Management of lateral pelvic lymph nodes in rectal cancer: Is it time to reach an Agreement?

Abstract

In this editorial, we proceed to comment on the article by Chua et al, addressing the management of metastatic lateral pelvic lymph nodes (mLLN) in stage II/III rectal cancer patients below the peritoneal reflection. The treatment of this nodal area sparks significant controversy due to the strategic differences followed by Eastern and Western physicians, albeit with a higher degree of convergence in recent years. The dissection of lateral pelvic lymph nodes without neoadjuvant therapy is a standard practice in Eastern countries. In contrast, in the West, preference leans towards opting for neoadjuvant therapy with chemoradiotherapy or radiotherapy, that would cover the treatment of this area without the need to add the dissection of these nodes to the total mesorectal excision. In the presence of high-risk nodal characteristics for mLLN related to radiological imaging and lack of response to neoadjuvant therapy, the risk of lateral local recurrence increases, suggesting the appropriate selection of strategies to reduce the risk of recurrence in each patient profile. Despite the heterogeneous and retrospective nature of studies addressing this area, an international consensus is necessary to approach this clinical scenario uniformly.

Keywords: Rectal cancer; Lateral pelvic lymph node metastases; Pelvic lymph node dissection; Total neoadjuvant therapy; Selective management of the lateral pelvic nodes; Prophylactic management of the lateral pelvic nodes; Chemoradiotherapy; Total mesorectal excision

Core Tip: The lack of consensus in managing metastatic lateral pelvic lymph nodes in stage II/III rectal cancer patients below the peritoneal reflection, with differing medical strategies between East and West, generates uncertainty due to limited available evidence. Characteristics such as lymph node size, neoadjuvant treatment, and selective dissection of lateral pelvic lymph nodes are part of the strategies, but the first steps toward a solid and global consensus must be taken to resolve the uncertainties present in this field.