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DoesSelectiveLateralPelvicLymphnodeDissectionaffectoutcomes
inLocallyAdvancedCarcinomaRectum?
ShubhamGarg1,Ashish Pokharkar1,VikramChaudhary1,Reena Engineer2,Supreeta Arya3,Vikas Ostwal4,Avanish Saklani1
1ColorectalServices,DepartmentofSurgicalOncology,2DepartmentofRadiotherapy,3DepartmentofRadiodiagnosis ,4DepartmentofMedicalOncology
TataMemorialHospitalMumbaiINDIA
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IntroductionLymphaticdrainageoftherectum
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Majorly - alongsuperiorrectalarterytoinferiormesentericarteryandparaaorticnodes.
5- 10% - alongmiddleandlowerrectalarterytotheobturator,internaliliac,externaliliac,andcommoniliaclymphnodes.
Introduction
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Currentsurgicalstandard- TME
Total mesorectal excision (TME) clears themesorectum but doesnt address thelateral pelvicnodes (LPN).
Lateral recurrences are more common inpost TME era.
Introduction• Incidence of Lateral Pelvic Nodes (LPLN) - 8.6 – 27%.
FujitaS,etal.BrJSurg 2003;90(12):1580–5.
• Incidence of lateral pelvic nodes depends on
– Location in relation to peritoneal reflection - 14.9% below vs 8.2% aboveMERCURYStudyGroup.BrJSurg.2011Dec;98(12):1798–804
– pathological T stage - pT2 - 7.1%, pT3 - 17.9%, and pT4 - 31.6%UenoHetal.AnnSurg.2007Jan;245(1):80–7
– Eveninabsenceofmesenteric nodes– 15%BrJSurg.2005Jun;92(6):756–63.
• AJCC classifies internal pelvic nodes as regional disease and is ambiguous
about nodes in external iliac and common iliac region.AJCCcancerstagingmanual.7th edition.NewYork:Springer;2010
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West(Metastatic)vs East(Regional)
• Dutch study (Kusters etal) & Nagawa etal established the role of preop RT insterilising the lateral pelvic nodes.
• Akiyoshi etal showed it behaves more like regional disease than metastaticdisease
Akiyoshi etal.AnnSurg.2012;255:1129–34
• Presence of LPLN is indication for NACTRT but incidence of nodal positivity inpersistent LPLN after NACTRT is as high as 71.1%
• LPLN dissection (LPLND) is still not standard of care but has showedencouraging results.
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Aims&Objective
• Aim:• Toascertaintheincidenceofpathologicallypositivenodespersisting
onMRIafterNACTRT
• Studyrecurrencepatternanddiseasefreesurvivalasintermediateoutcomes.
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MaterialsandMethods
• Retrospectiveaudit
• Timeperiod– 1st July2013– 31st March2015
• InclusionCriteria:
• All patients > 18 yrs with Locally Advanced RectalCancer (LARC)
• Within 10 cm fromanal verge
• Suspected LPLN on index MRI persisting afterNACTRT.
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MaterialsandMethods
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LocallyAdvancedRectalcancer
>18yrsWithin10cmfromanalvergeLPLNsuspectedonMRI1
NACTRT(50Gy/25#/5weeks+Capecetabine @825mg/m2 BD)
Reassesed onMRI2• Size>8mm• Roundshape• Irregularborders• Heterogeneoussignal
TMEonly(TME)
TME+Lat PelvicNodeDissection(TMPLND)
no yes
MaterialsandMethods
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MaterialsandMethods• Followingparametersnoted
– Demographicprofile– Diseasestatus
• DistancefromAV• Clinicalstage• CRMthreatened• Histologyanddifferentiation
– PerioperativesurgicalOutcomes• Bld loss• Durationofsurgery• PostopStay
– Finalhistopathology• CRMinvolved/not• Nodalyield
• Followup– Clinicopathologically
• History• Physicalexamination• SCEA• Imagingaspersymptomatology
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Results
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372patientsofLARC
40 12
LPLNonpresentation
11%
PersistentLPLN
30%TME(n=25)
3patientsweremetastaticonlaparotomy
TMPLND(n=12)
MRI1 MRI2
NACTRT
TME TMPLND
n 25 12
Age inyrs(Range) 40(19-80) 42 (32-68)
Gender Distribution
Male 60%(15) 91%(11)
Female 40%(10) 9%(1)
DiseaseStatus
T stageinMRI1
