Abstract
Objectives:
A total mesenteric excision (TME) with lateral pelvic lymph node dissection (LLND) is the standard treatment for advanced low rectal cancer in Japan. Recently, neoadjuvant (chemo)radiotherapy (n(C)RT) has been used with LLND to improve outcomes at multiple Japanese institutes. This study evaluates the benefits of adding nCRT to TME with LLND.
Methods:
Seventy-two consecutive patients who underwent TME and LLND with or without nCRT between 2006-2019 to treat advanced low rectal cancer were retrospectively reviewed. The clinicopathological data were compared and the risk factors for local recurrence were evaluated.
Results:
Fifty-seven patients (79.1%) underwent TME and LLND with nCRT, and 15 patients (20.9%) without nCRT. There was no significant difference in the clinicopathological characteristics except the clinical T stage. The occurrence of postoperative complications was statistically insignificant. The 5-year local recurrence rate of patients with nCRT was significantly lower than those without (4.0% versus 26.6%, in all patients, p=0.002). Multivariate analysis revealed that the absence of nCRT was an independent risk factor for local recurrences in patients who underwent TME with LLND (hazard ratio: 6.04, p=0.04).
Conclusions:
The administration of nCRT prevented local recurrences more effectively in patients with advanced low rectal cancer who underwent TME with LLND.
Keywords: lateral pelvic lymph node dissection, local recurrence, neoadjuvant chemoradiotherapy, advanced lower rectal cancer
Introduction
Total mesorectal excisions (TME) combined with neoadjuvant (chemo) radiotherapy (n(C)RT) reportedly have favorable oncological outcomes, especially improved local control[1,2]. This has become the standard treatment for patients with locally advanced rectal cancer in western countries[3]. Although lateral pelvic lymph nodes (LPLNs) are included in the regional lymph nodes of low rectal cancer by the Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines[4], LPLN metastases are considered distant metastases in western countries. Several studies that examined lateral pelvic lymph node dissection (LLND) were conducted in Japan and reported that TME with LLND achieved better local control than TME alone[5,6]. The JSCCR guidelines recommend LLND for patients with locally advanced low rectal cancer[4]. However, the local recurrence rate of stage II/III rectal cancer patients treated with TME and LLND was about 12.3 to 19.2%[6,7], necessitating the need for further improvements to ensure improved local control. The current practice of several institutes in western countries include LLND in addition to their standard treatment. The addition of LLND reportedly achieved better oncological outcomes[8,9]. It must be noted that the additional effects of nCRT with TME and LLND remain unclear.
The present study aimed to compare the oncological outcomes of locally advanced low rectal cancer patients treated by TME and LLND with or without nCRT, and to clearly define the additional impact of nCRT on their prognoses.
Methods
Study population
Two hundred and eighty-three consecutive patients who underwent operation for lower rectal cancer between 2006 and 2019 at the Kyoto Prefectural University of Medicine were enrolled in this study. Thirty-five patients with simultaneous malignant diseases, 30 patients with distant metastasis except LPLNs, and 111 patients with clinical Stage I tumor were excluded. Further, of 107 patients with locally advanced low rectal cancer, 35 patients who did not undergo LLND were excluded and the remaining 72 patients were included for analysis (Figure 1). A low rectum was defined as the rectum below peritoneal reflection by barium contrast radiography[10].
Figure 1.
Patients settings in this study.
A total of 57 patients who underwent TME and LLND with nCRT and 15 patients who underwent TME and LLND without nCRT for rectal cancer were analyzed in this study.
