Does Selective Lateral Pelvic Lymphnode Dissection affect … · 2016-07-29 · Does Selective Lateral Pelvic Lymphnode Dissection affect outcomes in Locally Advanced Carcinoma Rectum?

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

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Does Selective Lateral Pelvic Lymphnode Dissection affect … · 2016-07-29 · Does Selective Lateral Pelvic Lymphnode Dissection affect outcomes in Locally Advanced Carcinoma Rectum?