Management of lateral pelvic lymph nodes in rectal cancer:Is it time to reach an Agreement?

In this editorial,we proceed to comment on the article by Chua et al,addressing the management of metastatic lateral pelvic lymph nodes(mLLN)in stage II/III rectal cancer patients below the peritoneal reflection.The treatment of this nodal area sparks significant controversy due to the strategic differences followed by Eastern and Western physicians,albeit with a higher degree of convergence in recent years.The dissection of lateral pelvic lymph nodes without neoadjuvant therapy is a standard practice in Eastern countries.In contrast,in the West,preference leans towards opting for neoadjuvant therapy with chemoradiotherapy or radiotherapy,that would cover the treatment of this area without the need to add the dissection of these nodes to the total mesorectal excision.In the presence of high-risk nodal characteristics for mLLN related to radiological imaging and lack of response to neoadjuvant therapy,the risk of lateral local recurrence increases,suggesting the appropriate selection of strategies to reduce the risk of recurrence in each patient profile.Despite the heterogeneous and retrospective nature of studies addressing this area,an international consensus is necessary to approach this clinical scenario uniformly.

Feasibility and limitations of combined treatment for lateral pelvic lymph node metastases in rectal cancer

Colorectal cancer ranks among the most commonly diagnosed cancers globally,and is associated with a high rate of pelvic recurrence after surgery.In efforts to mitigate recurrence,pelvic lymph node dissection(PLND)is commonly advocated as an adjunct to radical surgery.Neoadjuvant chemoradiotherapy(NACRT)is a therapeutic approach employed in managing locally advanced rectal cancer,and has been found to increase the survival rates.Chua et al have proposed a combination of NACRT with selective PLND for addressing lateral pelvic lymph node metastases in rectal cancer patients,with the aim of reducing recurrence and improving survival outcomes.Nevertheless,certain studies have indicated that the addition of PLND to NACRT and total mesorectal excision did not yield a significant reduction in local recurrence rates or improvement in survival.Consequently,meticulous patient selection and perioperative chemotherapy may prove indispensable in ensuring the efficacy of PLND.

Current perspectives on the management of lateral pelvic lymph nodes in rectal cancer

Significant controversies exist with regards to the optimal management of lateral pelvic lymph nodes metastases(mLLN)in patients with low rectal cancer.The differing views held by Japanese and Western clinicians on the management of mLLN have been well documented.However,the adequacy of pelvic lymph node dissection(PLND)or neoadjuvant chemoradiation(NACRT)alone in addition to total mesorectal excision(TME)have recently come into question,due to the relatively high incidence of lateral local recurrences following PLND and TME,or NACRT and TME alone.Recently,a more selective approach to PLND has been suggested,involving a combination of neoadjuvant therapy,followed by PLND only to patients in whom the oncological benefit is likely to outweigh the risk of potential adverse events.A number of studies have attempted to retrospectively identify certain nodal characteristics on preoperative imaging,such as nodal size,appearance,and size reduction following neoadjuvant therapy.However,no consensus has been reached regarding the optimal criteria for a selective approach to PLND,partly due to the heterogeneity and retrospective nature of most of these studies.This review aims to provide an overview of recent evidence with regards to the diagnostic challenges,considerations for,and outcomes of the current management strategies for mLLN in rectal cancer patients.

Lateral pelvic lymph nodes for rectal cancer:A review of diagnosis and management

The current status and future prospects for diagnosis and treatment of lateral pelvic lymph node(LPLN)metastasis of rectal cancer are described in this review.Magnetic resonance imaging(MRI)is recommended for the diagnosis of LPLN metastasis.A LPLN-positive status on MRI is a strong risk factor for metastasis,and evaluation by MRI is important for deciding treatment strategy.LPLN dissection(LPLD)has an advantage of reducing recurrence in the lateral pelvis but also has a disadvantage of complications;therefore,LPLD may not be appropriate for cases that are less likely to have LPLN metastasis.Radiation therapy(RT)and chemoradiation therapy(CRT)have limited effects in cases with suspected LPLN metastasis,but a combination of preoperative CRT and LPLD may improve the treatment outcome.Thus,RT and CRT plus selective LPLD may be a rational strategy to omit unnecessary LPLD and produce a favorable treatment outcome.

