Lymph Node Metastases in Rectal Cancer After Preoperative Radiochemotherapy

Sprenger, Thilo; Rothe, H.; Becker, Heinz; Beißbarth, Tim; Homayounfar, Kia; Gauß, Korbinian Andreas; Kitz, Julia; Wolff, Hendrik A.; Scheel, Andreas H.; Ghadimi, Michael; Rödel, Claus; Conradi, Lena‐Christin; Liersch, Torsten

doi:10.1097/pas.0b013e3182886ced

Cited by 30 publications

(5 citation statements)

References 30 publications

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“…The authors found that irradiated nodes often show fibrous thickening of the capsule along with fibrosis or sclerosis of the nodal medulla, with a decrease in density of CD4+ T cells and dendritic cells in the nodal paracortex. In our study, the number and size of nodes is decreased, a finding that has been confirmed by other studies [ 3 , 9 , 17 ]. Koh et al showed that nodes that were no longer visible after CRT had a more benign appearance before CRT than the remaining nodes, which is in line with our finding that the nodes that could no longer be identified at post-CRT MRI were significantly smaller than the nodes that remained visible [ 3 ].…”

Section: Discussionsupporting

confidence: 92%

Nodal staging in rectal cancer: why is restaging after chemoradiation more accurate than primary nodal staging?

Heijnen

Maas

Beets‐Tan

et al. 2016

Int J Colorectal Dis

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PurposeThis study aims to explore the influence of chemoradiation treatment (CRT) on rectal cancer nodes and to generate hypotheses why nodal restaging post-CRT is more accurate than at primary staging.MethodsThirty-nine patients with locally advanced rectal cancer underwent MRI pre- and post-CRT. All visible mesorectal nodes were measured on a 3D T1-weighted gradient echo (3D T1W GRE) sequence with 1-mm3 voxels and matched between pre- and post-CRT-MRI and with histology by lesion-by-lesion matching. Change in number and size of nodes was compared between pre- and post-CRT-MRI. ROC curves were constructed to assess diagnostic performance of size.ResultsEight hundred ninety-five nodes were found pre-CRT: 44 % disappeared and 40 % became smaller post-CRT. Disappearing nodes were initially significantly smaller than nodes that remained visible post-CRT: 2.9 mm vs. 3.8 mm. cN+ stage was predicted in 97 % pre-CRT and 36 % of patients had ypN+ post-CRT. ypN+ patients had significantly larger nodes than ypN0 patients both pre- and post-CRT. Optimal size cutoff for post-CRT ypN stage prediction was 2.5 mm (area under the curve (AUC) of 0.78) at MRI.ConclusionsAfter CRT, most lymph nodes become smaller, and many disappear. Size predicts disappearance and node positivity. Together with a low prevalence of ypN+, this can explain the higher accuracy of nodal staging after CRT than in a primary staging setting, possibly of use when considering organ-preserving strategies after CRT.

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Section: Discussionsupporting

confidence: 92%

Nodal staging in rectal cancer: why is restaging after chemoradiation more accurate than primary nodal staging?

Heijnen

Maas

Beets‐Tan

et al. 2016

Int J Colorectal Dis

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“…Similarly, in a subsequent small study by the same group on restaging MRI after CRT, it was found that no nodes remained after CRT distal to the tumor [ 16 ]. Sprenger et al confirmed this observation by showing that—after CRT—only 9% of the nodes, regardless of their histopathological features, was found distal to the tumor [ 17 ]. Our current study in a significantly larger patient cohort confirmed previous literature: all persistent metastatic nodes were located at the tumor level or above and no metastatic nodes occurred distal to the tumor level.…”

Section: Discussionmentioning

confidence: 97%

“…Furthermore, information on the distribution of remaining positive nodes after CRT could hypothetically be used to plan a targeted boost of radiotherapy specifically focused on sterilizing these nodes. Finally, the nodal distribution after preoperative CRT has been suggested to withhold prognostic information regarding the risk of distant metastatic tumoral spread [ 25 ] as well as overall survival [ 17 ]. Leibold et al reported that patients with proximal lymph node metastases (i.e., along major supplying blood vessels) had a significantly higher risk for distant metastases compared with patients without proximal node involvement (46% vs. 25%, p < 0.001) [ 25 ] Similarly, Sprenger and colleagues found that patients with metastases in proximal lymph nodes after CRT had significantly impaired cancer-specific survival compared to patients with peritumoral nodal metastases only ( p < 0.05) [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

