Does a fine line exist between regional and metastatic pelvic lymph nodes in rectal cancer—striking discordance between national guidelines and treatment recommendations by US radiation oncologists

758 Background: Management of rectal cancer with involved lateral pelvic lymph nodes (LPLNs) at the time of diagnosis – the stage we refer institutionally to as Stage 3.5 – is controversial. Asian investigators consider internal, external and common iliac lymph nodes (LNs) as regional disease and treat these patients (pts) with curative intent, which often includes LPLN dissection. Conversely, AJCC 7thedition classifies internal iliac LNs as regional, whereas both external and common iliac LNs as metastatic. NCCN guidelines recommend definitive trimodality therapy for Stage III rectal cancer, and palliative chemotherapy for Stage IV disease. Radiation oncologists (ROs) in the U.S. irradiate iliac LNs in the setting of other pelvic malignancies, but it is unknown how they approach newly diagnosed rectal cancer pts with LPLN involvement. Methods: We conducted an anonymous IRB-approved online survey of practicing U.S. ROs, probing their approach to management of rectal cancer pts with clinically involved LPLNs. Results: We received 220 responses. Among the responders, 85 are academically affiliated and the majority self-declared a specialization in treating GI malignancies, with 98 seeing more than 10 rectal cancer pts annually. Among respondents, 10.5% and 34.2% recommend biopsy of clinically involved internal and common iliac LNs, respectively. The vast majority of responders – 98.6% and 94.5% – treat involved internal and common iliac LNs with curative intent, respectively. Respondents recommend treatment intensification to involved internal iliac LNs by dissection of the nodal basin (88.2%) and radiation therapy (RT) boost (59.1%), and treatment intensification to involved common iliac LNs by LN dissection (76.4%) and RT boost (63.6%). Conclusions: Our analysis reveals that the vast majority of surveyed U.S. ROs approach pts with involved LPLNs, both regional (internal iliac) and metastatic (i.e. common iliac) with curative intent. They recommend treatment intensification with surgical resection and/or RT boost to involved nodes. Prospective clinical trials need to determine the appropriate management of pts with Stage 3.5 rectal cancer.

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Malignant features present in pre-treatment lateral pelvic lymph nodes in low rectal cancer predict distant metastases and survival, but not local recurrences.

European Journal of Surgical Oncology ◽

10.1016/j.ejso.2020.11.205 ◽

2021 ◽

Vol 47 (2) ◽

pp. e23-e24

Author(s):

Hidde Kroon ◽

N. Dudi-Venkata ◽

S. Bedrikovetski ◽

J. Liu ◽

A. Haanappel ◽

...

Keyword(s):

Rectal Cancer ◽

Lymph Nodes ◽

Distant Metastases ◽

Low Rectal Cancer ◽

Pelvic Lymph Nodes ◽

Local Recurrences ◽

Pre Treatment ◽

Lateral Pelvic Lymph Nodes

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Clinically Enlarged Lateral Pelvic Lymph Nodes Do Not Influence Prognosis after Neoadjuvant Therapy and TME in Stage III Rectal Cancer

Journal of Gastrointestinal Surgery ◽

10.1007/s11605-011-1533-7 ◽

2011 ◽

Vol 15 (8) ◽

pp. 1368-1374 ◽

Cited By ~ 13

Author(s):

Sekhar Dharmarajan ◽

Dandan Shuai ◽

Alyssa D. Fajardo ◽

Elisa H. Birnbaum ◽

Steven R. Hunt ◽

...

Keyword(s):

Rectal Cancer ◽

Lymph Nodes ◽

Neoadjuvant Therapy ◽

Stage Iii ◽

Pelvic Lymph Nodes ◽

Lateral Pelvic Lymph Nodes

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EUS-guided alcohol ablation of metastatic pelvic lymph nodes after endoscopic resection of polypoid rectal cancer: the need for long-term surveillance

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2011.01.064 ◽

2011 ◽

Vol 74 (2) ◽

pp. 446-447 ◽

Cited By ~ 15

Author(s):

John DeWitt ◽

Mehdi Mohamadnejad

Keyword(s):

Rectal Cancer ◽

Lymph Nodes ◽

Endoscopic Resection ◽

Alcohol Ablation ◽

Pelvic Lymph Nodes

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Role of pelvic lymphadenectomy in rectal cancer

International Surgery Journal ◽

10.18203/2349-2902.isj20192150 ◽

2019 ◽

Vol 6 (6) ◽

pp. 1838

Author(s):

