Magnetic Resonance Imaging Directed Surgical Decision Making for Lateral Pelvic Lymph Node Dissection in Rectal Cancer After Total Neoadjuvant Therapy (TNT)

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.

[1]  G. Beets,et al.  Malignant Features in Pretreatment Metastatic Lateral Lymph Nodes in Locally Advanced Low Rectal Cancer Predict Distant Metastases , 2021, Annals of Surgical Oncology.

[2]  J. Lee,et al.  Surgical Outcomes in Cancer Patients Undergoing Elective Surgery After Recovering from Mild-to-Moderate SARS-CoV-2 Infection , 2021, Annals of Surgical Oncology.

[3]  C. V. D. van de Velde,et al.  Local recurrences in western low rectal cancer patients treated with or without lateral lymph node dissection after neoadjuvant (chemo)radiotherapy: An international multi-centre comparative study. , 2021, European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology.

[4]  H. Putter,et al.  Rectal cancer lateral lymph nodes: multicentre study of the impact of obturator and internal iliac nodes on oncological outcomes. , 2021, The British journal of surgery.

[5]  H. Putter,et al.  Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial. , 2020, The Lancet. Oncology.

[6]  E. Holliday,et al.  Robotic lateral pelvic lymph node dissection after chemoradiation for rectal cancer: a Western perspective , 2020, Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland.

[7]  K. Oba,et al.  Radiomics Approach Outperforms Diameter Criteria for Predicting Pathological Lateral Lymph Node Metastasis After Neoadjuvant (Chemo)Radiotherapy in Advanced Low Rectal Cancer , 2020, Annals of Surgical Oncology.

[8]  J. Meyerhardt,et al.  NCCN Guidelines Insights: Rectal Cancer, Version 6.2020. , 2020, Journal of the National Comprehensive Cancer Network : JNCCN.

[9]  G. Chang,et al.  The Landmark Series: Management of Lateral Lymph Nodes in Locally Advanced Rectal Cancer , 2020, Annals of Surgical Oncology.

[10]  Min Jung Kim,et al.  Oncological Impact of Lateral Lymph Node Dissection After Preoperative Chemoradiotherapy in Patients with Rectal Cancer , 2020, Annals of Surgical Oncology.

[11]  E. Holliday,et al.  Pathologic Response and Postoperative Complications After Short-course Radiation Therapy and Chemotherapy for Patients With Rectal Adenocarcinoma. , 2020, Clinical colorectal cancer.

[12]  G. Beets,et al.  Lateral Lymph Node Metastases in Locally Advanced Low Rectal Cancers May Not Be Treated Effectively With Neoadjuvant (Chemo)Radiotherapy Only , 2019, Front. Oncol..

[13]  E. Holliday,et al.  Who Should Get Lateral Pelvic Lymph Node Dissection After Neoadjuvant Chemoradiation? , 2019, Diseases of the colon and rectum.

[14]  H. Putter,et al.  Lateral Nodal Features on Restaging Magnetic Resonance Imaging Associated With Lateral Local Recurrence in Low Rectal Cancer After Neoadjuvant Chemoradiotherapy or Radiotherapy. , 2019, JAMA surgery.

[15]  G. Chang,et al.  Randomized clinical trial of accelerated enhanced recovery after minimally invasive colorectal cancer surgery (RecoverMI trial) , 2019, The British journal of surgery.

[16]  Masahiro Yoshida,et al.  Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer , 2019, International Journal of Clinical Oncology.

[17]  Hein Putter,et al.  Neoadjuvant (Chemo)radiotherapy With Total Mesorectal Excision Only Is Not Sufficient to Prevent Lateral Local Recurrence in Enlarged Nodes: Results of the Multicenter Lateral Node Study of Patients With Low cT3/4 Rectal Cancer. , 2019, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[18]  G. Chang,et al.  Robotic Lateral Pelvic Lymph Node Dissection after Neoadjuvant Chemoradiation: View from the West. , 2018, Diseases of the colon and rectum.

[19]  G. Chang,et al.  Lateral pelvic lymph node dissection and radiation treatment for rectal cancer: Mutually exclusive or mutually beneficial? , 2018, Annals of gastroenterological surgery.

[20]  M. Gonen,et al.  Adoption of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer , 2018, JAMA oncology.

[21]  Eun Sun Lee,et al.  Prediction of lateral pelvic lymph node metastasis in patients with locally advanced rectal cancer with preoperative chemoradiotherapy: Focus on MR imaging findings , 2018, PloS one.

[22]  Stuart A. Taylor,et al.  Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting , 2017, European Radiology.

[23]  G. Choi,et al.  Optimal treatment strategies for clinically suspicious lateral pelvic lymph node metastasis in rectal cancer , 2017, Oncotarget.

[24]  G. Chang,et al.  Treatment of rectal cancer in the East and West: Should it be different? , 2017, Surgery.

