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Management of Lateral Pelvic Lymph Nodes

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Rectal Cancer

Abstract

There are regional differences in the handling of the lateral pelvic lymph node (LPLN) in rectal cancer cases (in particular, the differences between Europe/the USA and Japan), with much still unknown in terms of the significance of LPLN dissection. In Japan, extended surgery, including LPLN dissection, but not preoperative chemoradiotherapy, has been the standard surgical procedure for locally advanced rectal cancer. According to Japanese studies, the frequency of LPLN metastasis in rectal cancer cases has been reported to be approximately 15%, while the 5-year overall survival rate of resected LPLN metastasis cases was approximately 40%. There are indications that the prognosis in cases of LPLN metastasis with no distant metastasis may improve by resection. It is difficult to make an accurate preoperative imaging diagnosis of LPLN metastasis, and it is unclear whether the omission of prophylactic dissection in cases diagnosed as negative for metastasis actually worsens the prognosis. A randomized controlled trial is underway in Japan. It also currently remains controversial as to whether the implementation of preoperative chemoradiotherapy makes it possible to avoid dissection (both curative dissection and prophylactic dissection).

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Abbreviations

AJCC:

American Joint Committee on Cancer

CRM:

Circumferential resection margin

CRT:

Chemoradiotherapy

CSS:

Cancer-specific survival

DFS:

Disease-free survival

ESMO:

European Society for Medical Oncology

EUS:

Endoscopic ultrasonography

LPLN:

Lateral pelvic lymph node(s)

OS:

Overall survival

RCT:

Randomized controlled trial

TME:

Total mesorectal excision

References

  1. Miles WE. A method of performing abdominoperineal excision for carcinoma of the rectum and the terminal portion of the pelvic colon. Lancet. 1908;2:1812–3.

    Article  Google Scholar 

  2. Sauer I, Bacon HE. A new approach for excision of carcinoma of the lower portion of the rectum and anal canal. Surg Gynecol Obstet. 1952;95(2):229–42.

    CAS  PubMed  Google Scholar 

  3. Bacon HE, Dirbas F, Myers TB, Ponce De Leon F. Extensive lymphadenectomy and high ligation of the inferior mesenteric artery for carcinoma of the left colon and rectum. Dis Colon Rectum. 1958;1(6):457–64. discussion 64–5

    Article  CAS  PubMed  Google Scholar 

  4. Stearns MW Jr, Deddish MR. Five-year results of abdominopelvic lymph node dissection for carcinoma of the rectum. Dis Colon Rectum. 1959;2(2):169–72.

    Article  PubMed  Google Scholar 

  5. Georgiou P, Tan E, Gouvas N, Antoniou A, Brown G, Nicholls RJ, et al. Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis. Lancet Oncol. 2009;10(11):1053–62.

    Article  PubMed  Google Scholar 

  6. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg. 1982;69(10):613–6.

    Article  CAS  PubMed  Google Scholar 

  7. Quirke P, Steele R, Monson J, Grieve R, Khanna S, Couture J, 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. Lancet. 2009;373(9666):821–8.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet. 1986;2(8514):996–9.

    Article  CAS  PubMed  Google Scholar 

  9. Colorectal Cancer Collaborative Group. Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507 patients from 22 randomised trials. Lancet. 2001;358(9290):1291–304.

    Article  Google Scholar 

  10. Folkesson J, Birgisson H, Pahlman L, Cedermark B, Glimelius B, Gunnarsson U. Swedish rectal cancer trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol. 2005;23(24):5644–50.

    Article  PubMed  Google Scholar 

  11. Peeters KC, Marijnen CA, Nagtegaal ID, Kranenbarg EK, Putter H, Wiggers T, et al. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg. 2007;246(5):693–701.

    Article  PubMed  Google Scholar 

  12. Bosset JF, Collette L, Calais G, Mineur L, Maingon P, Radosevic-Jelic L, et al. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med. 2006;355(11):1114–23.

    Article  CAS  PubMed  Google Scholar 

  13. Gerard JP, Conroy T, Bonnetain F, Bouche O, Chapet O, Closon-Dejardin MT, et al. Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: results of FFCD 9203. J Clin Oncol. 2006;24(28):4620–5.

    Article  PubMed  Google Scholar 

  14. Hojo K, Koyama Y. The effectiveness of wide anatomical resection and radical lymphadenectomy for patients with rectal cancer. Jpn J Surg. 1982;12(2):111–6.

