Management of para-aortic lymph node metastasis in colorectal patients: A systemic review. Surg Oncol. 2016;25:411-418. [PMID: 27916174 DOI: 10.1016/j.suronc.2016.09.008]

Long-term outcomes and prognostic factor of metachronous para-aortic lymph node metastasis in colorectal cancer

AIM

Despite the relatively rare incidence of para-aortic lymph node metastasis (PALNM) after surgery for colorectal cancer, it is often fatal, and treatment strategy is still debated. This study aimed to investigate the long-term outcomes of patients with metachronous PALNM and their prognostic factors.

METHOD

Thirty-six institutions belonging to the Japanese Society for Cancer of the Colon and Rectum participated in this retrospective cohort study. A total of 148 patients with metachronous PALNM after resection of primary colorectal cancer between January 2011 and December 2015 were included in the analysis.

RESULTS

Of the 148 patients, 37 received PALNM resection, whereas 111 did not. The primary tumour characteristics were not different between the resection and non-resection groups. The median number of PALNMs was significantly larger and synchronous metastasis other than PALNM was more frequent in the non-resection group than in the resection group (2 vs. 1, P = 0.030; 71.2% vs. 29.7%, P < 0.001). The 5-year overall survival rate in the whole cohort was 30.6%, which was significantly higher in the resection group than in the non-resection group (P < 0.0001). The resection method of PALNM did not affect survival. Undifferentiated tumour, ≥4 PALNMs, synchronous metastasis other than PALNM, and non-resection of PALNM were significant unfavourable prognostic factors in the multivariate Cox regression analysis.

CONCLUSION

PALNM resection appears desirable when it is feasible in patients with metachronous PALNM. However, surgeons should also consider unfavourable prognostic factors including undifferentiated tumour, ≥4 PALNMs and synchronous metastasis other than PALNM.

Role of Adjuvant Chemotherapy After Surgical Resection of Paraaortic Lymph Node Metastasis from Colorectal Cancer-A Multicenter Retrospective Study

BACKGROUND

Surgical removal of metastasized paraaortic lymph nodes (PALNs) can prolong the survival of certain patients with colorectal cancer (CRC). However, the role of postoperative chemotherapy in such patients remains unknown.

PATIENTS AND METHODS

This multicenter retrospective study examined 97 patients with PALN metastasis from CRC who underwent surgical resection at 36 centers in Japan between 2010 and 2015. On the basis of adjuvant chemotherapy (AC) after the lymphadenectomy, patients were classified into non-AC and AC groups (27 and 70 patients, respectively). After the exclusion of patients receiving irinotecan, the latter group was further categorized into 5-fluorouracil (5-FU) and oxaliplatin (L-OHP) subgroups (14 and 52 patients, respectively) according to the use of L-OHP. Background characteristics and postoperative survival were compared among the groups.

RESULTS

Marked differences were not seen in background characteristics, except for neoadjuvant treatment, between the non-AC and AC groups. The AC group exhibited better recurrence-free survival (RFS; p = 0.009) and overall survival (OS; p = 0.040 by the Wilcoxon test) than the non-AC group. However, RFS and OS of the 5-FU group did not differ from those of the L-OHP group (p = 0.73 and p = 0.92 by the Wilcoxon test, respectively).

CONCLUSIONS

AC may be associated with improved prognosis of patients after the removal of PALN metastasis from CRC, but L-OHP did not offer additional survival benefits. Prospective studies comparing non-AC with 5-FU- and L-OHP-based AC are needed to confirm these findings.

Real-world outcomes of stage II and III colorectal cancers treated by postoperative adjuvant chemotherapy based on the mismatch repair status

PURPOSE

In Japan, immunohistochemistry for mismatch repair (MMR) proteins targeted at stage II and III colorectal cancers (CRCs) has been covered by national insurance since October, 2022. This study aimed to clarify the long-term outcomes of patients with stage II and III CRCs receiving postoperative adjuvant chemotherapy based on their MMR status.

METHODS

The outcomes of 640 patients who underwent radical surgery for stage II and III CRCs were analyzed retrospectively.

RESULTS

Deficient MMR (dMMR) was diagnosed in 41 (13.3%) patients with stage II and 28 (9.1%) patients with stage III CRC. The overall survival and recurrence rates were not significantly different between the patients with stage II and those with stage III CRC. The risk factors for recurrence among those with stage II CRC were tumors on the left side, T4 disease, and the presence of BRAF wild type. The recurrence rates were lower in the stage II CRC patients with sporadic dMMR than in those with suspected Lynch syndrome (LS). The first site of recurrence was more frequently the peritoneum or distant lymph node in patients with dMMR.

CONCLUSIONS

Stage II CRC patients with sporadic dMMR were found to have a very good prognosis. On the other hand, peritoneal dissemination or distant lymph node metastasis tended to develop in patients with dMMR.

Focusing on chylous ascites: a noteworthy complication after laparoscopic/robotic para-aortic lymphadenectomy in left-sided colorectal cancer in a high-volume single center

BACKGROUND

This study aimed to evaluate the incidence, severity, and treatment modalities of chylous ascites after laparoscopic/robotic para-aortic lymph node (PALN) dissection for left-sided colorectal cancer (CRC).

METHODS

A cohort of 143 patients who underwent laparoscopic PALN dissection for left-sided CRC were included. The least absolute shrinkage and selection operator (LASSO) and logistic regression analysis were performed to identify risk factors for the occurrence of chylous ascites.

RESULTS

Chylous ascites occurred in 27 (18.8%) patients. Multivariate logistic regression analysis demonstrated that prognostic nutritional index (PNI ≤ 46, OR = 3.18, P = 0.03), use of indocyanine green (ICG) fluorescence imaging (OR = 2.92, P = 0.04), and number of total retrieved lymph nodes (LNs) > 25 (OR = 5.41, P = 0.01) were independently correlated with the occurrence of chylous ascites. A nomogram predicting postoperative chylous ascites was developed, with a C-index of 0.75. Based on the grading system, 63.0% (17/27) were classified as Grade A, 22.2% (6/27) as Grade B, and 14.8% (4/27) as Grade C. The use of ICG fluorescence during surgery and the number of total retrieved PALNs were correlated with prolonged resolution (Grade B/C) of chylous ascites (P = 0.02 and P = 0.04).

CONCLUSIONS

Postoperative chylous ascites represents a common and significant complication after laparoscopic/robotic PALN dissection for CRC surgery. PNI ≤ 46, ICG fluorescence imaging guidance, and total LN retrieval are independent risk factors. The use of ICG fluorescence during surgery and total retrieved PALNs are correlated with the prolonged resolution of chylous ascites. Further study is needed to validate these findings.

Indocyanine green highlights the lymphatic drainage pathways, enhancing the effectiveness of radical surgery for mid-low rectal cancer: A non-randomized controlled prospective study

BACKGROUND

Fluorescence-guided lymphadenectomy (FLND) using indocyanine green (ICG) has emerged as a promising technique to enhance the accuracy of lymphadenectomy in rectal cancer surgery. Effective lymphadenectomy is crucial for improving prognosis in patients with advanced rectal cancer, but it remains technically challenging and controversial.

METHODS

This prospective nonrandomized controlled study was conducted involving 129 patients underwent laparoscopic surgery, and 64 patients assisted by FLND. Patients received submucosal ICG injections before surgery to facilitate FLND. Lymph nodes were categorized as station 251, station 252, or station 253 based on their anatomical locations. The effectiveness of FLND was evaluated by comparing the number of harvested and metastatic lymph nodes between the FLND and control groups.

RESULTS

The FLND group demonstrated a significantly higher median number of harvested station 253 lymph nodes compared to the control group (2.0 vs. 1.0, P = 0.007). The FLND cohort had a shorter postoperative hospital stay (6 days vs. 8 days, P < 0.001) and similar rates of postoperative complications compared to the control cohort. The study found no significant differences in the median number of harvested station 251 (10.0 vs. 11.0, P = 0.872) and station 252 (6.0 vs. 5.0, P = 0.369) lymph nodes between the groups. Univariate and multivariate analyses indicated that FLND significantly increased the harvested lymph node count.

CONCLUSION

Radical surgery assisted by FLND significantly improves the accuracy and yield of lymphadenectomy in mid-low rectal cancer, enhancing surgical outcomes and patient prognosis. Future advancements in fluorescence imaging and related technologies hold promise for further improving the clinical effectiveness of this technique.

