and oncological outcomes of robotic LPLND at a single cancer centre. METHOD A retrospective analysis of a prospective database of consecutive patients undergoing robotic LPLND for rectal cancer between November 2012 and February 2020 was performed. The main outcomes were short-term perioperative and oncological outcomes. Major morbidity was defined as Clavien-Dindo grade 3 or above. RESULTS Forty patients underwent robotic LPLND during the study period. The mean age was 54 years (SD ± 15 years) and 13 (31.0%) were female. The median body mass index was 28.6 kg/m2 (IQR 25.5-32.6 kg/m2 ). Neoadjuvant CRT was performed in all patients. Resection of the primary rectal cancer and concurrent LPLND occurred in 36 (90.0%) patients, whilst the remaining 4 (10.0%) patients had subsequent LPLND after prior rectal resection. The median operating time was 420 min (IQR 313-540 min), estimated blood loss was 150 ml (IQR 55-200 ml) and length of hospital stay was 4 days (IQR 3-6 days). The major morbidity rate was 10.0% (n = 4). The median lymph node harvest from the LPLND was 6 (IQR 3-9) and 13 (32.5%) patients had one or more positive LPLNs. The median follow-up was 16 months (IQR 5-33 months), with 1 (2.5%) local central recurrence and 7 (17.5%) patients developing distant disease, resulting in 3 (7.5%) deaths. CONCLUSION Robotic LPLND for rectal cancer can be performed in Western patients to completely resect extra-mesorectal LPLNs and is associated with acceptable perioperative morbidity.
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Affiliation(s)
- O Peacock
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - T Limvorapitak
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - B K Bednarski
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - H Kaur
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - M W Taggart
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - A Dasari
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - E B Holliday
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - B D Minsky
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Y N You
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - G J Chang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Jones HG, Radwan RW, Sams E, Gibby M, Coomer W, Jeffries J, Codd RJ, Williams GL, Taylor G, Horwood J. Incidence and treatment of positive pelvic sidewall lymph nodes in patients with rectal cancer. Colorectal Dis 2020; 22:1560-1567. [PMID: 32506534 DOI: 10.1111/codi.15176] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/19/2020] [Indexed: 12/15/2022]
Abstract
AIM The involvement of pelvic sidewall (PSW) lymph nodes in rectal cancer is a marker of locally advanced disease and poor prognosis. Eastern countries generally advocate lateral lymph node dissection (LLND) over the Western approach of neoadjuvant chemoradiotherapy and more limited surgery. The aim of this study was to evaluate how these advanced cancers were treated in three UK Health Boards. METHODOLOGY This was a retrospective review of three colorectal multidisciplinary team meetings from 2008 to 2016. All patients with rectal cancer and suspicious PSW lymph nodes on pretreatment MRI were included. RESULTS There were 153 (6.2%) patients who met the inclusion criteria from a total of 2461 diagnosed rectal cancers. There was significant variability between the three centres with surgical intervention ranging from 59.2% to 84.4%, P = 0.015. There were 81 patients who had neoadjuvant chemoradiotherapy prior to surgery; of these 67 (82.7%) still had positive PSW nodes on the restaging MRI, but only 13 (19.4%) had LLND. There was no difference in local recurrence (15.3% vs 11.8%, P = 0.66), 5-year overall survival (69.2% vs 80.1%, P = 0.16) or 5-year disease-free survival (69.2% vs 79.4%, P = 0.72) between patients having LLND and those receiving standard neoadjuvant treatment followed by total mesorectal excision surgery. CONCLUSIONS This study has demonstrated that rectal cancer patients with PSW positive nodal disease have advanced disease, mostly of the lower rectum, and receive a highly heterogeneous spectrum of therapies, even within a relatively small geographical area. Greater accuracy in our preoperative staging is needed to select those patients who will benefit from LLND surgery.