    Article  CAS  PubMed  Google Scholar 

  15. Hojo K, Koyama Y, Moriya Y. Lymphatic spread and its prognostic value in patients with rectal cancer. Am J Surg. 1982;144(3):350–4.

    Article  CAS  PubMed  Google Scholar 

  16. Moriya Y, Hojo K, Sawada T, Koyama Y. Significance of lateral node dissection for advanced rectal carcinoma at or below the peritoneal reflection. Dis Colon Rectum. 1989;32(4):307–15.

    Article  CAS  PubMed  Google Scholar 

  17. Sugihara K, Kobayashi H, Kato T, Mori T, Mochizuki H, Kameoka S, et al. Indication and benefit of pelvic sidewall dissection for rectal cancer. Dis Colon Rectum. 2006;49(11):1663–72.

    Article  PubMed  Google Scholar 

  18. Kobayashi H, Mochizuki H, Kato T, Mori T, Kameoka S, Shirouzu K, et al. Outcomes of surgery alone for lower rectal cancer with and without pelvic sidewall dissection. Dis Colon Rectum. 2009;52(4):567–76.

    Article  PubMed  Google Scholar 

  19. Senba Y. An anatomical study of the lymphatic system of the rectum. J Hukuoka Med Coll. 1927;20:1213–68.

    Google Scholar 

  20. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. AJCC cancer staging manual. 7th ed. Yew York: Springer; 2010.

    Google Scholar 

  21. Rectum JSfCotCa, editor. Japanese cassification of colorectal carcinoma. 8th ed. Kanehara: Tokyo; 2013.

    Google Scholar 

  22. Sugihara K, Moriya Y, Akasu T, Fujita S. Pelvic autonomic nerve preservation for patients with rectal carcinoma. Oncologic and functional outcome. Cancer. 1996;78(9):1871–80.

    Article  CAS  PubMed  Google Scholar 

  23. Moriya Y, Sugihara K, Akasu T, Fujita S. Importance of extended lymphadenectomy with lateral node dissection for advanced lower rectal cancer. World J Surg. 1997;21(7):728–32.

    Article  CAS  PubMed  Google Scholar 

  24. Mori T, Takahashi K, Yasuno M. Radical resection with autonomic nerve preservation and lymph node dissection techniques in lower rectal cancer surgery and its results: the impact of lateral lymph node dissection. Langenbeck’s Arch Surg. 1998;383(6):409–15.

    Article  CAS  Google Scholar 

  25. Ueno H, Mochizuki H, Hashiguchi Y, Hase K. Prognostic determinants of patients with lateral nodal involvement by rectal cancer. Ann Surg. 2001;234(2):190–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Shirouzu K, Ogata Y, Araki Y, Sasatomi T, Nozoe Y, Nakagawa M, et al. Total mesorectal excision, lateral lymphadenectomy and autonomic nerve preservation for lower rectal cancer: significance in the long-term follow-up study. Kurume Med J. 2001;48(4):307–19.

    Article  CAS  PubMed  Google Scholar 

  27. Shimoyama M, Yamazaki T, Suda T, Hatakeyama K. Prognostic significance of lateral lymph node micrometastases in lower rectal cancer: an immunohistochemical study with CAM5.2. Dis Colon Rectum. 2003;46(3):333–9.

    Article  PubMed  Google Scholar 

  28. Ueno M, Oya M, Azekura K, Yamaguchi T, Muto T. Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer. Br J Surg. 2005;92(6):756–63.

    Article  CAS  PubMed  Google Scholar 

  29. Watanabe T, Itabashi M, Shimada Y, Tanaka S, Ito Y, Ajioka Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2010 for the treatment of colorectal cancer. Int J Clin Oncol. 2012;17(1):1–29.

    Article  PubMed  Google Scholar 

  30. Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM, Stoker J. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging--a meta-analysis. Radiology. 2004;232(3):773–83.

    Article  PubMed  Google Scholar 

  31. Schmoll HJ, Van Cutsem E, Stein A, Valentini V, Glimelius B, Haustermans K, et al. ESMO consensus guidelines for management of patients with colon and rectal cancer. A personalized approach to clinical decision making. Ann Oncol. 2012;23(10):2479–516.

