This retrospective analysis suggested that the indications for pulmonary resection of CRC metastases should be decided not only by the status of lung metastases, but also by pulmonary-related factors such as the T and N stage of the primary lesion, preoperative CEA level, and the DFI.

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The low PPV and high NPV indicate that it is difficult to identify patients who may benefit from LPLD. However, the results show that LPLD has no benefit in LPLN(-) and PRLN(-) cases and that these cases can be identified based on MRI findings.

Abstract. The present study presented a 35-year-old female patient in whom fecal occult blood was detected in a medical check-up. Colonoscopy revealed a superficial elevated-type tumor with central depression in the lower rectum. The tumor was diagnosed as T1 deep invasive cancer. No swollen lymph nodes or distant metastasis were found on computed tomography or [18 F]-fluorodeoxyglucose-positron emission tomography with computed tomography. However, a swollen right lateral pelvic lymph node (LPLN; short axis 4 mm) was revealed on magnetic resonance imaging (MRI). This lymph node exhibited high intensity on diffusion-weighted imaging (DWI), suggesting metastasis. Low anterior resection, regional lymph node dissection and right LPLN dissection (LPLD) were performed. Histological analysis revealed metastasis in the right LPLN, as suggested by the high DWI intensity. The indication for LPLD in the current Japanese guidelines is based on the tumor location and depth of invasion (≥T3), however, not on the status of LPLN metastasis in pre-operative evaluation. The present case was cT1, which is not included in this indication. DWI is sensitive for the diagnosis of lymph node metastasis of colorectal cancer, although inflammation-induced swelling of lymph nodes in advanced rectal cancer may cause a false-positive result, which is uncommon in T1 cases. Therefore, an LPLN with a high intensity DWI signal in T1 cases is likely to be metastasis-positive. Pre-operative DWI-MRI may be useful for identifying LPLN metastasis when planning the treatment strategy in these cases. The present study suggested reinvestigation of the indication for LPLD with inclusion of LPLN status on pre-operative imaging. IntroductionStrategies for the treatment of lateral pelvic lymph node (LPLN) metastasis in patients with lower rectal cancer has been controversial. In Western countries (1,2), LPLN dissection (LPLD) is rarely used since LPLN metastasis is viewed as a systemic disease. By contrast, in Japan, LPLN is categorized according to the regional lymph node and LPLN metastasis is treated as a localized lesion (3). Notably, a previous Japanese nationwide multi-institutional study (4) demonstrated that the survival rate of patients with internal iliac lymph node metastasis was comparable to that of cases with a tumor, node, metastasis (TNM) classification of N2a, and that the survival rate of patients with LPLN metastasis, which is more distant than the internal iliac lymph node, was comparable to that in cases with a classification of N2b. These previous findings suggested that LPLN metastasis can be recognized as local disease. The 5 year overall and cancer-specific survival rates of patients with LPLN metastasis were better compared with those of stage IV patients following curative resection (4). Total mesorectal excision (TME) with LPLD is the established method for advanced lower rectal cancer, and LPLD in Japan was effective in reducing the intrapelvic recurrence by 50% and improving the 5 year survival rate by 8-9% (5).The diagnostic ...

Comprehensive Cancer Network., 2014). Establishment of an indication for neoadjuvant therapy requires evaluation of nodal staging and T stage and mesorectal fascia (MRF) involvement. If the symptoms are underestimated due to inaccurate nodal staging, the patient