What To Do With Lateral Nodal Disease in Low Locally Advanced Rectal Cancer? A Call for Further Reflection and Research

Kusters, Miranda; Slater, Andrew; Muirhead, R.; Hompes, Roel; Guy, Richard; Jones, Oliver; George, Bruce; Lindsey, Ian; Mortensen, Neil; Cunningham, Chris

doi:10.1097/dcr.0000000000000834

Cited by 86 publications

(84 citation statements)

References 14 publications

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“…One study of 116 patients with ypN+ disease reported lateral pelvic recurrence rates of 35·7 and 87·5 per cent respectively when enlarged LLNs had a short‐axis diameter of 5–9·9 mm and 10 mm or more. Similar data have been reported from the West, with a recent study finding a lateral local recurrence rate of 33·3 per cent at 4 years when LLNs had a short‐axis diameter of 10 mm or above. A recent multi‐institutional international retrospective study from 12 institutions reported that patients with LLNs and a short‐axis diameter of at least 7 mm had a significantly higher risk of lateral local recurrence than patients with LLNs of less than 7 mm.…”

Section: Discussionsupporting

confidence: 85%

“…In contrast, in Western countries, neoadjuvant (C)RT protocols are mostly employed, resulting in local recurrence rates of less than 10 per cent, with minimal indication for LLND. Recently, however, Eastern and Western studies have suggested that (C)RT and TME without LLND may not be sufficient in patients with enlarged LLNs, with a lateral pelvic recurrence rate of 19·5 per cent in patients with LLNs 7 mm or more in size.…”

Section: Introductionmentioning

confidence: 99%

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Prognostic impact of residual lateral lymph node metastasis after neoadjuvant (chemo)radiotherapy in patients with advanced low rectal cancer

et al. 2019

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Background There is a lack of large studies focusing on the prognostic significance of lateral lymph node (LLN) metastasis following LLN dissection (LLND) in rectal cancer. The aim of this study was to evaluate the prognostic impact of LLN metastases on survival of patients with advanced low rectal cancer. Methods Consecutive patients with locally advanced, but not metastatic, extraperitoneal rectal cancer treated with neoadjuvant (chemo)radiotherapy plus total mesorectal excision between 2004 and 2015 were included in the study. LLND was performed when pretreatment imaging documented enlarged LLNs (7 mm or greater in size). Localization of nodal metastases and long‐term outcomes were analysed. Kaplan–Meier analysis was used to compare the survival of patients with ypN0 disease with that of patients with mesorectal ypN+/LLN− status and patients with positive LLNs. The Cox proportional hazards model was used to evaluate predictors of disease‐free survival (DFS) and local recurrence. Results A total of 613 patients were included in the study; LLND was performed in 212 patients (34·6 per cent) and 57 (9·3 per cent) had LLN metastasis. Patients with LLN metastasis had improved DFS and local recurrence cumulative incidence rates compared with patients with mesorectal ypN2+/LLN− disease (DFS: P = 0·014; local recurrence: P = 0·006). Although the DFS rate of patients with LLN metastasis was worse than that of patients with ypN0 disease (P < 0·001), the cumulative incidence of local recurrence was similar (P = 0·491). In multivariable analysis, residual LLN metastasis was not an independent predictor of worse DFS or local recurrence. Conclusion LLN metastasis is not an independent predictor of local recurrence or survival. Survival of patients presenting with LLN metastasis after (chemo)radiotherapy was intermediate between that of patients with ypN0 status and those with mesorectal ypN2 positivity.

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Section: Discussionsupporting

confidence: 85%

Section: Introductionmentioning

confidence: 99%

Prognostic impact of residual lateral lymph node metastasis after neoadjuvant (chemo)radiotherapy in patients with advanced low rectal cancer

et al. 2019

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“…Several Korean centres (that do not perform LLND) have shown increased local recurrence rates in patients with enlarged lateral lymph nodes on preoperative staging treated with neoadjuvant (chemo)radiotherapy and TME, suggesting this may be insufficient for adequate disease control. A recent small UK series suggested similar trends, with a high lateral local recurrence rate in patients with a lymph node short axis larger than 10 mm. In enlarged nodes, the combination of neoadjuvant chemoradiotherapy (CRT) and LLND in a Japanese series resulted in low local recurrence rates and good disease‐free survival, suggesting that lateral nodal disease is a local problem that can be cured.…”