    Article  CAS  PubMed  Google Scholar 

  32. Ueno H, Mochizuki H, Hashiguchi Y, Ishiguro M, Miyoshi M, Kajiwara Y, et al. Potential prognostic benefit of lateral pelvic node dissection for rectal cancer located below the peritoneal reflection. Ann Surg. 2007;245(1):80–7.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Blomqvist L, Rubio C, Holm T, Machado M, Hindmarsh T. Rectal adenocarcinoma: assessment of tumour involvement of the lateral resection margin by MRI of resected specimen. Br J Radiol. 1999;72(853):18–23.

    Article  CAS  PubMed  Google Scholar 

  34. Brown G, Richards CJ, Bourne MW, Newcombe RG, Radcliffe AG, Dallimore NS, et al. Morphologic predictors of lymph node status in rectal cancer with use of high-spatial-resolution MR imaging with histopathologic comparison. Radiology. 2003;227(2):371–7.

    Article  PubMed  Google Scholar 

  35. Klessen C, Rogalla P, Taupitz M. Local staging of rectal cancer: the current role of MRI. Eur Radiol. 2007;17(2):379–89.

    Article  PubMed  Google Scholar 

  36. Lu YY, Chen JH, Ding HJ, Chien CR, Lin WY, Kao CH. A systematic review and meta-analysis of pretherapeutic lymph node staging of colorectal cancer by 18F-FDG PET or PET/CT. Nucl Med Commun. 2012;33(11):1127–33.

    Article  PubMed  Google Scholar 

  37. Fujita S, Yamamoto S, Akasu T, Moriya Y. Prognostic factors of rectal cancer patients with lateral pelvic lymph node metastasis. Hepato-Gastroenterology. 2012;59(120):2494–7.

    PubMed  Google Scholar 

  38. Akiyoshi T, Watanabe T, Miyata S, Kotake K, Muto T, Sugihara K. Results of a Japanese nationwide multi-institutional study on lateral pelvic lymph node metastasis in low rectal cancer: is it regional or distant disease? Ann Surg. 2012;255(6):1129–34.

    Article  PubMed  Google Scholar 

  39. Nelson H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst. 2001;93(8):583–96.

    Article  CAS  PubMed  Google Scholar 

  40. Fujita S, Akasu T, Mizusawa J, Saito N, Kinugasa Y, Kanemitsu Y, 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. Lancet Oncol. 2012;13(6):616–21.

    Article  PubMed  Google Scholar 

  41. Moriya Y, Sugihara K, Akasu T, Fujita S. Nerve-sparing surgery with lateral node dissection for advanced lower rectal cancer. Eur J Cancer. 1995;31A(7-8):1229–32.

    Article  CAS  PubMed  Google Scholar 

  42. Watanabe T, Tsurita G, Muto T, Sawada T, Sunouchi K, Higuchi Y, et al. Extended lymphadenectomy and preoperative radiotherapy for lower rectal cancers. Surgery. 2002;132(1):27–33.

    Article  PubMed  Google Scholar 

  43. Nagawa H, Muto T, Sunouchi K, Higuchi Y, Tsurita G, Watanabe T, et al. Randomized, controlled trial of lateral node dissection vs. nerve-preserving resection in patients with rectal cancer after preoperative radiotherapy. Dis Colon Rectum. 2001;44(9):1274–80.

    Article  CAS  PubMed  Google Scholar 

  44. Watanabe T, Matsuda K, Nozawa K, Kobunai T. Lateral pelvic lymph node dissection or chemoradiotherapy: which is the procedure of choice to reduce local recurrence rate in lower rectal cancer? Ann Surg. 2008;248(2):342–3. author reply 3

    Article  PubMed  Google Scholar 

  45. Akiyoshi T, Ueno M, Matsueda K, Konishi T, Fujimoto Y, Nagayama S, et al. Selective lateral pelvic lymph node dissection in patients with advanced low rectal cancer treated with preoperative chemoradiotherapy based on pretreatment imaging. Ann Surg Oncol. 2014;21(1):189–96.

    Article  PubMed  Google Scholar 

  46. Taylor FG, Quirke P, Heald RJ, Moran B, Blomqvist L, Swift I, et al. Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study. Ann Surg. 2011;253(4):711–9.

