Selective Lateral Lymph Node Dissection Research Articles

Optimization of therapeutic strategies for selective lateral lymph node dissection after neoadjuvant chemoradiotherapy in patients with rectal cancer with clinical suspected lateral lymph node metastasis.

Selective lateral lymph node (LLN) dissection with total mesorectal excision after neoadjuvant chemoradiotherapy (nCRT) is pointed out to reduce lateral compartment recurrence and to improve survival in patients with rectal cancer with LLN metastases. This study aimed to explore the safety, surgical indications, and survival outcomes of LLN dissection after nCRT. This multicenter retrospective study included patients with rectal cancer with clinical evidence of LLN metastases (n = 466) treated across three hospitals in China. Patients who underwent total mesorectal excision and LLN dissection were grouped into nCRT (n = 155) and non-nCRT (n = 291), respectively. Propensity score matching was used to minimize selection bias. After matching, nCRT did not significantly increase the surgery duration, intraoperative blood loss or postoperative complications (P > 0.05). In a multivariate logistic regression analysis, poor/mucinous/signet adenocarcinoma (P = 0.042) and post-nCRT LLN short diameter ≥7 mm (P < 0.001) were independent risk factors for pathological LLN metastasis after nCRT. Overall survival (P < 0.001) and disease-free survival (P < 0.001) were significantly worse in patients with LLN metastasis, which was, however, not an independent risk factor for survival after eliminating confounders. Multivariate prognostic analysis of 40-patient subset with pathological LLN metastasis showed that distant metastasis, metastasis beyond the obturator or internal iliac region, and ≥2 LLN metastasis were independent predictors of poor overall survival. Selective LLN dissection after nCRT is safe and feasible with acceptable perioperative outcomes. Patients with a post-nCRT LLN short diameter ≥7 mm or poor/mucinous/signet adenocarcinoma should receive supplementary LLN dissection after nCRT. However, patients with distant metastasis, metastasis beyond the obturator or internal iliac region, and involvement of ≥2 LLN may not benefit from LLN dissection, and LLN dissection should be carefully considered in such patients.

Retracted: Efficacy and Safety of Radical Resection of Rectal Cancer Combined with Selective Lateral Lymph Node Dissection in the Treatment of Low Rectal Cancer under Meta-analysis.

[This retracts the article DOI: 10.1155/2022/8456677.].

ASO Visual Abstract: Adding Induction Chemotherapy Before Chemoradiotherapy with Total Mesorectal Excision and Selective Lateral Lymph Node Dissection in Patients with Poor-Risk, Locally Advanced, Mid-to-Low Rectal Cancer May Improve Oncological Outcomes-A Propensity Score-Matched Analysis.

ASO Visual Abstract: Adding Induction Chemotherapy Before Chemoradiotherapy with Total Mesorectal Excision and Selective Lateral Lymph Node Dissection in Patients with Poor-Risk, Locally Advanced, Mid-to-Low Rectal Cancer May Improve Oncological Outcomes-A Propensity Score-Matched Analysis.

ASO Author Reflections: Oncological Outcomes of Adding Induction Chemotherapy Before Chemoradiotherapy with Total Mesorectal Excision and Selective Lateral Lymph Node Dissection in Patients with Poor-Risk, Locally Advanced Rectal Cancer.

ASO Author Reflections: Oncological Outcomes of Adding Induction Chemotherapy Before Chemoradiotherapy with Total Mesorectal Excision and Selective Lateral Lymph Node Dissection in Patients with Poor-Risk, Locally Advanced Rectal Cancer.

Adding Induction Chemotherapy Before Chemoradiotherapy with Total Mesorectal Excision and Selective Lateral Lymph Node Dissection for Patients with Poor-Risk, Locally Advanced, Mid-to-Low Rectal Cancer May Improve Oncologic Outcomes: A Propensity Score-Matched Analysis.

This study aimed to investigate whether the addition of induction chemotherapy before chemoradiotherapy (CRT) and total mesorectal excision (TME) with selective lateral lymph node dissection improves disease-free survival for patients with poor-risk, mid-to-low rectal cancer. The authors' institutional prospective database was queried for consecutive patients with clinical stage II or III, primary, poor-risk, mid-to-low rectal cancer who received neoadjuvant treatment followed by TME from 2004 to 2019. The outcomes for the patients who received induction chemotherapy before neoadjuvant CRT (induction-CRT group) were compared (via log-rank tests) with those for a propensity score-matched cohort of patients who received neoadjuvant CRT without induction chemotherapy (CRT group). From 715 eligible patients, the study selected two matched cohorts with 130 patients each. The median follow-up duration was 5.4 years for the CRT group and 4.1 years for the induction-CRT group. The induction-CRT group had significantly higher rates of 3-year disease-free survival (83.5 % vs 71.4 %; p = 0.015), distant metastasis-free survival (84.3 % vs 75.2 %; p = 0.049), and local recurrence-free survival (98.4 % vs 94.4 %; p = 0.048) than the CRT group. The pathologically complete response rate also was higher in the induction-CRT group than in the CRT group (26.2 % vs 10.0 %; p < 0.001). Postoperative major complications (Clavien-Dindo classification ≥III) did not differ significantly between the two groups (12.3 % vs 10.8 %; p = 0.698). The addition of induction chemotherapy to neoadjuvant CRT appeared to improve oncologic outcomes significantly, including disease-free survival, for the patients with poor-risk, mid-to-low rectal cancer who underwent TME using selective lateral lymph node dissection.

