Selective Lateral Pelvic Lymph Node Dissection in Patients with Advanced Low Rectal Cancer Treated with Preoperative Chemoradiotherapy Based on Pretreatment Imaging

Background

The significance of lateral pelvic lymph node (LPLN) metastasis in advanced low rectal cancer treated with preoperative chemoradiotherapy (CRT) remains unclear. The objective of this study was to evaluate the outcomes of selective LPLN dissection (LPLD) based on the pretreatment imaging in patients with advanced low rectal cancer treated with preoperative CRT.

Methods

We reviewed 127 consecutive patients with clinical stage II–III low rectal cancer below the peritoneal reflection who underwent preoperative CRT and curative resection. LPLD was performed in patients with suspected LPLN metastasis based on MDCT or MRI before CRT (LPLD group, N = 38), and only total mesorectal excision (TME) was performed in patients without suspected LPLN metastasis (TME group, N = 89). Clinical characteristics and the oncological outcome were compared between groups.

Results

The median tumor-to-anal verge distance was 40 mm in both groups. The median maximum long-axis LPLN diameter before CRT was 0 mm in the TME group and 10.5 mm in the LPLD group. Pathological LPLN metastasis was confirmed in 25 patients (66 %) in the LPLD group. Local recurrence at LPLN developed in 3 patients (3.4 %) in the TME group and in none (0 %) of the LPLD group. Multivariate analysis showed that only ypN was an independent prognostic factor for relapse-free survival (RFS), but LPLN metastasis was not associated with poor RFS.

Conclusions

The incidence of LPLN metastasis is high even after preoperative CRT, and LPLD might improve local control and survival of patients with LPLN metastasis in advanced low rectal cancer treated with preoperative CRT.     

Lateral pelvic lymph node dissection for advanced lower rectal cancer

BACKGROUND: The oncological outcome of patients who underwent curative surgery for lower rectal cancer was investigated to clarify whether lateral pelvic lymph node dissection (LPLD) conferred any benefit. METHODS: A total of 246 patients who underwent curative surgery for stage II and III lower rectal cancer (below the peritoneal reflection) between 1985 and 1998 was reviewed. Forty-two of these patients did not undergo LPLD. RESULTS: Patients who did not undergo LPLD were older, more likely to have anterior resection and pelvic nerve preservation, and had smaller tumours and lymph node metastasis at an earlier stage than those who underwent LPLD. There was no difference in survival among patients with stage II and III disease between the two groups. However, in patients with pathological N1 lymph node metastasis, the 5-year disease-free survival rate was 73.3 per cent in patients who had LPLD compared with 35.3 per cent among those who did not (P = 0.013). Multivariate analysis showed that LPLD was a significant prognostic factor. CONCLUSION: LPLD improved the prognosis of patients with stage III disease and a small number of lymph node metastases. A randomized clinical trial is needed to verify the benefit of LPLD.     

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??Selective lateral pelvic lymph node dissection for mid-low rectal cancer WEI Ming-tian??WANG Zi-qiang. Department of Gastrointestinal Surgery??West China Hospital??Chengdu 610041??China
Corresponding author??WANG Zi-qiang??E-mail??wangzqzyh@163.com
Abstract Lateral pelvic lymph node metastasis is not uncommon in patients with advanced mid-low rectal cancer??and is also the cause of lateral recurrence. The latter has been indicated to be the most common kind of local recurrences in Asian reports. Presence of enlarged lateral lymph nodes at presentation is an independent risk factor for lateral pelvic recurrence after chemoradiotherapy (CRT) and total mesorectal excision. Controversy exists between Asian and western countries with respect to the use of CRT and lateral lymph node dissection (LLND) in the management of mid-low advanced rectal cancer. Primary reports indicated that thecombination of CRT and LLND was likely to be superior to either of the two strategies and provided more favourable local control and survival. So far??there is no consensus on the criteria to diagnose lateral lymph node metastases (LLNM) and the indication for selective LLND. More multicenter prospective cohort studies are warrant to address the issues, before we can provide better health care to the patients to improve their survival??as well as to avoid unnecessary LLND??which has been associated with more surgical complications and poorer quality of life.     

