Inferior Mesenteric Artery Lymph Node Research Articles

Safety and efficacy of indocyanine green fluorescence imaging-guided laparoscopic para-aortic lymphadenectomy for left-sided colorectal cancer:A preliminary case-matched study

This study is aimed to explore the safety and feasibility of indocyanine green (ICG) fluorescence imaging guidance in laparoscopic para-aortic lymph node (PALN) dissection for left-sided colorectal cancer (CRC) patients with clinically suspected PALN metastasis. A total of 151 patients who underwent primary tumor resection and laparoscopic PALN dissection for left-sided CRC were included, with 20 patients in the ICG group and 131 patients in the non-ICG group. The surgical outcomes, postoperative complications, and pathological results, such as the number of harvested and metastatic lymph nodes were compared between groups after propensity score matching. Following propensity score matching, the ICG group had 20 patients, and the non-ICG group had 53 patients, and the two groups were similar in baseline characteristics. No significant differences were observed in overall intraoperative and postoperative complications between groups, except for chylous leakage, where the ICG group had a longer time to a normal diet. The number of harvested pericolic/perirectal and intermediate lymph nodes were comparable between the two groups, while the ICG group had a significantly higher number of total harvested lymph nodes (39 [14-78] vs. 29 [11-70], P=0.001), inferior mesenteric artery lymph nodes (IMALN, 6 [0-17] vs. 3 [0-11], P=0.006), and PALNs (9 [3-29] vs. 5 [1-37], P=0.001). ICG fluorescence imaging could increase the retrieval of IMALN, PALN, and total lymph nodes, and potentially improve the completeness of laparoscopic PALN dissection in patients with left-sided CRC.

Development and validation of artificial intelligence models for preoperative prediction of inferior mesenteric artery lymph nodes metastasis in left colon and rectal cancer

BackgroundDissection of lymph nodes at the roots of the inferior mesenteric artery (IMAN) should be offered only to selected patients at a major risk of developing IMAN involvement. The aim of this study is to present the first artificial intelligence (AI) models to predict IMAN metastasis risk in the left colon and rectal cancer patients. MethodsA total of 2891 patients with descending colon including splenic flexure, sigmoid colon and rectal cancer undergoing major primary surgery and IMAN dissection were included as a study cohort, which was then split into a training set (67%) and a testing set (33%). Feature selection was conducted using the least absolute shrinkage and selection operator (LASSO) regression model. Seven AI algorithms, namely Support Vector Machine (SVM), Logistic Regression (LR), Extreme Gradient Boosting (XGB), Light Gradient Boosting (LGB), Decision Tree Classifier (DTC), Random Forest (RF) classifier, and Multilayer Perceptron (MLP), as well as traditional multivariate LR model were employed to construct predictive models. The optimal hyperparameters were determined with 5 fold cross-validation. The predictive performance of models and the expert surgeon was assessed and compared in the testing set independently. ResultsThe IMAN involvement incidence was 4.6%. The optimal set of features selected by LASSO included 10 characteristics: neoadjuvant treatment, age, synchronous liver metastasis, synchronous lung metastasis, signet ring adenocarcinoma, neural invasion, lymphovascular invasion, CA199, endoscopic obstruction, T stage evaluated by MRI. The most accurate model derived from MLP showed excellent prediction power with area under the receiver operating characteristic curve (AUROC) of 0.873 and produced 81.0% recognition sensitivity and 82.5% specificity in the testing set independently. In contrast, the judgment of IMAN metastasis by expert surgeon yield rather imprecise and unreliable results with a significantly lower AUROC of 0.509. Additionally, the proposed MLP had the highest net benefits and the largest reduction of unnecessary IMAN dissection without the cost of additional involved IMAN missed. ConclusionMLP model was able to maintain its prediction accuracy in the testing set better than other models and expert surgeons. Our MLP model could be used to help identify IMA nodal metastasis and to select candidates for individual IMAN dissection.