Good and complete responding locally advanced rectal tumors after chemoradiotherapy: where are the residual positive nodes located on restaging MRI?

et al. 2016

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PurposeAim of this study was to evaluate the distribution of persistent mesorectal lymph node metastases on restaging MRI in patients with a good or complete response of their primary tumor (ypT0-2) after CRT for locally advanced rectal cancer.MethodsTwo hundred and twenty eight locally advanced rectal cancer patients underwent CRT, which resulted in a good response (downstaging to yT0-2) in 144 patients. Forty-nine patients were excluded (no surgery/insufficient follow-up or lacking lesion-by-lesion histology results). This resulted in a final study group of 95 yT0-2 patients. For the patients with a yN+-status, a detailed lesion-by-lesion comparison between restaging MRI and histology was performed to evaluate the characteristics and distribution of the individual N+-nodes.Results7/95 patients (7%) had a yT0-2N+ status (11/880 (1%) N+ nodes): no N+ were found below the tumor level, 55% of the N+ nodes were located at the level of the tumor, and 45% proximal to the tumor (at a median distance of 1.4 cm above the tumor level). In axial plane, 82% of the nodes were located at the ipsilateral circumference of the tumor, at a median distance of 0.9 cm from the tumor/rectal wall.ConclusionsThe incidence of persistent metastatic mesorectal nodes after CRT in patients with a good tumor response after CRT is very low. No N+ nodes are found below the tumor level. All N+ nodes are located at the level of or proximal to the primary tumor, of which the majority very close to the tumor/lumen.

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“…48 49 Park et al reported that in rectal cancer undergoing CRT, there were 16% of nodal involvement, including 9.1% among patients with pT0, 50 while in other study, the rate was lower, ranging from 0 to 6% among pT0 cases. 51 52 Although MRI is the main staging technique for primary rectal tumor, it is not reliable for evaluating nodal status. 53 54 In van der Paardt et al's study, 35 the mean sensitivity and specificity for determining nodal stage were 76.5 and 59.8%, respectively, per patient, and 91.7 and 73% per lesion.…”

Section: Assessment Of Ccrmentioning

confidence: 99%

Nonoperative Management of dMMR/MSI-H Colorectal Cancer following Neoadjuvant Immunotherapy: A Narrative Review

Xiao

Ding

2023

Clin Colon Rectal Surg

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Immunotherapy with PD-1 blockade has achieved a great success in colorectal cancers (CRCs) with high microsatellite instability (MSI-H) and deficient mismatch repair (dMMR), and has become the first-line therapy in metastatic setting. Studies of neoadjuvant immunotherapy also report exciting results, showing high rates of clinical complete response (cCR) and pathological complete response. The high efficacy and long duration of response of immunotherapy has prompt attempts to adopt watch-and-wait strategy for patients achieving cCR following the treatment. Thankfully, the watch-and-wait approach has been proposed for nearly 20 years for patients undergoing chemoradiotherapy and has gained ground among patients as well as clinicians. In this narrative review, we combed through the available information on immunotherapy for CRC and on the watch-and-wait strategy in chemoradiotherapy, and looked forward to a future where neoadjuvant immunotherapy as a curative therapy would play a big part in the treatment of MSI-H/dMMR CRC.

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Lymph Node Metastases in Rectal Cancer After Preoperative Radiochemotherapy

Cited by 30 publications

References 30 publications

Nodal staging in rectal cancer: why is restaging after chemoradiation more accurate than primary nodal staging?

Nodal staging in rectal cancer: why is restaging after chemoradiation more accurate than primary nodal staging?

Good and complete responding locally advanced rectal tumors after chemoradiotherapy: where are the residual positive nodes located on restaging MRI?

Nonoperative Management of dMMR/MSI-H Colorectal Cancer following Neoadjuvant Immunotherapy: A Narrative Review

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