Impact of lateral pelvic lymph node dissection on evacuatory and urinary functions following low anterior resection for advanced rectal carcinoma

Background and aim Lateral pelvic lymph node dissection (LPLD) has been reported to be beneficial in terms of survival for locally advanced low rectal carcinoma. However, the impact of LPLD on bowel function has not yet been determined by means of anorectal physiologic investigation.Patients and methods Fifty-seven rectal cancer patients who underwent low anterior resection were evaluated with clinical and physiologic parameters. Of these, 15 patients had LPLD. The postoperative bowel and urinary function were evaluated with patients questionnaire and anorectal manometry before and after the operation.Results The proportion of patients who had pouch reconstruction, adjuvant radiation therapy, and autonomic nerve dissection were significantly higher in the LPLD group. The incidence of evacuatory dysfunction was significantly higher (80% vs 45%) postoperatively in the LPLD group. There was no significant difference in anal sphincter pressures, sensory threshold, and neorectal volumes between the groups postoperatively. In terms of urinary function, use of medication for urination was significantly frequent in the LPLD group. Multivariate analysis identified the level of anastomosis as an independent affecting factor for evacuatory dysfunction and LPLD for urinary dysfunction.Conclusion Although LPLD affected urinary dysfunction, it did not impair postoperative evacuatory function in the early postoperative period.     

Laparoscopic extended lateral pelvic node dissection following total mesorectal excision for advanced rectal cancer: initial clinical experience

Aim  

To evaluate the technical feasibility, safety, and oncological outcomes of laparoscopic extended lateral pelvic lymph node dissection (LPLD) following total mesorectal excision (TME) in patients with advanced low rectal cancer.     

中低位直肠癌选择性侧方淋巴结清扫策略

侧方淋巴结转移是中低位进展期直肠癌的较常见转移方式,也是亚洲人群新辅助放化疗后常见的局部复发方式,侧方型复发预后极差。侧方肿大淋巴结是放化疗后侧方型复发的独立危险因素,东西方国家关于放化疗与侧方淋巴结清扫等在中低位进展期直肠癌中的应用存在巨大争议。有限的研究显示,对可疑淋巴结转移病人联合应用放化疗与选择性侧方淋巴结清扫,有望进一步降低局部复发率及改善病人生存。对未接受侧方淋巴结清扫的病人,理论上有必要进行更严密的随访,早期发现侧方型复发,及时手术治疗可能带来长期生存。目前,关于新辅助放化疗后侧方淋巴结转移的诊断及选择性侧方淋巴结清扫的手术指征尚无统一意见,亟需大宗病例前瞻性队列研究加以阐明,以进一步改善病人的局部复发及长期生存,并减少因过度手术带来的并发症及生活质量下降。     

Single-incision Plus One Port Laparoscopic Total Mesorectal Excision and Bilateral Pelvic Node Dissection for Advanced Rectal Cancer—A Medial Umbilical Ligament Approach

