Abstract
BackgroundThe impact of lateral lymph node dissection (LLND) in locally advanced lower rectal cancer remains controversial. This study is to compare total mesorectal excision (TME) with or without LLND in lower rectal cancer cases of stage II/III.MethodsThe electronic databases were systematically searched that compared TME with or without LLND among patients with lower rectal cancer in clinical stage II/III. Subgroup analysis was performed considering neoadjuvant chemoradiotherapy (nCRT). The hazard ratios (HR), relative risk (RR), and weighted mean difference (WMD) were pooled.ResultsTwelve studies of 4458 patients of this meta-analysis demonstrate, LLND alone significantly reduced the local recurrence rate of patients who did not receive nCRT (RR 0.71, P = 0.004), while the difference was not significant when combined with nCRT (RR 0.70, P = 0.36). The analysis shows TME with LLND was associated with significantly longer operation time (WMD 90.73 min, P < 0.001), more intraoperative blood loss (WMD 303.20 mL, P < 0.001), and postoperative complications (RR = 1.35, P =0.02). Whereas urinary dysfunction (RR 1.44, P = 0.38), sexual dysfunction (RR 1.41, P = 0.17), and postoperative mortality (RR = 1.52, P = 0.70), were similar between these two groups. Statistically, no significant differences were observed in OS (HR 0.93, P = 0.62), DFS (HR 0.99, P = 0.96), total recurrence (RR 0.98, P = 0.83), lateral recurrence (RR 0.49, P = 0.14), or distal recurrence (RR 0.95, P = 0.78) between these two groups regardless of whether nCRT was performed or not.ConclusionsThe study shows LLND alone decreases the local recurrence without using nCRT irrespective of the survival advantage in locally advanced lower rectal cancer. The benefit of controlling local recurrence by LLND alone makes us reconsider the usage of nCRT with LLND.Trial registrationThe protocol for this meta-analysis was registered prospectively with PROSPERO (CRD42020135575) on 16 May 2019.
Highlights
The impact of lateral lymph node dissection (LLND) in locally advanced lower rectal cancer remains controversial
Studies have shown that preoperative neoadjuvant chemoradiotherapy (nCRT) could not completely eradicate the metastatic Lateral pelvic lymph nodes (LLNs), suggesting nCRT followed by total mesorectal excision (TME) and LLND may be more effective in the management of locally advanced lower rectal cancer [7, 8]
Full manuscripts were available for 11 studies, and the results of one Randomised controlled trial (RCT) were available as a conference proceeding presented on the 2017 ECCO European Cancer Congress [15]
Summary
The impact of lateral lymph node dissection (LLND) in locally advanced lower rectal cancer remains controversial. This study is to compare total mesorectal excision (TME) with or without LLND in lower rectal cancer cases of stage II/III. 14–30% of patients with lower rectal cancer in clinical stage II/III develop pelvic lateral lymph node (LLNs) metastases, which is beyond the surgical field of TME and is associated with an increased incidence of local recurrence and decreased survival [1, 2]. In Japan, lateral lymph node dissection (LLND) has been recommended as the standard treatment for patients with lower rectal cancer in clinical stage II/III since the 1970s [3, 4]. Preoperative nCRT instead of LLND has become the standard regimen for the treatment of locally advanced lower rectal cancer in Western countries [5, 6]. Studies have shown that preoperative nCRT could not completely eradicate the metastatic LLNs, suggesting nCRT followed by TME and LLND may be more effective in the management of locally advanced lower rectal cancer [7, 8]
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