Prognostic Impact of Para-Aortic Lymph Node Dissection in Colorectal Cancer Patients Suspected of Para-Aortic Lymph Node Metastasis: A Retrospective Cohort Study

BACKGROUND

Para-aortic lymph node metastasis (PALNM) is a rare occurrence in colorectal cancer (CRC), and the high risk of radical lymphadenectomy leads to persistent debate about the best treatment strategy. This study aims to evaluate the predictor for PALNM and the clinical value of para-aortic lymph node dissection (PALND) in CRC patients with radiologically suspected synchronous PALNM.

METHODS

Patients who have synchronous radiologically suspected PALNM and underwent primary tumor resection were included. Logistic regression and receiver operating characteristic curve analysis were used to assess the predictive value of lymph node short axis in preoperative CT, identifying the optimal cut-off value. Propensity score matching and Cox regression explored factors affecting overall and disease-free survival, while Kaplan-Meier curves and decision tree models identified patient characteristics suitable for synchronous para-aortic lymph node dissection.

RESULTS

A total of 578 patients were enrolled, and 125 patients received synchronous PALND. We found that simultaneous PALND significantly improved overall survival (HR, 0.56; 95% CI, 0.35-0.91; P = .019) in multivariate analysis, while disease-free survival showed no significant difference (P = .41). The short axis diameter of PALN on preoperative CT is a crucial predictor of PALNM (P < .001, AUC = 0.759) with a threshold of > 7 mm. N-stage and distant metastasis were included as independent predictors in the diagnostic model to enhance accuracy. A larger short axis diameter of PALN correlated with advanced tumor stage and poorer prognosis. Subgroup analysis revealed that PALND offers survival benefits for colorectal cancer patients at all stages with a short axis diameter >10 mm on preoperative CT (P = .037) and for stage III patients with a diameter between 7 to10 mm (P < .001, AUC = 0.810).

CONCLUSION

Synchronous PALND can improve overall survival in CRC patients with suspected PALNM, with the maximum short axis diameter of PALN serving as a key criterion for selecting patients for surgery.

Safety and efficacy of indocyanine green fluorescence imaging-guided laparoscopic para-aortic lymphadenectomy for left-sided colorectal cancer: Preliminary results of a case-matched study

AIM

This study is aimed to explore the safety and feasibility of indocyanine green (ICG) fluorescence imaging guidance in laparoscopic para-aortic lymph node (PALN) dissection for left-sided colorectal cancer (CRC) patients with clinically suspected PALN metastasis.

METHOD

A total of 151 patients who underwent primary tumor resection and laparoscopic PALN dissection for left-sided CRC were included, with 20 patients in the ICG group and 131 patients in the non-ICG group. The surgical outcomes, postoperative complications, and pathological results, such as the number of harvested and metastatic lymph nodes were compared between groups after propensity score matching.

RESULTS

Following propensity score matching, the ICG group had 20 patients, and the non-ICG group had 53 patients, and the two groups were similar in baseline characteristics. No significant differences were observed in overall intraoperative and postoperative complications between groups, except for chylous leakage, where the ICG group had a longer time to a normal diet. The number of harvested pericolic/perirectal and intermediate lymph nodes were comparable between the two groups, while the ICG group had a significantly higher number of total harvested lymph nodes (39 [14-78] vs. 29 [11-70], P = 0.001), inferior mesenteric artery lymph nodes (IMALN, 6 [0-17] vs. 3 [0-11], P = 0.006), and PALNs (9 [3-29] vs. 5 [1-37], P = 0.001).

CONCLUSION

ICG fluorescence imaging could increase the retrieval of IMALN, PALN, and total lymph nodes, and potentially improve the completeness of laparoscopic PALN dissection in patients with left-sided CRC.

Long-term Outcome After Surgical Resection of Para-aortic Lymph Node Metastasis of Colorectal Cancer: A Multicenter Retrospective Study

BACKGROUND

The significance of resection of para-aortic lymph node metastasis in colorectal cancer is controversial.

OBJECTIVE

To clarify the prognosis of colorectal cancer after para-aortic lymph node metastasis resection.

DESIGN

Multicenter retrospective study.

SETTINGS

Thirty-six institutions in Japan participated in this study. Database and medical records at each institution were used for data collection.

PATIENTS

Patients with resected and pathologically proven para-aortic lymph node metastasis of colorectal cancer between 2010 and 2015 were included.

MAIN OUTCOME MEASURES

Overall survival after para-aortic lymph node metastasis resection, recurrence-free survival, and recurrence patterns after R0 resection of para-aortic lymph node metastasis.

RESULTS

A total of 133 patients were included in the primary analysis population in this study. The 5-year overall survival rate (95% CI) was 41.0% (32.0-49.8), and the median survival (95% CI) was 4.1 (3.4-4.7) years. Independent prognostic factors for overall survival were the pathological T stage (pT4 vs pT1- 3, adjusted HR: 1.91, p = 0.006), other organ metastasis (present vs absent, adjusted HR: 1.98, p = 0.005), time to metastases (synchronous vs metachronous adjusted HR: 2.02, p = 0.02), and the number of para-aortic lymph node metastasis (3 or more vs less than 3, adjusted HR: 2.13, p = 0.001). The 5-year recurrence-free survival rate (95% CI) was 21.1% (13.5-29.7), with a median (95% CI) of 1.2 (0.9-1.4) years. The primary tumor location (left- vs right-sided colon, adjusted HR: 4.77, p = 0.01; rectum vs right-sided colon, adjusted HR: 5.27, p = 0.006), other organ metastasis (present vs absent, adjusted HR: 1.90, p = 0.03), number of para-aortic lymph node metastases (3 or more vs less than 3, adjusted HR: 2.20, p = 0.001), and hospital volume (less than 10 vs 10 or more, adjusted HR: 2.18, p = 0.02) were identified as independent prognostic factors for recurrence-free survival. Para-aortic lymph node recurrence was the most common at 33.3%.

LIMITATIONS

Selection bias cannot be ruled out because of the retrospective nature of the study.

CONCLUSIONS

Less than 3 para-aortic lymph node metastases were a favorable prognostic factor for overall and recurrence-free survival. However, para-aortic lymph node metastases were considered to be a systemic disease, and the significance of resection was limited. See Video Abstract .

RESULTADO A LARGO PLAZO POSTERIOR A LA RESECCIN QUIRRGICA DE METSTASIS EN GANGLIOS LINFTICOS PARAARTICOS DE CNCER COLORRECTAL UN ESTUDIO RETROSPECTIVO MULTICNTRICO

ANTECEDENTES:La importancia de la resección de metástasis en los ganglios linfáticos paraaórticos (PALNM) en el cáncer colorrectal (CCR) es controvertida.OBJETIVO:Aclarar el pronóstico del CCR después de la resección PALNM.DISEÑO:Estudio retrospectivo multicéntrico.ENTORNO CLINICO:Treinta y seis instituciones en Japón participaron en este estudio.PACIENTES:Pacientes con PALNM de CCR resecado y patológicamente probado entre 2010 y 2015.FUENTES DE DATOS:Base de datos y registros médicos de cada institución.PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia general (SG) después de la resección PALNM, supervivencia libre de recurrencia (SLR) y patrones de recurrencia después de la resección R0 de PALNM.RESULTADOS:Se incluyó un total de 133 pacientes en la población de análisis primario de este estudio. La tasa de SG a 5 años (intervalo de confianza [IC] del 95 %) fue del 41,0 % (32,0, 49,8) y la mediana de supervivencia (IC del 95 %) fue de 4,1 (3,4, 4,7) años. Los factores de pronóstico independientes para la SG fueron el estadio T patológico (pT4 vs. pT1-3, índice de riesgo ajustado [aHR]: 1,91, p = 0,006), metástasis en otros órganos (presente vs. ausente, aHR: 1,98, p = 0,005), tiempo hasta las metástasis (síncronas vs. metacrónicas, aHR: 2,02, p = 0,02) y número de PALNM (≥3 vs. <3, aHR: 2,13, p = 0,001). La tasa de SLR a 5 años (IC del 95%) fue del 21,1% (13,5, 29,7), con una mediana (IC del 95%) de 1,2 (0,9, 1,4) años. La ubicación del tumor primario (colon del lado izquierdo vs. derecho, aHR: 4,77, p = 0,01; recto vs. colon del lado derecho, aHR: 5,27, p = 0,006), metástasis en otros órganos (presente vs. ausente, aHR: 1,90, p = 0,03), el número de PALNM (≥3 vs. <3, aHR: 2,20, p = 0,001) y el volumen hospitalario (<10 vs. ≥10, aHR: 2,18, p = 0,02) se identificaron como independientes factores pronósticos del SLR. La recurrencia de los ganglios linfáticos paraaórticos fue la más común con un 33,3%.LIMITACIONES:No se puede descartar un sesgo de selección debido a la naturaleza retrospectiva del estudio.CONCLUSIONES:Menos de tres PALNM fue un factor pronóstico favorable tanto para la SG como para la SLR. Sin embargo, las PALNM se consideraron una enfermedad sistémica y la importancia de la resección fue limitada. (Traducción- Dr. Francisco M. Abarca-Rendon ).