We prove the safety and feasibility of single-incision plus 1 port (SILS+1) laparoscopic total mesorectal excision (TME) + lateral pelvic lymph node dissection (LPLD) via a medial umbilical approach for rectal cancer. Only a few reports have been published about single-incision multiport laparoscopic low anterior resection with LPLD. Recently, minimally invasive surgery such as single-incision plus 1 port (SILS + 1) for advanced rectal cancer has been reported as safe and feasible. To our knowledge, this is the first reported case of SILS + 1 used for LPLD. A wound protector was inserted through a 30-mm transumbilical incision. Next, a single-port access device was mounted to the wound protector and 3 ports (5 mm each) were placed. A 12-mm port was inserted in the right lower quadrant. Super-low anterior resection of the rectum and bilateral LPLD and temporary ileostomy were performed with SILS + 1, with a blood loss of 50 mL and a total surgical time of 525 minutes. The time for right lateral dissection was 74 minutes; the time for left lateral dissection was 118 minutes. The total number of dissected lymph nodes was 57 and the number of lateral lymph nodes dissected was 21 (8 left pelvic lymph nodes, 13 right pelvic lymph nodes). No postoperative anastomotic insufficiency or voiding dysfunction was observed. We have documented the safety and feasibility of SILS + 1-TME + LPLD via a medial umbilical approach for rectal cancer.Key words: Laparoscopic low anterior resection, Lateral pelvic node dissection, Reduced port surgery, Single-incision laparoscopic surgerySingle-incision laparoscopic surgery (SILS) has been successfully introduced for colectomy.¹ But for mid- to low-rectal procedures, such as total mesorectal excision, it can be technically complicated. Only a few reports have been published about single-incision laparoscopic low anterior resection without lateral pelvic node dissection (LPLD).^2–6 LPLD continues to be performed in Japan for advanced rectal cancer, with the aim of minimizing local recurrence and improving survival. According to advocates of LPLD, the overall incidence of metastases to lateral lymph nodes ranges from 8.6% to 27.0%, and such nodes are not cleared in patients who undergo total mesorectal excision (TME) only.^7–9 Recently, minimally invasive surgery such as single-incision plus 1 port (SILS + 1) for advanced rectal cancer has been reported as safe and feasible.¹⁰ However, laparoscopic LPLD for advanced rectal cancer has not been widely performed. Laparoscopic approaches may offer decreased surgical trauma, fewer perioperative complications, and faster postoperative recovery compared with conventional open surgery, with similar survival rates. In this study, we report a surgical technique using SILS + 1 via a medial umbilical approach for both low anterior resection and bilateral LPLD for advanced rectal cancer.     

Lateral Lymph Node Dissection for Lower Rectal Cancer

The mainstay of surgical therapy for rectal cancer is colectomy (including lesions) with lymph node dissection. The lymphatic spread of rectal cancer can proceed in two directions: medially toward the origin of the inferior mesenteric artery or laterally toward the pelvis aslong the internal iliac artery. To prevent postoperative recurrence, lymph nodes situated along these two axes should be adequately dissected, leaving no residual cancer cells. In Japan, the standard procedure for advanced lower rectal cancer is mesorectal excision and lateral lymph node dissection with autonomic nerve preservation. In Europe and North America, lateral lymph node dissection used to be performed, but it led to increased blood loss, complications, and dysfunction, with no improvement in survival. Lateral lymph node dissection is thus no longer performed. Instead, multidisciplinary therapy combining mesorectal excision with preoperative chemoradiotherapy is now the standard treatment for advanced rectal cancer. Although lateral lymph node dissection decreases the rate of local recurrence similar to preoperative chemoradiotherapy, whether it contributes to improved survival remains unclear. In addition, it is unlikely that prophylactic lateral lymph node dissection is required in all patients with rectal cancer. Definition of the indications for lateral lymph node dissection is thus an important concern.     

Lateral Lymph Node Metastasis Is a Major Cause of Locoregional Recurrence in Rectal Cancer Treated with Preoperative Chemoradiotherapy and Curative Resection

Background In rectal cancer patients treated with preoperative chemoradiotherapy (CRT) and curative resection, we evaluated the effect of clinical parameters on lateral pelvic recurrence and made an attempt to identify a risk factor for lateral pelvic recurrence. Methods The study involved 366 patients who underwent preoperative CRT and curative resection between October 2001 and December 2005. Clinical parameters such as gender, age, tumor size, histologic type, cT and cN classification, ypT and ypN classification, circumferential resection margin, tumor regression grade, chemotherapeutic regimen, and lateral lymph node size were analyzed to identify risk factors associated with lateral pelvic recurrence. Results Of the 366 patients, 29 patients (7.9%) had locoregional recurrence: 6 (20.7%) with central pelvic recurrence and 24 (82.7%) had lateral pelvic recurrence, of which 1 had simultaneous central and lateral pelvic recurrence. Multivariate analysis showed that ypN classification and lateral lymph node size were significantly associated with lateral pelvic recurrence (P < .001). Of 250 ypN0 patients, lateral pelvic recurrence developed in 1.4%, 2.9%, and 50% of patients with lateral lymph node sizes of <5, 5-9.9, and ≥10 mm, respectively (P < .001). Of 116 ypN+ patients, lateral pelvic recurrence developed in 4.3%, 35.7%, and 87.5% of patients with lateral lymph node sizes of <5, 5–9.9, and ≥10 mm, respectively (P < .001). Conclusions In our study, lateral pelvic recurrence was a major cause of locoregional recurrence, and ypN+ and lateral lymph node size were risk factors for lateral pelvic recurrence.     

