Rise and fall of total mesorectal excision with lateral pelvic lymphadenectomy for rectal cancer: an updated systematic review and meta-analysis of 11,366 patients

Abstract

The role of lateral lymph node dissection (LLND) during total mesorectal excision (TME) for rectal cancer is still controversial. Many reviews were published on prophylactic LLND in rectal cancer surgery, some biased by heterogeneity of overall associated treatments. The aim of this systematic review and meta-analysis is to perform a timeline analysis of different treatments associated to prophylactic LLND vs no-LLND during TME for rectal cancer. Methods A literature search was performed in PubMed, SCOPUS and WOS for publications up to 1 September 2020. We considered RCTs and CCTs comparing oncologic and functional outcomes of TME with or without LLND in patients with rectal cancer. Results Thirty-four included articles and 29 studies enrolled 11,606 patients. No difference in 5-year local recurrence (in every subgroup analysis including preoperative neoadjuvant chemoradiotherapy), 5-year distant and overall recurrence, 5-year overall survival and 5-year disease-free survival was found between LLND group and non LLND group. The analysis of post-operative functional outcomes reported hindered quality of life (urinary, evacuatory and sexual dysfunction) in LLND patients when compared to non LLND. Conclusion Our publication does not demonstrate that TME with LLND has any oncological advantage when compared to TME alone, showing that with the advent of neoadjuvant therapy, the advantage of LLND is lost. In this review, the most important bias is the heterogeneous characteristics of patients, cancer staging, different neoadjuvant therapy, different radiotherapy techniques and fractionation used in different studies. Higher rate of functional post-operative complications does not support routinely use of LLND.

Combination of extramural venous invasion and lateral lymph node size detected with magnetic resonance imaging is a reliable biomarker for lateral lymph node metastasis in patients with rectal cancer

“…As mentioned earlier in this section, Anania et al [ 30 ] reported that TME with LLN dissection does not offer an oncological advantage over TME without LLN dissection after neoadjuvant CRT. They suggested that there is no place for ‘routine’ LLN dissection in the management of rectal cancer.…”

“…On the other hand, in Western countries, LLN metastasis is considered a distant disease and is thus treated with preoperative therapy rather than LLN dissection, and the standard strategy for lower rectal cancer is CRT followed by ME. Anania et al [ 30 ] analyzed 34 articles and 29 studies regarding the role of LLN dissection during TME. They suggested that TME with LLN dissection does not offer an oncological advantage over TME without LLN dissection after neoadjuvant CRT.…”

“…In addition, there is an option of watch and wait strategy for cases with clinical complete response after neoadjuvant treatment [ 31 , 32 ]. Despite the different treatment strategies between Japan and Western countries, the local recurrence rates are similar [ 30 , 33 ]. Each treatment strategy has its advantages and disadvantages, and therefore, the treatment strategy is still controversial.…”

Significance of Lymph Node Metastasis in the Treatment of Gastric Cancer and Current Challenges in Determining the Extent of Metastasis

“…The Z0011 study demonstrated that additional axillary nodal dissection after sentinel node biopsy does not improve prognosis in patients with breast cancer (28)(29)(30). Similarly, in many carcinomas, lymph node metastasis is thought to be important for accurate staging, but prophylactic nodal dissection does not improve prognosis (31)(32)(33)(34)(35). In contrast, the therapeutic effect of prophylactic lymph node dissection in patients with gastric cancer has been verified.…”

Fusing Dexterity and Perception for Soft Robot-Assisted Minimally Invasive Surgery: What We Learnt from STIFF-FLOP

“…Accurate positioning of the end effector tool at the target point (operating site). This is key to all precision surgery, not least of all extended lymphatic dissection, which increasingly appears to be improving the overall survival of cancer patients [12][13][14]; 2.…”