Abstract
The goal of this retrospective study was to determine the effect of para-aortic lymphadenectomy on clinical outcome in patients with stage N+ rectal adenocarcinoma below the peritoneal reflection. A retrospective analysis was performed on the clinical outcome of 181 patients with stage N+ rectal adenocarcinoma below the peritoneal reflection who underwent total mesorectal excision (TME) with total pelvic lymph node (PLN) adenectomy, with or without para-aortic lymph node (PAN) adenectomy. Independent prognostic factors were determined by multivariate Cox regression analysis. Disease-free survival (DFS) was analyzed using Kaplan–Meier curves and the log-rank test. The incidence of PLN metastases was 39.2% (71/181) in all the patients, and the incidence of PAN metastases was 12% (12/100) in patients who received PLN + PAN adenectomies. The patients were divided into two groups: PLN adenectomy (n = 81) and PLN + PAN adenectomy (n = 100). There were no statistically significant differences in clinicopathological factors between the PLN adenectomy and PLN + PAN adenectomy groups. On univariate analysis, the gross tumor type (P = 0.012), histological differentiation (P = 0.013), CEA level (P = 0.019), T stage (P = 0.019), N stage (P < 0.0001), and the number of positive PLN sites (P < 0.0001) were associated with poor DFS. Gross tumor type (P = 0.031), N stage (P = 0.001), and the number of positive PLN sites (P < 0.0001) were independent prognostic factors for DFS as identified by multivariate Cox regression analysis. PLN + PAN adenectomy significantly improved DFS compared to PLN adenectomy alone in patients with noninfiltrating type (P = 0.001), but not in patients with infiltrating type (P = 0.075). PLN + PAN adenectomy significantly improved DFS compared to PLN adenectomy alone in patients with 0 or 1 positive PLN site (P = 0.001, P = 0.009 respectively), but not in patients with ≥2 positive PLN sites (P = 0.095). In the N1 and N2 stage groups, PLN + PAN adenectomy significantly improved DFS compared with PLN adenectomy alone (P = 0.001; P < 0.0001, respectively). Furthermore, mean DFS was longer in the absence of PAN metastasis (P < 0.0001). PAN metastases appear to be associated with reduced DFS. Total PAN adenectomy may improve DFS in patients with noninfiltrating type, stage III rectal cancer below the peritoneal reflection, who have <2 positive PLN sites.
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Hojo, K., Koyama, Y., & Moriya, Y. (1982). Lymphatic spread and its prognostic value in patients with rectal cancer. American Journal of Surgery, 144(3), 350–354.
Koyama, Y., Moriya, Y., & Hojo, K. (1984). Effects of extended systematic lymphadenectomy for adenocarcinoma of the rectum—significant improvement of survival rate and decrease of local recurrence. Japanese Journal of Clinical Oncology, 14(4), 623–632.
Moriya, Y., Sugihara, K., Akasu, T., & Fujita, S. (1997). Importance of extended lymphadenectomy with lateral node dissection for advanced lower rectal cancer. World Journal of Surgery, 21(7), 728–732.
Takahashi, T., Ueno, M., Azekura, K., & Ohta, H. (2000). Lateral node dissection and total mesorectal excision for rectal cancer. Diseases of the Colon & Rectum, 43(10 Suppl), S59–S68.
Morita, T., Murata, A., Koyama, M., Totsuka, E., & Sasaki, M. (2003). Current status of autonomic nerve-preserving surgery for mid and lower rectal cancers: Japanese experience with lateral node dissection. Diseases of the Colon & Rectum, 46(10), S78–S87.
Shiozawa, M., Akaike, M., Yamada, R., Godai, T., Yamamoto, N., Saito, H., et al. (2007). Lateral lymph node dissection for lower rectal cancer. Hepato-Gastroenterology, 54(76), 1066–1070.
Sato, H., Maeda, K., Maruta, M., Masumori, K., & Koide, Y. (2006). Who can get the beneficial effect from lateral lymph node dissection for Dukes C rectal carcinoma below the peritoneal reflection? Diseases of the Colon & Rectum, 49(10), S3–S12.
Ueno, H., Mochizuki, H., Hashiguchi, Y., Ishiguro, M., Miyoshi, M., Kajiwara, Y., et al. (2007). Potential prognostic benefit of lateral pelvic node dissection for rectal cancer located below the peritoneal reflection. Annals of Surgery, 245(1), 80–87.
Sugihara, K., Kobayashi, H., Kato, T., Mori, T., Mochizuki, H., Kameoka, S., et al. (2006). Indication and benefit of pelvic sidewall dissection for rectal cancer. Diseases of the Colon & Rectum, 49(11), 1663–1672.
Isozaki, H., Okajima, K., Fujii, K., Nomura, E., Izumi, N., Mabuchi, H., et al. (1999). Effectiveness of paraaortic lymph node dissection for advanced gastric cancer. Hepato-Gastroenterology, 46(25), 549–554.
Kayahara, M., Nagakawa, T., Ohta, T., Kitagawa, H., Ueno, K., Tajima, H., et al. (1999). Analysis of paraaortic lymph node involvement in pancreatic carcinoma: a significant indication for surgery? Cancer, 85(3), 583–590.
