Long-Term Outcomes of Surgical Resection of Pathologically Confirmed Isolated Para-Aortic Lymph Node Metastases in Colorectal Cancer: A Systematic Review

Abstract

Background: Para-aortic lymph node (PALN) metastases represent patterns of initial recurrence in only 2–6% CRC patients, after an estimated 23–28 month time interval. An increasing trend towards curative surgery has been witnessed in patients presenting with controlled PALN recurrence. Nevertheless, lack of consensus has impaired an unambiguous statement for PALN recurrence resection. Methods: We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines, which led us to gain deeper insight into the prognostic factors and long-term outcomes after resection for synchronous or metachronous pathologically confirmed CRC isolated para-aortic lymph node metastases (PALNM). Pubmed/MEDLINE, Embase, Scopus, Cochrane Library and Web of Science databases were used to search all related literature. Results: The nine articles included covered a study period of 30 years (1988–2018), with a total of 161 patients. At presentation, most primary CRCs were located in the colon (74%) and 95.6%, 87.1% and 76.9% patients had T3–T4, N1–N2 and well/moderately differentiated CRC, respectively. We identified a 59.4–68% 3-year OS rate and 53.4–87.5% 5-year OS rate, with a 25–84 months median OS, 26.3–61% 3-year DFS rate and 0–60.5% 5-year DFS rate, with a 14–24 month median DFS. Overall, 62.1% re-recurrence rate ranged from 43.8% to 100%. Conclusions: Although PALNMs resection in CRC patients may be considered a feasible and beneficial option, no conclusions or recommendations can be made taking into account the current evidence. Therefore, further randomized, possibly multicenter trials are strongly recommended and mandatory if we want to have our results confirmed and patient selection criteria clearly identified.

Survival outcomes after synchronous para‐aortic lymph node metastasis in colorectal cancer: A systematic review

“…The extent of PALND is also varied making it difficult to compare outcomes. Previous systematic reviews on this topic have failed to discriminate tumour location (rectal vs. colon) and the ultimate management goal of PALNM 30–32 . Rectal and colon cancer are very different disease entities in terms of the immunological processes, embryological development and ultimate treatment strategy 33–36 .…”

“…Previous systematic reviews on this topic have failed to discriminate tumour location (rectal vs. colon) and the ultimate management goal of PALNM. 30 , 31 , 32 Rectal and colon cancer are very different disease entities in terms of the immunological processes, embryological development and ultimate treatment strategy. 33 , 34 , 35 , 36 In addition, the studies do not have adequate data on the location of PALNM, extent of resection, adverse histopathological details (differentiation, presence of lymphovascular or perineural invasion, tumour budding) and/or molecular subtype details.…”

Outcomes of surgical resection and intraoperative electron radiotherapy for patients with para-aortic recurrences of gastrointestinal and gynecologic malignancies

“…Zizzo et al performed a systemic review for patients with colorectal primary tumors which included 9 studies over the last 30 years. They reported a mean second recurrence rate of 62%, 14–24 months median disease-free survival (DFS), and 3-year OS of 53–88% from the pooled population [ 14 ]. 16–29% of re-recurrences were in the para-aortic lymph nodes [ 14 ].…”

Management of Surgically Accessible Lymph Nodes Beyond Normal Resection Planes

“…In contrast, the anal canal lymphatics drain through peri-rectal, perianal, and pudendal channels into the inguinal lymph nodes. 44,45 This difference in lymphatic drainage systems is the basis for why the American Joint Committee on Cancer 8th Edition classifies inguinal lymph node metastases for anal cancer as locoregional disease whereas they are considered systemic disease for rectal cancer. This sharp division in classification does not take into account the variability in disease presentation and progression that can occur depending on the location of the rectal tumor with relation to the anorectal junction.…”