HEP, liver metastasis; LLND, lateral pelvic lymph node dissection; LPLN, lateral pelvic lymph node metastasis; nCRT, neoadjuvant chemoradiotherapy; PALN, para aortic lymph node metastasis; PER, peritoneal dissemination; PUL, lung metastasis; TME, total mesorectal excision
In this study, the prognostic outcomes were compared between patients who received nCRT (nCRT group) and those who did not (Non-nCRT group). The patients' clinicopathological data and clinical courses were collected retrospectively from hospital records. The tumor staging was done as per the UICC/TNM staging system[11]. The diagnosis of a clinical lymph node metastasis was defined as the presence of mesenteric and lateral lymph nodes with a diameter of 7.0 and 5.0 mm or greater in the short axis, respectively, as detected on 1.0 to 5.0 mm sliced computed tomography or 3.0 to 4.0 mm sliced magnetic resonance image findings, and/or by positron emission tomography. Complications were defined as those occurring within 30 days after surgery and assessed according to the Clavien-Dindo classification[12]. The histological regression of the tumor by nCRT was graded in accordance with the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma[10].
Informed consent was obtained from the participants. The procedures performed in this study were in accordance with the ethical standards of the institutional research committee and the 1964 Helsinki Declaration, including its later amendments or comparable ethical standards. The study protocol was reviewed and approved by the Kyoto Prefectural University of Medicine Independent Ethics Committee (approval number: ERB-C-1178-1).
Neoadjuvant chemoradiotherapy and surgical procedure
The use of nCRT was introduced into the standard treatment at our institute in 2008, which previously involved TME with bilateral LLND for patients with cT3 or deeper tumors without distant metastases other than LPLNs. The patients who declined nCRT did not receive the treatment. Additionally, LLND was not performed in some patients due to old age, poor general conditions, and severe comorbidities. The area of the LPLNs was included in the target of radiation therapy, and the total dose of radiation was 45 Gy. The combined chemotherapy regimen was tegafur/gimeracil/oteracil (S-1) alone or S-1 plus irinotecan. Curative surgery was performed at 6 to 8 weeks post-nCRT completion. The region of the LPLNs for the LLND was the internal iliac and the obturator area[13].
Survival analysis
We generally introduced adjuvant chemotherapy for patients with pathological Stage III tumors. The oncological outcomes were assessed by the 5-year relapse-free survival (RFS), overall survival (OS), the cumulative local recurrence (LR), and cumulative distant recurrence (DR). Local recurrence was defined as clinical, radiologic, and pathologic findings of locoregional relapse, including intrapelvic peritoneal dissemination, recurrence at an anastomotic site, and a tumor bed treated by previous surgery within the entire follow-up period[9,14]. In addition, the local recurrence was divided into two subgroups, lateral and central pelvic recurrence. The lateral recurrence was defined as recurrence outside the pelvic nerve plexus, along the obturator and the internal, external and common iliac vessels. The central pelvic recurrence was defined as recurrence in the tumor bed, anastomosis site, anterior pelvic organs, and within the pelvic nerve plexus and perineum[15].
Statistical analyses
Statistical analyses were performed using JMP version 14 (SAS Institute, Cary, NC, USA). A Fisher's exact test or chi-square test was used to evaluate the differences in proportions, and a Student's t-test was used to evaluate the continuous variables. The survival outcomes were analyzed using the Kaplan-Meier method, and the differences were assessed using the log-rank test. A propensity score, calculated using a logistic regression model, was used to match the patients in the cohort. Multivariate analyses using covariates with a p-value less than 0.10 were done by the Cox regression analysis. In all analyses, a p-value less than 0.05 was considered statistically significant.