Fujimoto, T., Nanjyo, H., Nakamura, A., Yokoyama, Y., Takano, T., Shoji, T., et al. (2007). Para-aortic lymphadenectomy may improve disease-related survival in patients with multipositive pelvic lymph node stage IIIc endometrial cancer. Gynecologic Oncology, 107(2), 253–259.
Choi, P. W., Kim, H. C., Kim, A. Y., Jung, S. H., Yu, C. S., & Kim, J. C. (2010). Extensive lymphadenectomy in colorectal cancer with isolated para-aortic lymph node metastasis below the level of renal vessels. Journal of Surgical Oncology, 101(1), 66–71.
Kim, J. C., Takahashi, K., Yu, C. S., Kim, H. C., Kim, T. W., Ryu, M. H., et al. (2007). Comparative outcome between chemoradiotherapy and lateral pelvic lymph node dissection following total mesorectal excision in rectal cancer. Annals of Surgery, 246(5), 754–762.
Miles, W. E. (1971). A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon (1908). CA–A Cancer Journal for Clinicians, 21(6), 361–364.
Lowry, A. C., Simmang, C. L., Boulos, P., Farmer, K. C., Finan, P. J., Hyman, N., et al. (2001). Consensus statement of definitions for anorectal physiology and rectal cancer: report of the Tripartite Consensus Conference on Definitions for Anorectal Physiology and Rectal Cancer, Washington, D.C., May 1, 1999. Diseases of the Colon & Rectum, 44(7), 915–919.
Colquhoun, P., Wexner, S. D., & Cohen, A. (2003). Adjuvant therapy is valuable in the treatment of rectal cancer despite total mesorectal excision. Journal of Surgical Oncology, 83(3), 133–139.
Moriya, Y., Sugihara, K., Akasu, T., & Fujita, S. (1995). Nerve-sparing surgery with lateral node dissection for advanced lower rectal cancer. European Journal of Cancer, 31A(7–8), 1229–1232.
Fujita, S., Yamamoto, S., Akasu, T., & Moriya, Y. (2003). Lateral pelvic lymph node dissection for advanced lower rectal cancer. British Journal of Surgery, 90(12), 1580–1585.
Ueno, M., Oya, M., Azekura, K., Yamaguchi, T., & Muto, T. (2005). Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer. British Journal of Surgery, 92(6), 756–763.
Kim, T. H., Jeong, S. Y., Choi, D. H., Kim, D. Y., Jung, K. H., Moon, S. H., et al. (2008). Lateral lymph node metastasis is a major cause of locoregional recurrence in rectal cancer treated with preoperative chemoradiotherapy and curative resection. Annals of Surgical Oncology, 15(3), 729–737.
Grinnell, R. S. (1965). Results of ligation of inferior mesenteric artery at the aorta in resections of carcinoma of the descending and sigmoid colon and rectum. Surgery, Gynecology and Obstetrics Journal, 120, 1031–1036.
Phillips, R. K., Hittinger, R., Blesovsky, L., Fry, J. S., & Fielding, L. P. (1984). Local recurrence following ‘curative’ surgery for large bowel cancer: I. The overall picture. British Journal of Surgery, 71(1), 12–16.
Min, B. S., Kim, N. K., Sohn, S. K., Cho, C. H., Lee, K. Y., & Baik, S. H. (2008). Isolated paraaortic lymph-node recurrence after the curative resection of colorectal carcinoma. Journal of Surgical Oncology, 97(2), 136–140.
Bowne, W. B., Lee, B., Wong, W. D., Ben-Porat, L., Shia, J., Cohen, A. M., et al. (2005). Operative salvage for locoregional recurrent colon cancer after curative resection: an analysis of 100 cases. Diseases of the Colon & Rectum, 48(5), 897–909.
Shibata, D., Paty, P. B., Guillem, J. G., Wong, W. D., & Cohen, A. M. (2002). Surgical management of isolated retroperitoneal recurrences of colorectal carcinoma. Diseases of the Colon & Rectum, 45(6), 795–801.
Gwin, J. L., Hoffman, J. P., & Eisenberg, B. L. (1993). Surgical management of nonhepatic intra-abdominal recurrence of carcinoma of the colon. Diseases of the Colon & Rectum, 36(6), 540–544.
Leggeri, A., Roseano, M., Balani, A., & Turoldo, A. (1994). Lumboaortic and iliac lymphadenectomy: What is the role today? Diseases of the Colon & Rectum, 37(2), S54–S61.
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Yan-Long Liu and Yi-Hui Wang contributed equally to this work.
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Liu, YL., Wang, YH., Yang, YM. et al. The Role of Para-Aortic Lymphadenectomy in Surgical Management of Patients with Stage N+ Rectal Cancer Below the Peritoneal Reflection. Cell Biochem Biophys 62, 41–46 (2012). https://doi.org/10.1007/s12013-011-9256-7
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DOI: https://doi.org/10.1007/s12013-011-9256-7