Lymphadenectomy in

Rectal Cancers

Presenter : Dr. Akhil Thomas Jacob

Moderator : Dr. Chandramohan K
Roadmap …

● Introduction
● Anatomy and nodal spread
● Evolution of rectal cancer surgery
● Standard lymphadnectomy
● Extended lymohadenectomy
● Inguinal and paraaortic node metastasis:
palliative → curative
Introduction

Lymphadenectomy:
○ Part of primary specimen resection with
mesorectal clearance
○ Extended dissection to clear nodal areas
Anatomy and Spread
Evolution of rectal cancer surgery

1950 1982
1907

Miles Moynihan Geddish Heald

vs MIles
APR Radical Abdomino Holy Plane
pelvic
High vs low tie Lymphadenectomy
Radical Abdominopelvic
lymphadenectomy
Standard
lymphadenectomy
Minimum number

● > 12 nodes: survival advantage

● CME/TME: to ensure adequate clearance
● Pathological assessment: manual dissection vs
acetone compression/ methylene blue
technique
● Post NACTRT: 12 nodes may not be achieved
Fresh sample dissection of TME specimen: RCC
data : Dr. Athul Vasudev

● Primary : 30 nodes
● Post NACTRT: 13- 15 nodes
● Time of dissection 70 minute
● Remarks: Japanese protocol: dissection of CRM by
surgeon⇒ reason for high nodal yield?
o D1- nodes present in the fibro fatty tissue distal to the tumor: first 2.5
cm

o D2- nodes in 2.5 to the distal most end of the specimen, varies
depending on the length of the specimen

o S- nodes present at the tumor site (along the length of tumour)

o P1- nodes located 2.5cm proximally from the tumor

P2- nodes located at a distance of 2.5-5cm from the primary tumor
P3- Lymph nodes at a distance of 5-10cm from the tumor
P4- peri colic located nodes along the rectum or sigmoid colon at a
distance 10-15 cm from the primary tumor. May be absent depending
on the length of the resected specimen.
P5- peri colic nodes > 15 cm from the primary tumor, if there any
And Apical & principal nodes - nodes at the root of the IMA
Apical Nodal dissection
Japanese Western
● Based on nodal station ● Based on number of
● Apical node: N3 nodes
● Lateral node dissection ● Apical node based
is part of standard on number
surgery
● Lateral node
○ Below peritoneal
dissection is not
reflection
○ >T2
mandatory
● Apical node: from IMA ● AN: 1 cm from IMA
origin to LCA origin
Apical Nodal dissection : RCC data

● Node identification 52%

● Node positivity: 3.4%
Apical node dissection
● Apical node positivity is not an independent
prognostic factor: it is more often seen with
deeper tumor and more nodal burden
● RFS: CEA, T status
● CSS: CEA, Age,Postoperative complications and
tumor positive node burden: prognostic
importance
● Independent predictor of systemic disease in
high risk stage III (T1-3N2 or T4N1-2)
● Poorer survival
Japanese School
● Proximal internal iliac
nodes (263P)
● Distal internal iliac nodes
(263D)
● Obturator nodes (283)
● Common iliac nodes (273)
● External iliac nodes (293)
● Lateral sacral nodes (260)
● Median sacral nodes (270)
● Aortic bifurcation nodes
(280)
● Inguinal nodes (292)
Rectum

● Main : 253
● Intermediate 252
● Pericolic: Lowest sigmoidal artery inflow to a
point 3 cm ( RS /Ra ) or 2cm (Rb) distal to tumor
● D0: Incomplete pericolic/perirectal lymph node
dissection
● D1: Complete pericolic/perirectal lymph node
dissection
● D2: Complete pericolic/perirectal and
intermediate lymph node dissection
● D3: Pericolic/perirectal, intermediate, and main
lymph nodes are dissected
● Adenocarcinoma of anal canal : inguinal nodes
considered as intermediate group
Lateral Node dissection
 Significant nodes