Oncologic Outcomes After Radical Surgery Following Preoperative Chemoradiotherapy for Locally Advanced Lower Rectal Cancer: Abdominoperineal Resection Versus Sphincter-Preserving Procedure

Background  Over the past several years, preoperative chemoradiotherapy (CRT) has contributed remarkably to make more sphincter-preserving procedure (SPP) possible for lower rectal cancer. The aim of this study was to compare the outcomes between abdominoperineal resection (APR) and SPP after preoperative CRT in patients with locally advanced lower rectal cancer. Methods  A retrospective investigation was conducted with a total of 122 patients who underwent radical surgery combined with preoperative CRT for locally advanced lower rectal cancer. Of these, 50 patients underwent APR and 72 received SPP. Surgery was performed 6–8 weeks after completion of preoperative CRT. Oncologic outcomes were compared between the two groups, and the clinicopathologic factors affecting the treatment outcomes were evaluated. Results  Circumferential resection margin (CRM) involvement (P = 0.037) and postoperative complication rate (P = 0.032) were significantly different between APR and SPP. Patients who underwent APR had a higher 5-year local recurrence (22.0% vs. 11.5%, P = 0.028) and lower 5-year cancer-specific survival (52.9% vs. 71.1%, P = 0.03) rate than those who underwent SPP. Pathologic N stage was the most critical predictor for local recurrence and survival. Conclusions  Our study shows that APR following preoperative CRT exhibited more adverse oncologic outcomes compared with SPP. This result may be due to higher rates of CRM involvement in APR even with preoperative CRT. We suggest that sharp perineal dissection and wider cylindrical excision at the level of the anorectal junction are required to avoid CRM involvement and improve oncologic outcomes in patients who undergo APR following preoperative CRT.     

Chemoradiation combined with total mesorectal excision for patients with locally advanced rectal cancer

Rectal cancer is characterized by a high rate of local recurrence. Although it is widely believed that local control results in improved patient outcome, its strategy is still controversial. In Japan, total mesorectal excision (TME) or tumor-specific mesorectal excision (TSME) with pelvic sidewall dissection is regarded as the standard procedure, while TME or TSME with preoperative chemoradiotherapy (CRT) is common in Western countries. Most clinical data have indicated that preoperative CRT is not associated with improved long-term survival but with a lower incidence of local recurrence. In addition, CRT is known to enhance the severity of impaired sphincter function. Currently, trials using CRT regimens with newly developed chemotherapy agents are ongoing to elucidate the effect on the control of distant metastasis. According to clinical reports, the prognosis of Japanese patients undergoing surgery alone is as favorable as that in patients undergoing surgery plus CRT in the West, which implies that CRT is not a necessary treatment but a selective option. The precise prediction of tumor response and advances in CRT regimens resulting in better survival may improve the treatment of rectal cancer in the future.     

Current surgical management of rectal cancer

The management of rectal cancer has undergone significant evolution over the past decade with improvements in both surgical technique and adjuvant therapies. The progression of surgical management has been of particular interest, as surgery is the only potentially curative treatment. The major goals of surgery are to optimize oncologic outcome and maintain anorectal and genitourinary function. There are presently two approaches to rectal cancer surgery: total mesorectal excision (TME), which is the gold standard in the Western world, and lateral lymph node dissection, which was originally developed in Japan. Although the results of lateral lymph node dissection are similar to TME with prior radiotherapy, low positive lateral lymph node yields, questionable prognostic significance, and high morbidity are the main drawbacks of this procedure. Despite the current quality of these surgical procedures, locoregional treatment is limited as advanced primary rectal cancer may be associated with systemic spread of disease. Adjuvant therapy therefore plays a key role in obtaining further improvement in survival. In this article, evidence for the use and benefits of lateral lymph node dissection surgery for rectal cancer patients in Japan is reviewed, and its application in association with TME and other modalities considered.     