Results
Clinical background and surgical outcomes in patients with or without nCRT
A total of 72 patients who underwent a curative resection with or without nCRT were enrolled in this study: 57 (79.1%) in the nCRT group and 15 (20.9%) in the Non-nCRT group (Figure 1). The clinical characteristics of the two groups are summarized in Table 1. There were no significant differences between the two groups except the clinical T stage, in which the nCRT group had significantly deeper tumors than the Non-nCRT group (p=0.03). The positive rate of clinical LPLN metastasis was the same (33%) in both groups. The details of cLPLN status were as follows: the median size of cLPLN with short axis was 7.4 mm (5.0-18.2), the median number of cLPLN was 1 (1-7), unilateral and bilateral cLPLN metastases were 18 and 6, respectively. The surgical and pathological outcomes are shown in Table 2. Although there were no statistically significant differences between the two groups in any of the variables, including the rate of R0 resection and postoperative complications, the nCRT group had a relatively lower positive rate of pathological LPLN metastasis when compared to the Non-nCRT group (9% versus 27%, p=0.08). The performance rate of the adjuvant chemotherapy in the Non-nCRT group was relatively higher than that in the nCRT group (53% versus 28%, p=0.07). The regimens of adjuvant chemotherapy were summarized in Supplementary Table 1.
Table 1.
Clinical Characteristics of 72 Patients.
| Total | Non-nCRT | nCRT | |||
|---|---|---|---|---|---|
| Variables | n=72 | n=15 | n=57 | p value | |
| Age, year | 61 (36-78) | 60 (44-69) | 61 (36-78) | 0.61 | |
| Sex | Female | 25 (35%) | 7 (47%) | 18 (32%) | 0.28 |
| Male | 47 (65%) | 8 (53%) | 39 (68%) | ||
| cT stage | T1 | 1 (1%) | 1 (7%) | 0 (0%) | 0.03* |
| T2 | 3 (4%) | 2 (13%) | 1 (2%) | ||
| T3 | 53 (74%) | 11 (73%) | 42 (74%) | ||
| T4 | 15 (21%) | 1 (7%) | 14 (24%) | ||
| cMLN metastasis | Absence | 18 (25%) | 5 (33%) | 13 (23%) | 0.41 |
| Presence | 54 (75%) | 10 (67%) | 44 (77%) | ||
| cLPLN metastasis | Absence | 48 (67%) | 10 (67%) | 38 (67%) | 1.00 |
| Presence | 24 (33%) | 5 (33%) | 19 (33%) | ||
| CEA, ng/ml | 5.4 (0.5-212.6) | 6.0 (1.3-212.6) | 5.3 (0.5-169.0) | 0.43 | |
| CA19-9, U/ml | 7.1 (2.0-540.0) | 9.4 (2.0-61.7) | 6.5 (2.0-540.0) | 0.89 | |
| Completion rate of nCRT | - | - | 87.7% | ||
| Date of operation | 2006-2012 | 41 (57%) | 9 (60%) | 32 (56%) | 0.78 |
| 2013-2019 | 31 (43%) | 6 (40%) | 25 (44%) |
* Statistically significant p < 0.05.
Continuous data are expressed as the median (range).
LPLN, lateral pelvic lymph node; MLN, mesenteric lymph node; nCRT, neoadjuvant chemoradiotherapy
Table 2.
Surgical and Pathological Outcomes.