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Affiliation(s)
- H G Jones
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
| | - R W Radwan
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
| | - E Sams
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
| | - M Gibby
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
| | - W Coomer
- Radiology Department, University Hospital of Wales, Cardiff, UK
| | - J Jeffries
- Radiology Department, University Hospital of Wales, Cardiff, UK
| | - R J Codd
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
| | - G L Williams
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
| | - G Taylor
- Department of Colorectal Surgery, Morriston Hospital, Swansea, UK
| | - J Horwood
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
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35
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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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36
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Yang B, Huang J, Zhou S, Tan J, Zhong G, Gao H, Han F. Laparoscopic versus open selective lateral pelvic lymph node dissection following total mesorectal excision for locally advanced low rectal cancer. Int J Colorectal Dis 2020; 35:1301-1309. [PMID: 32361937 DOI: 10.1007/s00384-020-03609-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 02/04/2023]
Abstract
PURPOSES Lateral pelvic lymph node (LPLN) dissection represents a technically challenging procedure with a high potential risk of surgical morbidity. The purpose of this study was to compare the technical feasibility, safety, and oncological efficacy of laparoscopic LPLN dissection (LPLD) following total mesorectal excision (TME) with open LPLD for locally advanced low rectal cancer (LALRC). METHODS Between January 2010 and December 2016, consecutive patients with LALRC and swollen LPLNs who underwent laparoscopic or open TME with LPLD at our institution were enrolled in this retrospective observational study. Data regarding patient demographics, perioperative characteristics, and oncological outcomes were analyzed and compared. RESULTS A total of 64 patients met the inclusion criteria. Thirty-four patients underwent open procedure, and 30 underwent laparoscopic procedure. The mean blood loss volume was significantly less in the laparoscopic group than in the open group (165 vs. 422 mL; P = 0.012). The mean operative time was not significantly different between the laparoscopic and the open groups (354 ± 91 vs. 315 ± 78 min; P = 0.522). The overall postoperative complication rates were 30.0% and 35.3% for the laparoscopic and open groups (P = 0.428), respectively. Postoperative urinary retention was significantly less in the laparoscopic group than in the open group (14.7 vs. 0%; P = 0.036).The duration of postoperative hospital stay was significantly shorter in the laparoscopic group (8.5 ± 3.8 vs. 13.6 ± 6.5 days; P = 0.025). The numbers of harvested lymph nodes and positive resection margin rates showed no significant differences. Pathological LPLN metastases were confirmed in 10 patients (29.4%) in the open group and 11 (36.7%) in the laparoscopic group (P = 0.537). The median follow-up duration was 41.5 months (range 3-98). The laparoscopic and open groups also showed a similar 3-year overall survival rate (88.2% vs. 85.3%; P = 0.577), relapse-free survival rate (73.3% vs. 67.6%; P = 0.889), and local recurrence rate (3.3 vs. 5.9%; P = 0.653). CONCLUSIONS Laparoscopic TME with LPLD is technically feasible and safe in selected patients with LALRC and is associated with similar oncological outcomes as open approach.
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Affiliation(s)
- Bin Yang
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, China
| | - Jing Huang
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, China
| | - Shengning Zhou
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, China
| | - Jianan Tan
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, China
| | - Guangyu Zhong
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, China
| | - Han Gao
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, China
| | - Fanghai Han
- Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, China.
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Robotic Lateral Pelvic Lymph Node Dissection: Description of A Technique. THE JOURNAL OF MINIMALLY INVASIVE SURGERY 2020; 23:103-105. [PMID: 35600055 PMCID: PMC8985642 DOI: 10.7602/jmis.2020.23.2.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/04/2020] [Indexed: 11/10/2022]
Abstract
Different surgical approaches have been reported in the management of lateral pelvic lymph node dissection (LPND) including open, laparoscopic and robotic. Since the introduction of Da Vinci robotic system in the early 2000s. It has been useful for more meticulous dissection of deep and narrow spaces and easier to gain access. In this article we describe our approach using the Da Vinci Xi robotic system in LPND and with a supplementary video.
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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: 3.8] [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.
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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.