Prophylactic para-aortic lymph node dissection in Colo-rectal cancer; pilot study

BACKGROUND

Colorectal cancer is the 3rd most common cancer worldwide, representing 10% of all cancer types, and is considered the 2nd leading cause of cancer-related deaths. It usually metastasizes to the liver or lung. Para-aortic lymph node metastasis is considered a metastatic disease (stage 4) according to the AJCC and is considered a regional disease (stage 3) according to the JSCCR. Para-aortic lymph node metastases occur in about 1% of cases. Neoadjuvant CTH, followed by PALN, is the best option for metastatic para-aortic LNs in colorectal cancer patients. This study addresses the value of prophylactic para-aortic LN dissection among colon-rectal cancer patients (overtreatment protocol).

METHODOLOGY

This is a prospective study that included patients attending NCI, Cairo University, from December 2020 to December 2023 who were complaining of left colonic cancer or recto-sigmoid cancer and underwent left hemicolectomy, sigmoid colectomy, or LAR. All patients underwent formal mesenteric LN dissection and prophylactic para-aortic LN dissection.

RESULTS

Among 60 patients who underwent colorectal surgery with prophylactic para-aortic LN dissection, 21 cases (35%) were in the descending colon, 22 cases (36.7%) were in the sigmoid colon, 11 cases (18.3%) were in the recto-sigmoid, and 6 cases (10%) were in the upper rectum. 55 cases (91.7%) were in grade 2, and 5 cases (8.3%) were in grade 3. Neoadjuvant CTH was given in 3 cases (5%) while neoadjuvant RTH was given in 6 cases (10%). Regarding reported postoperative complications, lymphorrhea was reported in 2 patients (3.3%) and wound infection occurred in 6 patients (10%). A recurrence was reported among 8 cases (13.4%).

CONCLUSIONS

We aimed in this study to highlight the value of prophylactic para-aortic lymph node dissection among colorectal cancer patients (over-treatment protocol) and report its reflection on predicting the behavior of the disease and subsequently selecting the patients who will be suitable to do this procedure.

Para-aortic Lymph Node Dissection for Colorectal Cancer: Predicting Pathologic Lymph Node Positivity and Optimizing Outcomes

INTRODUCTION

In colorectal cancer, the presence of para-aortic lymph nodes (PALN) indicates extraregional disease. Appropriately selecting patients for whom PALN dissection will provide oncologic benefit remains challenging. This study identified factors to predict survival among patients undergoing PALN dissection for colorectal cancer.

METHODS

An institutional database was queried for patients who underwent curative-intent resection of clinically positive PALN for colorectal cancer between 2007 and 2020. Preoperative radiologic images were reviewed, and patients who did and did not have positive PALN on final pathology were compared. Survival analysis was performed to evaluate the impact of pathologically positive PALN on recurrence-free (RFS) and overall survival (OS).

RESULTS

Of 74 patients who underwent PALN dissection, 51 had PALN metastasis at the time of primary tumor diagnosis, whereas 23 had metachronous PALN disease. Preoperative chemotherapy ± radiotherapy was given in 60 cases (81.1%), and 28 (37.8%) had pathologically positive PALN. Independent factors associated with positive PALN pathology included metachronous PALN disease and pretreatment and posttreatment radiographically abnormal PALN. On multivariable analysis, pathologically positive PALN was significantly associated with decreased RFS (hazard ratio 3.90) and OS (HR 4.49). Among patients with pathologically positive PALN, well/moderately differentiated histology was associated with better OS, and metachronous disease trended toward an association with better OS.

CONCLUSIONS

Pathologically positive PALN are associated with poorer RFS and OS after PALN dissection for colorectal cancer. Clinicopathologic factors may predict pathologic PALN positivity. Curative-intent surgery may provide benefit, especially in patients with well-to-moderately differentiated primary tumors and possibly metachronous PALN disease.

Surgical navigation for targeted retroperitoneal lymph-node removal: a randomised, controlled, phase 3 trial

Background

Metastatic retroperitoneal lymph node dissection (LND) for nodal recurrence is applied for a variety of cancers, such as urological, gynaecological and rectal cancer. Precise localisation and resection of these lymph nodes (LNs) during surgery can be challenging, especially after previous radiotherapy or surgery. The objective of this study was to assess the added value of surgical navigation for targeted LND in the retroperitoneum.

Methods

We performed an open-label randomised, controlled, phase 3 trial at the Netherlands Cancer Institute, Amsterdam. Eligible participants were over 18 years of age, scheduled for targeted retroperitoneal LND by laparotomy, with removal of one or more suspected (targeted) LN(s) as assessed by diagnostic imaging. Patients were randomised (1:1) between conventional LND and LND using surgical navigation, by means of a minimisation method stratified for tumour origin (urological, colorectal and other). For the surgical navigation, a digital 3D model of the patients' anatomy was created from diagnostic CT scans, including delineation of the targeted LN(s). The 3D model was linked to the patients' position in the operation room. Using an electromagnetic tracking system, with a sterile tracked pointer, the actual position of the pointer was shown in the 3D model, enabling the surgeon to localize the targeted LN(s). The primary outcome of the study was the percentage of successful procedures. Success was defined as no residual target LN(s) visible on postoperative CT imaging. This study was registered with ClinicalTrials.gov, NCT05867095.

Findings

From January 2017 to December 2020, 69 participants were included in the study, 35 (51%) in the conventional arm and 34 (49%) in the navigation arm. Four patients were not evaluable and excluded from further analysis; three in the conventional arm (patients withdraw from study participation), one in the navigation arm (discontinued surgery, misclassified diagnosis). According to intention-to-treat analysis, 50% (16/32) of the surgical procedures was successful in the conventional arm, versus 85% (28/33) in the surgical navigation arm (one-tailed p = 0.0028, 90% CI: 14%-56%). Using the Clavien-Dindo classification, the overall complication rate was comparable between the conventional arm and the navigation arm. Surgeons judged the surgical navigation setup as valuable, the median preference score to use surgical navigation was 3.7 (3.3-4.0) (scale 1-5), and the median system usability score was 75 (70-85) (scale 0-100).

Interpretation

Surgical navigation allows for significantly better localisation and removal of target LN(s) in the retroperitoneum.

Funding

This research was supported by the KWF-Alpe d'HuZes (NKI 2014-6596) and by an institutional grant of The Dutch Cancer Society and of the Dutch Ministry of Health, Welfare and Sport.

Standardize the surgical technique and clarify the oncologic significance of robotic D3-D4 lymphadenectomy for upper rectum and sigmoid colon cancer with clinically more than N2 lymph node metastasis

BACKGROUND

The territory of D3-D4 lymphadenectomy for upper rectal and sigmoid colon cancer varies, and its oncological efficacy is unclear. This prospective study aimed to standardize the surgical technique of robotic D3-D4 lymphadenectomy and clarify its oncologic significance.

METHODS

Patients with upper rectal or sigmoid colon cancer with clinically suspected more than N2 lymph node metastasis were prospectively recruited to undergo standardized robotic D3-D4 lymphadenectomy. Immediately postsurgery, the retrieved lymph nodes were mapped to five N3-N4 nodal stations: the inferior mesenteric artery, para-aorta, inferior vena cava, infra-renal vein, and common iliac vessels. Patients were stratified according to their nodal metastasis status to compare their clinicopathological data and overall survival. Univariate and multivariate analyses were performed to determine the relative prognostic significance of the five specific nodal stations. Surgical outcomes and functional recovery of the patients were assessed using the appropriate variables.

