Possibilities for and limits of upfront surgical strategy with lateral pelvic node dissection for low rectal cancer

Abstract

Background Metastatic lateral pelvic nodes represent an important cause of pelvic recurrence in low rectal cancer patients even after preoperative chemoradiotherapy. This study aimed to evaluate the prognostic benefit of an upfront lateral pelvic nodes dissection strategy. Methods A total of 175 consecutive patients with stage II/III low rectal adenocarcinoma who underwent mesorectal excision with lateral pelvic nodes dissection between 1998 and 2013 were identified. Regional lateral pelvic nodes were categorized as LD2 nodes (internal iliac, hypogastric and obturator) and LD3 nodes (external iliac, common iliac, lateral sacral, presacral and sacral promontory) according to the current Japanese Society for Cancer of the Colon and Rectum classification. Results Five-year cumulative risks of local recurrence and recurrence-free survival were 4.8% and 78.1% for stage II patients, and 11.8% and 61.7% for stage III patients, respectively. Among stage III patients, no differences were observed in cumulative risks of local recurrence (5 years: 9.3% vs 14.7%, P= 0.463) and recurrence-free survival (5 years: 65.1 vs 61.2%, P = 0.890) between lateral pelvic nodes (−) and LD2 (+) patients. In multivariate analyses, metastatic lateral pelvic nodes had no impact on cumulative risks of local recurrence (hazard ratioadj: 1.389; 95% confidence interval: 0.409–4.716) and recurrence-free survival (hazard ratioadj: 0.884; 95% confidence interval: 0.425–1.837). Conclusions Metastatic lateral pelvic nodes had no impact on cumulative risks of local recurrence and recurrence-free survival based on an upfront lateral pelvic nodes strategy. Lateral pelvic nodes can improve recurrence and survival outcomes in locally advanced low rectal cancer patients with metastatic lateral pelvic nodes.

Correlation of Presacral Tumour Recurrence with Tumour Metastasis and Long-Term Tumour Recurrence Risk in Patients with Rectal Cancer

“…Especially, local recurrence will involve soft tissue and bony structure in front of the sacrum backward, which is presacral tumour recurrence. The proportion of patients with presacral tumour recurrence accounts for 15.63%–41.67% of patients with local recurrence after surgery, and the recurrence rate of presacral tumour after surgery is 2.8%–4.8% [ 11 , 12 ]. Patients with presacral tumour recurrence will not only suffer unbearable pain due to the influence on bone structure but also face higher treatment difficulty, which seriously compromise their quality of life [ 13 ].…”

Oncological outcome after lateral pelvic lymphadenectomy for low rectal carcinoma: not only an N‐status matter

“…Ouchi and colleagues evaluated the prognostic benefit of an upfront lateral pelvic dissection strategy for low rectal cancer; in multivariate analyses microscopic residual tumours were correlated with local recurrences and survival whereas metastatic LPLNs had no impact on cumulative risk of local recurrence and recurrence free‐survival and overall survival. These results suggest that LPLD can improve recurrence and survival outcome in low rectal cancer patients with metastatic LPLNs and additional treatment including preoperative chemo‐radiotherapy can improve the risk of central pelvis recurrence due to microscopic residual tumour 18 . Yagi et al .…”

“…These results suggest that LPLD can improve recurrence and survival outcome in low rectal cancer patients with metastatic LPLNs and additional treatment including preoperative chemo-radiotherapy can improve the risk of central pelvis recurrence due to microscopic residual tumour. 18 Yagi et al were the first to highlight the clinical significance of extramesorectal TDs, that is, TDs in the lateral pelvic area. Among 172 patients with stage II or III rectal cancer, Yagi et al identified LPLN metastasis in 32 patients and lateral pelvic TDs in 14 patients.…”

“…9,[13][14][15][16] and there is a limitation in the prediction of metastatic LPLNs based only on their diameter in preoperative imaging. 17,18 A combination of the short LPLN axis, tumour location, extramural vascular invasion (EMVI) and short perirectal lymph node (LN) axis has been identified to be optimal for predicting potential LPLN metastasis. A well-validated nomogram using these factors has been developed.…”