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

BACKGROUND: There remains a lack of international consensus on the appropriate management of lateral nodal disease. Although the East manages this more aggressively with lateral lymph node dissections, the West aims to eradicate small-volume disease with neoadjuvant chemoradiotherapy and lateral nodal disease is not considered for routine surgical treatment. However, recent studies have shown that, despite neoadjuvant treatment, a significant number of patients with lateral nodal disease develop local recurrence in the lateral compartment after total mesorectal excision. OBJECTIVE: The aim of this study is to assess the role of the pretreatment features of lateral nodes on MRI in regard to local recurrence. DESIGN: All patients operated on for low locally advanced rectal cancer over a 5-year period were evaluated retrospectively. SETTINGS: This study was conducted at a single expert center. PATIENTS: The MRIs of a total of 313 patients were reviewed, and only those with rectal cancers up to 8 cm from the anorectal junction, measured on MRI, were selected. This left 185 patients; of these, 58 patients had clinical T1 or T2 tumors as assessed on MRI, identifying 127 patients who had cT3/T4 tumors that were included in this study. MAIN OUTCOME MEASURES: The primary outcomes measured were lateral local recurrence and multivariate analyses. RESULTS: The lateral local recurrence rate was significantly higher (33.3% 4-year rate) in patients with nodes larger than 10 mm than in patients with smaller nodes (10.1%, p = 0.03), despite patients being irradiated in the lateral compartment. LIMITATIONS: Because this is a relatively uncommon disease, patient numbers are low, and a multicenter study is needed to further address lateral nodal disease in low rectal cancer. CONCLUSIONS: Chemoradiotherapy with total mesorectal excision might not be sufficient in a selected group of patients. Further research is needed about which pretreatment features of the lateral nodes predict local recurrence and what is needed to prevent these from developing. See Video Abstract at http://links.lww.com/DCR/A338.

[1]  M. Kusters,et al.  The treatment of all MRI‐defined low rectal cancers in a single expert centre over a 5‐year period: is there room for improvement? , 2016, Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland.

[2]  Y. Akagi,et al.  A randomized trial comparing mesorectal excision with or without lateral lymph node dissection for clinical stage II, III lower rectal cancer: Primary endpoint analysis of Japan Clinical Oncology Group study JCOG0212. , 2016 .

[3]  M. Kusters,et al.  Local Recurrence in the Lateral Lymph Node Compartment: Improved Outcomes with Induction Chemotherapy Combined with Multimodality Treatment , 2016, Annals of Surgical Oncology.

[4]  R. Muirhead,et al.  Rectal Radiotherapy--Intensity-modulated Radiotherapy Delivery, Delineation and Doses. , 2016, Clinical oncology (Royal College of Radiologists (Great Britain)).

[5]  L. Påhlman,et al.  Time trends, improvements and national auditing of rectal cancer management over an 18‐year period , 2015, Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland.

[6]  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.

[7]  Tae Gyu Kim,et al.  Factors associated with lateral pelvic recurrence after curative resection following neoadjuvant chemoradiotherapy in rectal cancer patients , 2014, International Journal of Colorectal Disease.

[8]  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.

[9]  E. Huang.  Randomized phase III study comparing preoperative radiotherapy with chemoradiotherapy in nonresectable rectal cancer , 2009 .

[10]  Sung Ho Moon,et al.  Lateral Lymph Node Metastasis Is a Major Cause of Locoregional Recurrence in Rectal Cancer Treated with Preoperative Chemoradiotherapy and Curative Resection , 2007, Annals of Surgical Oncology.

[11]  A. Norman,et al.  Neoadjuvant capecitabine and oxaliplatin followed by synchronous chemoradiation and total mesorectal excision in magnetic resonance imaging-defined poor-risk rectal cancer. , 2006, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[12]  K. Sugihara,et al.  Nerve-sparing surgery with lateral node dissection for advanced lower rectal cancer. , 1995, European journal of cancer.

[13]  K. Hojo,et al.  Postoperative follow-up studies on cancer of the colon and rectum. , 1982, American journal of surgery.

[14]  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.