Copyright ©2010 Baishideng. All rights reserved.
World J Gastrointest Surg. Apr 27, 2010; 2(4): 95-100
Published online Apr 27, 2010. doi: 10.4240/wjgs.v2.i4.95
Preoperative chemoradiation and extended pelvic lymphadenectomy for rectal cancer: Two distinct principles
Tsuyoshi Konishi, Toshiaki Watanabe, Hirokazu Nagawa, Masatoshi Oya, Masashi Ueno, Hiroya Kuroyanagi, Yoshiya Fujimoto, Takashi Akiyoshi, Toshiharu Yamaguchi, Tetsuichiro Muto
Tsuyoshi Konishi, Masatoshi Oya, Masashi Ueno, Hiroya Kuroyanagi, Yoshiya Fujimoto, Takashi Akiyoshi, Toshiharu Yamaguchi, Tetsuichiro Muto, Department of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, 135-8550, Japan
Tsuyoshi Konishi, Hirokazu Nagawa, Department of Surgical Oncology, University of Tokyo, Tokyo, 113-8655, Japan
Toshiaki Watanabe, Department of Surgery, Teikyo University School of Medicine, Tokyo, 173-8605, Japan
Author contributions: Konishi T drafted the manuscript, collected and interpreted data; Watanabe T, Nagawa H and Muto T critically revised the manuscript; Oya M, Ueno M, Kuroyanagi H, Fujimoto Y, Yamaguchi T and Akiyoshi T participated in the collection and interpretation of data.
Correspondence to: Tsuyoshi Konishi, MD, Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan. tsuyoshikonishi@pop07.odn.ne.jp
Telephone: +81-3-35200111 Fax: +81-3-35700343
Received: January 4, 2010
Revised: February 14, 2010
Accepted: February 21, 2010
Published online: April 27, 2010

Extended pelvic lymphadenectomy (EPL) with total mesorectal excision (TME) has been reported to provide oncological benefit in lower rectal cancer in Japan. In Western countries EPL is not widely accepted because of frequent morbidity but instead preoperative chemoradiation (CRT) followed by TME has been established as a standard treatment for decreasing local recurrence. Recently, several studies have focused on the comparison between these two distinct therapeutic approaches in Western countries and Japan. A study comparing Dutch trial data and Japanese data revealed that EPL and RT are almost equivalent in decreasing local recurrence in lower rectal cancer as compared with TME alone. Considering that almost 45% survival can be achieved by EPL even in the presence of metastatic lateral lymph nodes (LLNs), EPL performed by experienced surgeons definitely contributes to decrease local recurrence. On the other hand, a randomized controlled trial in Japan that compared EPL with conventional TME following preoperative RT revealed that EPL is associated with a higher frequency of sexual and urinary dysfunction without oncological benefits in the presence of preoperative RT. On this point, preoperative CRT followed by conventional TME without EPL would be a better therapeutic approach in patients without evident metastatic LLNs. For future treatment, it would be desirable to have a narrower indication for EPL using full advantage of recent improvement in image diagnosis. Although objective comparison of these two principles between Japan and the West is difficult due to differences in patient groups, further studies would lead to the next great step towards future improvement in treating lower rectal cancer.

Keywords: Rectal cancer, Extended lymphadenectomy, Chemoradiation, Pelvic lymph node, Lateral lymph node