Efficacy and Safety of Radical Resection of Rectal Cancer Combined with Selective Lateral Lymph Node Dissection in the Treatment of Low Rectal Cancer under Meta-analysis.

Rectal cancer mostly occurs in the middle and low position in China, and many anatomical evidence has confirmed that Lateral Lymph Node Metastasis (LLNM) exists in middle and low rectal cancer. Laparoscopic surgery can penetrate into the pelvic cavity and magnify and narrow the visual field, which is helpful for lymph node dissection and vascular nerve protection, while it has minimally invasive characteristics and is considered to be more suitable for LLND. Relevant articles published from January 2000 to May 2022 are searched using “Rectal cancer, Lateral lymph node dissection, Radical resection of rectal cancer, Low rectal cancer, Laparoscopic therapy, Treatment of rectal cancer” as test terms, analyzed and assessed using Rev Man 5.3 software and Stata software to assess the risk bias of included references, and heterogeneity among each study is evaluated using Q test and heterogeneity (I2). The experimental results show that there is no heterogeneity among the studies (I2 = 8.46%). The heterogeneity of lymphatic metastasis in the included literature is evaluated, and the results show that there is heterogeneity between the studies (I2 = 52.06%).

Lateral lymph node dissection in rectal cancer: State of the art review

Half of the local regional recurrences from rectal cancer are nowadays located in the lateral compartments, most likely due to lateral lymph node (LLN) metastases. There is evidence that a lateral lymph node dissection (LLND) can lower the lateral local recurrence rate. An LLND without neoadjuvant (chemo)radiotherapy in patients with or without suspected LLN metastases has been the standard of care in the East, while Western surgeons believed LLN metastases to be cured by neoadjuvant treatment and total mesorectal excision (TME) only. An LLND in patients without enlarged LLNs might result in overtreatment with low rates of pathological LLNs, but in patients with enlarged LLNs who are treated with (C)RT and TME only, the risk of a lateral local recurrence significantly increases to 20%. Certain Eastern and Western centers are increasingly performing a selective LLND after neoadjuvant treatment in the presence of suspicious LLNs due to new scientific insights, but (inter)national consensus on the indication and surgical approach of LLND is lacking. An LLND is an anatomically challenging procedure with intraoperative risks such as bleeding and postoperative morbidity. It is therefore essential to carefully select the patients who will benefit from this procedure and where possible to perform the LLND in a minimally invasive manner to limit these risks. This review gives an overview of the current evidence of the assessment of LLNs, the indications for LLND, the surgical technique, pitfalls in performing this procedure and the future studies are discussed, aiming to contribute to more (inter)national consensus.

Management, treatment and prognostic significance of lateral lymph node metastases in rectal cancer\u2014a regional cohort study

PurposeLateral lymph node metastases in rectal cancer remain a clinical challenge. Different treatment regimens have been suggested. This retrospective regional cohort study examines outcome after combined oncological and surgical treatment of MRI-positive lateral lymph nodes (LLN).MethodsData from the Swedish Colorectal Cancer Registry (SCRCR) and patient records were used for retrospective analysis of resected high-risk rectal cancers between 2009 and 2014. The aim was to compare tumour characteristics, neoadjuvant therapy, recurrence and outcome after lateral lymph node dissection.ResultsOne thousand and one hundred nineteen cases were identified and after exclusion 344 patients with cT3–T4 ≤ 10 cm from the anal verge were analysed. Thirty (8.7%) patients with MRI-positive LLN were identified. Synchronous distant metastases were associated with MRI-positive LLN (p-value 0.019). Long-course chemoradiotherapy was clinical practice in cases of MRI-positive LLN. No differences in local (p-value 0.154) or distant (p-value 0.343) recurrence rates between MRI-positive LLN patients and MRI-negative patients were detected. Only four patients underwent lateral lymph node dissection (LLND). There was no significant difference in overall survival during follow-up between the MRI-negative (CI at 95%; 99–109 months) and MRI-positive group (CI at 95%; 69–108 months; p-value 0.14).ConclusionLateral lymph node metastases present a challenging clinical situation. The present study shows that combination of neoadjuvant therapy and selective LLND is an applicable strategy in cases of MRI-positive LLN.

