Optimization of treatment strategies based on preoperative imaging features and local recurrence areas for locally advanced lower rectal cancer after lateral pelvic lymph node dissection

Zhao Xu; Mandula Bao; Qiang Cai; Qian Wang; Wei Xing; Qian Liu

doi:10.3389/fonc.2023.1272808

Optimization of treatment strategies based on preoperative imaging features and local recurrence areas for locally advanced lower rectal cancer after lateral pelvic lymph node dissection

Front Oncol. 2024 Feb 5:13:1272808. doi: 10.3389/fonc.2023.1272808. eCollection 2023.

Authors

Zhao Xu^#¹, Mandula Bao^#², Qiang Cai³, Qian Wang⁴, Wei Xing¹, Qian Liu²

Affiliations

¹ Department of General Surgery, Hebei Province Hospital of Chinese Medicine, Affiliated Hospital of Hebei University of Chinese Medicine, Shijiazhuang, China.
² Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
³ Department of Gastric and Colorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, China.
⁴ Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.

^# Contributed equally.

Abstract

Purpose: Local recurrence (LR) is the main cause of treatment failure in locally advanced lower rectal cancer (LALRC). This study evaluated the preoperative risk factors for LR in patients with LALRC to improve the therapeutic strategies.

Patients and methods: LALRC patients who underwent total mesorectal excision (TME) with lateral pelvic lymph node (LPN) dissection (LPND) from January 2012 to December 2019 were reviewed. The log-rank test was used to assess local recurrence-free survival (LRFS), and multivariate Cox regression was used to identify the prognostic risk factors for LRFS. Follow-up imaging data were used to classify LR according to the location.

Results: Overall, 376 patients were enrolled, and 8.8% (n=33) of these patients developed LR after surgery. Multivariate analysis identified positive clinical circumferential resection margin (cCRM) as an independent prognostic factor for LRFS (HR: 4.94; 95% CI, 1.75-13.94; P=0.003). The most common sites for LR were the pelvic plexus and internal iliac area (PIA) (54.5%), followed by the central pelvic area (CPA) (39.4%) and obturator area (OA) (6.1%). Following a subgroup analysis, LR in the OA was not associated with positive cCRM. Patients treated with upfront surgery (n=35, 14.1%) had a lower cCRM positive rate when compared with patients treated with neoadjuvant chemoradiotherapy (nCRT) (n=12, 23.5%). However, the LR rate in the nCRT group was still lower (n=28, 36.4%) than that in the upfront surgery group (n=35, 14.%). Among patients with positive cCRM, the LR rate in patients with nCRT remained low (n=3, 10.7%).

Conclusion: Positive cCRM is an independent risk factor for LR after TME plus LPND in LALRC patients. LPND is effective and adequate for local control within the OA regardless of cCRM status. However, for LALRC patients with positive cCRM, nCRT should be considered before LPND to further reduce LR in the PIA and CPA.

Keywords: circumferential resection margin; lateral pelvic lymph node dissection; local recurrence; neoadjuvant chemoradiotherapy; rectal cancer.

Grants and funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This study received funding from the National Key Research and Development Program/Prevent and Control Research for Important Non-Communicable Diseases (No. 2019YFC1315705) and the Beijing Hope Run Special Fund of Cancer Foundation of China (LC2022L01).