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Chen JN, Liu Z, Wang ZJ, Mei SW, Shen HY, Li J, Pei W, Wang Z, Wang XS, Yu J, Liu Q. Selective lateral lymph node dissection after neoadjuvant chemoradiotherapy in rectal cancer. World J Gastroenterol 2020; 26:2877-2888. [PMID: 32550762 PMCID: PMC7284184 DOI: 10.3748/wjg.v26.i21.2877] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/17/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lateral lymph node metastasis is one of the leading causes of local recurrence in patients with advanced mid or low rectal cancer. Neoadjuvant chemoradiotherapy (NCRT) can effectively reduce the postoperative recurrence rate; thus, NCRT with total mesorectal excision (TME) is the most widely accepted standard of care for rectal cancer. The addition of lateral lymph node dissection (LLND) after NCRT remains a controversial topic. AIM To investigate the surgical outcomes of TME plus LLND, and the possible risk factors for lateral lymph node metastasis after NCRT. METHODS This retrospective study reviewed 89 consecutive patients with clinical stage II-III mid or low rectal cancer who underwent TME and LLND from June 2016 to October 2018. In the NCRT group, TME plus LLND was performed in patients with short axis (SA) of the lateral lymph node greater than 5 mm. In the non-NCRT group, TME plus LLND was performed in patients with SA of the lateral lymph node greater than 10 mm. Data regarding patient demographics, clinical workup, surgical procedure, complications, and outcomes were collected. Multivariate logistic regression analysis was performed to evaluate the possible risk factors for lateral lymph node metastasis in NCRT patients. RESULTS LLN metastasis was pathologically confirmed in 35 patients (39.3%): 26 (41.3%) in the NCRT group and 9 (34.6%) in the non-NCRT group. The most common site of metastasis was around the obturator nerve (21/35) followed by the internal iliac artery region (12/35). In the NCRT patients, 46% of patients with SA of LLN greater than 7 mm were positive. The postoperative 30-d mortality rate was 0%. Two (2.2%) patients suffered from lateral local recurrence in the 2-year follow up. Multivariate analysis showed that cT4 stage (odds ratio [OR] = 5.124, 95% confidence interval [CI]: 1.419-18.508; P = 0.013), poor differentiation type (OR = 4.014, 95%CI: 1.038-15.520; P = 0.044), and SA ≥ 7 mm (OR = 7.539, 95%CI: 1.487-38.214; P = 0.015) were statistically significant risk factors associated with LLN metastasis. CONCLUSION NCRT is not sufficient as a stand-alone therapy to eradicate LLN metastasis in lower rectal cancer patients and surgeons should consider performing selective LLND in patients with greater LLN SA diameter, poorer histological differentiation, or advanced T stage. Selective LLND for NCRT patients can have a favorable oncological outcome.
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Affiliation(s)
- Jia-Nan Chen
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Zhi-Jie Wang
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Shi-Wen Mei
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Hai-Yu Shen
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Juan Li
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Wei Pei
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Zheng Wang
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Xi-Shan Wang
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Jun Yu
- Departments of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD 21218, United States
| | - Qian Liu
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
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Wang X, Qiu A, Liu X, Shi Y. Total mesorectal excision plus lateral lymph node dissection vs TME on rectal cancer patients: a meta-analysis. Int J Colorectal Dis 2020; 35:997-1006. [PMID: 32356120 DOI: 10.1007/s00384-020-03610-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Our study is the first meta-analysis to compare total mesorectal excision (TME) plus lateral lymph node dissection (LLND) with TME on rectal cancer patients regarding outcomes including overall survival, disease-free survival, local recurrence, complications, urinary dysfunction, and sexual dysfunction. METHODS PubMed, Embase, and Cochrane library were searched for publications up to October 2019. Two investigators independently screened the studies for eligibility and extracted specific data. Relevant data were analyzed by Review Manager version 5.3. RESULTS Patients in TME + LLND group suffered more complications (OR = 1.48, 95% CI [1.07, 2.03], P = 0.02) compared with TME group; no significant difference was observed in overall survival (HR = 1.11, 95% CI [0.77, 1.61], P = 0.57), disease-free survival (HR = 1.05, 95% CI [0.85, 1.30], P = 0.64), local recurrence (OR = 0.93, 95% CI [0.56, 1.54], P = 0.78), and urinary dysfunction (OR = 1.60, 95% CI [0.66, 3.87], P = 0.3). CONCLUSION TME + LLND may cause more complications compared with TME on rectal cancer patients. However, the definite conclusion still requires more researches.
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Affiliation(s)
- Xingmeng Wang
- The First School of Clinical Medicine, Nanjing Medical University, Nanjing, People's Republic of China.,Department of General Surgery, The First People's Hospital of Yancheng City, Yancheng, People's Republic of China
| | - Aifeng Qiu
- Department of General Surgery, The Third People's Hospital of Yancheng City, Yancheng, People's Republic of China
| | - Xiaobing Liu
- Department of General Surgery, The Third People's Hospital of Yancheng City, Yancheng, People's Republic of China
| | - Yuhua Shi
- Department of General Surgery, The Third People's Hospital of Yancheng City, Yancheng, People's Republic of China.