Indications and oncological outcomes of selective dissection for clinically suspected lateral lymph node metastasis in patients with rectal cancer based on pretreatment imaging.

The aim of this study was to identify the indications and oncological outcomes of selective lateral lymph node dissection (sLLND) in rectal cancer patients. A retrospective study was conducted on consecutive patients with rectal cancer who had standard total mesorectal excision and sLLND at our institution. Clinicopathological characteristics and oncological outcomes were analyzed. We performed subgroup analysis and multivariate analysis based on patients with or without preoperative chemoradiotherapy to identify the related risk factors. A total of 77 consecutive patients with TME and sLLND were included. Twenty-two (28.6%) patients with pathological positive lateral lymph nodesmetastasis (LLNM) were identified. Forty-seven (61%) patients accepted neoadjuvant chemoradiotherapy (nCRT). The pretreatment maximum short-axis diameters of LLN (≥ 8mm) were the independent risk factors for LLNM among patients with LLN ≥ 5mm. Lymph nodemetastasis weresignificantly higher in patients with pretreatment LLN ≥ 8mm than in patients with LLN 5-8mm (63% vs. 10%, p < 0.001). The receiver operating curve analysis suggested that the optimal cutoff value of LLN short-axis diameter for predicting LLNM was 8mm. At amedian follow-up of 42 months (range 6-140 months) 3(3.9%) patients with lateral pelvic recurrence were observed. The 3-year cumulative overall survival in patients with LLNM and patients without LLNM was 76.7% and 89.8%, respectively (p = 0.01). The 3-year cumulative disease-free survival was 53.6% in patients with LLNM and 88.3% in patients without LLNM (p = 0.008). Patients with LLNM had a worse prognosis. The pretreatment maximum short-axis diameter of LLN (≥ 8mm) should be considered as an indication for sLLND.

Selective lateral lymph node dissection after neoadjuvant chemoradiotherapy in rectal cancer.

BACKGROUNDLateral lymph node metastasis is one of the leading causes of local recurrence in patients with advanced mid or low rectal cancer. Neoadjuvant chemoradiotherapy (NCRT) can effectively reduce the postoperative recurrence rate; thus, NCRT with total mesorectal excision (TME) is the most widely accepted standard of care for rectal cancer. The addition of lateral lymph node dissection (LLND) after NCRT remains a controversial topic.AIMTo investigate the surgical outcomes of TME plus LLND, and the possible risk factors for lateral lymph node metastasis after NCRT.METHODSThis retrospective study reviewed 89 consecutive patients with clinical stage II-III mid or low rectal cancer who underwent TME and LLND from June 2016 to October 2018. In the NCRT group, TME plus LLND was performed in patients with short axis (SA) of the lateral lymph node greater than 5 mm. In the non-NCRT group, TME plus LLND was performed in patients with SA of the lateral lymph node greater than 10 mm. Data regarding patient demographics, clinical workup, surgical procedure, complications, and outcomes were collected. Multivariate logistic regression analysis was performed to evaluate the possible risk factors for lateral lymph node metastasis in NCRT patients.RESULTSLLN metastasis was pathologically confirmed in 35 patients (39.3%): 26 (41.3%) in the NCRT group and 9 (34.6%) in the non-NCRT group. The most common site of metastasis was around the obturator nerve (21/35) followed by the internal iliac artery region (12/35). In the NCRT patients, 46% of patients with SA of LLN greater than 7 mm were positive. The postoperative 30-d mortality rate was 0%. Two (2.2%) patients suffered from lateral local recurrence in the 2-year follow up. Multivariate analysis showed that cT4 stage (odds ratio [OR] = 5.124, 95% confidence interval [CI]: 1.419-18.508; P = 0.013), poor differentiation type (OR = 4.014, 95%CI: 1.038-15.520; P = 0.044), and SA ≥ 7 mm (OR = 7.539, 95%CI: 1.487-38.214; P = 0.015) were statistically significant risk factors associated with LLN metastasis.CONCLUSIONNCRT is not sufficient as a stand-alone therapy to eradicate LLN metastasis in lower rectal cancer patients and surgeons should consider performing selective LLND in patients with greater LLN SA diameter, poorer histological differentiation, or advanced T stage. Selective LLND for NCRT patients can have a favorable oncological outcome.

Oncological Impact of Lateral Lymph Node Dissection After Preoperative Chemoradiotherapy in Patients with Rectal Cancer.