Preoperative carbon nanoparticle injection improves inferior mesenteric artery lymph node retrieval in patients with rectal cancer

BackgroundInferior mesenteric artery lymph node (station 253 node) metastasis occurs in approximately 0.3% to 13.9% of rectal cancer patients. This study examined whether carbon nanoparticles could aid in harvesting more station 253 nodes and evaluated the relationship between the number of station 253 nodes retrieved and station 253 node metastasis. MethodA total of 480 consecutive rectal cancer patients were enrolled in this prospective cohort study between August 2014 and October 2018. Ninety-one patients (18.96%) received a preoperative submucosal injection of carbon nanoparticles (CN+ group), and 389 patients did not receive an injection (CN- group). The number of lymph node retrievals was analyzed, and the relevant risk factors for station 253 node metastasis were identified using univariate and multivariate analyses. ResultsThe mean number of station 251, 252, and 253 lymph nodes and total lymph nodes retrieved in the CN+ group were higher than that retrieved in the CN- group. The percentage of patients with ≥4 station 253 nodes retrieved (54.0% vs 28.3%, P = .004) were higher in the CN+ group than in the CN- group. Retrieval of ≥4 station 253 nodes was an independent risk factor for station 253 node metastasis (OR: 2.40, 95% CI: 1.22–4.74, P = .012). ConclusionThe preoperative submucosal injection of carbon nanoparticles was helpful for increasing the number of station 253 nodes harvested, and a minimum of 4 examined station 253 nodes was necessary for standard D3 lymph node dissection in rectal cancer.

Impact of Inferior Mesenteric Artery Lymph Node Metastasis on the Prognosis of Left-sided Colorectal Cancer.

This study aimed to investigate the impact of the inferior mesenteric artery (IMA) lymph node metastasis [IMALN (+)] on prognosis in left-sided colorectal cancer (LCRC). A total of 285 patients with stage III LCRC and 118 patients with stage IV LCRC who underwent resection of primary tumor between 2005 and 2016 were included. IMALN (+) patients (n=10) had worse overall survival (OS) than patients without IMA lymph node metastasis [IMALN (-); n=275] in stage III LCRC (p=0.007). Multivariate analysis revealed that IMALN (+) was a prognostic factor in stage III LCRC (OS, HR=3.09, p=0.043). Conversely, there was no difference between the OS of IMALN (+) and stage IV LCRC with distant lymph node metastasis only [stage IV LCRC (LYM); n=21; p=0.434]. The prognosis of IMALN (+) was worse than that of IMALN (-); it was similar to that of stage IV LCRC (LYM).

Prognostic value of apical lymph node metastasis at the inferior mesenteric artery in sigmoid and rectal cancer patients who undergo laparoscopic surgery.

Evidence supporting the importance of apical lymph nodes (LNs) and the potential long-term impact of LN metastases at the inferior mesenteric artery (IMA) lymphectomy remains limited. This study aimed to evaluate the prognostic value of LNs at the IMA (IMA-LN) in sigmoid and rectal cancer patients undergoing laparoscopic surgery. We retrospectively evaluated 265 consecutive patients who underwent laparoscopic sigmoid or rectal cancer surgery between August 2016 and May 2020. They were divided into two groups according to the pathological results of the IMA LNs: IMA-LN negative (n = 248) and IMA-LN positive (n = 17). The IMA-LN negative group had significantly better overall survival (OS) (p = .020) and disease-free survival (DFS) (p = .000) than did the IMA-LN positive group. IMA-LN metastasis was associated with worse OS and DFS regardless of the pN stage. Patients with IMA-LN metastasis had a higher risk of postoperative recurrence, especially liver (p = .000) and lung (p = .025) metastasis, than did those without metastasis. However, there was no significant difference in the local recurrence rate between the two groups. IMA-LN metastasis is an independent risk factor for poor prognosis in sigmoid and rectal cancer. Dissecting and evaluating IMA-LN separately is a more accurate and practical method for predicting prognosis.