Management of synchronous lateral pelvic nodal metastasis in rectal cancer in the era of neoadjuvant chemoradiation: A systemic review

BACKGROUND Lateral pelvic lymph node(LLN)metastasis(LLNM)occur in up to 28%of patients with low rectal tumours.While prophylactic lateral pelvic lymph node dissection(LLND)has been abandoned by most western institutions in the era of neoadjuvant chemoradiation therapy(CRT),the role of selective LLND in patients with enlarged LLN on pre-CRT imaging remains unclear.Some studies have shown improved survival and recurrence outcomes when LLNs show"response"to CRT.However,no management algorithm exists to differentiate treatment for"responders"vs"non-responders".AIM To determine if selective LLND in patients with enlarged LLNs results in improved survival and recurrence outcomes.METHODS A systemic search of Pub Med and Embase databases for studies reporting on patients with synchronous radiologically suspicious LLNM(s-LLNM)in rectal cancer receiving preoperative-CRT was performed.RESULTS Fifteen retrospective,single-centre studies were included.793 patients with sLLNM were evaluated:456 underwent TME while 337 underwent TME with7,LLND post-CRT.In the TME group,local recurrence(LR)rates range from 12.5%to 36%.Five-year disease free survival(DFS)was 42%to 75%.In the TME with LLND group,LR rates were 0%to 6%.Five years DFS was 41.2%to 100%.Radiological response was seen in 58%.Pathologically positive LLN was found in up to 94%of non-responders vs 0%to 20%in responders.Young age,low tumour location and radiological non-response were associated with final positive LLNM and lowered DFS.CONCLUSION LLND is associated with local control in patients with s-LLNM.It can be performed in radiological non-responders given a large majority represent true LLNM.Its role in radiological responders should be considered in selected high risk patients.

Early drainage removal in the management of lymphatic leakage after robotic pelvic lymph node dissection

Background:Radical prostatectomy(RP)and radical cystectomy(RC)with concurrent pelvic lymph node dissection(PLND)are considered as the curative surgical treatment options for localized prostate cancer(PC)or muscle-invasive bladder cancer(BC).Regarding lymphatic leakage management after PLND,there is no standard of care,with different therapeutic approaches having been reported with varying success rates.Methods:Seventy patients underwent pelvic lymphadenectomy during robotic RP and RC with postoperative pelvic drainage volume more than 50 mL/day before the removal of drainage tube,were retrospectively evaluated in this study between August 2015 and June 2023.If the pelvic drainage volume on postoperative Day 2 was more than 50 mL/day,a drainage fluid creatinine was routinely tested to rule out urine leakage.We removed the drainage if the patient had no significant abdominal free fluid collection,no abdominal distension or pain,no fever,and no abdominal tenderness.After 1-day observation of the vital signs and abdominal symptoms,the patient was discharged and followed-up in clinic for 2 weeks after surgery.Results:Forty-one cases underwent the early drainage removal even if the pelvic drainage volume was more than 50mL/day.Among these forty-one cases,twenty-five drainage tubes were removed when drainage volume was more than 100 mL/day.All the forty-one cases with pelvic drainage volume greater than 50mL/day were successfully managed with the early drainage removal.No paracentesis or drainage placement was required.No readmission occured during the follow-up period.Conclusion:It is safe to manage the high-volume pelvic lymphatic leakage by early clamping of the drainage tube,ultrasonography assessment of no significant residual fluid in the abdominal and pelvic cavity,and then the early removal of the drainage tube.

Differences in rates of pelvic lymph node dissection in National Comprehensive Cancer Network favorable,unfavorable intermediate-and high-risk prostate cancer across United States SEER registries

Background:The National Comprehensive Cancer Network(NCCN)guidelines recommend pelvic lymph node dissection(PLND)in NCCN high-and intermediate-risk prostate cancer patients.We tested for PLND nonadherence(no-PLND)rates within the Surveillance Epidemiology and End Results(2010-2015).Materials and methods:We identified all radical prostatectomy patients who fulfilled the NCCN PLND guideline criteria(n=23,495).Nonadherence rates to PLND were tabulated and further stratified according to NCCN risk subgroups,race/ethnicity,geographic distribution,and year of diagnosis.Results:Overall,the no-PLND rate was 26%;it was 41%,25%,and 11%in the NCCN intermediate favorable,intermediate unfavorable,and high-risk prostate cancer patients,respectively(p<0.001).Overtime,the no-PLND rates declined in the overall cohort and within each NCCN risk subgroup.Georgia exhibited the highest no-PLND rate(49%),whereas New Jersey exhibited the lowest(15%).Finally,no-PLND race/ethnicity differences were recorded only in the NCCN intermediate unfavorable subgroup,where Asians exhibited the lowest no-PLND rate(20%)versus African Americans(27%)versus Whites(26%)versus Hispanic-Latinos(25%).Conclusions:The lowest no-PLND rates were recorded in the NCCN high-risk patients followed by NCCN intermediate unfavorable and favorable risk in that order.Our findings suggest that unexpectedly elevated differences in no-PLND rates warrant further examination.In all the NCCN risk subgroups,the no-PLND rates decreased over time.