| Total | Non-nCRT | nCRT | |||
|---|---|---|---|---|---|
| Variables | n=72 | n=15 | n=57 | p value | |
| Surgical procedure | LAR/ISR | 35 (49%) | 6 (40%) | 29 (51%) | 0.45 |
| APR/TPE | 37 (51%) | 9 (60%) | 28 (49%) | ||
| Surgical approach | Laparotomy | 44 (61%) | 8 (53%) | 36 (63%) | 0.49 |
| Laparoscopy/Robot | 28 (39%) | 7 (47%) | 21 (37%) | ||
| LLND | Unilateral | 6 (8%) | 1 (7%) | 5 (9%) | 0.78 |
| Bilateral | 66 (92%) | 14 (93%) | 52 (91%) | 0.48 | |
| Operation time, min | 371 (224-806) | 340 (224-790) | 385 (230-806) | 0.55 | |
| Bleeding, g | 454 (50-2230) | 425 (50-1200) | 470 (55-2230) | 0.44 | |
| pT stage | T0 | 5 (7%) | 0 (0%) | 5 (9%) | 0.22 |
| T1 | 3 (4%) | 1 (7%) | 2 (4%) | ||
| T2 | 17 (24%) | 3 (20%) | 14 (24%) | ||
| T3 | 42 (58%) | 11 (73%) | 31 (54%) | ||
| T4 | 5 (7%) | 0 (0%) | 5 (9%) | ||
| pMLN metastasis | Absence | 46 (64%) | 7 (47%) | 39 (68%) | 0.12 |
| Presence | 26 (36%) | 8 (53%) | 18 (32%) | ||
| pLPLN metastasis | Absence | 63 (88%) | 11 (73%) | 52 (91%) | 0.08 |
| Presence | 9 (12%) | 4 (27%) | 5 (9%) | ||
| Histological type | Differentiated | 53 (74%) | 12 (80%) | 41 (72%) | 0.46 |
| Undifferentiated | 16 (22%) | 3 (20%) | 13 (23%) | ||
| Scar | 3 (4%) | 0 (0%) | 3 (5%) | ||
| Residual tumor | R0 | 65 (90%) | 13 (87%) | 52 (91%) | 0.60 |
| R1 | 7 (10%) | 2 (13%) | 5 (9%) | ||
| Histological regression | Grade 1 | - | 22 (39%) | - | |
| Grade 2 | - | 33 (58%) | |||
| Grade 3 | - | 2 (3%) | |||
| Complication, CD | Grade 0-2 | 56 (78%) | 10 (67%) | 46 (81%) | 0.26 |
| Grade 3- | 16 (22%) | 5 (33%) | 11 (19%) | ||
| Adjuvant chemotherapy | Absence | 48 (67%) | 7 (47%) | 41 (72%) | 0.07 |
| Presence | 24 (33%) | 8 (53%) | 16 (28%) |
APR, abdominoperineal resection; CD, Clavien-Dindo classification; ISR, intersphincteric resection; LAR, low anterior resection; LPLN, lateral pelvic lymph node; MLN, mesenteric lymph node; nCRT, neoadjuvant chemoradiotherapy; TPE, total pelvic exenteration
Survival outcomes and the prognostic impact of nCRT
The median follow-up period of the nCRT and non-nCRT group was 2158 (168-4248) days and 1851 (505-3473) days, respectively. The 5-year RFS and OS curves for the two groups are depicted in Figure 2A, 2B, respectively. The 5-year RFS rates of the nCRT group and the Non-nCRT group were 73.7% and 60.0%, respectively, and there was no statistically significant difference (p=0.15). Further, the 5-year OS rates of the nCRT group and the Non-nCRT group were 92.1% and 78.7%, respectively, and there was no statistically significant difference (p=0.10).
Figure 2.
Survival analysis based on the nCRT status.
(A) relapse free survival and (B) overall survival in patients who received LLND plus nCRT or LLND only.
LLND, lateral lymph node dissection; nCRT, neoadjuvant chemoradiotherapy
The 5-year cumulative DR rates showed no statistically significant difference between the two groups (21.7% versus 33.3% in the nCRT and Non-nCRT group, respectively, p=0.25) (Figure 3A), whereas the 5-year LR rate in the nCRT group was significantly lower than that in the Non-nCRT group (4.0% versus 26.6%, p=0.002) (Figure 3B). In addition, the 5-year lateral LR rate in the nCRT group was significantly lower than that in the Non-nCRT group (0.0% versus 14.4%, p=0.003) and the 5-year central LR rate in the nCRT group was also significantly lower than that in the Non-nCRT group (1.7% versus 21.4%, p=0.01). The details of local recurrence are shown in Supplementary Table 2. Regarding the relatively high rates of non-R0 resection as shown in Table 2 (8.7% and 13.3% in the nCRT and Non-nCRT group, respectively), we further analyzed the 5-year LR rates in patients with R0 resection and found relatively lower LR rates in the nCRT group compared to the Non-nCRT group (4.4% versus 15.3%, p=0.11) (Figure 3C). In addition, LR rates adjusted for clinical T stage were analyzed because of the difference of clinical T stage between two groups. Clinical backgrounds and surgical outcomes were summarized in Supplementary Table 3 and 4. The 5-year LR rate in the nCRT group tended to be lower than in the Non-nCRT group (0.0% versus 23.8%, p=0.08) (Supplementary Figure 1).