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41
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Kim MJ, Chang GJ, Lim HK, Song MK, Park SC, Sohn DK, Chang HJ, Kim DY, Park JW, Jeong SY, Oh JH. Oncological Impact of Lateral Lymph Node Dissection After Preoperative Chemoradiotherapy in Patients with Rectal Cancer. Ann Surg Oncol 2020; 27:3525-3533. [PMID: 32385767 DOI: 10.1245/s10434-020-08481-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE To evaluate the efficacy of selective lateral lymph node dissection (LLND) and the effect of preoperative chemoradiotherapy (PCRT) in patients with LLN ≥ 5 mm. METHODS Patients who underwent PCRT for rectal cancer were classified: (A) total mesorectal excision (TME)-only with LLN < 5 mm (2001-2009, n = 474), (B) TME-only with LLN < 5 mm (2011-2016, n = 273), (C) TME-only with LLN ≥ 5 mm (2001-2009, n = 102), and (D) TME-LLND with LLN ≥ 5 mm (2011-2016, n = 69). Subgroup analysis was performed in patients with LLN ≥ 5 mm based on the reduction in LLN size to < 5 mm or not on restaging MRI after PCRT. RESULTS Oncological outcomes did not differ between groups A and B. Group D had lower 3-year local recurrence (LR) (20.13% vs 5.39%, P = 0.0013) and higher relapse-free survival (RFS) (65.83% vs 77.11%, P = 0.0436) than group C, while the 3-year overall survival (OS) was not significantly different between the two groups (87.64% vs 93.53%, P = 0.0670). In patients with reduction of LLN size from ≥ 5 mm to < 5 mm, LLND significantly reduced LR than did TME alone, but there were no significant differences in survival outcomes. In patients without reduction of LLN size to < 5 mm, LLND reduced LR and improved RFS compared with TME alone. CONCLUSIONS Selective LLND reduced LR and improved RFS in patients with LLN ≥ 5 mm. Selective LLND reduced LR in patients with reduction of LLN size from ≥ 5 mm to < 5 mm after PCRT, and improved both LR and RFS in patients without reduction of LLN size to < 5 mm.
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Affiliation(s)
- Min Jung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - George J Chang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Han-Ki Lim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Mi Kyung Song
- Biostatistics Collaboration Unit, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Dae Yong Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea.
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Wong KY, Tan AMN. Short term outcomes of minimally invasive selective lateral pelvic lymph node dissection for low rectal cancer. World J Gastrointest Surg 2020; 12:178-189. [PMID: 32426097 PMCID: PMC7215974 DOI: 10.4240/wjgs.v12.i4.178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/18/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pelvic recurrence after rectal cancer surgery is still a significant problem despite the introduction of total mesorectal excision and chemoradiation treatment (CRT), and one of the most common areas of recurrence is in the lateral pelvic lymph nodes. Hence, there is a possible role for lateral pelvic lymph node dissection (LPND) in rectal cancer.
AIM To evaluate the short-term outcomes of patients who underwent minimally invasive LPND during rectal cancer surgery. Secondary outcomes were to evaluate for any predictive factors to determine lymph node metastases based on pre-operative scans.
METHODS From October 2016 to November 2019, 22 patients with stage II or III rectal cancer underwent minimally invasive rectal cancer surgery and LPND. These patients were all discussed at a multidisciplinary tumor board meeting and most of them received neoadjuvant chemoradiation prior to surgery. All patients had radiologically positive lateral pelvic lymph nodes on the initial staging scans, defined as lymph nodes larger than 7 mm in long axis measurement, or abnormal radiological morphology. LPND was only performed on the involved side.
RESULTS Majority of the patients were male (18/22, 81.8%), with a median age of 65 years (44-81). Eighteen patients completed neoadjuvant CRT pre-operatively. 18 patients (81.8%) had unilateral LPND, with the others receiving bilateral surgery. The median number of lateral pelvic lymph nodes harvested was 10 (3-22) per pelvic side wall. 8 patients (36.4%) had positive metastases identified in the lymph nodes harvested. The median pre-CRT size of these positive lymph nodes was 10mm. Median length of stay was 7.5 d (3-76), and only 2 patients failed initial removal of their urinary catheter. Complication rates were low, with only 1 lymphocele and 1 anastomotic leak. There was only 1 mortality (4.5%). There have been no recurrences so far.