    Article  PubMed  Google Scholar 

  47. Konishi T, Kuroyanagi H, Oya M, Ueno M, Fujimoto Y, Akiyoshi T, et al. Multimedia article. Lateral lymph node dissection with preoperative chemoradiation for locally advanced lower rectal cancer through a laparoscopic approach. Surg Endosc. 2011;25(7):2358–9.

    Article  PubMed  Google Scholar 

  48. Mukai T, Akiyoshi T, Ueno M, Fukunaga Y, Nagayama S, Fujimoto Y, et al. Laparoscopic total pelvic exenteration with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer. Asian J Endos Surg. 2013;6(4):314–7.

    Article  Google Scholar 

  49. Bae SU, Saklani AP, Hur H, Min BS, Baik SH, Lee KY, et al. Robotic and laparoscopic pelvic lymph node dissection for rectal cancer: short-term outcomes of 21 consecutive series. Ann Surg Treat Res. 2014;86(2):76–82.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Kagawa H, Kinugasa Y, Shiomi A, Yamaguchi T, Tsukamoto S, Tomioka H, et al. Robotic-assisted lateral lymph node dissection for lower rectal cancer: short-term outcomes in 50 consecutive patients. Surg Endosc. 2014;29(4):995–1000.

    Article  PubMed  Google Scholar 

  51. Hojo K, Sawada T, Moriya Y. An analysis of survival and voiding, sexual function after wide iliopelvic lymphadenectomy in patients with carcinoma of the rectum, compared with conventional lymphadenectomy. Dis Colon Rectum. 1989;32(2):128–33.

    Article  CAS  PubMed  Google Scholar 

  52. Masui H, Ike H, Yamaguchi S, Oki S, Shimada H. Male sexual function after autonomic nerve-preserving operation for rectal cancer. Dis Colon Rectum. 1996;39(10):1140–5.

    Article  CAS  PubMed  Google Scholar 

  53. Pilipshen SJ, Heilweil M, Quan SH, Sternberg SS, Enker WE. Patterns of pelvic recurrence following definitive resections of rectal cancer. Cancer. 1984;53(6):1354–62.

    Article  CAS  PubMed  Google Scholar 

  54. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg. 1998;133(8):894–9.

    Article  CAS  PubMed  Google Scholar 

  55. Gunderson LL, Sosin H. Areas of failure found at reoperation (second or symptomatic look) following “curative surgery” for adenocarcinoma of the rectum. Clinicopathologic correlation and implications for adjuvant therapy. Cancer. 1974;34(4):1278–92.

    Article  CAS  PubMed  Google Scholar 

  56. Kim TH, Jeong SY, Choi DH, Kim DY, Jung KH, Moon SH, et al. Lateral lymph node metastasis is a major cause of locoregional recurrence in rectal cancer treated with preoperative chemoradiotherapy and curative resection. Ann Surg Oncol. 2008;15(3):729–37.

    Article  PubMed  Google Scholar 

  57. Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345(9):638–46.

    Article  CAS  PubMed  Google Scholar 

  58. Kanemitsu Y, Hirai T, Komori K, Kato T. Prediction of residual disease or distant metastasis after resection of locally recurrent rectal cancer. Dis Colon Rectum. 2010;53(5):779–89.

    Article  PubMed  Google Scholar 

  59. Kusters M, Dresen RC, Martijn H, Nieuwenhuijzen GA, van de Velde CJ, van den Berg HA, et al. Radicality of resection and survival after multimodality treatment is influenced by subsite of locally recurrent rectal cancer. Int J Radiat Oncol Biol Phys. 2009;75(5):1444–9.

    Article  PubMed  Google Scholar 

  60. Bakx R, van Tinteren H, van Lanschot JJ, Zoetmulder FA. Surgical treatment of locally recurrent rectal cancer. Eur J Surg Oncol. 2004;30(8):857–63.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan

    Toshiaki Watanabe & Soichiro Ishihara

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  1. Toshiaki Watanabe
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  2. Soichiro Ishihara
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Correspondence to Toshiaki Watanabe .

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Editors and Affiliations

  1. Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA

    George J. Chang

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Watanabe, T., Ishihara, S. (2018). Management of Lateral Pelvic Lymph Nodes. In: Chang, G. (eds) Rectal Cancer. Springer, Cham. https://doi.org/10.1007/978-3-319-16384-0_13

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  • DOI: https://doi.org/10.1007/978-3-319-16384-0_13

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