Ibrahim H. Aboelatta ◽

Soliman A. El-Shakhs ◽

Abd Elmieniem F. Mohammed ◽

Mohammed H. Milegy

Keyword(s):

Rectal Cancer ◽

Lymph Nodes ◽

Total Mesorectal Excision ◽

Cancer Treatment ◽

Pelvic Lymphadenectomy ◽

Mesorectal Excision ◽

Pelvic Lymph Nodes ◽

Rectal Cancer Treatment ◽

Lymph Nodes Dissection ◽

Lateral Pelvic Lymph Nodes

Background: Rectal cancer constitutes about one third of all colorectal cancer cases. Total mesorectal excision has become the gold standard in rectal cancer treatment. However total mesorectal excision does not involve any approaches for lateral pelvic lymph nodes (LPLN), which may be asource of local recurrences. Tumor containing LPLN were reported to be found in about 10%-20% of the rectal cancer patients. In japan lateral pelvic lymph node metastasis is accepted to be curable with excision.Methods: This study included 20 patients presented to Menofia Hospital for elective colorectal re sections and LPLN dissection, in the period from July 2016 to January 2019.Results: This study on 13 male (65%), 7 female (35%), all patients included in the study underwent preoperative chemoradiation according to the technique described by Marks et al. with an overall administration of 45 cGy over 5 weeks. Dissection of 180 lymph nodes was retrieved (20%) lymph nodes pathologically were positive for malignancy.Conclusions: Lateral pelvic lymph nodes dissection is an important in rectal cancer treatment.

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Lateral pelvic lymph nodes: the next phase in rectal cancer surgery

ANZ Journal of Surgery ◽

10.1111/ans.15999 ◽

2020 ◽

Vol 90 (7-8) ◽

pp. 1226-1227

Author(s):

Thomas S. Suhardja ◽

Kim‐Chi Phan‐Thien ◽

David Z. Lubowski

Keyword(s):

Rectal Cancer ◽

Lymph Nodes ◽

Cancer Surgery ◽

Rectal Cancer Surgery ◽

Pelvic Lymph Nodes ◽

Lateral Pelvic Lymph Nodes

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Current patterns of care for patients with stage I testicular seminoma: Survey of U.S. radiation oncologists on treatment recommendations.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.6_suppl.418 ◽

2017 ◽

Vol 35 (6_suppl) ◽

pp. 418-418

Author(s):

Timur Mitin ◽

Aditya Jain ◽

Catherine Degnin ◽

Yiyi Chen ◽

Arthur Hung ◽

...

Keyword(s):

Best Practices ◽

Compliance Rate ◽

Clinical Work ◽

Treatment Recommendations ◽

Stage I ◽

National Guidelines ◽

Online Questionnaire ◽

Chi Square ◽

Testicular Seminoma ◽

Radiation Oncologists

418 Background: Most men with Stage I testicular seminoma are cured with surgery alone, now a preferred strategy per national guidelines. The current pattern of practice among US radiation oncologists (RO) is unknown. Methods: We have surveyed practicing US RO via a short online questionnaire. Respondents’ characteristics, self-rated knowledge, perceived patient (pt) compliance rates with observation protocols and expected rate of infertility with and without adjuvant treatments were analyzed for association with treatment recommendations. Results: We received 353 responses from practicing US RO, of whom 23% consider themselves experts. Recommendations are summarized in the table. 34% believe that survival is jeopardized in case of recurrence on observation, but this belief does not impact the recommendation. Over 70% of respondents rate non-compliance with observation at > = 30%. Responders with a higher perceived non-compliance rate are more likely to recommend adjuvant therapy (Fisher’s exact p < 0.01). 52% routinely advise fertility assessment and/or sperm banking for pts who elect observation or chemotherapy, and 74% advise for pts undergoing RT. Respondents are more likely to recommend fertility assessment if they perceive a higher rate of infertility (Mantel-Haenszel Chi-square p < 0.01). 45% administer adjuvant RT in pts with elevated pre-orchiectomy alpha-fetoprotein levels. Conclusions: There is a dramatic uptake of observation as the recommended approach to pts with Stage I seminoma in US RO practices, despite a significant concern among practitioners about pt compliance. Further clinical work must establish best practices to minimize the effect on fertility, as well as guidelines for pts with Stage IS testicular seminoma. [Table: see text]

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