Amsterdam University Medical Centers / Miranda Kusters*
Abstract
PURPOSE:
Improvements in magnetic resonance imaging (MRI), total mesorectal excision (TME) surgery, and the use of (chemo)radiotherapy ([C]RT) have improved local control of rectal cancer; however, we have been unable to eradicate local recurrence (LR). Even in the face of TME and negative resection margins (R0), a significant proportion of patients with enlarged lateral lymph nodes (LLNs) suffer from lateral LR (LLR). Japanese studies suggest that the addition of an LLN dissection (LLND) could reduce LLR. This multicenter pooled analysis aims to ascertain whether LLNs actually pose a problem and whether LLND results in fewer LLRs.
PATIENTS AND METHODS:
Data from 1,216 consecutive patients with cT3/T4 rectal cancers up to 8 cm from the anal verge who underwent surgery in a 5-year period were collected. LLND was performed in 142 patients (12%). MRIs were re-evaluated with a standardized protocol to assess LLN features.
RESULTS:
On pretreatment MRI, 703 patients (58%) had visible LLN, and 192 (16%) had a short axis of at least 7 mm. One hundred eight patients developed LR (5-year LR rate, 10.0%), of which 59 (54%) were LLRs (5-year LLR rate, 5.5%). After multivariable analyses, LLNs with a short axis of at least 7 mm resulted in a significantly higher risk of LLR (hazard ratio, 2.060; P = .045) compared with LLNs of less than 7 mm. In patients with LLNs at least 7 mm, (C)RT plus TME plus LLND resulted in a 5-year LLR of 5.7%, which was significantly lower than that in patients who underwent (C)RT plus TME (5-year LLR, 19.5%; P = .042).
CONCLUSION:
LLR is still a significant problem after (C)RT plus TME in LLNs with a short axis at least 7 mm on pretreatment MRI. The addition of LLND results in a significantly lower LLR rate.
Author information
Ogura A1,2,3, Konishi T3,4, Cunningham C5, Garcia-Aguilar J4, Iversen H6, Toda S7, Lee IK8, Lee HX8, Uehara K2, Lee P9, Putter H1, van de Velde CJH1, Beets GL10, Rutten HJT11,12, Kusters M11,13; Lateral Node Study Consortium.
1
1 Leiden University Medical Center, Leiden, the Netherlands.
2
2 Nagoya University Graduate School of Medicine, Nagoya, Japan.
3
3 Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
4
4 Memorial Sloan Kettering Cancer Center, New York, NY.
5
5 Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom.
6
6 Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.
7
7 Toranomon Hospital, Tokyo, Japan.
8
8 The Catholic University of Korea, Seoul St Mary's Hospital Seoul, Republic of Korea.
9
10 Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.
10
11 The Netherlands Cancer Institute, Amsterdam, the Netherlands.
11
12 Catharina Hospital, Eindhoven, the Netherlands.
12
13 Maastricht University, Maastricht, the Netherlands.
13
14 Amsterdam University Medical Centers, Location VUMC, the Netherlands.
편집위원
직장암에서 lateral lymph node에 대한 연구가 주로 동양을 중심으로 발표되어 오던 중, 후향적 분석이기는 하나 서구의 대규모 다기관 연구의 결과로 이를 뒷받침했다는 데에 의의가 있겠음
2019-02-22 16:40:35
편집위원
Rectal cancer에서 MRI상 7mm이상의 lateral LNE가 관찰되는 경우 lateral LN recurrence를 감소시키기 위해 LLLD을 추천하였다. 방사선치료시에도 lateral LNE 여부 및 이에 대한 boost등을 고려하는데 도움을 줄 것으로 생각됩니다.
2019-02-22 17:07:49