RESULTS

A total of 104 patients who successfully completed the treatment protocol were assessed. The standardized D3-D4 lymph node dissection harvested sufficient lymph nodes (34.4±7.2) for a precise pathologic staging. Based on histopathological analysis, 28 patients were included in the N3-N4 nodal metastasis-negative group and 33, 34, and nine patients in the single-station, double-station, and triple-station nodal metastasis-positive groups, respectively. Survival analysis indicated no significant difference between the single-station nodal metastasis-positive and N3-N4 nodal metastasis-negative groups in the estimated 5-year survival rate [53.6% (95% CI: 0.3353-0.7000) vs. 71.18% (95% CI: 0.4863-0.8518), P=0.563], whereas patients with double-station or triple-station nodal metastatic disease had poor 5-year survival rates (24.76 and 22.22%), which were comparable to those of AJCC/UICC stage IV disease than those with single-station metastasis-positive disease. Univariate analysis showed that the metastatic status of the five nodal stations was comparable in predicting the overall survival; in contrast, multivariate analysis indicated that common iliac vessels and infra-renal vein were the only two statistically significant predictors (P<0.05) for overall survival.

CONCLUSIONS

Using a robotic approach, D3-D4 lymph node dissection could be safely performed in a standardized manner to remove the relevant N3-N4 lymphatic basin en bloc, thereby providing significant survival benefits and precise pathological staging for patients. This study encourages further international prospective clinical trials to provide more solid evidence that would facilitate the optimization of surgery and revision of the current treatment guidelines for such a clinical conundrum.

Pathologic Complete Response and Long-Term Survival After Preoperative Chemotherapy for Transverse Colon Cancer With Para-Aortic Lymph Node Metastases

A 52-year-old male patient was diagnosed with transverse colon cancer and synchronous stage IVA para-aortic lymph node (PALN) metastases (cT3N1bM1a of the lymph node). Six courses of mFOLFOX6 plus bevacizumab were administered as neoadjuvant chemotherapy. Computed tomography showed shrinkage of the primary tumor and PALN metastases. Extended right hemicolectomy, D3 lymph node dissection, and PALN dissection were performed. A pathologic examination indicated that the tumor had completely changed and comprised necrotic tissue with no viable cells. Therefore, it was considered that mFOLFOX6 plus bevacizumab resulted in a pathologic complete response. Postoperatively, six courses of mFOLFOX6 were administered. Six years postoperatively, the patient did not exhibit any signs of recurrence. There have been few reports of pathologic complete response after neoadjuvant therapy and resection for colon cancer with synchronous PALN metastases. This report describes a unique case involving a pathologic complete response with long-term survival after mFOLFOX6 plus bevacizumab and radical resection, including PALN dissection. Preoperative mFOLFOX6 plus bevacizumab followed by radical resection and adjuvant mFOLFOX6 therapy was safe and resulted in a good outcome. This regimen should be considered for advanced colon cancer with PALN metastases.

The management of clinically suspicious para-aortic lymph node metastasis in colorectal cancer: A systematic review

Approximately 1%-2% of patients with colorectal cancer (CRC) develop para-aortic lymph node (PALN) metastases, which are typically considered markers of systemic disease, and are associated with a poor prognosis. The utility of PALN dissection (PALND) in patients with CRC is of ongoing debate and only small-scale retrospective studies have been published on this topic to date. This systematic review aimed to determine the utility of resecting PALN metastases with the primary outcome measure being the difference in survival outcomes following either surgical resection or non-resection of these metastases. A comprehensive systematic search was undertaken to identify all English-language papers on PALND in the PubMed, Medline, and Google Scholar databases. The search results identified a total of 12 eligible studies for analysis. All studies were either retrospective cohort studies or case series. In this systematic review, PALND was found to be associated with a survival benefit when compared to non-resection. Metachronous PALND was found to be associated with better overall survival as compared to synchronous PALND, and the number of PALN metastases (2 or fewer) and a pre-operative carcinoembryonic antigen level of <5 was found to be associated with a better prognosis. No PALND-specific complications were identified in this review. A large-scale prospective study needs to be conducted to definitively determine the utility of PALND. For the present, PALND should be considered within a multidisciplinary approach for patients with CRC, in conjunction with already established treatment regimens.

Multicenter study of prognostic factors in paraaortic lymph node dissection for metastatic colorectal cancer

Purpose

The role of paraaortic lymph node dissection (PALND) in colorectal cancer (CRC) has been less evaluated than surgical treatments for other distant metastases. We evaluated surgical outcomes after PALND and identified prognostic factors.

Methods

The medical records of patients who underwent PALND for paraaortic lymph node metastasis (PALNM) were reviewed retrospectively. All patients were categorized into the M1a group (isolated PALNM, n = 27), and the M1bc group (distant metastases other than PALNM, n = 26). Three severity factors (PALNM-SF: number of harvested paraaortic lymph nodes [hLN], ≥14; number of metastatic paraaortic lymph nodes [mLN], ≥5; and lymph nodes ratio [mLN/hLN], ≥0.5) were defined to determine their effects on survival.

Results

The 5-year overall survival (OS) of the M1a and M1bc groups were 61.1% and 6.4%, respectively (P = 0.0013). The 5-year disease-free survival (DFS) of the M1a group was 47.4%, and the 3-year DFS of the M1bc group was 9.1% (P < 0.001). Patients with 2 or more PALNM-SFs showed worse OS than those with 1 PALNM-SF (P = 0.017). In multivariate analysis, M1bc (non-isolated PALNM) was the only significant factor for survival. In the M1a group, patients with 2 or more PALNM-SFs showed significantly worse survival than those with a single PALNM-SF. In multivariate analysis, 2 or more PALNM-SF was a significant factor for survival.

Conclusion

PALND for CRC provided favorable outcomes in the survival of an isolated PALNM, although this was uncertain for non-isolated PALNMs. The PALNM-SFs helped assess the prognosis after PALND.

Outcomes of surgical resection and intraoperative electron radiotherapy for patients with para-aortic recurrences of gastrointestinal and gynecologic malignancies

BACKGROUND

Para-aortic lymph node (PALN) metastases from primary pelvic malignancies are often treated with resection, but recurrence is common. We report toxicity and oncologic outcomes for patients with PALN metastases from gastrointestinal and gynecologic malignancies treated with resection and intraoperative electron radiotherapy (IORT).

METHODS

We retrospectively identified patients with recurrent PALN metastases who underwent resection with IORT. All patients were included in the local recurrence (LR) and toxicity analyses. Only patients with primary colorectal tumors were included in the survival analysis.

RESULTS

There were 26 patients with a median follow up of 10.4 months. The rate of para-aortic local control (LC) was 77% (20/26 patients) and the rate of any cancer recurrence was 58% (15/26 patients). Median time from surgery and IORT to any recurrence was 7 months. The LR rate for those with positive/close margins was 58% (7/12 patients) versus 7% (1/14 patients) for those with negative margins (p = 0.009). 15% (4/26 patients) developed surgical wound and/or infectious complications, 8% (2/26 patients) developed lower extremity edema, 8% (2/26 patients) experienced diarrhea, and 19% (5/26 patients) developed an acute kidney injury. There were no reported nerve injuries, bowel perforations, or bowel obstructions. For patients with primary colorectal tumors (n = 19), the median survival (OS) was 23 months.

CONCLUSIONS

We report favorable LC and acceptable toxicity for patients receiving surgical resection and IORT for a population that has historically poor outcomes. Our data show disease control rates similar to literature comparisons for patients with strong risk factors for LR, such as positive/close margins.

Survival outcomes after synchronous para-aortic lymph node metastasis in colorectal cancer: A systematic review

BACKGROUND

Synchronous para-aortic lymph node metastasis (PALNM) in colorectal cancer (CRC) is a relatively rare clinical entity. There is a lack of consensus on management of these patients, and the role of para-aortic lymph node dissection (PALND) remains controversial. This systematic review aims to describe the survival outcomes in colorectal cancer with synchronous PALNM when lymph node dissection is performed.

METHODS

A systematic review of Pubmed, Embase and Web of Science databases for PALND in CRC was performed. Studies including patients with synchronous PALNM undergoing resection with curative intent, published from the year 2000 onwards, were included.

RESULTS

Twelve retrospective studies were included. Four studies reported survival outcomes for rectal cancer, two for colon cancer and six as colorectal. Survival outcomes for 356 patients were included. Average 5-year overall survival (OS) was 22.4%, 33.9% and 37.7% in the rectal, colon and colorectal groups respectively. Three year OS in the groups was 53.6%, 46.2% and 65.7%.