Figure 3.
Local and distant recurrence analysis based on the nCRT status.
(A) distant recurrence and (B) local recurrence in all patients who received LLND plus nCRT or LLND only. (C) local recurrence in patients with R0 resection who received LLND plus nCRT or LLND only.
LLND, lateral lymph node dissection; nCRT, neoadjuvant chemoradiotherapy
The prognostic factors affecting the incidence of LR were evaluated, as presented in Table 3. The univariate analysis revealed that a lack of preoperative CRT was a significant prognostic factor for higher LR rates. The multivariate analysis revealed that the lack of preoperative CRT was the only independent prognostic factor (hazard ratio: 6.04, p=0.04) for higher LR rates.
Table 3.
Analysis for Risk Factors of Postoperative Local Recurrence in Patients who Underwent TME with LLND.
| Univariate | Multivariate | ||||||
|---|---|---|---|---|---|---|---|
| Variables | Group | n | 5-year LRR (%) | p value | HR | 95% CI | p value |
| Age, years | >65 | 45 | 9.6 | 0.85 | |||
| ≤65 | 27 | 7.4 | |||||
| Sex | Male | 47 | 9.2 | 0.96 | |||
| Female | 25 | 8.1 | |||||
| nCRT | Absence | 15 | 26.6 | 0.002* | 6.04 | 1.06-46.95 | 0.04* |
| Presence | 57 | 4.0 | |||||
| CEA, ng/ml | <5 | 33 | 13.0 | 0.29 | |||
| ≥5 | 38 | 5.2 | |||||
| CA19-9, U/ml | ≥37 | 9 | 22.2 | 0.11 | |||
| <37 | 63 | 6.9 | |||||
| pT stage | T0-T3 | 67 | 9.4 | 0.51 | |||
| T4 | 5 | 0.0 | |||||
| pMLN metastasis | Presence | 26 | 15.3 | 0.12 | |||
| Absence | 36 | 5.3 | |||||
| pLPLN metastasis | Presence | 9 | 33.3 | 0.001* | 4.10 | 0.59-26.62 | 0.14 |
| Absence | 63 | 5.2 | |||||
| Residual tumor | R1 | 7 | 25.0 | 0.06 | 2.97 | 0.37-18.39 | 0.27 |
| R0 | 65 | 6.7 | |||||
| Adjuvant chemotherapy | Presence | 24 | 12.5 | 0.39 | |||
| Absence | 48 | 7.1 |
* Statistically significant p < 0.05.
CA19-9, carbohydrate antigen 19-9; CEA, carcinoembryonic antigen; CI, confidence interval; HR, hazard ratio; LLND, lateral lymph node dissection; LRR, cumulative local recurrence rate; LPLN, lateral pelvic lymph node; MLN, mesenteric lymph node; nCRT, neoadjuvant chemoradiotherapy
Discussion
This study demonstrated that the administration of nCRT with TME and LLND independently contributed to the reduction of LR rates in patients diagnosed with locally advanced lower rectal cancer. In contrast, the rates of OS, RFS, and DR did not significantly improve by the addition of nCRT.
