Neoadjuvant (chemo)radiotherapy and Lateral Node Dissection: Is It Mutually Exclusive?
The importance of total mesorectal excision (TME) has been the global standard of care in patients with rectal cancer. However, there is no universal strategy for lateral lymph nodes (LLN). The treatment of the lateral compartment remains controversial and has gone to the opposite directions between Eastern and Western countries in the past decades. In the East, mainly Japan, surgeons consider LLN metastases as regional disease and have performed TME with lateral lymph node dissection (LLND) without neoadjuvant (chemo)radiotherapy ([C]RT) in patients with clinical Stage II/III rectal cancer below the peritoneal reflection. In the West, neoadjuvant radiotherapy or has been the standard, and surgeons do not perform LLND assuming the (C)RT can sterilize most lateral lymph node metastasis (LLNM). Recent evidences show that lateral nodes are the major cause of local recurrence after (C)RT plus TME, and LLND reduces local recurrence particularly from the lateral compartment. Probably a combination of the two strategies, that is, neoadjuvant (C)RT plus LLND, would be needed to improve outcomes in patients with lateral nodal disease.
Keywordsrectal cancer - lateral lymph node - lateral lymph node dissection - radiotherapy - chemoradiotherapy
22 September 2020 (online)
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- 1 Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986; 1 (8496): 1479-1482
- 2 Konishi T, Watanabe T, Nagawa H. et al. Preoperative chemoradiation and extended pelvic lymphadenectomy for rectal cancer: two distinct principles. World J Gastrointest Surg 2010; 2 (04) 95-100
- 3 Watanabe T, Muro K, Ajioka Y. et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2016 for the treatment of colorectal cancer. Int J Clin Oncol 2017
- 4 Georgiou P, Tan E, Gouvas N. et al. Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis. Lancet Oncol 2009; 10 (11) 1053-1062
- 5 Kusters M, Beets GL, van de Velde CJ. et al. A comparison between the treatment of low rectal cancer in Japan and the Netherlands, focusing on the patterns of local recurrence. Ann Surg 2009; 249 (02) 229-235
- 6 Fujita S, Mizusawa J, Kanemitsu Y. , et al; Colorectal Cancer Study Group of Japan Clinical Oncology Group. Mesorectal excision with or without lateral lymph node dissection for clinical stage II/III lower rectal cancer (JCOG0212): a multicenter, randomized controlled, noninferiority trial. Ann Surg 2017; 266 (02) 201-207
- 7 Benson III AB, Venook AP, Bekaii-Saab T. et al. Rectal Cancer, Version 2.2015. J Natl Compr Canc Netw 2015; 13 (06) 719-728 , quiz 728
- 8 Glynne-Jones R, Wyrwicz L, Tiret E. , et al; ESMO Guidelines Committee. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28 (Suppl. 04) iv22-iv40
- 9 Kim TH, Jeong SY, Choi DH. 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 (03) 729-737
- 10 Iversen H, Martling A, Johansson H, Nilsson PJ, Holm T. Pelvic local recurrence from colorectal cancer: surgical challenge with changing preconditions. Colorectal Dis 2018; 20 (05) 399-406
- 11 Akiyoshi T, Watanabe T, Miyata S, Kotake K, Muto T, Sugihara K. ; Japanese Society for Cancer of the Colon and Rectum. 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 (06) 1129-1134
- 12 Cedermark B, Dahlberg M, Glimelius B, Påhlman L, Rutqvist LE, Wilking N. ; Swedish Rectal Cancer Trial. Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 1997; 336 (14) 980-987
- 13 Kapiteijn E, Marijnen CA, Nagtegaal ID. , et al; Dutch Colorectal Cancer Group. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001; 345 (09) 638-646
- 14 Bosset JF, Collette L, Calais G. , et al; EORTC Radiotherapy Group Trial 22921. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 2006; 355 (11) 1114-1123
- 15 Nagawa H, Muto T, Sunouchi K. 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 (09) 1274-1280
- 16 Watanabe T, Tsurita G, Muto T. et al. Extended lymphadenectomy and preoperative radiotherapy for lower rectal cancers. Surgery 2002; 132 (01) 27-33
- 17 Kim MJ, Kim TH, Kim DY. et al. Can chemoradiation allow for omission of lateral pelvic node dissection for locally advanced rectal cancer?. J Surg Oncol 2015; 111 (04) 459-464
- 18 Kusters M, Slater A, Muirhead R. et al. What to do with lateral nodal disease in low locally advanced rectal cancer? A call for further reflection and research. Dis Colon Rectum 2017; 60 (06) 577-585
- 19 Schaap DP, Ogura A, Nederend J. et al. Prognostic implications of MRI-detected lateral nodal disease and extramural vascular invasion in rectal cancer. Br J Surg 2018; 105 (13) 1844-1852
- 20 Akiyoshi T, Ueno M, Matsueda K. 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 (01) 189-196
- 21 Ishihara S, Kawai K, Tanaka T. et al. Oncological outcomes of lateral pelvic lymph node metastasis in rectal cancer treated with preoperative chemoradiotherapy. Dis Colon Rectum 2017; 60 (05) 469-476
- 22 Oh HK, Kang SB, Lee SM. et al. Neoadjuvant chemoradiotherapy affects the indications for lateral pelvic node dissection in mid/low rectal cancer with clinically suspected lateral node involvement: a multicenter retrospective cohort study. Ann Surg Oncol 2014; 21 (07) 2280-2287
- 23 Kim HJ, Choi GS, Park JS. et al. Optimal treatment strategies for clinically suspicious lateral pelvic lymph node metastasis in rectal cancer. Oncotarget 2017; 8 (59) 100724-100733
- 24 Ogura A, Konishi T, Cunningham C. et al. Neoadjuvant (chemo)radiotherapy with total mesorectal excision only is not sufficient to prevent lateral local recurrence in enlarged nodes: results of the multicenter lateral node study of patients with low CT3/4 rectal cancer. J Clin Oncol 2018; JCO1800032