CONCLUSION

There remains a lack of quality data to confidently make recommendations regarding the management of synchronous PALNM in colon and rectal cancer cohorts. Retrospective data suggests a benefit in highly selective cohorts and therefore a case-by-case evaluation remains the standard of care.

Retroperitoneal Lymph Node Dissection in Colorectal Cancer with Lymph Node Metastasis: A Systematic Review

The benefits and prognosis of RPLND in CRC have not yet been fully established. This systematic review aimed to evaluate the outcomes for CRC patients with RPLNM undergoing RPLND. A literature search of MEDLINE, EMBASE, EMCare, and CINAHL identified studies from between January 1990 and June 2022 that reported data on clinical outcomes for patients who underwent RPLND for RPLNM in CRC. The following primary outcome measures were derived: postoperative morbidity, disease free-survival (DFS), overall survival (OS), and re-recurrence. Nineteen studies with a total of 541 patients were included. Three hundred and sixty-three patients (67.1%) had synchronous RPLNM and 178 patients (32.9%) had metachronous RPLNM. Perioperative chemotherapy was administered in 496 (91.7%) patients. The median DFS was 8.6-38.0 months and 5-year DFS was 24.4% (10.0-60.5%). The median OS was 25.0-83.0 months and 5-year OS was 47.0% (15.0-87.5%). RPLND is a feasible treatment option with limited morbidity and possible oncological benefit for both synchronous and metachronous RPLNM in CRC. Further prospective clinical trials are required to establish a better evidence base for RPLND in the context of RPLNM in CRC and to understand the timing of RPLND in a multimodality pathway in order to optimise treatment outcomes for this group of patients.

Minimally invasive para-aortic lymph node dissection in left-sided colonic and rectal cancer: experience based on a high-volume centre

AIM

There is no established consensus on the optimal surgical approach to para-aortic lymph node (PALN) dissection in patients with colorectal cancer. This study aimed to demonstrate the technical and oncological safety of minimally invasive PALN dissection for left-sided colonic and rectal cancer patients with clinically suspected infrarenal PALN metastasis.

METHOD

One hundered and one patients who underwent primary tumour resection and minimally invasive (laparoscopic n = 92, robotic n = 9) PALN dissection for left-sided colonic and rectal cancer were included. Logistic regression analysis was used to identify risk factors for PALN metastasis. Survival outcomes were evaluated using the Kaplan-Meier (log-rank) method.

RESULTS

Para-aortic lymph node metastasis was pathologically confirmed in 23 patients (22.8%). Postoperative complications occurred in 22 patients (21.8%). Pathological N2 stage (OR = 9.337, p = 0.003) and inferior mesenteric artery LN metastasis (OR = 7.499, p = 0.009) were independently associated with PALN metastasis. The median follow-up time was 32 months (range 3-92 months). In all patients, the 5-year overall survival (OS) and progression-free survival (PFS) rates were 76.1% and 69.5%, respectively. The 5-year OS and PFS rates in patients with PALN metastasis were 49.8% and 47.5%, respectively. Patients with PALN metastasis had lower 5-year OS (p = 0.023) and PFS rates (p = 0.035) than those without PALN metastasis.

CONCLUSION

Minimally invasive PALN dissection had acceptable postoperative complications and may be oncologically beneficial in selected patients with clinically suspicious PALN metastasis.

Robotic retroperitoneal lymph node dissection in colorectal cancer

In select colorectal cancer patients with metastatic retroperitoneal lymph node disease, surgical resection can be performed. We discuss our robotic technique.

Novel Drug Delivery Method Targeting Para-Aortic Lymph Nodes by Retrograde Infusion of Paclitaxel into Pigs’ Thoracic Duct

Gastrointestinal cancer with massive nodal metastases is a lethal disease. In this study, using a porcine model, we infused the anti-cancer drug Paclitaxel (PTX) into thoracic ducts to examine the efficiency of drug delivery to intra-abdominal lymph nodes. We established a technical method to catheterize the thoracic duct in the necks of pigs. We then compared the pharmacokinetics of PTX administered intrathoracically with those of systemic (intravenous) infusion. Serum, liver, and spleen concentrations of PTX were significantly lower following thoracic duct (IT) infusion than after intravenous (IV) administration approximately 1–8 h post-infusion. However, PTX levels in abdominal lymph nodes were maintained at relatively high levels up to 24 h after IT infusion compared to after IV infusion. Concentrations of PTX in urine were much higher after IT administration than after IV administration. After IT infusion, the same concentration of PTX was obtained in abdominal lymph nodes, but the serum concentration was lower than after systemic infusion. Therefore, IT infusion may be able to achieve higher PTX doses than IV infusion. IT delivery of anti-cancer drugs into the thoracic duct may yield clinical benefits for patients with extensive lymphatic metastases in abdominal malignancies.

Effect of radical lymphadenectomy in colorectal cancer with para-aortic lymph node metastasis: a systematic review and meta-analysis

Background

Colorectal cancer (CRC) with para-aortic lymph node metastasis (PALNM) is an intractable clinical situation, and the role of radical lymphadenectomy in the treatment of CRC with PALNM is still controversial. The aim of the current system review and meta-analysis is to evaluate the clinical efficacy and safety of radical lymphadenectomy in CRC patients with PALAN.

Methods

We performed a systematic search of PubMed, Embase, Cochrane Library and other online databases up to 31 October 2021. The clinical data including overall survival and postoperative complications were screened and analyzed after data extraction. Odds ratios (ORs) were applied to analyze these dichotomous outcomes with a fixed effects model.

Results

A total of 7 available retrospective clinical studies involving 327 patients were finally included. CRC patients with PALNM who underwent radical lymphadenectomy showed significantly overall survival (OR: 6.80, 95% CI: 3.46–13.38, P < 0.01; I² = 0%) when compared to those who did not receive radical lymphadenectomy. Moreover, in terms of postoperative complications (OR: 0.71, 95% CI: 0.35–1.44, P = 0.48; I² = 0%), there was no statistical difference between radical lymphadenectomy treatment and control groups.

Conclusions

The radical lymphadenectomy treatment has showed the expected clinical efficacy in prolonging overall survival time of CRC patients with PALAN. Moreover, the preemptive radical lymphadenectomy could not cause additional postoperative complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01631-x.

Local Therapies in Advanced Colorectal Cancer

Curative intent surgical resection of colorectal metastases to the liver and lungs in eligible patients results in improved disease control and prolonged overall survival with the potential for cure in a subset of patients. Additional ablative and local therapies for use in the liver, lungs, and other body sites have been developed with emerging data on the utility and toxicity of these treatments. Future studies should focus on identification of appropriate candidates for treatment and determining the optimal modality and timing of treatment accounting for both patient and disease factors.

Para-aortic lymph node dissection in left-sided colorectal cancer: Risk factors, prognostic impact, and therapeutic value

AIM

This study aimed to clarify risk factors, prognostic impact, and the therapeutic value of para-aortic lymph node (PALN) dissection in left-sided colorectal cancer.

METHOD

One hundred and fifty-four patients who underwent primary tumor resection and PALN dissection for left-sided colorectal cancer were included. Logistic regression analysis was used to identify risk factors for PALN metastasis. Cox regression analysis was performed to identify risk factors for overall survival (OS).

RESULTS

PALN metastasis was pathologically confirmed in 47 patients (30.5%). Postoperative complications occurred in 42 patients (27.3%). Pathological N stage (OR = 4.661, p = 0.034) and inferior mesenteric artery LNs metastasis (OR = 6.048, p = 0.003) remained to be independently associated with PALN metastasis, the 5-year OS rate and median survival in patients with PALN metastasis was 37.7% and 24 months. Elevated preoperative serum CA19-9 level (HR = 1.006, p = 0.007), number of positive LNs > 7 (HR = 7.263, p = 0.001), and mucinous adenocarcinoma or signet ring cell carcinoma (HR = 6.511, p = 0.001) were independently associated with OS in patients with PALN metastasis.

CONCLUSION

PALN dissection in addition to primary tumor resection have acceptable postoperative complications and may be oncologically beneficial in selected left-sided colorectal cancer patients with clinically suspicious PALN metastasis.

Long-Term Outcomes of Surgical Resection of Pathologically Confirmed Isolated Para-Aortic Lymph Node Metastases in Colorectal Cancer: A Systematic Review

BACKGROUND

Para-aortic lymph node (PALN) metastases represent patterns of initial recurrence in only 2-6% CRC patients, after an estimated 23-28 month time interval. An increasing trend towards curative surgery has been witnessed in patients presenting with controlled PALN recurrence. Nevertheless, lack of consensus has impaired an unambiguous statement for PALN recurrence resection.