Operative safety and oncologic outcomes in rectal cancer based on the level of inferior mesenteric artery ligation: a stratified analysis of a large Korean cohort

PurposeTo compare high and low inferior mesenteric artery (IMA) ligation in a large number of patients, and investigate the short-term and long-term outcomes.MethodsThis retrospective study compared outcomes between high IMA ligation and low IMA ligation with dissection of lymph nodes (LNs) around the IMA origin. A total of 1,213 patients underwent elective low anterior resection with double-stapling anastomosis for stage I–III rectal cancer located ≥6 cm from the anal verge (835 patients underwent IMA ligation at the IMA origin; 378 patients underwent IMA ligation directly distal to the root of the left colic artery along with dissection of LNs around the IMA origin).ResultsThere was no difference in anastomotic leakage rate between groups. The 2 groups did not significantly differ in intraoperative blood loss, perioperative complications, total number of harvested LNs, and metastatic IMA LNs. However, more metastatic LNs were harvested in the high-tie than in the low-tie group (1.3 ± 2.9 vs. 0.8 ± 1.9, P = 0.002), and the incidence of positive pathologic nodal status was higher in the high-tie group (37.9% vs. 28.6%, P = 0.001). The 5-year local recurrence-free and metastasis-free survival rates were similar between groups, as were the 5-year overall and cancer-specific survival rates.ConclusionLow IMA ligation with dissection of LNs around the IMA origin showed no differences in anastomotic leakage rate compared with high IMA ligation, without affecting oncologic outcomes. High IMA ligation did not seem to increase the number of total harvested LNs, whereas the ratio of metastatic apical LNs were similar between groups.

Prognostic value of inferior mesenteric artery lymph node metastasis in cancer of the descending colon, sigmoid colon and rectum.

This study aimed to analyse the potential significance of metastasis to the inferior mesenteric artery lymph node (IMA-LN) in patients with malignancy of the left colon and rectum. A retrospective analysis of a cohort of 890 patients collected prospectively who underwent radical resection of a primary tumour of the descending colon, sigmoid colon and rectum in our department from 1 January 2009 to 31 December 2015 was performed. Patients were divided into an IMA-LN metastasis (IMA-LN (+)) group (n=51) and a non IMA-LN metastasis (IMA-LN (-)) group (n=839). A total of 801 patients were followed by a designated member of the study staff. Clinical features, pathological characteristics, recurrence patterns and survival rates were compared between the two groups. In the IMA-LN (+) group, the risk ratio of overall recurrence and tumour related death was 7.786 (95% CI 4.142-14.637) and 7.756 (95% CI 4.142-14.525) respectively. Significant differences were found in overall survival (log-rank: χ2 =69.06, P<0.0001) and disease-free survival (log-rank: χ2 =69.06, P<0.0001) between the two groups. Furthermore, there were significant differences in overall survival (log-rank: χ2 =18.47, P<0.0001) and disease-free survival (log-rank: χ2 =16.99, P<0.0001) between the IMA-LN (-) and IMA-LN (+) subgroups of patients with Stage N2 disease. Multivariate survival analysis indicated that IMA-LN (+) was an independent risk factor of poor prognosis. There was no difference in the prognosis between high tie and low tie with IMA-LN dissection. Inferior mesenteric artery lymph node metastasis was an independent predictive factor for high systemic recurrence. Low ligation of the IMA with IMA-LN dissection was not inferior to high ligation.

Inferior Mesenteric Artery Lymph Node Metastasis Is an Independent Prognostic Factor for Stage III Sigmoid Colon and Rectal Cancer