[25]  Masaaki Ito,et al.  Mesorectal Excision With or Without Lateral Lymph Node Dissection for Clinical Stage II/III Lower Rectal Cancer (JCOG0212): A Multicenter, Randomized Controlled, Noninferiority Trial , 2017, Annals of surgery.

[26]  G. Chang,et al.  Lateral Node Dissection in Low Rectal Cancer: Time for a Global Approach? , 2017, Annals of surgery.

[27]  R. Muirhead,et al.  What To Do With Lateral Nodal Disease in Low Locally Advanced Rectal Cancer? A Call for Further Reflection and Research , 2017, Diseases of the colon and rectum.

[28]  T. Morikawa,et al.  Oncological Outcomes of Lateral Pelvic Lymph Node Metastasis in Rectal Cancer Treated With Preoperative Chemoradiotherapy , 2017, Diseases of the colon and rectum.

[29]  Yasushi Ichikawa,et al.  Prediction of Lateral Pelvic Lymph-Node Metastasis in Low Rectal Cancer by Magnetic Resonance Imaging , 2016, World Journal of Surgery.

[30]  J. Guillem,et al.  Organ Preservation in Rectal Adenocarcinoma: a phase II randomized controlled trial evaluating 3-year disease-free survival in patients with locally advanced rectal cancer treated with chemoradiation plus induction or consolidation chemotherapy, and total mesorectal excision or nonoperative manageme , 2015, BMC Cancer.

[31]  Daniel J Sargent,et al.  Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial. , 2015, JAMA.

[32]  Tae Hyun Kim,et al.  Can chemoradiation allow for omission of lateral pelvic node dissection for locally advanced rectal cancer? , 2015, Journal of surgical oncology.

[33]  J. Park,et al.  Neoadjuvant Chemoradiotherapy Affects the Indications for Lateral Pelvic Node Dissection in Mid/Low Rectal Cancer with Clinically Suspected Lateral Node Involvement: A Multicenter Retrospective Cohort Study , 2014, Annals of Surgical Oncology.

[34]  Gina Brown,et al.  Preoperative magnetic resonance imaging assessment of circumferential resection margin predicts disease-free survival and local recurrence: 5-year follow-up results of the MERCURY study. , 2014, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[35]  Daniel Chu,et al.  Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes , 2013, The British journal of surgery.

[36]  T. Muto,et al.  Selective Lateral Pelvic Lymph Node Dissection in Patients with Advanced Low Rectal Cancer Treated with Preoperative Chemoradiotherapy Based on Pretreatment Imaging , 2013, Annals of Surgical Oncology.

[37]  M. Ohue,et al.  Postoperative morbidity and mortality after mesorectal excision with and without lateral lymph node dissection for clinical stage II or stage III lower rectal cancer (JCOG0212): results from a multicentre, randomised controlled, non-inferiority trial. , 2012, The Lancet. Oncology.

[38]  Sunil Krishnan,et al.  Neoadjuvant treatment response as an early response indicator for patients with rectal cancer. , 2012, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[39]  Harmeet Kaur,et al.  MR imaging for preoperative evaluation of primary rectal cancer: practical considerations. , 2012, Radiographics : a review publication of the Radiological Society of North America, Inc.

[40]  Karin Haustermans,et al.  Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. , 2010, The Lancet. Oncology.

[41]  L. Påhlman,et al.  Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. , 2017, Annals of oncology : official journal of the European Society for Medical Oncology.

[42]  C. Compton,et al.  The American Joint Committee on Cancer: the 7th Edition of the AJCC Cancer Staging Manual and the Future of TNM , 2010, Annals of Surgical Oncology.

[43]  P. Tekkis,et al.  Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis. , 2009, The Lancet. Oncology.

[44]  J. Monson,et al.  Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial , 2009, The Lancet.

[45]  H. Putter,et al.  A Comparison Between the Treatment of Low Rectal Cancer in Japan and the Netherlands, Focusing on the Patterns of Local Recurrence , 2009, Annals of surgery.

[46]  Phil Quirke,et al.  What is the role for the circumferential margin in the modern treatment of rectal cancer? , 2008, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[47]  H. Yano,et al.  The incidence of lateral pelvic side‐wall nodal involvement in low rectal cancer may be similar in Japan and the West , 2007, The British journal of surgery.

[48]  N. Demartines,et al.  Classification of Surgical Complications: A New Proposal With Evaluation in a Cohort of 6336 Patients and Results of a Survey , 2004, Annals of Surgery.

[49]  H. Johansson,et al.  The Stockholm II trial on preoperative radiotherapy in rectal carcinoma: long-term follow-up of a population-based study , 2002 .

[50]  P. Quirke,et al.  LOCAL RECURRENCE OF RECTAL ADENOCARCINOMA DUE TO INADEQUATE SURGICAL RESECTION Histopathological Study of Lateral Tumour Spread and Surgical Excision , 1986, The Lancet.