METHODS

We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines, which led us to gain deeper insight into the prognostic factors and long-term outcomes after resection for synchronous or metachronous pathologically confirmed CRC isolated para-aortic lymph node metastases (PALNM). Pubmed/MEDLINE, Embase, Scopus, Cochrane Library and Web of Science databases were used to search all related literature.

RESULTS

The nine articles included covered a study period of 30 years (1988-2018), with a total of 161 patients. At presentation, most primary CRCs were located in the colon (74%) and 95.6%, 87.1% and 76.9% patients had T3-T4, N1-N2 and well/moderately differentiated CRC, respectively. We identified a 59.4-68% 3-year OS rate and 53.4-87.5% 5-year OS rate, with a 25-84 months median OS, 26.3-61% 3-year DFS rate and 0-60.5% 5-year DFS rate, with a 14-24 month median DFS. Overall, 62.1% re-recurrence rate ranged from 43.8% to 100%.

CONCLUSIONS

Although PALNMs resection in CRC patients may be considered a feasible and beneficial option, no conclusions or recommendations can be made taking into account the current evidence. Therefore, further randomized, possibly multicenter trials are strongly recommended and mandatory if we want to have our results confirmed and patient selection criteria clearly identified.

A real-world, population-based study for the outcomes of patients with metastatic colorectal cancer to the liver with distant lymph node metastases treated with metastasectomy

Aim: To assess the impact of metastasectomy on survival outcomes of patients with concurrent liver and distant nodal metastases. Materials & methods: Surveillance, Epidemiology, and End Results (SEER) database was accessed and patients with colorectal liver metastases (with or without distant lymph node involvement) were reviewed. Kaplan-Meier survival estimates were then used to assess the impact of the presence of distant lymph node metastases as well as the impact of metastasectomy on overall and cancer-specific survival. A propensity score matching was then conducted between patients with distant lymph node metastases who had surgery versus those who did not have surgery. Results: A total of 15,325 patients were included in the current analysis including 1603 patients who have liver and distant nodal metastases (10.5%) and 13,722 patients who have liver metastases only (89.5%). The following factors were associated with better overall survival (OS): younger age (hazard ratio [HR] with increasing age: 1.024; 95% CI: 1.022-1.025), white race (HR for African-American race vs white race: 1.233; 95% CI: 1.175-1.295), distal site of the primary (HR: 0.808; 95% CI: 0.778-0.840), absence of distant lymph nodes (HR: 0.697; 95% CI: 0.659-0.737), metastasectomy (HR for no metastasectomy vs metastasectomy: 1.954; 95% CI: 1.858-2.056). Within the postpropensity cohort, metastasectomy was associated with improved OS among patients with concurrent distant lymph node and liver metastases (median OS of 20 vs 11 months; p < 0.001). Conclusion: Metastasectomy seems to be associated with improved survival among patients with concurrent lymph node and liver metastases. It is unclear if improved survival is related to the surgical intervention or to the fact that surgically treated patients have a better baseline general condition and hence improved outcomes.

Effect of lymphadenectomy in colorectal cancer with isolated synchronous para-aortic lymph node metastasis

AIM

There is controversy about the treatment of para-aortic lymph node (PALN) metastasis and usefulness of surgical removal. We investigated the clinical effects of synchronous isolated PALN dissection in patients with this metastasis.

METHODS

Patients with colorectal cancer with isolated PALN metastasis were selected between January 2008 and December 2016 at Samsung Medical Center. Patients who were selected for gross-free PALN dissection were set as the dissection group (DG). Patients who did not undergo PALN dissection or underwent biopsy were set as the non-dissection group (NDG). The oncological and operative outcomes were compared.

RESULTS

A total of 73 patients were recruited. The most clinical and pathological characteristics were not significantly different. The incidence of postoperative complications was also similar. The 5-year overall survival of DG patients was 33.9%, that of NDG patients was 10.1%, and the survival curves were significantly different (P = 0.044). Multivariate analysis revealed that location of tumour in the left colon rather than in the right colon was a risk factor affecting survival in sub-analysis.

CONCLUSION

PALN dissection did not increase postoperative complications and had a better effect on patient survival. It is suggested that lymphadenectomy be performed more aggressively when PALN metastasis is seen in patients with right colon cancer.

Reconsideration of recurrence and metastasis in colorectal cancer

To discuss recurrence patterns and their significance in colorectal cancer. Preexisting medical hypotheses and the clinical phenomena of recurrence in colorectal cancer were evaluated and integrated. Colorectal cancer recurrence/ metastasis consists of two types: recurrence from the activation of dormant cancer cells and recurrence from postoperative residual cancer cells. These two recurrences have their own unique mechanisms, biological behaviors, responses to therapy, and prognoses. For type 1 recurrences, surgical resection should be considered. Type 2 recurrences should be managed systematically in addition to surgical resection. The two types of colorectal cancer recurrence should be evaluated and managed separately.

Treatment and Outcomes of Oligometastatic Colorectal Cancer Limited to Lymph Node Metastases

INTRODUCTION

The optimal management of isolated distant lymph node metastases (IDLNM) from a colorectal primary, is not clearly established. We aimed to analyze the outcomes of patients with IDLNM treated with systemic therapies plus locoregional therapy with curative intent versus systemic therapies with palliative intent.

MATERIALS & METHODS

Clinical data were collected and reviewed from the Treatment of Recurrent and Advanced Colorectal Cancer registry, a prospective, comprehensive registry for metastatic colorectal cancer (mCRC) treated at multiple tertiary hospitals across Australia. Clinicopathological characteristics, treatment modalities and survival outcomes were analyzed in patients with IDLNM and compared to patients with disease at other sites.

RESULTS

Of 3408 mCRC patients diagnosed 2009 to 2020, with median follow-up of 38.0 months, 93 (2.7%) were found to have IDLNM. Compared to mCRC at other sites, patients with IDLNM were younger (mean age: 62.1 vs. 65.6 years, P = .02), more likely to have metachronous disease (57.0% vs. 38.9%, P < .01), be KRAS wild-type (74.6% vs. 53.9%, P< .01) and BRAF mutant (12.9% vs. 6.2%, P = .01). Amongst mCRC patients with IDLNM, 24 (25.8%) received treatment with curative intent and had a significantly better overall median survival than those treated with palliative intent (73.5 months vs. 23.2 months, P = .01). These 24 patients had an overall median survival similar (62.7 months, P = .82) to patients with isolated liver or lung metastases also treated with curative intent.

CONCLUSION

Curative treatment strategies (radiotherapy or surgery), with or without systemic therapy, should be considered for mCRC patients with IDLNM where appropriate as assessed by the multidisciplinary team.

Prognostic significance of enlarged paraaortic lymph nodes detected during left-sided colorectal cancer surgery: a single-center retrospective cohort study

Background

Very few studies have been conducted on the treatment strategy for enlarged paraaortic lymph nodes (PALNs) incidentally detected during surgery. The purpose of this study was to investigate the benefit of lymph node dissection in patients with incidentally detected enlarged PALNs.

Methods

We retrospectively reviewed patients with left colon and rectal cancer who underwent surgical resection with PALN dissection between January 2010 and December 2018. The predictive factors for pathologic PALN metastasis (PALNM) were analyzed, and survival analyses were conducted to identify prognostic factors.

Results

Among 263 patients included, 19 (7.2%) showed pathologic PALNM and 5 (26.33%) had enlarged PALNs incidentally detected during surgery. These 5 patients accounted for 2.2% of 227 patients who had no evidence of PALNM on preoperative radiologic examination. Radiologic PALNM (odds ratio [OR] 12.737, 95% confidence interval [CI] 3.472–46.723) and radiologic distant metastasis other than PALNM (OR = 4.090, 95% CI 1.011–16.539) were independent predictive factors for pathologic PALNM. Pathologic T4 stage (hazard ratio [HR] 2.196, 95% CI 1.063–4.538) and R2 resection (HR 4.643, 95% CI 2.046–10.534) were independent prognostic factors for overall survival (OS). In patients undergoing R0 resection, pathologic PALNM was not associated with 5-year OS (90% vs. 82.2%, p = 0.896).

Conclusion

Dissection of enlarged PALNs incidentally detected during colorectal surgery may benefit patients with favorable survival outcomes.

