Results of a nationwide Japanese study on lateral pelvic lymph node metastasis in low rectal cancer: Is it regional or distant disease?

Akiyoshi, Tsuyoshi; Watanabe, Tôru; Miyata, Satoshi; Kotake, Kenjiro; Muto, T; Sugihara, K.

doi:10.1200/jco.2011.29.15_suppl.3551

Cited by 43 publications

(68 citation statements)

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“…The incidence of LPLN-positive status (18.3%) in our study was similar to that of pathological LPLN metastasis of previous reports, in which patients underwent surgery alone (1)(2)(3)(4)(5). Following preoperative CRT, 7 of the 19 (36.8%) initially LPLN-positive patients exhibited LPLN downsizing to <7 mm; none of these 7 patients developed recurrence.…”

Section: Discussionsupporting

confidence: 75%

“…LPLN dissection is often performed with TME in advanced low RC in Japan, as TME does not remove LPLN, which may contain metastasis and lead to local recurrence. The incidence of LPLN metastasis is reportedly 10-20% in patients with advanced low RC who undergo LPLN dissection (1)(2)(3)(4)(5). Although a retrospective analysis has suggested that LPLN dissection is equivalent to preoperative CRT in terms of local control for patients with lower RC (6), the effect of preoperative CRT on patients with involved LPLN has not been fully investigated.…”

Section: Introductionmentioning

confidence: 99%

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Clinical significance of enlarged lateral pelvic lymph nodes before and after preoperative chemoradiotherapy for rectal cancer

Inoue

Saigusa

Hiro

et al. 2016

Molecular and Clinical Oncology

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Abstract. Preoperative chemoradiotherapy (CRT) with total mesorectal excision (TME) is the widely accepted treatment for rectal cancer (RC) in Western countries. However, there remains controversy as to whether preoperative CRT is useful in tumors that extend beyond the mesorectum, including metastasis to the lateral pelvic lymph nodes (LPLN). The aim of this study was to assess the prognostic significance of LPLN enlargement in patients with RC who receive preoperative CRT followed by TME without LPLN dissection. We evaluated the prognostic effect of radiographic LPLN enlargement before and after CRT, as well as the patients' clinicopathological and genetic profiles. Of the 104 patients investigated, pretreatment imaging identified 19 (18%) as LPLN-positive (>7 mm in diameter). Of these 19 patients, 7 (37%) exhibited LPLN downsizing to <7 mm following CRT. The median follow-up period was 52 months. The 5-year cancer-specific survival (CSS) or relapse-free survival (RFS) did not differ significantly between patients who did and those who did not have positive LPLN on pretreatment imaging. However, LPLN that remained positive after CRT were significantly associated with poorer 5-year CSS (73 vs. 84%, respectively; P=0.0052) and RFS (32 vs. 78%, respectively; P=0.0264). None of the patients whose LPLN were downsized to <7 mm following CRT developed recurrence; however, those with positive LPLN after CRT had a 55% higher recurrence rate, characterized by delayed local recurrence, a pattern that may be affected by certain chemokines. In conclusion, changes in initially positive LPLN (>7 mm) may predict the prognosis of patients with RC who receive preoperative CRT-TME. LPLN positivity after CRT was associated with shorter CSS and RFS. Strategies to improve patient survival may include selective LPLN dissection or more aggressive multimodality therapy.

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Section: Discussionsupporting

confidence: 75%

Section: Introductionmentioning

confidence: 99%

Clinical significance of enlarged lateral pelvic lymph nodes before and after preoperative chemoradiotherapy for rectal cancer

Inoue

Saigusa

Hiro

et al. 2016

Molecular and Clinical Oncology

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“…In contrast, a retrospective multicenter study conducted in Japan demonstrated that LLN dissection was effective for local control and might be indicated in patients with T3/T4 lower rectal cancer (4). Akiyoshi et al (5) recently reported, based on a Japanese nationwide study on LLN metastasis in patients with lower rectal cancer, that the survival of patients with LLN metastasis extending beyond the internal iliac area was poorer than that of patients with metastasis limited to the internal iliac area (5), in concurrence with the AJCC staging. Thus, accurate preoperative staging including the site of LLNs (i.e.…”

mentioning

confidence: 72%

Prediction of metastasis to mesorectal, internal iliac and obturator lymph nodes according to size criteria in patients with locally advanced lower rectal cancer

Hatano

Ishida

Ishiguro

et al. 2014

Japanese Journal of Clinical Oncology

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Objective: This study was performed to clarify whether size criteria could be applied to the prediction of metastasis to the mesorectal, internal iliac and obturator lymph nodes in patients with lower rectal cancer. Methods: A total of 915 lymph nodes (416 mesorectal, 199 internal iliac and 300 obturator) from 53 patients with lower rectal cancer who underwent a curative resection were examined; 83 lymph nodes were positive. The sizes of the lymph nodes immediately after removal and those of paraffinembedded sections were compared for 175 lymph nodes. Then, size criteria for discriminating the status of metastasis were evaluated in 915 paraffin-embedded lymph nodes. Results: Regardless of the metastatic status and the site of the lymph nodes, a positive relationship was observed between the sizes of the lymph nodes immediately after removal and those of paraffinembedded sections (P < 0.01). The area under the curve generated by a receiver-operating characteristics curve showed no significant differences between the short-axis diameter and the long-axis diameter, regardless of the lymph node location. Specifically, the optimal cutoff value of the short-axis diameter for discriminating the status of metastasis in mesorectal, internal iliac and obturator lymph nodes extrapolated to the living body was set at 6.2, 5.0 and 4.8 mm, with accuracies of 72.4, 63.8 and 59.3% and with positive predictive values of 29.9, 16.3 and 7.1%, respectively. Conclusions: Size criteria were applicable for discriminating the metastatic status of lymph nodes from three different locations, although the positive predictive values of the size criteria for the internal iliac and obturator lymph nodes were lower than that for the mesorectal lymph nodes.

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“…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.…”

Section: Introductionmentioning

confidence: 90%

Diagnosis of lateral pelvic lymph node metastasis of T1 lower rectal cancer using diffusion-weighted magnetic resonance imaging: A case report with lateral pelvic lymph node dissection of lower rectal cancer

Ogawa

Itabashi

Hirosawa

et al. 2016

Molecular and Clinical Oncology

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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 ...

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Results of a nationwide Japanese study on lateral pelvic lymph node metastasis in low rectal cancer: Is it regional or distant disease?

Cited by 43 publications

References 0 publications

Clinical significance of enlarged lateral pelvic lymph nodes before and after preoperative chemoradiotherapy for rectal cancer

Clinical significance of enlarged lateral pelvic lymph nodes before and after preoperative chemoradiotherapy for rectal cancer

Prediction of metastasis to mesorectal, internal iliac and obturator lymph nodes according to size criteria in patients with locally advanced lower rectal cancer

Diagnosis of lateral pelvic lymph node metastasis of T1 lower rectal cancer using diffusion-weighted magnetic resonance imaging: A case report with lateral pelvic lymph node dissection of lower rectal cancer

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