It is unclear whether the number or distribution of lymph node metastases can provide a more accurate prognosis. The aim of this study was to evaluate the prognostic impact of inferior mesenteric artery (IMA) lymph node metastasis (LNM) in sigmoid colon and rectal cancer. We included 188 patients who underwent curative resection for stage III sigmoid colon and rectal cancer between January 2001 and December 2012. Patients were divided into 2 groups based on the presence of IMA-LNM (LNM-positive versus LNM-negative group). Clinicopathologic characteristics, 3-year recurrence-free survival and 5-year overall survival rates, and recurrence patterns were compared between the 2 groups. Of 188 patients, 9 patients (4.79%) were in the LNM-positive group. After curative resection, 3-year recurrence-free survival and 5-year overall survival rates were significantly lower in the LNM-positive group compared to the LNM-negative group (44.44% versus 69.98%, P = 0.016 for 3-year recurrence-free survival and 48.61% versus 81.73%, P = 0.018 for 5-year overall survival). Multivariate analysis revealed that the presence of IMA-LNM (P = 0.04), not the number of LNMs (P = 0.153), was an independent prognostic factor for recurrence-free survival. The para-aortic LNM rate was significantly higher in the LNM-positive group (P = 0.0078). IMA-LNM is an independent predictor of survival for stage III sigmoid colon and rectal cancer patients. Evaluation of IMA-LNM enables accurate estimation of patient prognosis and enhances appropriate postoperative therapy.

Inferior mesenteric artery lymph node metastasis in rectal cancer treated with neoadjuvant chemoradiotherapy: Incidence, prediction and prognostic impact

AimTo assess the effect of neoadjuvant chemoradiotherapy (nCRT) on inferior mesenteric artery (IMA) nodal metastasis and identify predictors for IMA nodal metastasis in locally advanced rectal cancer (LARC) after nCRT. MethodPropensity score matching of 1167 patients with LARC was performed. Clinicopathological predictors and survival rates were analyzed using univariate and multivariate analyses. ResultsCompared to surgery alone, nCRT reduced the incidence of IMA nodal metastasis (before matching, 4.8% vs 9.1%, p = 0.004; after matching, 4.3% vs 10.1%, p = 0.002). Logistic regression analysis revealed that poorly differentiated (OR = 5.955, p < 0.001), tumors located above the peritoneal reflection (OR = 3.513, p = 0.005), and preoperative CEA levels ≧10 ng/ml (OR = 4.774, p = 0.005) were associated with IMA nodal metastasis. Time intervals to surgery ≧6 weeks were associated with fewer IMA nodal metastasis (OR = 0.274, p = 0.009).Over a median 40-month follow-up, the 3-year overall survival and disease-free survival rates were 63.0% and 43.1% in IMA-positive patients, respectively, which were significantly lower than the corresponding 89.0% and 82.4% rates in IMA-negative patients. Cox regression analysis revealed that IMA nodal metastasis was independently associated with unfavorable 3-year DFS. ConclusionnCRT reduced the incidence of IMA node metastasis. Tumors located above the peritoneal reflection, poorly differentiated, and higher preoperative CEA levels were associated with IMA nodal metastasis after nCRT. IMA lymph node dissection is beneficial to certain patients with IMA nodal metastases, and the oncologic benefit may be improved if IMA nodal metastasis can be predicted.

AB045. Extended lymphadenectomy versus non-extended lymphadenectomy in radical cystectomy for bladder cancer: a meta-analysis