● Nodes > 5mm SAD

● Response: post CTRT response: indicates good
outcome
● Even post NACTRT: 8-12% pelvic recurrence can occur
(Korean literature)
● Dutch Trial: local failure at pre sacral region rather than
LP
● Laparoscopic approach is feasible with similar
oncologic outcome and less blood loss and duration of
stay
Extend of lateral node dissection

● LD0: LD is not performed

● LD1: LD does not satisfy LD2
● LD2: Dissection of 263D, 263 P, and 283 is
performed
● LD3: Dissection of all lateral lymph nodes is
performed
Inclusion

● Stage II/III
● Rectal lesion , with the lower margin below the
peritoneal reflection
● No lateral pelvic lymph node enlargement
(<1cm)
● Peformance Status of 0 or 1
● 20 to 75 years
● 701 patients
● ME vs ME +LLND
● Post ME→ Macroscopic R0+ macroscopic N0 for LN→
randomisation
● Unblinded
● Post procedure stage III→ Rosewell Park regimen:
5FU+LV
● No RT
● FNR of imaging for LN : 7.4% (JCOG1410A underway)
● Primary end point RFS: ME alone: was not
proven non inferior
● Lateral node recurrence was main cause of
failure ( vs central group in Dutch Trial)
● Local recurrence: ME: 13% ME+LLND: 7%
(Dutch TME+ RT: 6% vs 12% TME alone group)
Definitions

● Low rectal Cancer : lower margin below

peritoneal reflection
● High risk lateral nodes ⇒ 2 or more nodes +
obturator & beyond involved
● Prolonged operating time by 76 minutes
● Increased intraop blood loss
● Increased male sexual (76% vs 40%) and urinary
disturbances(40% vs 9 %)
● No survival advantage locoregionally
● Increased grade 3/ 4 morbidity without DFS
advantage
● Does not improve local or distant recurrence
rate
● Longer operating time(+72m) ; More blood loss
● Increased morbidity
● No improvement in overall survival
● No improvement in local recurrence
Inguinal Node
metastasis
Palliation……
……To curative
● OS: 1y :83% 5y:52%
● 3 year overall survival: 76.5%; 5yr: 55%
● No difference between anal and rectal
adenocarcinoma
● Absence of lateral node positive and WD tumor:
better indicators of survival
Positive node:
ILN >10 mm
ELN> 8 mm
Round irregular contour ; LOFH
Mixed signals
ILN and ELN may be excluded from elective CTV in
low rectal cancer with acceptable level of failure
Paraaortic node
metastasis
● Criteria:
○ > 5mm
○ Heterogeneous appearance
○ Irregular/ spiculated borders
○ PET uptake
● PPV: 45% for imaging
Balance
● Personalised approach combining CTRT with
LPLND
● Low risk cT1/T2/earlyT3 (and Ra) with clinically
negative LPLN on MRI;
● Moderate risk (cT3+/T4 with negative LPLN on
MRI)
● High risk (clinically abnormal LPLN on MRI)
● Low risk: TME
● Moderate risk: NACTRT + TME or TME +
LPLN dissection
● • High risk:NACTRT + TME + LPLND
PALND

● 1950 Dr. Deddish: prophylactic PALND→

increased morbidity with no survival advantage
● Left Renal vein to bilateral common iliac
● Choi et al: Survival advantage of 53% vs 12%
● Morbidity 7-30%
● Metachronus PALN metastasis:(>6 months)
● Predictor of better survival in sPALN
○ Well differentiated primary
○ Concurrent surgery for primary and mets
○ Low burden < 2 PALN
● Predictors of better OS metachronus
○ Longer DFI
○ Tumor < 5 cm
○ Infrarenal
○ R0 feasible
● Survival outcome : similar in synchronous vs
metachronous
● Worse outcome for non operative management
with Chemo RT vs surgery (57% vs 36%) in
previous studies: but now improved
● CR> PR (61% vs 25%)
● May be used as NAT
● 80% recurrence
● 25% RFS
● 39% OS
● Recurrence 26% PALN > lung, liver
Thankyou!!!