T2 16%(4) 8%(1)
T3 76%(19) 66%(8)
T4 8%(2) 25%(3)
CRMinMRI1Involved 36%(9) 50%(6)
Free 64%(16) 50%(6)
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PatientandDiseaseCharacteristics
Results
p value0.595
p value0.049
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DetailsofSurgicalproceduredone
4844
8
33.3
50
16.7
0
10
20
30
40
50
60
AR+ISR APR EXENTERATION
TME
TMEPLND
Results
TME(n =25) TMPLND(n=12)
Surgical outcome
MedianBloodLossInml(Range)
400(100- 1500)
800(250- 2000)
Median PostopStayInDays(Range)
7(4– 35)
8(6 – 27)
Histopathology
CRMinvolved None None
MedianLPLN yield(Range)
7(3– 24)
NodalPositivity 33%(4/12)
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Surgicaloutcomes
Results
p value0.626
p value0.227
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ResultsPatternofrecurrence TME
(n= 25)TMPLND(n=12)
MedianFollow up– 19months
Recurrence(%) 5(20%) 5(41.7%)
Nodal 2 3
Distant 1 2
Nodal+Distant 2 Nil
DFS@19months 90.4% 83.3%
Allrecurrenceswereinthosewhichshowedpathologicallynegativenodes
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Results
KaplanMeiercurveshowingDFS
TME
TMEPLND
Logranktest- Insignificant
• Incidence(Radiologically)
– OverallLPLNinLARC– 11%– PersistentLPLNafterNACTRT–30%
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Discussion
• InTMPLNDgroup,Nodalpositivity –33%(4/12)
NodespositiveonLPND(4) +Nodesrecurredlateron(3)
=7outof12ie 58.3%
• InTMEgroup– 4/25ie 16% developednodalrecurrence
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Discussion• Nodalpositivity –33%
NodespositiveonLPND(4) +Nodesrecurredlateron(3)
=7outof12ie 58.3%• InTMEgroup– 4/25ie 16% developednodalrecurrence
LARC+LPLNafterNACTRT
OnthebasisofMRI
Nodenegative
Nodepositive 58%
16%
TotalnodalpositivityafterNACTRT
=4 +3 +4 =11/40=25%CTRT
aloneisnt
GOOD
MRIIsnt
GOODENOUGH
FalsePositive– 42%
FalseNegative– 16%
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Discussion• NeedforbetterImaging– modality/interpretation– High-resolutionMRIforLPLN
• 67%sensitivity,• 75%specificity,and• 73%overallaccuracy.
Matsuokaetal.Optimaldiagnosticcriteriaforlateralpelviclymphnodemetastasisinrectalcarcinoma.AnticancerRes.2007Sep-Oct;27(5B):3529-33.
– DiffusionweightedMRIwithApparentDiffusionCoefficient(ADC)measurement• differentiatingmetastaticLNsfrombenignLNs
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Discussion• RoleoftherapeuticLPNDs– shouldweoffertoallwithLPLN
• Metaanalysisof5500ptswithextendedlymphnodedissectionvsconventionalrectalcancersurgery Georgiouetal.LancetOncol.2009;10:1053–62.
• nosignificantDFS/OSbenefit• Intraoperativebloodloss,• durationofhospitalstay,and• sexualandurinarydysfunctions complications
• SelectiveLPLDreceivingNACTRTonbasisofpreoperativeimagingAkiyoshi T.Ann.Surg.Oncol.2014;21:189–96
– Pathologicalnodalpostivity – 66%– NolocalrecurrencesinLPLDgroup (0%)vs 3.4%inTMEgroup– significant– Didnotaffectrecurrencefreesurvival.
Similartoourstudy
Conclusion• IncidenceofLPLNsonMRI
– Overall– 11%– PersistingafterNACTRT– 30%
• LocalrecurrencesafterNACTRT(TME+TMPLND)=25%ie CTRTalonecannotbereliedaloneassinglemodalityoftreatmentforLPLNs.
• MRIasanevaluationmodalitymaynotbecompletelyreliabletoassessresponsepostneoadjuvant treatment.
• Increasedsurgicalmorbiditybutnosignificantdiseasefreesurvivalnotedwithinthetwogroups.
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Conclusion• Henceneedforawell-conductedrandomizedtrialtoestablish
thebestapproachwithpossibletrialdesigntorandomizethepatientswithresiduallateralpelvicnodesafterNACTRTintoanLPLNDgroupandobservationgroup.
• However,suchatrialwouldrequireverylargenumberofpatientsandmaynotbefeasible.
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Shortcomings• Smallnumber
– N=40– Difficulttodrawanystatisticalconclusions
• Shortfollowup– MedianFU– 19months– Cannotcommentuponsurvival
• Postoperativefunctionaloutcomesmissing– Urinary/sexualfunctions
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Thank YouTMH – A Beacon of Hope