CONCLUSION Chemoradiation is inadequate in completely eradicating lateral wall metastasis and there are still technical limitations in accurately diagnosing metastases in these areas. A pre-CRT lymph node size of ≥ 10 mm is suggestive of metastases. LPND may be performed safely with minimally invasive surgery.
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Affiliation(s)
- Kar Yong Wong
- Colorectal Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Aloysius MN Tan
- Colorectal Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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Tsukamoto S, Fujita S, Ota M, Mizusawa J, Shida D, Kanemitsu Y, Ito M, Shiomi A, Komori K, Ohue M, Akazai Y, Shiozawa M, Yamaguchi T, Bando H, Tsuchida A, Okamura S, Akagi Y, Takiguchi N, Saida Y, Akasu T, Moriya Y. Long-term follow-up of the randomized trial of mesorectal excision with or without lateral lymph node dissection in rectal cancer (JCOG0212). Br J Surg 2020; 107:586-594. [PMID: 32162301 DOI: 10.1002/bjs.11513] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/29/2019] [Accepted: 12/18/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Japan Clinical Oncology Group (JCOG) 0212 (ClinicalTrials.gov NCT00190541) was a non-inferiority phase III trial of patients with clinical stage II-III rectal cancer without lateral pelvic lymph node enlargement. The trial compared mesorectal excision (ME) with ME and lateral lymph node dissection (LLND), with a primary endpoint of recurrence-free survival (RFS). The planned primary analysis at 5 years failed to confirm the non-inferiority of ME alone compared with ME and LLND. The present study aimed to compare ME alone and ME with LLND using long-term follow-up data from JCOG0212. METHODS Patients with clinical stage II-III rectal cancer below the peritoneal reflection and no lateral pelvic lymph node enlargement were included in this study. After surgeons confirmed R0 resection by ME, patients were randomized to receive ME alone or ME with LLND. The primary endpoint was RFS. RESULTS A total of 701 patients from 33 institutions were assigned to ME with LLND (351) or ME alone (350) between June 2003 and August 2010. The 7-year RFS rate was 71.1 per cent for ME with LLND and 70·7 per cent for ME alone (hazard ratio (HR) 1·09, 95 per cent c.i. 0·84 to 1·42; non-inferiority P = 0·064). Subgroup analysis showed improved RFS among patients with clinical stage III disease who underwent ME with LLND compared with ME alone (HR 1·49, 1·02 to 2·17). CONCLUSION Long-term follow-up data did not support the non-inferiority of ME alone compared with ME and LLND. ME with LLND is recommended for patients with clinical stage III disease, whereas LLND could be omitted in those with clinical stage II tumours.
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Affiliation(s)
- S Tsukamoto
- Department of Colorectal Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - S Fujita
- Department of Surgery, Tochigi Cancer Centre, Tochigi, Japan
| | - M Ota
- Department of Surgery, Yokohama City University Medical Centre, Kanagawa, Japan
| | - J Mizusawa
- Japan Clinical Oncology Group Data Centre and Operations Office, National Cancer Centre Hospital, Tokyo Medical University Hospital, Tokyo, Japan
| | - D Shida
- Department of Colorectal Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Y Kanemitsu
- Department of Colorectal Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - M Ito
- Colorectal Surgery Division, National Cancer Centre Hospital East, Chiba, Japan
| | - A Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Centre Hospital, Shizuoka, Japan
| | - K Komori
- Department of Surgery, Aichi Cancer Centre Hospital, Aichi, Japan
| | - M Ohue
- Department of Gastroenterological Surgery, Suita Municipal Hospital, Osaka International Cancer Institute, Japan
| | - Y Akazai
- Department of Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - M Shiozawa
- Department of Surgery, Kanagawa Cancer Centre, Kanagawa, Japan
| | - T Yamaguchi
- Department of Surgery, Kyoto Medical Centre, Kyoto, Japan
| | - H Bando
- Department of Surgery, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | - A Tsuchida
- Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - S Okamura
- Department of Surgery, Suita Municipal Hospital, Osaka, Japan
| | - Y Akagi
- Department of Surgery, Kurume University, Fukuoka, Japan
| | - N Takiguchi
- Department of Gastrointestinal Surgery, Chiba Cancer Centre, Chiba, Japan
| | - Y Saida
- Department of Surgery, Toho University Ohashi Medical Centre, Tokyo, Japan
| | - T Akasu
- Hospital of the Imperial Household, Tokyo, Japan
| | - Y Moriya
- Department of Surgery, Miki Hospital, Iwate, Japan
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Haanappel A, Kroon HM, Schaap DP, Bedrikovetski S, Dudi-Venkata NN, Lee HX, Thomas ML, Liu J, van der Valk MJM, Rutten HJT, Beets GL, Kusters M, Sammour T. Lateral Lymph Node Metastases in Locally Advanced Low Rectal Cancers May Not Be Treated Effectively With Neoadjuvant (Chemo)Radiotherapy Only. Front Oncol 2019; 9:1355. [PMID: 31850231 PMCID: PMC6901685 DOI: 10.3389/fonc.2019.01355] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022] Open
Abstract
