3. BACKGROUND
Lateral local recurrences (LLR) are currently the most common type of
locoregional recurrence (LR) after rectal cancer surgery . In the past, LR
was often due to an incomplete resection, but this has significantly
improved since the introduction of total mesorectal excision (TME)
surgery and neoadjuvant (chemo)radiotherapy ((C)RT) . LLRs are most
likely caused by lateral lymph node (LLN) metastases, which primarily
occur in locally advanced rectal tumors situated below the peritoneal
reflection.
4. AIM
. This review provides an overview of recent literature evaluating the
indications for LLND,
a description of the technique and current discussion points important
for daily practice
5. METHODOLOGY
Review of recent Studies and guidelines evaluating:
1- prophylactic Vs selective LLND
2- role of radiotherapy.
3- criteria of suspicious LLND
3-role of restaging MRI
4-different surgical techniques / minimal invasive vs open / complications
6. RESULTS
Role of adjuvant therapy:
The guidelines from the
European Society Medical
Oncology (ESMO) declare that
the addition of neoadjuvant
(C)RT is considered superior
(higher efficacy and/or less
morbidity) to surgical resection
of the LLNs
prophylactic LLND
LLND in patients without LLN
enlargement, a randomized
controlled trail (RCT) was
performed in Japan between
2003 and 2010 with 701
patients. The JCOG0212 s.
No neoadjuvant therapy ??
7. RESULTS
Criterion suspicious
LLNs:MRI/PETCT
JCOG0212 (10 mm short-axis).
Kawai et al. (8 mm long-axis)
Kim et al : > 5mm short axis)
Ishihara et al. SUVmax 1.6
Lateral Node Study
Consortium:7mm(short axis)
The role of restaging MRI:
Malakorn et al: >5 mm short
axis.
Lateral Node Study
Consortium:(4 mm for internal
iliac LLNs and 6 mm for
obturator LLNs).
8. RESULTS:
SELECTIVE LLND AFTER
(C)RT
In the Lateral Node Consortium
Study in some centers LLND was
performed selectively.(1216
patients)When an LLND was
performed in patients with an
LLN 7 mm, the risk of LLR
declined to 5.7% from 19.5
Kroon et al. investigated the
added value of LLND after (C)RT
in Western patients. This study
was conducted in six
international referral centers.
LLND (>5mm)decrease LLR to
3% from 11 %
9. RESULTS
COMPLICATIONS:
JCOG0212 study had longer
operation times and a higher
rate of grade 3/4 complications
Akasu et al. indicate that an
LLND had worse functional
genitourinary outcomes
TECHMIQUES:
- Medial plane: ureter and pelvic
plexus e ureterohypogastric
fascia - Lateral plane: psoas and
internal obturator muscles -
Dorsal plane: internal iliac
vessels and the sciatic nerve
10.
11. RESULTS
Yamaguchi et al :indicate that
both laparoscopic and robotic
LLND appear to have favorable
short outcomes, especially
considering the minimal amount
of blood loss
12. CONCLUSION
Patient with suspicious LLN >7 mm in pre neoadjuvant therapy who
subsequently got insufficient response (>4 mm in the internal iliac
compartment and >6 mm in the obturator compartment) may be
offered LLND
LLND for patients with suspicious lymph nodes found to decrease LLR .
Can be safely performed via laparoscopic or robotic approach
LLND caries high risk of morbidity
13. DISCUSSION
Large scale of literature review
Included different views
Different LLN definitions
Learning curve