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??Significance of lateral lymph node dissection in rectal cancer after neoadjuvant chemoradiotherapy LIU Qian??WANG Xi-shan. Department of Colorectal Surgery, National Cancer Center & National Clinical Research Center for Cancer & Cancer Hospital??Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021??China
Corresponding author??WANG Xi-shan??E-mail??fcwpumxh@163.com
Abstract Lateral lymph node metastasis is an important pathway for metastasis of middle and low rectal cancer??and it is also a major factor leading to recurrence of rectal cancer. The treatment strategy for lateral lymph node metastasis of rectal cancer has been a hot topic in the field of surgery. Western scholars oppose lateral lymph node dissection??and neoadjuvant and adjuvant chemoradiotherapy are the main methods for the treatment of lateral lymph node metastasis. For patients with swollen lateral lymph node after neoadjuvanttherapy??if only TME surgery is performed?? it will lead to positive lymph node residue and cannot achieve R0 resection. For this situation??how to choose optimal targeted treatment strategy according to the specific condition??and the LLND for R0 resection is of great significance for further reducing local recurrence??improving prognosis and improving patients' quality of life.     

两种手术方案治疗进展期胃中上部癌的临床对比研究

目的:探讨D2淋巴结清扫术与全系膜切除术治疗进展期胃中上部癌的临床疗效及安全性。方法:选取2011年5月至2014年1月收治的100例进展期胃中上部癌患者,分为对照组(n=50)与观察组(n=50),分别采用D2淋巴结清扫术与全系膜切除术,比较两组患者手术相关临床指标、术后并发症发生率、随访复发率及生存率。结果:观察组手术时间、术中出血量均优于对照组(P0.05),两组淋巴结清扫数量、首次排气时间、首次下床活动时间、住院时间、术后并发症发生率及随访复发率差异无统计学意义(P0.05),观察组随访生存率高于对照组(P0.05)。结论:全系膜切除术治疗进展期胃中上部癌可有效缩短手术时间,减少医源性创伤,并有助于提高远期生存率,优于D2淋巴结清扫术。     

Efforts to improve local control in rectal cancer compromise survival by the potential morbidity of optimal mesorectal excision

BACKGROUND: The technique of total mesorectal excision (TME) increases the risk of anastomotic leakage. The impact of postoperative morbidity of TME on longterm survival has never been described. We retrospectively analyzed factors that might influence survival after TME for rectal cancer, including postoperative morbidity. STUDY DESIGN: From 1994 to 2001, 300 patients (192 men and 108 women; mean age, 64 years) had TME for rectal cancer. Preoperative radiotherapy was given in 202 patients. Age, gender, tumor height, size and circular invasion of the tumor, pathologic tumor and nodal status, distal and circumferential margins, number of lymph nodes analyzed, type of surgery, postoperative pelvic sepsis, preoperative radiotherapy, and adjuvant chemotherapy were examined; their association with overall and disease-free survival was evaluated by the log-rank test in univariate analysis and by multivariable Cox proportional hazards analysis. RESULTS: Postoperative morbidity was 38% (113 of 300 patients) and included 18% (54 of 300 patients) pelvic sepsis. The local recurrence rate was 6% (18 of 300 patients), and the distant metastasis rate was 24% (73 of 300 patients). Recurrence was three times more frequent distally than locally, including patients with pelvic sepsis The 5-year overall and disease-free survival rates were 72% and 60%, respectively. Independent predictors of overall survival were age older than 64 years (odds ration [OR]=2.19, 95% CI 1.32 to 4.17), pelvic sepsis (OR=2.06, 95% CI 1.10 to 3.87), circumferential surgical margin (OR=3.19, 95% CI 1.67 to 6.09), pathologic tumor (OR=2.69, 95% CI1.23 to 5.88), and nodal status (OR=3.18, 95% CI 1.79 to 5.64). Independent predictors of disease-free survival were pelvic sepsis (OR=2.17, 95% CI 1.31 to 3.58), circumferential surgical margin (OR=2.61, 95 CI 1.52 to 4.49), pathologic tumor (OR=1.82, 95% CI 1.04 to 3.20), and nodal status (OR=2.67, 95% CI 1.68 to 4.23). Patients with pelvic sepsis had a 5-year disease-free survival of 39% compared with 65% without pelvic sepsis (p<0.001). CONCLUSIONS: After TME for rectal cancer, pelvic sepsis is a common complication that is associated with increased risk of distant recurrence and decreased longterm survival. Efforts are necessary to decrease postoperative morbidity in surgical treatment of rectal cancer.     