Background: In the West, pre-treatment abnormal lateral lymph nodes (LLN+) in patients with a low locally advanced rectal cancer (AJCC Stage III), are treated with neoadjuvant (chemo)radiotherapy (nCRT), without a lateral lymph node dissection (LLND). It has been suggested, however, that LLN+ patients have higher local recurrence (LR) rates than similarly staged patients with abnormal mesorectal lymph nodes only (LLN−), but no comparative data exist. Therefore, we conducted this international multi-center study in the Netherlands and Australia of Stage III rectal cancer patients with either LLN+ or LLN− to compare oncological outcomes from both groups. Materials and Methods: Patients with Stage III low rectal cancer with (LLN+ group) or without (LLN− group) abnormal lateral lymph nodes on pre-treatment MRI were included. Patients underwent nCRT followed by rectal resection surgery with curative intent between 2009 and 2016 with a minimum follow-up of 2-years. No patient had a LLND. Propensity score matching corrected differences in baseline characteristics. Results: Two hundred twenty-three patients could be included: 125 in the LLN+ group and 98 in the LLN− group. Between groups, there were significant differences in cT-stage and in the rate of adjuvant chemotherapy administered. Propensity score matching resulted in 54 patients in each group, with equal baseline characteristics. The 5-year LR rate in the LLN+ group was 11 vs. 2% in the LLN− group (P = 0.06) and disease-free survival (DFS) was 64 vs. 76%, respectively (P = 0.09). Five-year overall survival was similar between groups (73 vs. 80%, respectively; P = 0.90). Conclusions: In Western patients with Stage III low rectal cancer, there is a trend toward worse LR rate and DFS rates in LLN+ patients compared to similarly staged LLN− patients. These results suggest that LLN+ patients may currently not be treated optimally with nCRT alone, and the addition of LLND requires further consideration.
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Affiliation(s)
- Anouck Haanappel
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.,Department of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis P Schaap
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.,Discipline of Surgery, Faculty of Health and Medical Science, School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Nagendra N Dudi-Venkata
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.,Discipline of Surgery, Faculty of Health and Medical Science, School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Hong X Lee
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Michelle L Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jianliang Liu
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands.,GROW, School of Oncology and Developmental Biology, University of Maastricht, Maastricht, Netherlands
| | - Geerard L Beets
- Department of Surgery, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Miranda Kusters
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.,Discipline of Surgery, Faculty of Health and Medical Science, School of Medicine, University of Adelaide, Adelaide, SA, Australia
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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.
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Yang X, Gu C, Hu T, Bi L, Wei M, Deng X, Wang Z, Zhou Z. Is laparoscopic selective lateral lymph node dissection for locally advanced rectal cancer after neoadjuvant chemoradiotherapy safe? ANZ J Surg 2019; 89:E492-E497. [PMID: 31566296 DOI: 10.1111/ans.15449] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/26/2019] [Accepted: 08/18/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND This study aimed to evaluate the technical feasibility, safety and oncological outcomes of laparoscopic total mesorectal excision (TME) with selective lateral lymph node (LLN) dissection (sLLND) in patients with locally advanced rectal cancer (LARC) and clinically suspected swollen LLNs treated with preoperative neoadjuvant chemoradiotherapy (nCRT). METHODS Consecutive patients with LARC and swollen LLNs who underwent laparoscopic TME and sLLND following nCRT between October 2012 and October 2018 were reviewed from the prospectively collected database. Patient demographics, operation safety, perioperative complications and oncological outcomes were analysed. RESULTS A total of 43 patients were identified. All procedures were completed under laparoscopy without conversion to open surgery. The median operation time was 313 min (range 170-570 min). The median blood loss was 80 mL (range 30-450 mL). The median number of LLNs harvested was 11 (range 1-29). LLN metastasis was found in 12 patients (27.9%). Major post-operative complications were found in four patients (9.3%). The median hospital stay was 7 days (range 4-27 days). The median time to tolerance to liquid food was 72 h (range 36-120 h). The post-operative 30-day mortality rate was 0%. Over the median follow-up of 24 months, no lateral pelvic recurrence developed. For the whole group of patients, the 2-year cumulative overall survival and disease-free survival were 90.5% and 78.1%, respectively. CONCLUSION With the advantages of a minimally invasive approach, laparoscopic TME and sLLND following preoperative nCRT in patients with LARC and swollen LLNs is safe and feasible. This procedure provides acceptable perioperative and oncological outcomes.
