Regional lymph node metastasis and locoregional recurrence of rectal carcinoma in the era of TNM surgery. Implications for treatment decisions

Abstract

Background and aimsFor rectal carcinoma treated according to the concept of total mesorectal excision (TME surgery), the independent influence
of regional lymph node metastasis on the locoregional recurrence risk is still in discussion. A reliable assessment of this
risk is important for an individualised selective indication for neoadjuvant radio-/radiochemotherapy.

MethodsAnalysis of literature, especially of the last 20years, and consideration of pathological and oncological basic research.
Multivariate analysis of data of the Erlangen Registry of Colorectal Carcinoma.

ResultsThe clinical assessment of the pretherapeutic regional lymph node status by the present available imaging methods is still
unreliable. The analysis of the association between pretherapeutic regional lymph node status and locoregional recurrence
risk has to be based on follow-up data of patients treated by primary surgery and has to be distinguished between patients
treated by conventional and optimised quality-assured TME surgery, respectively. Data from Erlangen show an increase of the
local recurrence risk for patients with at least four involved regional lymph nodes.

ConclusionsFor patients with at least four involved regional lymph nodes, a neoadjuvant radiochemotherapy may be indicated. However,
today, the pretherapeutic diagnosis is uncertain and results in overtherapy in 40%. Thus, in case of positive lymph node findings
by imaging methods, the benefits and risk of neoadjuvant therapy in such situations should always be discussed with the patient
in the sense of informed consent and shared decision.

KeywordsLocal recurrence-Neoadjuvant treatment-Rectal carcinoma-Regional lymph node metastasis-TME (Total mesorectal excision) surgery