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Total mesorectal excision (TME), involving almost complete removal of the lymphoid channels in the mesorectum, has vastly reduced the incidence of locoregional recurrence in rectal cancer. However, around 10-25% of the patients with locally advanced mid and low rectal cancer display an extramesorectal spread to lateral pelvic nodes. These nodes are not removed during the standard TME and may be a potential site of local recurrence.
Neoadjuvant chemoradiotherapy may reduce and eradicate the regional lymph nodes involved, including those in the lateral pelvis. Several studies have showed no differences in locoregional recurrence between neoadjuvant chemoradiotherapy and lateral pelvic lymph-node dissection. But these studies did not include patients with suspected lateral pelvic lymph node metastasis, so the benefit of lateral pelvis dissection remains unclear.
Professor Peter Sagar, from St. James’s University Hospital in Leeds (England) discusses the management of these lymph nodes after neoadjuvant chemoradiation and suggests that only those that persist after neoadjuvant treatment should undergo dissection.