Standardize the surgical technique and clarify the oncologic significance of robotic D3-D4 lymphadenectomy for upper rectum and sigmoid colon cancer with clinically more than N2 lymph node metastasis.
Journal
International journal of surgery (London, England)
ISSN: 1743-9159
Titre abrégé: Int J Surg
Pays: United States
ID NLM: 101228232
Informations de publication
Date de publication:
01 Apr 2024
01 Apr 2024
Historique:
received:
13
09
2023
accepted:
21
12
2023
medline:
26
4
2024
pubmed:
26
4
2024
entrez:
26
4
2024
Statut:
epublish
Résumé
The territory of D3-D4 lymphadenectomy for upper rectal and sigmoid colon cancer varies, and its oncological efficacy is unclear. This prospective study aimed to standardize the surgical technique of robotic D3-D4 lymphadenectomy and clarify its oncologic significance. Patients with upper rectal or sigmoid colon cancer with clinically suspected more than N2 lymph node metastasis were prospectively recruited to undergo standardized robotic D3-D4 lymphadenectomy. Immediately postsurgery, the retrieved lymph nodes were mapped to five N3-N4 nodal stations: the inferior mesenteric artery, para-aorta, inferior vena cava, infra-renal vein, and common iliac vessels. Patients were stratified according to their nodal metastasis status to compare their clinicopathological data and overall survival. Univariate and multivariate analyses were performed to determine the relative prognostic significance of the five specific nodal stations. Surgical outcomes and functional recovery of the patients were assessed using the appropriate variables. A total of 104 patients who successfully completed the treatment protocol were assessed. The standardized D3-D4 lymph node dissection harvested sufficient lymph nodes (34.4±7.2) for a precise pathologic staging. Based on histopathological analysis, 28 patients were included in the N3-N4 nodal metastasis-negative group and 33, 34, and nine patients in the single-station, double-station, and triple-station nodal metastasis-positive groups, respectively. Survival analysis indicated no significant difference between the single-station nodal metastasis-positive and N3-N4 nodal metastasis-negative groups in the estimated 5-year survival rate [53.6% (95% CI: 0.3353-0.7000) vs. 71.18% (95% CI: 0.4863-0.8518), P=0.563], whereas patients with double-station or triple-station nodal metastatic disease had poor 5-year survival rates (24.76 and 22.22%), which were comparable to those of AJCC/UICC stage IV disease than those with single-station metastasis-positive disease. Univariate analysis showed that the metastatic status of the five nodal stations was comparable in predicting the overall survival; in contrast, multivariate analysis indicated that common iliac vessels and infra-renal vein were the only two statistically significant predictors (P<0.05) for overall survival. Using a robotic approach, D3-D4 lymph node dissection could be safely performed in a standardized manner to remove the relevant N3-N4 lymphatic basin en bloc, thereby providing significant survival benefits and precise pathological staging for patients. This study encourages further international prospective clinical trials to provide more solid evidence that would facilitate the optimization of surgery and revision of the current treatment guidelines for such a clinical conundrum.
Sections du résumé
BACKGROUND
BACKGROUND
The territory of D3-D4 lymphadenectomy for upper rectal and sigmoid colon cancer varies, and its oncological efficacy is unclear. This prospective study aimed to standardize the surgical technique of robotic D3-D4 lymphadenectomy and clarify its oncologic significance.
METHODS
METHODS
Patients with upper rectal or sigmoid colon cancer with clinically suspected more than N2 lymph node metastasis were prospectively recruited to undergo standardized robotic D3-D4 lymphadenectomy. Immediately postsurgery, the retrieved lymph nodes were mapped to five N3-N4 nodal stations: the inferior mesenteric artery, para-aorta, inferior vena cava, infra-renal vein, and common iliac vessels. Patients were stratified according to their nodal metastasis status to compare their clinicopathological data and overall survival. Univariate and multivariate analyses were performed to determine the relative prognostic significance of the five specific nodal stations. Surgical outcomes and functional recovery of the patients were assessed using the appropriate variables.