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Affiliation(s)
- Xuyang Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chaoyang Gu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Hu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Liang Bi
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Mingtian Wei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiangbing Deng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zongguang Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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Ogura A, Konishi T, Beets GL, Cunningham C, Garcia-Aguilar J, Iversen H, Toda S, Lee IK, Lee HX, Uehara K, Lee P, Putter H, van de Velde CJH, Rutten HJT, Tuynman JB, Kusters M. Lateral Nodal Features on Restaging Magnetic Resonance Imaging Associated With Lateral Local Recurrence in Low Rectal Cancer After Neoadjuvant Chemoradiotherapy or Radiotherapy. JAMA Surg 2019; 154:e192172. [PMID: 31268504 DOI: 10.1001/jamasurg.2019.2172] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Previously, it was shown in patients with low rectal cancer that a short-axis (SA) lateral node size of 7 mm or greater on primary magnetic resonance imaging (MRI) resulted in a high lateral local recurrence (LLR) rate after chemoradiotherapy or radiotherapy ([C]RT) with total mesorectal excision (TME) and that this risk was lowered by a lateral lymph node dissection (LLND). The role of restaging MRI after (C)RT with regard to LLR risk and which specific patients might benefit from an LLND is not fully understood. Objective To determine the factors on primary and restaging MRI that are associated with LLR in low rectal cancer after (C)RT and to formulate specific guidelines on which patients might benefit from an LLND. Design, Setting, and Participants In this retrospective, multicenter, pooled cohort study, patients who underwent surgery for cT3 or cT4 low rectal cancer with a curative intent from 12 centers in 7 countries from January 2009 to December 2013 were included. All patients' MRIs were rereviewed according to a standardized protocol, with specific attention to lateral nodal features. The original cohort included 1216 patients. For this study, patients who underwent (C)RT and had a restaging MRI were selected, leaving 741 for analyses across 10 institutions, including 651 who underwent (C)RT with TME and 90 who underwent (C)RT with TME and LLND. Main Outcomes and Measures The main purpose was to identify the factors on primary and restaging MRI associated with LLR after (C)RT with TME. Whether high-risk patients might benefit in terms of LLR reduction from an LLND was also studied. Results Of the 741 included patients, 480 (64.8%) were male, and the mean (SD) age was 60.4 (12.0) years. An SA lateral node size of 7 mm or greater on primary MRI resulted in a 5-year LLR rate of 17.9% after (C)RT with TME. At 3 years, there were no LLRs in 28 patients (29.2%) with lateral nodes that were 4 mm or less on restaging MRI. Nodes that were 7 mm or greater on primary MRI and greater than 4 mm on restaging MRI in the internal iliac compartment resulted in a 5-year LLR rate of 52.3%, significantly higher compared with nodes in the obturator compartment of that size (9.5%; hazard ratio, 5.8; 95% CI, 1.6-21.3; P = .003). Compared with (C)RT with TME alone, treatment with (C)RT with TME and LLND in these unresponsive internal nodes resulted in a significantly lower LLR rate of 8.7% (hazard ratio, 6.2; 95% CI, 1.4-28.5; P = .007). Conclusions and Relevance Restaging MRI is important in clinical decision making in lateral nodal disease. In patients with shrinkage of lateral nodes from an SA node size of 7 mm or greater on primary MRI to an SA node size of 4 mm or less on restaging MRI, which occurs in about 30% of cases, LLND can be avoided. However, persistently enlarged nodes in the internal iliac compartment indicate an extremely high risk of LLR, and an LLND lowered LLR in these cases.
