Ricerc@Sapienza

We have read with extremely interest the article of Fujita
et al. “Mesorectal Excision With or Without Lateral
Lymph Node Dissection for Clinical Stage II/III Lower
Rectal Cancer (JCOG0212) A Multicenter, Randomized
Controlled, Noninferiority Trial” published on Annals of
Surgery.
The guidelines of Japanese Society for Cancer of the
Colon and Rectum (JSCCR) for the treatment of colorectal
cancer recommend lateral lymph node dissection (LLND)
for clinical Stage II/III Lower Rectal: “Lateral lymph node
dissection is indicated when the lower border of the tumor is
located distal to the peritoneal reflection and the tumor has
invaded beyond the muscularis propria”. In effect, a study of
JSCCR reported that “the incidence of lateral lymph node
metastasis was 20.1% among patients whose lower rectal tumor
border was located distal to the peritoneal reflection and whose
cancer invaded beyond the muscularis propria. After performing
lateral lymph node dissection for this indication, it is expected that
the risk of intrapelvic recurrence decreases by 50%, and 5-year
survival improves by 8% to 9%”. Otherwise in Western
countries, surgical societies do not suggest to perform
LLND in patients without clinically suspected lateral pelvic
lymph node metastasis.
In Japan lateral pelvic lymph node metastasis is
considered to be a localized disease, differently in West
this same problem is considered to be a systemic disease
associated with a very poor prognosis. For these reasons,
in Japan prophylactic LLND is performed in all patients
with for Clinical Stage II/III Lower Rectal Cancer for
reducing local recurrence and improving survival. In
Western countries, lateral pelvic lymph node metastases
have been considered a systemic neoplastic spread and for
this reason the oncologists treated the lateral pelvic lymph
node metastases only by chemoradiation therapy. Other
reasons of this behaviour were including the few number of
lateral pelvic lymph node metastasis, the negligible survival
impact of LLDN over chemoradiation therapy and the high
post-operative morbidity associated at LLND.
This trial of Fujita represents the high Evidence Basic
Medicine milestone in the controversies between East and
West in rectal cancer surgery. Nowadays, the neoadjuvant
chemo-radiotherapy and the successively TME is the choice
treatment for clinical Stage II/III Lower Rectal Cancer in
Western countries, the goals are to reduce the risk of cancer
recurrence and to shrink the cancer prior to surgery.
The role of neoadjuvant chemo-radiotherapy on lateral
pelvic lymph node metastasis in advanced low rectal
cancer remains unclear. Nowadays, in literature there are
few reports about the oncologic outcome of patients with
lateral pelvic lymph node metastasis underwent neoadjuvant
chemo-radiotherapy.
Recently some European societies guidelines suggest the neoadjuvant
chemo-radiotherapy and TME with LLND in T3-Ta rectal
tumours with involved lateral pelvic lymph node (obturator,
internal iliac nodes).
The conclusions are the same:
lateral pelvic lymph node metastasis cannot be eradicated
completely by neoadjuvant chemo-radiotherapy, for these
reasons the Authors recommended to perform LLND
for the reduction of local recurrence at lateral pelvic
lymph node.
Fujita et al. included only patients with no clinical
evidence of lateral pelvic lymph node enlargement and
lateral pelvic lymph nodes less than 10 mm in short-axis
diameter as detected on MDCT or MRI were defined
as negative nodes; this last choice in the inclusion
criteria is very important because the patients enrolled are
homogeneous and the risk of local recurrence at lateral
pelvic lymph node is the same. Differently, Yamaoka
reported a different optimal cut-off value for determining
metastasis: 6.0 mm, with a sensitivity of 78.5% and
specificity of 82.9% . In effect, Fujita et al. reported
th