RESULTS
RESULTS
A total of 104 patients who successfully completed the treatment protocol were assessed. The standardized D3-D4 lymph node dissection harvested sufficient lymph nodes (34.4±7.2) for a precise pathologic staging. Based on histopathological analysis, 28 patients were included in the N3-N4 nodal metastasis-negative group and 33, 34, and nine patients in the single-station, double-station, and triple-station nodal metastasis-positive groups, respectively. Survival analysis indicated no significant difference between the single-station nodal metastasis-positive and N3-N4 nodal metastasis-negative groups in the estimated 5-year survival rate [53.6% (95% CI: 0.3353-0.7000) vs. 71.18% (95% CI: 0.4863-0.8518), P=0.563], whereas patients with double-station or triple-station nodal metastatic disease had poor 5-year survival rates (24.76 and 22.22%), which were comparable to those of AJCC/UICC stage IV disease than those with single-station metastasis-positive disease. Univariate analysis showed that the metastatic status of the five nodal stations was comparable in predicting the overall survival; in contrast, multivariate analysis indicated that common iliac vessels and infra-renal vein were the only two statistically significant predictors (P<0.05) for overall survival.
CONCLUSIONS
CONCLUSIONS
Using a robotic approach, D3-D4 lymph node dissection could be safely performed in a standardized manner to remove the relevant N3-N4 lymphatic basin en bloc, thereby providing significant survival benefits and precise pathological staging for patients. This study encourages further international prospective clinical trials to provide more solid evidence that would facilitate the optimization of surgery and revision of the current treatment guidelines for such a clinical conundrum.
Identifiants
pubmed: 38668657
doi: 10.1097/JS9.0000000000001061
pii: 01279778-202404000-00016
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
2034-2043Informations de copyright
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
Références
Dumont F, Kothodinis K, Goéré D, et al. Central retroperitoneal recurrences from colorectal cancer: are lymph node and locoregional recurrences the same disease? Eur J Surg Oncol 2012;38:611–616.
Sahara K, Watanabe J, Ishibe A, et al. Long-term outcome and prognostic factors for patients with para-aortic lymph node dissection in left-sided colorectal cancer. Int J Colorectal Dis 2019;34:1121–1129.
Arimoto A, Uehara K, Kato T, et al. Clinical significance of para-aortic lymph node dissection for advanced or metastatic colorectal cancer in the current era of modern chemotherapy. Dig Surg 2015;32:439–444.
Min BS, Kim JS, Kim NK, et al. Extended lymph node dissection for rectal cancer with radiologically diagnosed extramesenteric lymph node metastasis. Ann Surg Oncol 2009;16:3271–3278.
Ushigome H, Yasui M, Ohue M, et al. The treatment strategy of R0 resection in colorectal cancer with synchronous para-aortic lymph node metastasis. World J Surg Oncol 2020;18:229.
Gagnière J, Dupré A, Chabaud S, et al. Retroperitoneal nodal metastases from colorectal cancer: curable metastases with radical retroperitoneal lymphadenectomy in selected patients. Eur J Surg Oncol 2015;41:731–737.
Nakai N, Yamaguchi T, Kinugasa Y, et al. Long-term outcomes after resection of para-aortic lymph node metastasis from left-sided colon and rectal cancer. Int J Colorectal Dis 2017;32:999–1007.
Yamada K, Tsukamoto S, Ochiai H, et al. Improving selection for resection of synchronous para-aortic lymph node metastases in colorectal cancer. Dig Surg 2019;36:369–375.
Sakamoto J, Ozawa H, Nakanishi H, et al. Oncologic outcomes after resection of para-aortic lymph node metastasis in left-sided colon and rectal cancer. PLoS One 2020;15:e0241815.
Wong JSM, Tan GHC, Teo MCC. Management of para-aortic lymph node metastasis in colorectal patients: a systemic review. Surg Oncol 2016;25:411–418.
Sun Y, Yu D, Zhong J, et al. Para-aortic lymph node dissection in left-sided colorectal cancer: risk factors, prognostic impact, and therapeutic value. J Surg Oncol 2022;125:1251–1259.
Aylward C, Noori J, Tyrrell J, et al. Survival outcomes after synchronous para-aortic lymph node metastasis in colorectal cancer: a systematic review. J Surg Oncol 2023;127:645–656.
Feng LF, Yan PJ, Chu XJ, et al. A scientometric study of the top 100 most-cited publications based on Web-of-Science regarding robotic versus laparoscopic surgery. Asian J Surg 2021;44:440–451.