Selecting lymph node-positive patients for adjuvant therapy after radical prostatectomy and extended pelvic lymphadenectomy:An outcome analysis of 100 node-positive patients managed without adjuvant therapy

Objective:The aim of the study is to evaluate the effect of deferred androgen deprivation therapy on biochemical recurrence(BCR)and other survival parameters in node-positive prostate cancer patients after robot-assisted radical prostatectomy with bilateral extended pelvic lymph node dissection(RARP+EPLND).Materials and methods:Of the 453 consecutive RARP procedures performed from 2011 to 2018,100 patients with no prior use of androgen deprivation therapy were found to be lymph node(LN)positive and were observed,with initiation of salvage treatment at the time of BCR only.Patients were divided into 1 or 2 LNs(67)-and more than 2 LNs(33)-positive groups to assess survival outcomes.Results:At a median follow-up of 21 months(1-70 months),the LN group(p<0.000),preoperative prostate-specific antigen(PSA,p=0.013),tumor volume(TV,p=0.031),and LND(p=0.004)were significantly associated with BCR.In multivariate analysis,only the LN group(p=0.035)and PSA level(p=0.026)were statistically significant.The estimated BCR-free survival rates in the 1/2 LN group were 37.6%(27%-52.2%),26.5%(16.8%-41.7%),and 19.9%(9.6%-41.0%)at 1,3,and 5 years,respectively,with a hazard of developing BCR of 0.462(0.225-0.948)compared with the more than 2 LN-positive group.Estimated 5-year overall survival,cancer-specific,metastasis-free,and local recurrence-free survival rates were 88.4%(73.1%-100%),89.5%(74%-100%),65.1%(46.0%-92.1%),and 94.8%(87.2%-100.0%),respectively,for which none of the factors were significant.Based on cutoff values for PSA,TV,and LND of 30 ng/mL,30%,and 10%,respectively,the 1/2 LN group was substratified,wherein the median BCR-free survival for the low-and intermediate-risk groups was 40 and 12 months,respectively.Conclusions:Nearly one fourth and one fifth of 1/2 node-positive patients were BCR-free at 3 and 5 years after RARP+EPLND.Further substratification using PSA,TV,and LN density may help in providing individualized care regarding the initiation of adjuvant therapy.

Fluorescence imaging-guided pelvic lymph node localization and resection of bladder cancer after intracutaneous injection of indocyanine green into the lower limbs and perineum

Background:Pelvic lymph node dissection(PLND)in radical cystectomy(RC)is of great significance,but the method and scope of PLND remain controversial.Based on the principle of indirect lymphadenography,we designed a method to localize the whole pelvic lymph nodes by intradermal injection of indocyanine green(ICG)through the lower limbs and perineum,and to evaluate the effectiveness of this method. Methods:In a single center,54 bladder cancer patients who underwent RC and PLND participated in a prospective clinical trial,which began on February 28,2022 and ended on December 30,2022.ICG solution was injected subcutaneously at the medial malleolus of both lower extremities and at both sides of the midline of the perineum.The fluorescent laparoscopy was used to trace,locate,and remove the targeted areas under the image fusion mode.The consistency of lymph node resection was determined by histopathological diagnosis.The impact of ICG guidance on the surgical time of PLND was compared with that of 11 bladder cancer patients who underwent RC and PLND without ICG injection,serving as the control group. Results:Perineal lower limb combined injection can provide comprehensive visualization of pelvic lymph nodes.This technique reduces PLND surgical time and increases the accuracy of PLND. Conclusion:Intracutaneous injection of ICG into the lower limbs and perineum can specifically mark pelvic lymph nodes.Intraoperative fluores-cence imaging can accurately identify,locate,and resect lymph nodes in the pelvic region,reducing PLND surgical time and increasing the accuracy of PLND.