Neoadjuvant (Chemo)radiotherapy With Total Mesorectal Excision Only Is Not Sufficient to Prevent Lateral Local Recurrence in Enlarged Nodes: Results of the Multicenter Lateral Node Study of Patients With Low cT3/4 Rectal Cancer

Abstract

Purpose: Improvements in magnetic resonance imaging (MRI), total mesorectal excision (TME) surgery, and the use of (chemo)radiotherapy ([C]RT) have improved local control of rectal cancer; however, we have been unable to eradicate local recurrence (LR). Even in the face of TME and negative resection margins (R0), a significant proportion of patients with enlarged lateral lymph nodes (LLNs) suffer from lateral LR (LLR). Japanese studies suggest that the addition of an LLN dissection (LLND) could reduce LLR. This multicenter pooled analysis aims to ascertain whether LLNs actually pose a problem and whether LLND results in fewer LLRs.

Patients and methods: Data from 1,216 consecutive patients with cT3/T4 rectal cancers up to 8 cm from the anal verge who underwent surgery in a 5-year period were collected. LLND was performed in 142 patients (12%). MRIs were re-evaluated with a standardized protocol to assess LLN features.

Results: On pretreatment MRI, 703 patients (58%) had visible LLN, and 192 (16%) had a short axis of at least 7 mm. One hundred eight patients developed LR (5-year LR rate, 10.0%), of which 59 (54%) were LLRs (5-year LLR rate, 5.5%). After multivariable analyses, LLNs with a short axis of at least 7 mm resulted in a significantly higher risk of LLR (hazard ratio, 2.060; P = .045) compared with LLNs of less than 7 mm. In patients with LLNs at least 7 mm, (C)RT plus TME plus LLND resulted in a 5-year LLR of 5.7%, which was significantly lower than that in patients who underwent (C)RT plus TME (5-year LLR, 19.5%; P = .042).

Conclusion: LLR is still a significant problem after (C)RT plus TME in LLNs with a short axis at least 7 mm on pretreatment MRI. The addition of LLND results in a significantly lower LLR rate.

FIG 1.

(A) Lateral local recurrence rate, (B) local recurrence, (C) distant recurrence, and (D) cancer-specific survival according to lateral lymph node (LLN) short axis (SA) size in patients who received (chemo)radiotherapy.

FIG 2.

Effect of lateral lymph node dissection (LLND) on lateral local recurrence in patients with a short axis ≥ 7 mm on pretreatment magnetic resonance imaging in patients who received (chemo)radiotherapy.

FIG A1.

An example slide of the color map atlas of the pelvis. (A) Atlas of the pelvis. (B) The obturator and internal iliac areas are divided by the lateral border of the main trunk of the internal iliac vessels. External iliac region (red); obturator region (green); internal iliac region (blue); internal iliac artery (arrow head). (C) Benign long-stretched node just behind distal portion of the external iliac vein that should not be included in the assessment (arrow head). EIA, external iliac artery; EIV, external iliac vein; ObV, obturator vein; IOM, internal obturator muscle; Inf VV, inferior vesical vein; Int pud. a/v, internal pudendal artery/vein; Coccygeal m., coccygeal muscle (arrow).