ObjectiveBladder cancer (BCa) is the most common tumor of male urinary reproductive system. Radical cystectomy (RC) with pelvic lymph node dissection (PLND) is the standard treatment for muscle invasive and high-risk non-muscle invasive bladder cancer. But the 5-year overall survival is only about 50%, the majority of the death causes are the tumor local recurrence and metastasis. Local residual micro-lesions and lymph node metastasis are the most important factors of tumor local recurrence and metastasis. At present, radical cystectomy with pelvic lymph node dissection is a necessary step and an important part of radical cystectomy to remove lymph node metastases, an effective means to accurately determine the clinical stage, and is also effective in reducing tumor recurrence and improve the disease-free survival. At present, the extent of lymph node dissection for radical cystectomy remains controversial and has not formed a conclusion. Now the common extent of lymph node dissection including local pelvic lymph node dissection (lPLND, including the obturator and internal iliac lymph nodes), standard pelvic lymph node dissection (sPLND, including the obturator, internal iliac and external iliac lymph nodes), and extended pelvic lymph node dissection (ePLND, including the obturator, internal iliac, external iliac, common iliac, presacral and para-aortic lymph nodes to the inferior mesenteric artery lymph nodes). That lPLND is inaccurate for clinical staging, tumor cured and recurrence rate. sPLND is the most often used clinical technique. In recent years, a growing number of studies have shown that ePLND not only able to provide more accurate tumor clinical staging, but also may complete removal of lymph node metastasis, and the micrometastases can not be detected, thereby reducing the local recurrence, distant metastasis and improve survival, especially non-organ confirmed, and even the patients with lymph node metastasis. However, with extended the extent of lymph node dissection, operative difficulty, operative time, blood loss and surgical complications are bound to increase too far. In pursuing a thorough lymph node dissection may affect the recovery of postoperative urinary control and sexual function. Surgical complications and postoperative lower quality of life, which also will affect the patients received the confidence and motivation for further treatment. Moreover, there is no large sample of multi-center prospective randomized controlled study confirms the cure effect of EL arm is better than the non-EL arm.MethodsA comprehensive literature search was performed in electronic databases including PubMed, EMBASE and the Cochrane Library (last search March 2012). There were no restrictions to publication time or language. Radical cystectomy with EL was the trial arm (extended lymphadenectomy, EL group), and radical cystectomy with non-EL (standard or local lymph node dissection, non-EL group) was the control arm. The software of RevMan5.1 and Stata11 were used for this meta-analysis (MTA). Data including 5-year overall survival (5-year OS), and 5-year recurrence-free survival (5-year RFS) and total recurrence (TR) were extracted from the EL arm and non-EL arm respectively. Useing the index of hazards ratio (HR), odds ratio (odds ratio, OR) or the weighted mean difference (WMD) to express the result for the categorical variable.ResultsTen studies published from 1998 to 2012 fulfilled the inclusion criteria and were included in the meta-analysis. There was one prospective non-randomized controlled study, and the remaining studies were retrospective. Analysis was performed on 1865 patients in the EL arm and 1,524 in the non-EL arm. The results show that the lymph node numbers (LNs) increased significantly, and there were significant differences (WMD16.79, 95% CI, 11.14–22.43; P<0.00001); lymph node density (LD) were no significant differences (OR 1.39, 95% CI, 0.97–2.01; P=0.07); There were no significant differences in 5-year overall survival (HR 0.84,95% CI, 0.66–1.08; P=0.17); 5-year recurrence-free survival were higher in EL arm (HR 0.81, 95% CI, 0.68–0.98; P=0.03); There were no significant differences in total recurrence (OR 0.89, 95% CI, 0.75–1.05; P=0.17). There was no significant difference in peri-operative complication (P=0.08).ConclusionsThis study showed that radical cystectomy with extended lymph node dissection can improve the patient’s 5-year recurrence-free survival, but no sufficient evidence can improve the 5-year overall survival and reduce the overall recurrence. Extended lymph node dissection does not increase peri-operative morbidity and mortality.

A scoring system to predict inferior mesenteric artery lymph node metastasis and prognostic value of its involvement in rectal cancer

The aim of this study is to establish a prediction scoring system for inferior mesenteric artery (IMA) lymph node metastasis and to assess the prognostic impact of dissection of positive IMA node on patients with stage III rectal cancer. A retrospective study was performed in 264 patients with stage III rectal cancer undergoing curative surgery. Clinicopathological, survival, and recurrence data were compared between 29 patients with positive IMA nodes and 235 patients with negative IMA nodes. Clinicopathological data which were found to be significantly associated with IMA nodal status were incorporated into a scoring system. In the training samples, tumor differentiation and preoperative serum CEA were significant predictors of IMA node metastasis in multivariate analysis, which were incorporated into a scoring system. Using receiver operating characteristic curve analysis, we determined a cutoff value of 46.5 for scores, at which the system's sensitivity was 86 % and specificity 61 %. When applied to testing sample, the sensitivity was 80 % and specificity 60 %. Survival analysis showed that 5-year disease-free survival rate (5-DFS) and 5-year overall survival (5-OS) in the positive IMA node group (24.4 and 27.6 %, respectively) were significantly lower than in the negative IMA node group (61.8 and 71.3 %, respectively) (P < 0.001). Furthermore, multivariate analysis indicated that IMA lymph node metastasis was an unfavorable independent prognostic factor for 5-DFS and 5-OS. IMA lymph node metastasis is an independent poor prognostic factor for stage III rectal cancer. The prediction scoring system for IMA node metastasis would be beneficial in determining the appropriate level of IMA ligation.