Postoperative local recurrence is one of the most serious concerns for patients with locally advanced rectal cancer because of the poor survival outcomes and negative impact on quality of life. Tumors located at the lower rectum spread through the lateral lymphatic drainage as well as the superior lymphatic drainage[16]. Local recurrences at the lateral pelvic site are most frequently observed in patients who underwent TME without nCRT or LLND[6,15], and this rate was reported to be 7.9 to 19.2%[6,7,15]. Further, the presence of pathological LPLN metastasis is relatively common. Kobayashi et al. retrospectively reviewed 784 patients diagnosed with low rectal cancer who also underwent LLND and reported that 117 patients (14.9%) had LPLN metastasis[17]. In addition to TME, the non-surgical method, n(C)RT is widely performed to improve the outcomes of patients with locally advanced rectal cancer in the western world. The 5-year local recurrence rate of additional nCRT was reported to be 8.1 to 8.7%[1,2]. On the contrary, the additional surgical method, LLND, is the standard treatment in Japan and the 5-year local recurrence rate of additional LLND was reported to be 7.0 to 18.5%[6,7]. Our institute introduced both the treatments, thus, the comparison between nCRT followed by TME with LLND and only TME with LLND could be conducted.
The direct comparisons between LLND and n(C)RT to investigate the additional effects of TME have been rarely studied[5]. Law et al. found that the 5-year local recurrence rates of patients who received nCRT with or without LLND were 4.35% and 10.06% respectively, but this difference was not statistically significant (p=0.12)[18]. However, Ogura et al. verified the effect of adding LLND to TME with nCRT and demonstrated that the combined strategy of TME with LLND after nCRT significantly reduced the incidence of local recurrences in preoperative metastatic LPLN-positive patients when compared with only TME after nCRT[9]. Nagasaki et al. also demonstrated that additional nCRT reduced local recurrence in patients with LPLN metastasis who underwent TME with therapeutic LLND[19]. In this cohort, additional nCRT could reduce local recurrence in patients with clinical mesenteric lymph node (cMLN) and/or cLPLN metastasis, while the additional nCRT had no impact for patients without cMLN nor cLPLN metastasis (Supplementary Figure 2). Thus, although further research is needed, additional nCRT may be omitted for patients without cLPLN nor cMLN metastasis.
In this study, the addition of nCRT did not significantly reduce distant recurrences or improve OS. Furthermore, previous studies reported no significant impact on the control of distant recurrence when comparing TME with nRT and TME with nCRT[1,2]. Thus, more intensive treatment strategies are necessary for the effective treatment of locally advanced rectal cancer. In recent years, total neoadjuvant treatment (TNT), a combination of preoperative radiation therapy and systemic chemotherapy, has been developed to improve oncological outcomes of patients with locally advanced rectal cancer. Several randomized trials have reported that TNT was more effective than nCRT in suppressing distant metastasis with a higher pathological complete response rate[20-22]. Thus, TNT is a treatment option in the NCCN guidelines[3]. Consequently, using TNT instead of nCRT with LLND may further improve prognoses of patients with locally advanced rectal cancer. This needs further investigation.
The Colorectal Cancer Study Group of Japan Clinical Oncology Group conducted a randomized controlled study to assess the safety of LLND, and showed that although LLND caused increase of intraoperative bleeding amount and prolongment of operative time, postoperative complications, like urinary dysfunction and male sexual dysfunction, did not differ significantly between patients with and without LLND[23,24]. Further, Akiyoshi et al. reported that selective LLND after nCRT did not significantly increase postoperative complications[25]. In this study, additional nCRT also did not increase short-term postoperative complications. Thus, although further research is needed, the addition of nCRT to TME with LLND may be feasible.