To evaluate the efficacy of selective lateral lymph node dissection (LLND) and the effect of preoperative chemoradiotherapy (PCRT) in patients with LLN ≥ 5mm. Patients who underwent PCRT for rectal cancer were classified: (A) total mesorectal excision (TME)-only with LLN < 5mm (2001-2009, n = 474), (B) TME-only with LLN < 5mm (2011-2016, n = 273), (C) TME-only with LLN ≥ 5mm (2001-2009, n = 102), and (D) TME-LLND with LLN ≥ 5mm (2011-2016, n = 69). Subgroup analysis was performed in patients with LLN ≥ 5mm based on the reduction in LLN size to < 5mm or not on restaging MRI after PCRT. Oncological outcomes did not differ between groups A and B. Group D had lower 3-year local recurrence (LR) (20.13% vs 5.39%, P = 0.0013) and higher relapse-free survival (RFS) (65.83% vs 77.11%, P = 0.0436) than group C, while the 3-year overall survival (OS) was not significantly different between the two groups (87.64% vs 93.53%, P = 0.0670). In patients with reduction of LLN size from ≥ 5mm to < 5mm, LLND significantly reduced LR than did TME alone, but there were no significant differences in survival outcomes. In patients without reduction of LLN size to < 5mm, LLND reduced LR and improved RFS compared with TME alone. Selective LLND reduced LR and improved RFS in patients with LLN ≥ 5mm. Selective LLND reduced LR in patients with reduction of LLN size from ≥ 5mm to < 5mm after PCRT, and improved both LR and RFS in patients without reduction of LLN size to < 5mm.

Is laparoscopic selective lateral lymph node dissection for locally advanced rectal cancer after neoadjuvant chemoradiotherapy safe?

This study aimed to evaluate the technical feasibility, safety and oncological outcomes of laparoscopic total mesorectal excision (TME) with selective lateral lymph node (LLN) dissection (sLLND) in patients with locally advanced rectal cancer (LARC) and clinically suspected swollen LLNs treated with preoperative neoadjuvant chemoradiotherapy (nCRT). Consecutive patients with LARC and swollen LLNs who underwent laparoscopic TME and sLLND following nCRT between October 2012 and October 2018 were reviewed from the prospectively collected database. Patient demographics, operation safety, perioperative complications and oncological outcomes were analysed. A total of 43 patients were identified. All procedures were completed under laparoscopy without conversion to open surgery. The median operation time was 313 min (range 170-570 min). The median blood loss was 80 mL (range 30-450 mL). The median number of LLNs harvested was 11 (range 1-29). LLN metastasis was found in 12 patients (27.9%). Major post-operative complications were found in four patients (9.3%). The median hospital stay was 7 days (range 4-27 days). The median time to tolerance to liquid food was 72 h (range 36-120 h). The post-operative 30-day mortality rate was 0%. Over the median follow-up of 24 months, no lateral pelvic recurrence developed. For the whole group of patients, the 2-year cumulative overall survival and disease-free survival were 90.5% and 78.1%, respectively. With the advantages of a minimally invasive approach, laparoscopic TME and sLLND following preoperative nCRT in patients with LARC and swollen LLNs is safe and feasible. This procedure provides acceptable perioperative and oncological outcomes.

Outcomes and prognostic factors of selective lateral pelvic lymph node dissection with preoperative chemoradiotherapy for locally advanced rectal cancer.

The clinical significance of preoperative chemoradiotherapy (CRT) and lateral lymph node dissection (LLND) for locally advanced rectal cancer remains unclear. We have employed total mesorectal excision and selective LLND following preoperative CRT for patients with locally advanced rectal cancer. The validity of our strategy was evaluated. A total of 45 patients with locally advanced rectal cancer who underwent curative surgery after CRT from November 2005 to September 2016 were retrospectively analyzed. LLND was performed only for the patients with lateral lymph nodes suspected to have metastasis based on the pretreatment images. Rates of 5-year overall survival (OS) and 5-year relapse-free survival (RFS) were 85.7 and 61.8%, respectively. Univariate and multivariate analyses detected only histological response (grades 2 and 3 vs. grade 1) as a significant prognostic factor for OS and local recurrence. ypN and ypStage were significant factors for RFS by univariate analysis, while no significant factor was detected by multivariate analysis. There was no significant factor for distant recurrence. In good responders (grades 2 and 3), the local recurrence rate was 0% (P = 0.006, vs. grade 1), while distant recurrence developed in 4 of 20 cases (20%, P = 0.615, vs. grade 1). There was no local recurrence in LLND (-) group regardless the histological response. Although selective LLND with preoperative CRT seems effective and valid for good responders, new treatment strategy is necessary for poor responders. Therefore, development of reliable biomarkers for histological response to CRT is an urgent need.