Oncologic outcomes after resection of para-aortic lymph node metastasis in left-sided colon and rectal cancer

Aim

The optimal surgical management strategy for para-aortic lymph node (PALN) metastasis has not attracted as much attention as surgery for liver or lung metastasis. The purpose of this retrospective study was to evaluate the oncologic outcomes after synchronous resection of PALN metastasis in left-sided colon and rectal cancer.

Methods

Between January 1986 and August 2016, 29 patients with pathologically positive PALN metastases who underwent curative resection at our hospital were retrospectively reviewed. We examined clinicopathological characteristics, long-term oncologic outcomes, and factors related to favorable prognosis in these patients.

Results

The 3-year overall survival and recurrence-free survival (RFS) rates were 50.5% and 17.2%, respectively. In total, 6 (20.7%) patients experienced no recurrence in the 3 years after surgery, while postoperative complications were seen in 9 (31.0%) patients. The 3-year RFS rate was significantly better in the pM1a group than in the pM1b/pM1c group (26.3% and 0.0%, respectively, p = 0.032).

Conclusion

PALN dissection for patients without other organ metastases in left-sided colon or rectal cancer is a good indication as it is for liver and lung metastasis.

The Role of Radiotherapy in the Treatment of Retroperitoneal Lymph Node Metastases from Colorectal Cancer

Purpose

Retroperitoneal lymph node metastases are rare in colorectal cancer. Optimal treatment strategies are still unknown.

Patients and Methods

We retrospectively enrolled colorectal cancer patients who had received radiotherapy for retroperitoneal lymph node metastases from 2009 to 2018. Patients with isolated retroperitoneal lymph node metastases or retroperitoneal lymph nodes with extra-retroperitoneal metastases were all included. A median dose of 60 Gy was delivered.

Results

A total of 68 patients were enrolled in this study; 28 (41%) of them had extra-retroperitoneal metastases. In the isolated retroperitoneal lymph node metastases group, complete response was found in 5 patients (12.5%), partial response was achieved in 20 patients (50%), 9 patients (22.5%) had stable disease. The 1-, 2- and 3-year local control rates were 87.5%, 77.5%, and 70%. In the extra-retroperitoneal metastases group, the disease control rate was 75%, including complete response in 1 patient (3.6%), partial response in 4 patients (14.3%) and stable disease in 16 patients (57.1%). The 1-, 2- and 3-year local control rates were 57.1%, 42.8%, and 0%. The median overall survival was 59.4 months and 19 months in the isolated retroperitoneal lymph node metastases group and extra-retroperitoneal metastases group, respectively. In the isolated retroperitoneal lymph node metastases group, the 1-year and 3-year overall survival values were 90.2% and 75.8%, respectively. The 1-year and 3-year progression-free survival values were 57.9% and 0%, respectively. The extra-retroperitoneal metastases group experienced worse survival outcome (1-year overall survival: 57.9%, P<0.05; and 1-year progression-free survival: 22.5%, P<0.05).

Conclusion

For patients with isolated retroperitoneal lymph node metastases, radiotherapy combined with systemic treatment can be used as a method to achieve no evidence of disease and can result in good local control and survival. For patients with extra-retroperitoneal metastases, although the survival is much worse than that of isolated retroperitoneal lymph node metastases, radiotherapy is an effective palliative treatment to relieve pain and obstruction based on systemic treatment.

The treatment strategy of R0 resection in colorectal cancer with synchronous para-aortic lymph node metastasis

BACKGROUND

Synchronous metastatic para-aortic lymph node (mPALN) dissectionin colorectal cancer has relatively good oncological outcomes, though many patients develop recurrence. Universal prognostic factor remain unclear and no definitive perioperative chemotherapy is available, making the treatment of mPALN controversial. In the present study, we aimed to establish a treatment strategy for synchronous mPALN.

METHODS

This retrospective study involved 20 patients with pathological mPALN below the renal vein who underwent R0 resection. Long-term outcomes, recurrence type, and prognostic factors for survival were investigated.

RESULTS

The 5-year overall survival and recurrence-free survival rates were 39% and 25%, respectively. Seventeen patients (85%) developed recurrence, including 13 (76%) within 1 year after surgery, and ~ 70% of all recurrences were multiple recurrences. Four patients (20%) survived > 5 years. Pathological T stage (p= 0.011), time to recurrence (p = 0.007), and recurrence resection (p = 0.009) were identified as prognostic factors for long-term survival.

CONCLUSIONS

R0 resection of synchronous mPALN in colorectal cancer resulted in acceptable oncological outcomes, though we found a high rate of early unresectable recurrence. If the recurrence occurs late or isolated, surgical resection should be considered for longer survival.

Dosimetry, efficacy, and safety of three-dimensional printing noncoplanar template-assisted and CT-guided 125I seed implantation for recurrent retroperitoneal lymphatic metastasis after external beam radiotherapy

OBJECTIVES

To evaluate the dosimetry, efficacy, and safety of radioactive ¹²⁵I seed implantation (RISI) assisted by three-dimensional printing noncoplanar template (3D-PNCT) and CT for recurrent retroperitoneal lymphatic metastasis (RRLM) after previous external beam radiotherapy.

METHODS AND MATERIALS

From June 2016 to August 2018, 32 patients with RRLM successfully underwent 3D-PNCT-assisted and CT-guided RISI. The dosimetry, pain relief rate, performance improvement rate, overall response rate, disease control rate, local control time (LCT), overall survival (OS), and safety profiles were evaluated.

RESULTS

Dosimetric results showed that the D90, D100, V100, V150, V200, and homogeneity index were consistent in preoperation and postoperation (p > 0.05), except for the external index and conformal index (p = 0.048, p = 0.034). After RISI, 81.3% of the patients achieved pain relief, and 71.9% achieved an improvement of performance. The overall response rate and disease control rate were 85.3% and 94.1%, respectively. The LCT rates reached 66.2% and 43.2% in 1 year and two years, respectively, with a median LCT of 15.8 months. The OS rates were 74.1% and 28.1% in 1 year and two year, respectively, with a median OS reaching 17.6 months. Univariate analysis showed that when D90 > 130 Gy or D100 > 63 Gy or tumor size ≤49.8 cm³, LCT was extended significantly, but not for OS. Except for two patients developing Grade 1 retroperitoneal hematomas, no other severe adverse events were observed.

CONCLUSIONS

3D-PNCT and CT guidance provide excellent accuracy for RISI, which can be an effective and safe alternative for RRLM after external beam radiotherapy. Radiation dose and tumor size seem to significantly influence the local control.

The importance of synchronicity in the management of colorectal peritoneal metastases with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Background

Colorectal peritoneal metastases (CPM) occur in up to 13% of patients with colorectal cancer, presenting either synchronously or metachronously. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC) have been increasingly utilised for selected CPM patients with favourable outcomes, though its benefits may differ for synchronous (s-CPM) and metachronous CPM (m-CPM).

Methods

A retrospective analysis of CPM patients treated with CRS and HIPEC at the National Cancer Centre Singapore over 15 years was performed. In the s-CPM group, CPM was diagnosed at primary presentation with CRS and HIPEC performed at the time of or within 6 months from primary surgery. In the m-CPM group, patients developed CPM > 6 months after primary curative surgery.

Results

One hundred two patients with CPM were treated with CRS and HIPEC. Twenty (19.6%) patients had s-CPM and 82 (80.4%) had m-CPM. Recurrences occurred in 45% of s-CPM and in 54% of m-CPM (p = 0.619). Median overall survival was significantly prolonged in patients with m-CPM (45.2 versus 26.9 months, p = 0.025). In a subset of m-CPM patients with limited PCI in whom ICU stay was not required, a survival advantage was seen (p = 0.031).

Conclusion

A survival advantage was seen a subset of m-CPM patients, possibly representing differences in disease biology.

Resection of isolated distant nodal metastasis in metastatic colorectal cancer

BACKGROUND

Little is known regarding the role of resection in patients with colorectal cancer (CRC) who present with isolated non-regional lymph node metastasis (NRLNM).

METHODS

Using the Surveillance, Epidemiology and End Results database, we identified patients diagnosed with CRC and NRLNM from 2004 to 2013.