This study has limitations. This is a single-center, retrospective study, with a small sample size, resulting in the possibility of a selection bias for treatment decisions. Moreover, as our institute encouraged the addition of nCRT to the treatment regimen, the non-nCRT group was smaller. Second, the pCR rate of the nCRT group in this study was only 3%, i.e., lower than that in previous studies[2]. However, in the nCRT group, the positive rates of mesenteric and lateral lymph node metastases after nCRT were reduced compared with those before nCRT, but not in the non-nCRT group. These results suggested that our nCRT regimen effectively tackled the tumors, at least locally. Third, the 5-year LR rate of patients in the non-nCRT group was relatively high (26.6%) compared to that in previous studies (5.7 to 19.5%)[6,9]. This result could be caused by high non-R0 resection rates in this study (10.5% and 13.3% in the nCRT and Non-nCRT group, respectively) compared to those in previous studies (2.0 to 6.1%)[6,9]. The 5-year LR rate of patients in the non-CRT group with R0 resection was 15.3%, which was supposed to be feasible. Interestingly, the 5-year LR rates in patients with R1 resection were 0.0% (0/5) and 100.0% (2/2) in the nCRT and Non-nCRT group, respectively. These results indicated that preoperative CRT might be also effective in preventing local recurrence even in patients with R1 resection. Fourth, although this study showed that the addition of nCRT did not increase the complication rate, surgical procedure was not same between the two groups as shown in Table 2. Fifth, the rate of adjuvant chemotherapy in the non-nCRT group was not high enough, 53%, and needs to be increased to improve their prognoses. Sixth, as the mesorectum was removed at the time of specimen examination, the circumferential resection margin, a crucial factor in local recurrence, could not be evaluated. Further randomized trials with a large number of patients in both groups are necessary for further accurate assessment.
In conclusion, the addition of nCRT prevented local recurrence to a significantly greater extent in patients who underwent TME and LLND without increasing postoperative complications. Therefore, this treatment strategy is promising for the effective treatment of locally advanced low rectal cancer.
Conflicts of Interest
There are no conflicts of interest.
Author Contributions
Study conception design by KT and HS. Data acquisition by KT, HS, YK, TA and JK. Data analysis and interpretation by: KT, HS, TK, HF, and EO. Drafting the article by KT and HS. Critical revision for intellectual content by YK, TA, JK, TK, HF and EO. All authors approved of the final manuscript and agreed to be accountable for all aspects of work. Kazuya Takabatake and Hiroki Shimizu contributed equally to this work.
Approval by Institutional Review Board (IRB)
ERB-C-1178-1
The Kyoto Prefectural University of Medicine Independent Ethics Committee
Supplementary Files
Local recurrence analysis based on the nCRT status in adjusted groups.
Local recurrence in 26 patients adjusted for clinical T factor who received LLND plus nCRT or LLND only.
LLND, lateral lymph node dissection; nCRT, neoadjuvant chemoradiotherapy
Local recurrence analysis based on the status of clinical lymph node metastasis.
Local recurrence in patients (A) with cLPLN and/or cMLN metastasis (2.7% versus 40.0% in the nCRT and Non-nCRT group, respectively, p<0.001) and (B) without cLPLN nor cMLN metastasis (11.1% versus 0.0% in the nCRT and Non-nCRT group, respectively, p=0.50) who received LLND plus nCRT or LLND only.
LLND, lateral lymph node dissection; LPLN, lateral pelvic lymph node; MLN, mesenteric lymph node; nCRT, neoadjuvant chemoradiotherapy
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Supplementary Materials
Local recurrence analysis based on the nCRT status in adjusted groups.
Local recurrence in 26 patients adjusted for clinical T factor who received LLND plus nCRT or LLND only.
LLND, lateral lymph node dissection; nCRT, neoadjuvant chemoradiotherapy
Local recurrence analysis based on the status of clinical lymph node metastasis.
Local recurrence in patients (A) with cLPLN and/or cMLN metastasis (2.7% versus 40.0% in the nCRT and Non-nCRT group, respectively, p<0.001) and (B) without cLPLN nor cMLN metastasis (11.1% versus 0.0% in the nCRT and Non-nCRT group, respectively, p=0.50) who received LLND plus nCRT or LLND only.
LLND, lateral lymph node dissection; LPLN, lateral pelvic lymph node; MLN, mesenteric lymph node; nCRT, neoadjuvant chemoradiotherapy