Clinical pathological analysis of rectal cancer lymph node skip metastasis

To analyze clinical and pathological of lymph node skip metastasis of rectal cancer and discuss the meaning of the high vascular ligation. A retrospective analysis of 207 cases for radical resection of rectal cancer was made, meanwhile the skip metastasis of the roots of the inferior mesenteric artery lymph nodes was studied. Combined with clinical data, the relevance of clinical and pathological factors with the skip metastasis was analyzed. The 207 cases of rectal cancer patients surgical resection specimen detected 2305 pieces of lymph node, the transfer of 168 patients with. The statistical analysis found that skip metastasis related with tumor differentiation (χ(2) = 113.65, P = 0.037) and depth of tumor invasion (χ(2) = 108.22, P = 0.042), but gender, age, location, size, preoperative carcinoembryonic antigen level, gross type and tissue types factors were not significantly correlation. Preoperative differentiation of cancer and tumor invasion depth assessment can help prompt the existence of lymph node skip metastasis. The assessment of the risk of skip metastasis for patients should be performed the high vascular ligation and lymph node dissection.

Reply about “Prognostic Impact of Inferior Mesenteric Artery Lymph Node Metastasis in Colorectal Cancer”

Reply about “Prognostic Impact of Inferior Mesenteric Artery Lymph Node Metastasis in Colorectal Cancer”

Does the routine histological examination of the inferior mesenteric artery lymph nodes have a prognostic value in elderly patients with sigmoid colon and rectum tumors?

The purpose of our study is to estimate the frequency of the histopathological exam, analyze the prognostic/therapeutic value of central LN examination and determine their advantage in elderly patients.

The oncologic benefit of high ligation of the inferior mesenteric artery in the surgical treatment of rectal or sigmoid colon cancer

It remains controversial as to whether high ligation of the inferior mesenteric artery (IMA) should be performed during surgical treatment for sigmoid colon or rectal cancer. The purpose of this study is to attempt to clarify the extent of the oncologic benefit of high ligation of the IMA. From January 1995 to July 2001, a total of 1,389 patients underwent high ligation of the IMA; 387 patients featured non-disseminated sigmoid colon cancer and 1,002 patients had rectal cancer. Pathology of the primary tumors, IMA nodes, and clinical outcome were reviewed. Forty-three patients (3.1%) revealed IMA node metastasis. Of these 43 patients, 29 (67.4%) featured tumor recurrences/metastases. After a minimum 5-year follow-up, 11 of these 43 patients (25.6%) were alive and disease free. Of these 43 patients, the 5-year disease-free survival rate for patients featuring sigmoid cancer was 50% and for patients with rectal cancer 13.8%. The beneficial rate of high ligation of the IMA for non-disseminated sigmoid colon cancer and rectal cancer was 0.8%, for non-disseminated sigmoid colon cancer 1.8%, and for non-disseminated rectal cancer, the rate was only 0.4%. The rates of IMA metastasis in patients with T stage tumors were 0% (pT1), 1.0% (pT2), 2.6% (pT3), and 4.3% (pT4). Although patients afflicted with IMA node metastasis revealed a rather high incidence of tumor recurrence/metastasis, 25.6% of these patients remained disease free following IMA node dissection after a minimum 5-year follow-up. We consider that IMA node dissection is more beneficial in patients with non-disseminated sigmoid pT4 tumor.