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Obturator Canal Lymph Node Metastasis from Rectal Carcinoid Tumors: Total Mesorectal Excision May Be Insufficient

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Optimal surgical treatment for small early rectal carcinoids is controversial. Large tumors (greater than 2 cm) and those with imaging evidence of lymph node metastasis are generally treated by low anterior resection (LAR) with total mesorectal excision (TME). We first observed and reported that midgut carcinoid with extensive mesenteric lymphadenopathy often develops alternated lymphatic drainage pathways. We hypothesize that rectal carcinoids have the same potential to develop alternated lymphatic pathways outside the mesorectal envelope, which allows tumor deposits to be missed by traditional TME.

Methods

Twenty-two consecutive rectal carcinoid surgical patient charts were reviewed to determine if alternated lymphatic drainage occurred and resulted in extra-mesorectal metastasis. We attempted to identify any risk factor(s) that may lead to developing such alternated lymphatic drainage pathways.

Results

Thirteen patients underwent initial LAR with TME (13/22, 59 %) and nine underwent a staged debulking for locoregional residual disease or regional/distant metastasis after previous resection (9/22, 41 %). Fourteen (14/22, 64 %) underwent radio-guided surgery in attempt to achieve a higher level of pelvic/distant metastatic disease detection and debulking. Six patients (6/22, 27 %) had obturator canal lymph node metastases confirmed histologically.

Conclusions

Based on our study, at least 27 % of rectal carcinoid patients may have extra-mesorectal metastasis that would be missed by the traditional TME. Radio-guided surgery can identify and remove such metastasis. The effect of having such extra-mesorectal metastasis and its surgical removal on long-term survival has yet to be determined.

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Authors and Affiliations

  1. Department of Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Room 747, New Orleans, LA, 70112, USA

    Yi-Zarn Wang, David T. Beyer & Michael Hall

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  1. Yi-Zarn Wang
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  2. David T. Beyer
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Correspondence to Yi-Zarn Wang.

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Wang, YZ., Beyer, D.T. & Hall, M. Obturator Canal Lymph Node Metastasis from Rectal Carcinoid Tumors: Total Mesorectal Excision May Be Insufficient. J Gastrointest Surg 20, 1247–1252 (2016). https://doi.org/10.1007/s11605-016-3128-9

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  • DOI: https://doi.org/10.1007/s11605-016-3128-9

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