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Affiliation(s)
- Atsushi Ogura
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Konishi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Chris Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Henrik Iversen
- Center for Digestive Diseases, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Shigeo Toda
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - In Kyu Lee
- Department of Surgery, Seoul St Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hong Xiang Lee
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Keisuke Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Peter Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Center (SOuRCe), Sydney Local Health District, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,School of Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, the Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Miranda Kusters
- Department of Surgery, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
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Wang P, Zhou S, Zhou H, Liang J, Zhou Z. Evaluating predictive factors for determining the presence of lateral pelvic node metastasis in rectal cancer patients following neoadjuvant chemoradiotherapy. Colorectal Dis 2019; 21:791-796. [PMID: 30801862 DOI: 10.1111/codi.14595] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 02/07/2019] [Indexed: 12/20/2022]
Abstract
AIM The need or otherwise for lateral pelvic node dissection (LPND) in rectal cancer patients with clinical lateral pelvic node metastasis (LPNM) after neoadjuvant chemoradiotherapy (nCRT) is controversial. This study was designed to explore the predictive factors for pathological LPNM in rectal cancer patients with clinical LPNM after nCRT. METHOD From January 2010 to February 2018, a consecutive series of patients with rectal cancer and clinical LPNM after nCRT who underwent total mesorectal excision and LPND were reviewed. Patient demographics, operative and pathological outcomes were collected and analysed. RESULTS A total of 76 consecutive cases were included in this study: 53 (69.7%) patients underwent unilateral LPND and 23 (30.3%) bilateral LPND. The pathological results showed that LPNM was found in 13 (17.1%) patients. Multivariate logistic regression analysis showed that the post-nCRT lateral pelvic node size ≥ 5 mm (OR = 7.67, 95% CI = 1.45-40.63, P = 0.017) and mucinous/signet-ring adenocarcinoma (OR = 4.60, 95% CI = 1.11-19.08, P = 0.035) were independent risk factors for pathological LPNM. CONCLUSION Post-nCRT lateral pelvic node size ≥ 5 mm and mucinous/signet-ring adenocarcinoma were independent predictive factors of pathological LPNM for rectal cancer patients with clinical LPNM after nCRT, and patients with these characteristics may benefit from LPND.
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Affiliation(s)
- P Wang
- 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
| | - S 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
| | - H 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
| | - J 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
| | - Z 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
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Sapci I, Delaney CP, Liska D, Amarnath S, Kalady MF, Steele SR, Gorgun E. Oncological Outcomes of Patients with Locally Advanced Rectal Cancer and Lateral Pelvic Lymph Node Involvement. J Gastrointest Surg 2019; 23:1454-1460. [PMID: 31012043 DOI: 10.1007/s11605-019-04224-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 03/29/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The optimal management of patients with radiologically positive lateral pelvic lymph nodes in locally advanced rectal cancer remains unclear. We compared local recurrence rates and oncological outcomes of patients with locally advanced cancer with and without lateral pelvic lymph nodes. METHODS Patients who underwent curative surgery for stage III rectal adenocarcinoma between 2009 and 2014 and had a preoperative MRI at our institution as well as preoperative neoadjuvant treatment were included. Patients with positive lateral pelvic lymph nodes (iliac or obturator nodes) on preoperative MRI (LPND +) were compared to patients with no lateral pelvic nodal disease (LPND -). Data were collected from a prospectively maintained institutional database. Differences between the groups were compared in univariate analysis. Log-rank test was used to evaluate overall and disease-free survival between the groups. RESULTS A total of 125 patients met inclusion criteria with a mean age of 56.3 ± 12.2 and 75% were male. Median follow-up was 44 months (IQR 32, 106). Positive LPND was present on preoperative MRI in 43/125 (34.4%) patients who were in the LPND (+) group. Seventeen out of 43 patients had a post-neoadjuvant treatment MRI and 15 patients had a decrease in size of nodes or disappearance of LPND. On univariate analysis, LPND (+) and LPND (-) groups were comparable. Local recurrence rates were higher in the LPND (+) group, although this was not statistically significant (16.3% vs. 6%, p = 0.06). Overall and disease-free survival rates were comparable between the LPND (+) and LPND (-) groups (p = 0.97, p = 0.51). CONCLUSIONS Management of patients with advanced rectal cancer and radiologically positive lateral pelvic lymph nodes is challenging due to high local recurrence rates. Further studies are needed to develop care pathways for the optimal treatment processes.
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Affiliation(s)
- Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Sudha Amarnath
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Matthew F Kalady
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA.
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