Comparison of tumor recurrence between laparoscopic total mesorectal excision with sphincter preservation and laparoscopic abdominoperineal resection for low rectal cancer

Background

By traditional open surgery, the tumor recurrence rate of total mesorectal excision with sphincter-preserving procedure was lower than that of abdominoperineal resection (APR) for the treatment of low rectal cancer. The present study aimed to rescrutinize whether the same conclusion can be drawn when both surgical procedures are performed laparoscopically.

Methods

We retrospectively reviewed the prospectively recorded clinicopathologic data of 344 consecutive patients with low rectal cancer, in which 170 patients underwent preoperative chemoradiotherapy followed by laparoscopic total mesorectal excision (TME), whereas 174 patients underwent laparoscopic TME directly without chemoradiotherapy. Such patients were further stratified according to the pathologic tumor, node, metastasis stage (stage II or III disease) and surgical strategy (APR or sphincter-preserving operation [SPO]). The surgical procedures are presented in supplemental videos. The disease-free survival, recurrence patterns, and functional recovery of patient groups stratified as appropriate were compared.

Results

In patients who received preoperative chemoradiotherapy, the estimated recurrence rate were similar between laparoscopic TME with SPO and laparoscopic APR with 10.6 %, 7 of 66, versus 18.5 %, 5 of 27, in stage II disease (p = 0.811, log-rank test); and 19.3 %, 11 of 57, versus 20 %, 4 of 20, in stage III disease (p = 0.980). In patients without preoperative chemoradiotherapy, the recurrence rate was significantly higher in laparoscopic APR than in the laparoscopic TME with SPO group of patients with stage III disease (45 %, 9 of 20, vs. 19.3 %, 16 of 83, p = 0.025), whereas the recurrence rate of the two procedures was similar (21.4 %, 3 of 14, vs. 17.5 %, 10 of 57, p = 0.702) in stage II disease.

Conclusions

When low rectal cancer was operated on by laparoscopic approach, the poorer prognosis of APR compared to SPO was only observed in stage III patients without preoperative chemoradiotherapy.     

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??Objective:o observe tumor volume,volume reduction rate with postoperative histopathologic tumor downstaging,lymph node status in rectal cancer after preoperative chemoradiotherapy (CRT) and to investigate the usefulness of MRI volumetry for predicting response to neoadjuvant chemoradiotherapy. Methods:orty??two patients with locally advanced rectal cancer admitted between December 2004 and October 2006 were performed preoperative CRT,followed by surgical resection.DWI volumetry was performed before and after CRT.Pre?? and post CRT tumor volume and percent of volume reduction,according to postoperative T??downstaging, histopathologic lymph node staging in accordance with the AJCC TNM classification were compared. Results:ighteen patients demonstrated a tumor downstaging after chemoradiation therapy.Both pre?? and post??treatment MRI tumor volumes were significantly smaller in downstaged patients than in not downstaged patients (P??0.01??,but the percentage of volume reduction rates was not significantly higher in downstaged patients (P??0.05).According to N staging,the patients were divided into N0 group and N1-2 group.There was not significant difference in mean tumor volume before preoperative CRT between N0 group and N1-2 group (P??0.05). Conclusion:The higher tumor volume reduction rate does not correlate with histopathologic downstaging,and initially smaller tumors are more likely to be downstaging tumor. So it might be unsafe to evaluate tumor response and to select the surgical method on the basis.The tumor volume before chemoradiotherapy does not correlate with histopathologic lymph node status,but the tumor volume after chemoradiotherapy and tumor volume reduction rate in patients with node??matastasis are significantly different with those in patients without node??matastasis.So the higher DWI volumetric tumor reduction rate is more inclined to have negative nodes in rectal cancer with preoperative chemoradiotherapy.     