An L, Hwang KS, Park SH, et al; Korean Association of Robotic Surgeons (KAROS) Study Group. Trends of robotic-assisted surgery for thyroid, colorectal, stomach and hepatopancreaticobiliary cancer: 10 year Korea trend investigation. Asian J Surg 2021;44:199–205.
Chen PJ, Su WC, Chang TK, et al. Oncological outcomes of robotic-assisted total mesorectal excision after neoadjuvant concurrent chemoradiotherapy in patients with rectal cancer. Asian J Surg 2021;44:957–963.
Song SH, Park SY, Park JS, et al. Laparoscopic para-aortic lymph node dissection for patients with primary colorectal cancer and clinically suspected para-aortic lymph nodes. Ann Surg Treat Res 2016;90:29–35.
Liang JT, Huang KC, Lai HS, et al. Oncologic results of laparoscopic D3 lymphadenectomy for male sigmoid and upper rectal cancer with clinically positive lymph nodes. Ann Surg Oncol 2007;14:1980–1990.
Chen TC, Liang JT. Robotic D4 lymphadenectomy for the treatment of rectal cancer with metastasis to N3-N4 lymph nodes - a video vignette. Colorectal Dis 2018;20:352–353.
Mathew G, Agha R, Albrecht J, et al; STROCSS Group. STROCSS 2021: strengthening the reporting of cohort, cross-sectional and case-control studies in surgery. Int J Surg 2021;96:106165.
Nakai N, Yamaguchi T, Kinugasa Y, et al. Diagnostic value of computed tomography (CT) and positron emission tomography (PET) for paraaortic lymph node metastasis from left-sided colon and rectal cancer. Asian J Surg 2020;43:676–682.
Hashiguchi Y, Muro K, Saito Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol 2020;25:1–42.
Amin MB, Greene FL, Edge SB, et al. The Eighth Edition AJCC cancer staging manual: continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. CA Cancer J Clin 2017;67:93–99.
Union for International Cancer Control. TNM classification of malignant tumours, 8th edition. John Wiley & Sons, Ltd; 2017.
Clavien PA, Barkun J, De Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009;250:187–196.
Kim HJ, Choi GS, Park JS, et al. The impact of robotic surgery on quality of life, urinary and sexual function following total mesorectal excision for rectal cancer: a propensity score-matched analysis with laparoscopic surgery. Colorectal Dis 2018;20:O103–O113.
Ha RK, Park B, Park SC, et al. Effect of lateral lymph node dissection on the quality of life and genitourinary function after neoadjuvant chemoradiotherapy for rectal cancer. Ann Surg Treat Res 2021;100:109–118.
Dou R, He S, Deng Y, et al. Comparison of guidelines on rectal cancer: exception proves the rule? Gastroenterol Rep (Oxf) 2021;9:290–298.
Kang J, Hur H, Min BS, et al. Prognostic impact of inferior mesenteric artery lymph node metastasis in colorectal cancer. Ann Surg Oncol 2011;18:704–710.
Min BS, Kim NK, Sohn SK, et al. Isolated paraaortic lymph-node recurrence after the curative resection of colorectal carcinoma. J Surg Oncol 2008;97:136–140.
Choi PW, Kim HC, Kim AY, et al. Extensive lymphadenectomy in colorectal cancer with isolated para-aortic lymph node metastasis below the level of renal vessels. J Surg Oncol 2010;101:66–71.
Bae SU, Han YD, Cho MS, et al. Oncologic outcomes of colon cancer patients with extraregional lymph node metastasis: comparison of isolated paraaortic lymph node metastasis with resectable liver metastasis. Ann Surg Oncol 2016;23:1562–1568.
Ogura A, Akiyoshi T, Takatsu Y, et al. The significance of extended lymphadenectomy for colorectal cancer with isolated synchronous extraregional lymph node metastasis. Asian J Surg 2017;40:254–261.
Velikova G, Wright P, Smith AB, et al. Self-reported quality of life of individual cancer patients: concordance of results with disease course and medical records. J Clin Oncol 2001;19:2064–2073.
De Palma GD, Luglio G. Quality of life in rectal cancer surgery: what do the patient ask? World J Gastrointest Surg 2015;7:349–355.
Traa MJ, Vries JD, Roukema JA, et al. Sexual (dys)function and the quality of sexual life in patients with colorectal cancer: a systematic review. Ann Oncol 2012;23:19–27.