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

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.

Outcomes of metachronous para-aortic lymphadenectomy in colorectal cancer: a systematic review of the literature

INTRODUCTION AND AIM

Para-aortic lymph node metastasis associated with colorectal cancer is a very rare occurrence, but at the same time an important predictor of survival. Despite its importance, there is still no gold standard management strategy, particularly for lymph nodes detected during follow-up, after resection of the primary tumour. Therefore, this review was undertaken to examine the evidence available on the surgical and non-surgical management of metachronous para-aortic lymph node metastasis (m-PALNM) in colorectal cancer treatment.

METHODS

This is a systematic review using the patient, intervention, comparison, outcome and study strategy. The literature search was undertaken using Cochrane, MEDLINE, EMBASE and PubMed databases with the following MeSH terms: lymph node excision, para-aortic lymph node, metastasis, metachronous and colorectal neoplasms.

RESULTS

Five original papers met the study criteria including 188 patients in total (55.3% male, 44.7% female). Surgical resection of the m-PALND was the management of choice in 64% of patients. Reporting styles on survival outcomes were heterogeneous. However, patients undergoing surgical management for m-PALNM had longer disease-free survival and overall survival rates.

CONCLUSION

There is significant paucity in the evidence available on the management of m-PALNM. However, the evidence reported by this review suggests that surgical management should be considered whenever possible, with the aim of prolonging survival. Future randomised trials are needed in order to provide further high-level evidence on m-PALNM management.

Survival benefits of para-aortic lymphadenectomy in colorectal cancer with clinically suspected para-aortic lymph node metastasis: a meta-analysis and systematic review

BACKGROUND AND OBJECTIVES

In patients with colorectal cancer and clinically suspected para-aortic lymph node metastasis, the survival benefit of para-aortic lymphadenectomy is unknown. We conducted a meta-analysis and systematic review to investigate it.

METHODS

PubMed, Web of Science, and EMBASE were searched until January 2000 to April 2022 to identify studies reporting overall survivals, complication rates, and hazard ratios of prognostic factors in patients with colorectal cancer undergoing para-aortic lymphadenectomy, and those data were pooled.

RESULTS

Twenty retrospective studies (1021 patients undergoing para-aortic lymphadenectomy) met the inclusion criteria. Meta-analysis indicates that participants undergoing para-aortic lymphadenectomy were associated with 5-year survival benefit, compared to those not receiving para-aortic lymphadenectomy (odds ratio = 3.73, 95% confidence interval: 2.05-6.78), but there was no significant difference in complication rate (odds ratio = 0.97, 95% confidence interval: 0.46-2.08). Further analysis of para-aortic lymphadenectomy group showed that 5-year survival of the positive group with pathologically para-aortic lymph node metastasis was lower than that of the negative group (odds ratio = 0.19, 95% confidence interval: 0.11-0.31). Moreover, complete resection (odds ratio = 5.26, 95% confidence interval: 2.02-13.69), para-aortic lymph node metastasis (≤4) (hazard ratio = 1.88, 95% confidence interval: 0.97-3.62), and medium-high differentiation (hazard ratio = 2.98, 95% confidence interval: 1.48-5.99) were protective factors for survival. Preoperative extra-retroperitoneal metastasis was associated with poorer relapse-free survival (hazard ratio = 1.85, 95% confidence interval: 1.10-3.10).

CONCLUSION

Para-aortic lymphadenectomy had promising clinical efficacy in prolonging survival rather than complication rate in patients with colorectal cancer and clinically diagnostic para-aortic lymph node metastasis. Further prospective studies should be performed.

TRIAL REGISTRATION

PROSPERO: CRD42022379276.

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.

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.

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.

Applicability of minimally invasive surgery for clinically T4 colorectal cancer

The role of minimally invasive surgery (MIS) to treat clinically T4 (cT4) colorectal cancer (CRC) remains uncertain and deserves further investigation. A retrospective cohort study was conducted between September 2006 and March 2019 recruiting patients diagnosed as cT4 CRC and undergoing MIS at a university hospital and its branch. Patients’ demography, clinicopathology, surgical and oncological outcomes, and radicality were analyzed. A total of 128 patients were recruited with an average follow-up period of 33.8 months. The median time to soft diet was 6 days, and the median postoperative hospitalization periods was 11 days. The conversion and complication (Clavien–Dindo classification ≥ II) rates were 7.8% and 27.3%, respectively. The 30-day mortality was 0.78%. R0 resection rate was 92.2% for cT4M0 and 88.6% for pT4M0 patients. For cT4 CRC patients, the disease-free survival and 3-year overall survival were 86.1% and 86.8% for stage II, 54.1% and 57.9% for stage III, and 10.8% and 17.8% for stage IV. With acceptable conversion, complication and mortality rate, MIS may achieve satisfactory R0 resection rate and thus lead to good oncological outcomes for selected patients with cT4 CRC.