Section: Introductionmentioning

confidence: 94%

Prognostic implications of MRI-detected lateral nodal disease and extramural vascular invasion in rectal cancer

Schaap

Ogura

Maas

et al. 2018

British Journal of Surgery

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“…Chemoradiation therapy without LPLND among patients with lateral compartment lymph nodes[10 mm on short axis risks local failures in 33.3%. 6 However, when followed by selective LPLND for patients with lymph nodes greater than 7-8 mm is associated with a low risk (0.9-3.4%) of lateral compartment failure with an incidence of pathologically confirmed persistent lateral node involvement in more than half the dissected patients. 7,8 Although the jury has not determined whether the decision of dissection may be made after evaluation of the posttreatment response, a selective LPLND strategy has the potential to identify the few patients who may benefit from LPLND and safely avoid it in nearly all other patients.…”

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confidence: 99%

Selective Lateral Pelvic Lymph Dissection for Rectal Cancer

Chang

2017

Ann Surg Oncol

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While the approach to curative treatment of low rectal cancer in the West has included preoperative radiation therapy (RT) followed by total mesorectal excision (TME), in Japan the ''gold standard'' traditionally has been TME with prophylactic dissection of the iliac and obturator lymph nodes without pelvic radiotherapy.1,2 The divergent philosophy in the approach to curative management of pelvic micrometastases was most recently highlighted by the JCOG 0212 trial, which evaluated the noninferiority of TME alone to TME with routine prophylactic lateral pelvic lymph node dissection (LPLND) among patients without clinical evidence of lateral pelvic lymph node metastasis.3 In this study, no patients received radiotherapy and the experimental treatment strategy of TME alone was inferior to the control strategy of TME ? LPLND for local control. JCOG 0212 also demonstrated that lateral pelvic lymph node metastases occurred in 7% of patients who were radiographically nodenegative within the lateral compartment before surgery and that the addition of LPLND resulted in a 5.2% absolute reduction in the rate of local failure. 4 While in the experienced hands of the JCOG 0212 investigators and in Japanese patients, the addition of LPLND had a limited effect on the overall rate of postoperative complications (22% vs. 16% grade 3-4 for TME ? LPLND vs. TME alone, respectively), it did add significantly to the length of operation and to total blood loss. Furthermore, the results of JCOG 0212 would suggest that 93% of patients may have undergone LPLND unnecessarily.In this issue of Annals of Surgical Oncology, Miyake and colleagues report the use of a one-step nucleic acid amplification (OSNA) strategy to aid in the selection of patients at risk for lateral pelvic lymph node metastasis, who are candidates for prophylactic LPLND. The OSNA assay semiquantitatively detects the mRNA of cytokeratin 19 (CK19) and was developed for the purpose of rapidly identifying sentinel lymph node (SLN) metastasis during breast cancer surgery without the need for a pathologist to perform frozen-section evaluation. The strategy of identifying SLN metastases plays a critical role in operative decision making for patients with breast cancer; however, the utility of such a strategy has not been established in colorectal cancer, in part because mesenteric lymphadenectomy is still an obligatory part of colorectal cancer resection and adds no significant morbidity to the primary bowel resection. However, the addition of LPLND is not an obligatory procedure and itself is associated with increased operative time, blood loss, and potential for morbidity. Thus, there is a significant appeal to identify an easily performed, rapid intraoperative assessment to guide decision-making.While the OSNA assay may lack specificity, in this study it was highly sensitive with a high negative predictive value, even after preoperative chemotherapy. An OSNA-guided strategy could have avoided the need for prophylactic LPLND in 18 of 25 (72%) patients, and all 4 (16%) of the ...

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What To Do With Lateral Nodal Disease in Low Locally Advanced Rectal Cancer? A Call for Further Reflection and Research

Cited by 86 publications

References 14 publications

Prognostic impact of residual lateral lymph node metastasis after neoadjuvant (chemo)radiotherapy in patients with advanced low rectal cancer

Prognostic impact of residual lateral lymph node metastasis after neoadjuvant (chemo)radiotherapy in patients with advanced low rectal cancer

Prognostic implications of MRI-detected lateral nodal disease and extramural vascular invasion in rectal cancer

Selective Lateral Pelvic Lymph Dissection for Rectal Cancer

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