RESULTS

A total of 849 patients presented with CRC and isolated NRLNM. Of these, 90 (10.6%) underwent resection of NRLNM. Median overall survival (OS) did not differ for patients who underwent resection of NRLNM compared to those who did not (33 versus 29 months, p = 0.68). Subgroup analysis by primary tumor site, also did not demonstrate a difference in median OS. Cox proportional hazard model revealed older age (Hazard ratio [HR] 1.34, 95% Confidence Interval [CI] 1.17-1.53, p < 0.0001), higher tumor grade (HR 1.81, 95% CI 1.52-2.16, p < 0.0001), and earlier year of diagnosis (HR 1.34, 95% CI 1.17-1.53, p < 0.0001) were associated with decreased OS. There was no survival difference between those who underwent resection of NRLNM compared to those who had not (HR 0.997, p = 0.28).

CONCLUSION

Resection of NRLNM in patients with CRC is not associated with an OS benefit. Further studies are needed to determine if there is a subset of patients who could potentially benefit from this resection strategy.

Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer

The number of deaths from colorectal cancer in Japan continues to increase. Colorectal cancer deaths exceeded 50,000 in 2016. In the 2019 edition, revision of all aspects of treatments was performed, with corrections and additions made based on knowledge acquired since the 2016 version (drug therapy) and the 2014 version (other treatments). The Japanese Society for Cancer of the Colon and Rectum guidelines 2019 for the treatment of colorectal cancer (JSCCR guidelines 2019) have been prepared to show standard treatment strategies for colorectal cancer, to eliminate disparities among institutions in terms of treatment, to eliminate unnecessary treatment and insufficient treatment and to deepen mutual understanding between healthcare professionals and patients by making these guidelines available to the general public. These guidelines have been prepared by consensuses reached by the JSCCR Guideline Committee, based on a careful review of the evidence retrieved by literature searches and in view of the medical health insurance system and actual clinical practice settings in Japan. Therefore, these guidelines can be used as a tool for treating colorectal cancer in actual clinical practice settings. More specifically, they can be used as a guide to obtaining informed consent from patients and choosing the method of treatment for each patient. Controversial issues were selected as clinical questions, and recommendations were made. Each recommendation is accompanied by a classification of the evidence and a classification of recommendation categories based on the consensus reached by the Guideline Committee members. Here, we present the English version of the JSCCR guidelines 2019.

Laparoscopic para-aortic lymphadenectomy for colorectal cancer with clinically suspected lymph node metastasis

INTRODUCTION

The optimal surgical management strategy for isolated para-aortic lymph node (PALN) metastases from colorectal cancer (CRC) remains unclear. However, the complication rates for open approaches remain high. In this study, the outcomes of laparoscopic para-aortic lymphadenectomy in patients with clinically suspected PALN metastasis were evaluated.

METHODS

Between April 2013 and April 2018, we performed laparoscopic primary resection and para-aortic lymphadenectomy in 11 patients with advanced colorectal cancer and clinically suspected PALN metastasis. This study was a single-center, retrospective, case series analysis, and the surgical outcomes were reviewed.

RESULTS

There were no cases of perioperative mortality, and conversion to open surgery was necessary in only one patient (9%) because of invasion into a rib. One patient (9%) required a blood transfusion. Postoperative complications occurred in three patients, and the morbidity rate was 27% (3/11). Pathologically, PALN metastasis was confirmed in five patients (45%), all of whom received postoperative chemotherapy. The median survival time for all patients was 25 months, and one patient died of recurrence at 25 months after the initial surgery. Two other patients were alive with recurrence after 47 and 36 months, and two patients were alive without recurrence after 17 and 2 months.

CONCLUSION

Laparoscopic para-aortic lymphadenectomy for advanced colorectal cancer with clinically suspected PALN is technically feasible and may be beneficial in selected patients. It is necessary to investigate the feasibility of this procedure in a future case series, and information regarding true oncologic outcome will require long-term follow-up.

Management of isolated para-aortic lymph node recurrence of colorectal cancer

Isolated para-aortic lymph node recurrence (PALNR) after curative surgery for colorectal cancer (CRC) is rare and its optimal management is not defined clearly. This review investigates the best outcomes among published studies on the management of PALNR in the field of CRC. We searched the PubMed database for studies reporting on the management of isolated PALNR in CRC, published in English or Japanese from January, 2000 to December, 2018. Studies including patients with other metastases were excluded. A total of 24 retrospective studies including 227 patients with PALNR were evaluated. The 3-year overall survival (OS) ranged from 60 to 100%, with a median OS of 34-80 months for patients who underwent PALNR dissection, and 14-42 months for patients who received non-surgical treatment. No surgery-related mortality was reported and the incidence of surgical, mainly low-grade, complications ranged from 33 to 52%. The predictors of improved survival outcome included R0 resection margins. Dissection for PALNR from CRC is considered a feasible treatment option that may yield a better prognosis than non-surgical treatment alone. Preoperative chemotherapy or CRT should be considered for their potential benefits, including a reduction in cancer volume and improved R0 resection rates.

Clinical Implications of Lymph Node Metastasis in Colorectal Cancer: Current Status and Future Perspectives

Lymph node metastasis is regarded as an indubitable prognostic factor for predicting disease recurrence and survival in patients with colorectal cancer. Lymph node status based on examination of a resected specimen is a key element of the current staging system and is also a crucial factor to determine use of adjuvant chemotherapy after surgical resection. However, the current tumor-node-metastasis (TNM) staging system only incorporates the number of metastatic lymph nodes in the N category. Numerous attempts have been made to supplement this simplified N staging including lymph node ratio, distribution of metastatic lymph nodes, tumor deposits, or extracapsular invasion. In addition, several attempts have been made to identify more specific prognostic factors in resected colorectal specimens than lymph node status. In this review, we will discuss controversies in lymph node staging and factors that may influence survival beyond lymph node status.

Long-term outcome and prognostic factors for patients with para-aortic lymph node dissection in left-sided colorectal cancer

BACKGROUND

Para-aortic lymph node (PALN) metastasis of colorectal cancer is rare, and the treatment strategy for PALN metastasis (PALNM) is not established in contrast to liver or lung metastases. We sought to evaluate the survival outcomes and prognostic factors among patients undergoing surgery combined with extended lymphadenectomy for PALNM from left-sided colorectal cancer.

METHODS

From 1992 to 2012, 322 patients who underwent PALN dissection (PALND) synchronously with primary resection, among 1819 left-sided colorectal surgical cases, were retrospectively examined. We investigated the overall survival (OS) and prognostic factors for patients with PALNM.

RESULTS

Of the 322 patients, 62 (19.3%) were histologically confirmed to have PALNM. The 5-year OS in patients with and without PALNM was 19.5% and 67.0% (p < 0.001), respectively. Among patients with PALNM, on the multivariable analysis, the positive resection margin (hazard ratio (HR) 3.61; 95% confidence interval (CI) 1.85-7.06), undifferentiated histological type ((por/muc/sig), HR 4.51; 95% CI, 2.22-9.19), ≥ 4 PALNMs (HR 3.34; 95% CI 1.53-7.31), and preoperative CEA ≥ 10 ng/mL (HR 2.1; 95% CI 1.11-4.27) were significant prognostic factors. Among R0 resected cases, the 5-year OS of the 17 cases with ≤ 3 PALNM and well/moderately differentiated adenocarcinoma was 54.2%, which was comparable to that of patients undergoing PALND and diagnosed with stage IIIC (49.6%).

CONCLUSION

Patients with PALNM of colorectal cancer had a poor prognosis. However, curative resection, ≤ 3 PALNM, and well/moderately differentiated histology type were associated with the long-term survival.

Abdominoperineal Resection for Unexpected Distal Intramural Spreading of Rectal Cancer

Introduction

In rectal cancer, distal intramural spread may sometimes occur, but a maximum extent of distal spread of > 6 cm is very rare.

Case Presentation

A 65-year-old Japanese male with an advanced rectal cancer tumor with para-aortic lymph node metastasis was admitted. We performed a low anterior resection with lymphadenectomy, but the intraoperative frozen-section analysis of margins revealed malignant cell positivity; we, therefore, performed an abdominoperineal resection. Pathological findings showed that the maximum extent of distal spread was 6 cm. After 12 courses of FOLFOX4 as adjuvant chemotherapy, abdominal computed tomography revealed whole lymph node metastases, including Virchow's node. Though FOLFIRI + panitumumab was started, he was not eligible for additional chemotherapy after 10 cycles.

Conclusion

An intraoperative frozen pathology examination was helpful for the additional resection, when unexpected distal spreading had occurred in rectal cancer. The evidence of a distal negative margin should not be underestimated.