Lateral pelvic node dissection after neoadjuvant chemoradiation in rectal cancer with right internal iliac node metastasis but without regional node metastasis: A case report

Introduction and importanceTotal mesorectal excision (TME) with lateral pelvic node dissection was routinely done in low clinical T3 rectal tumors below the peritoneal reflection as stated in the Japanese guidelines for colorectal cancer. Our institution follows the same practice in selected patients. This is our first reported case wherein a patient with rectal cancer underwent total mesorectal excision with lateral lymphadenectomy after neoadjuvant treatment with a positive lateral node on histopathology.Case presentationA 49 year old female rectal had rectal adenocarcinoma 4 cm FAV. Pelvic MRI revealed a low rectal tumor abutting the mesorectal fascia anteriorly, anal sphincters not involved, and confluent enlarged right iliac nodes. After neoadjuvant treatment, interval decrease in size of the rectal lesion and the right iliac nodes were noted. Patient underwent partial intersphincteric resection, lateral pelvic node dissection and protective loop ileostomy.Clinical discussionHistopathology revealed a rectal adenocarcinoma with one right internal iliac lymph node was positive for tumor involvement. Circumferential resection margin was 4.0 mm. Patient is currently on 4th cycle of adjuvant chemotherapy. Preoperative chemoradiation could not completely eradicate lateral pelvic node metastasis. Therefore, lateral pelvic node dissection should be considered if lateral pelvic lymph node metastasis is suspected even after neoadjuvant therapy.ConclusionUnlike TME, performance of a routine lateral lymphadenectomy in rectal cancer surgery varies by geographic location. Reports from Asian countries and our practice in our institution shows that it can be performed safely. This could improve the oncologic outcomes of patients especially if combined with neoadjuvant chemoradiotherapy.     

低位直肠癌常规行No.253淋巴结清扫的争议与共识

低位直肠癌是否常规行No.253淋巴结清扫,目前仍存在诸多争议,且东西方观点有所不同。西方学者更强调全直肠系膜切除（TME）,保证直肠系膜的完整性是手术根治的关键,良好的TME手术质量可降低局部复发率。对于T2以上的低位直肠癌日本学者和我国学者除了强调全直肠系膜切除外,还注重对肠系膜下动脉根部淋巴结（即No.253淋巴结）的清扫（D3根治术）。近年来,低位直肠癌是否常规行No.253淋巴结清扫观点趋于统一：如怀疑No.253淋巴结转移,建议行新辅助化疗,或术中行快速冰冻病理学检查,如证实No.253淋巴结转移则进行彻底的清扫。对于分期在T2以内的低位直肠癌,若术前检查和术中探查No.253淋巴结阴性则不作为低位直肠癌的常规清扫范围,因为在清扫No.253淋巴结时很容易损伤腰内脏神经和肠系膜下神经丛,造成术后泌尿生殖功能障碍。多数学者认为对于T2以内的低位直肠癌不常规行No.253淋巴结清扫,而对于T3以上的低位直肠癌如术前检查怀疑No.253淋巴结发生转移,则更强调新辅助放化疗联合TME及行No.253淋巴结清扫的D3根治术。     

下段直肠淋巴引流途径和低位直肠癌侧方淋巴结清扫的必要性

下段直肠癌已被证明存在向上、向下、侧方3个淋巴引流途径，直肠癌通过侧方淋巴引流途径形成的淋巴结转移是其治疗后盆腔复发的重要原因。大量循证医学证据表明，术前同步放化疗并不能彻底清扫侧方转移淋巴结，其阳性残留比例>60%。对术前同步放化疗后仍然存在侧方淋巴结转移的病例，手术清扫转移淋巴结是最重要的治疗手段，甚至是病人获得长期生存的惟一途径。严格掌握侧方淋巴结清扫指征，提高病理学检查准确率，进行规范的淋巴结清扫，通过精准操作降低手术并发症发生率，有望为直肠癌侧方淋巴结转移病人带来局部复发率的下降和生存延长的双重获益。