Download PDF
Clin Colon Rectal Surg 2024; 37(02): 071-079
DOI: 10.1055/s-0043-1761474
Review Article

Management of Surgically Accessible Lymph Nodes Beyond Normal Resection Planes

Daniel deLahunta
1   Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
,
Surya Nalamati
1   Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

This article discusses the management of isolated metastatic lymph nodes for colon and rectal cancer. There are traditionally significant differences in how certain regions of lymph nodes for colon and rectal cancer are managed in the East and West. This has led to the development of the lateral lymph node dissection for rectal cancer and extended lymphadenectomy techniques for colon cancer. This article will evaluate the literature on these techniques and what the surgical and oncological outcomes are at this time. In addition, colon and rectal cancers can occasionally have isolated distant lymph node metastases. These would traditionally be treated as systemic disease with chemotherapy. There is consideration though that these could be treated as similar to isolated liver or lung metastases which have been shown to be able to be treated surgically with good oncological results. The literature for these isolated distant lymph node metastases will be reviewed and treatment options available will be discussed.

Keywords

colorectal cancer - isolated lymph nodes - inguinal nodes - para-aortic nodes - lateral pelvic nodes


Publication History

Article published online:
22 February 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Compton CC, Fielding LP, Burgart LJ. et al. Prognostic factors in colorectal cancer. College of American Pathologists Consensus Statement 1999. Arch Pathol Lab Med 2000; 124 (07) 979-994
    PubMedGoogle Scholar
  • 2 Baxter NN, Virnig DJ, Rothenberger DA, Morris AM, Jessurun J, Virnig BA. Lymph node evaluation in colorectal cancer patients: a population-based study. J Natl Cancer Inst 2005; 97 (03) 219-225
    CrossrefPubMedGoogle Scholar
  • 3 Mahmoud N, Bullard Dunn K. Metastasectomy for stage IV colorectal cancer. Dis Colon Rectum 2010; 53 (07) 1080-1092
    CrossrefPubMedGoogle Scholar
  • 4 Nelson H, Petrelli N, Carlin A. et al; National Cancer Institute Expert Panel. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 2001; 93 (08) 583-596
    CrossrefPubMedGoogle Scholar
  • 5 McDonald JR, Renehan AG, O'Dwyer ST, Haboubi NY. Lymph node harvest in colon and rectal cancer: current considerations. World J Gastrointest Surg 2012; 4 (01) 9-19
    CrossrefPubMedGoogle Scholar
  • 6 Benson AB, Venook AP, Al-Hawary MM. et al. Colon Cancer, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19 (03) 329-359
    CrossrefPubMedGoogle Scholar
  • 7 Norwood MG, Sutton AJ, West K, Sharpe DP, Hemingway D, Kelly MJ. Lymph node retrieval in colorectal cancer resection specimens: national standards are achievable, and low numbers are associated with reduced survival. Colorectal Dis 2010; 12 (04) 304-309
    CrossrefPubMedGoogle Scholar
  • 8 Swanson RS, Compton CC, Stewart AK, Bland KI. The prognosis of T3N0 colon cancer is dependent on the number of lymph nodes examined. Ann Surg Oncol 2003; 10 (01) 65-71
    CrossrefPubMedGoogle Scholar
  • 9 Shiozawa M, Ueno H, Shiomi A. et al. Study protocol for an international prospective observational cohort study for optimal bowel resection extent and central radicality for colon cancer (T-REX study). Jpn J Clin Oncol 2021; 51 (01) 145-155
    CrossrefPubMedGoogle Scholar
  • 10 Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome. Colorectal Dis 2009; 11 (04) 354-364 discussion 364–365
    CrossrefPubMedGoogle Scholar
  • 11 Japanese Society for Cancer of the Colon and Rectum. Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma: the 3d English Edition [Secondary Publication]. J Anus Rectum Colon 2019; 3 (04) 175-195
    CrossrefPubMedGoogle Scholar
  • 12 Kobayashi H, West NP. CME versus D3 dissection for colon cancer. Clin Colon Rectal Surg 2020; 33 (06) 344-348
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Kobayashi H, West NP, Takahashi K. et al. Quality of surgery for stage III colon cancer: comparison between England, Germany, and Japan. Ann Surg Oncol 2014; 21 (suppl (Suppl. 03) S398-S404
    CrossrefPubMedGoogle Scholar
  • 14 Karachun A, Panaiotti L, Chernikovskiy I. et al. Short-term outcomes of a multicentre randomized clinical trial comparing D2 versus D3 lymph node dissection for colonic cancer (COLD trial). Br J Surg 2020; 107 (05) 499-508
    CrossrefPubMedGoogle Scholar
  • 15 Gouvas N, Agalianos C, Papaparaskeva K, Perrakis A, Hohenberger W, Xynos E. Surgery along the embryological planes for colon cancer: a systematic review of complete mesocolic excision. Int J Colorectal Dis 2016; 31 (09) 1577-1594
    CrossrefPubMedGoogle Scholar
  • 16 Gao Z, Wang C, Cui Y. et al. Efficacy and safety of complete mesocolic excision in patients with colon cancer: three-year results from a prospective, nonrandomized, double-blind, controlled trial. Ann Surg 2020; 271 (03) 519-526
    CrossrefPubMedGoogle Scholar
  • 17 Crane J, Hamed M, Borucki JP, El-Hadi A, Shaikh I, Stearns AT. Complete mesocolic excision versus conventional surgery for colon cancer: a systematic review and meta-analysis. Colorectal Dis 2021; 23 (07) 1670-1686
    CrossrefPubMedGoogle Scholar
  • 18 Numata M, Sawazaki S, Aoyama T. et al. D3 lymph node dissection reduces recurrence after primary resection for elderly patients with colon cancer. Int J Colorectal Dis 2019; 34 (04) 621-628
    CrossrefPubMedGoogle Scholar
  • 19 Bertelsen CA, Neuenschwander AU, Jansen JE. et al. 5-year outcome after complete mesocolic excision for right-sided colon cancer: a population-based cohort study. Lancet Oncol 2019; 20 (11) 1556-1565
    CrossrefPubMedGoogle Scholar
  • 20 Olofsson F, Buchwald P, Elmståhl S, Syk I. No benefit of extended mesenteric resection with central vascular ligation in right-sided colon cancer. Colorectal Dis 2016; 18 (08) 773-778
    CrossrefPubMedGoogle Scholar
  • 21 Olofsson F, Buchwald P, Elmståhl S, Syk I. High tie or not in resection for cancer in the sigmoid colon?. Scand J Surg 2019; 108 (03) 227-232
    CrossrefPubMedGoogle Scholar
  • 22 Vogel JD, Felder SI, Bhama AR. et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of colon cancer. Dis Colon Rectum 2022; 65 (02) 148-177
    CrossrefPubMedGoogle Scholar
  • 23 Hashiguchi Y, Muro K, Saito Y. et al; Japanese Society for Cancer of the Colon and Rectum. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol 2020; 25 (01) 1-42
    CrossrefPubMedGoogle Scholar
  • 24 Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery--the clue to pelvic recurrence?. Br J Surg 1982; 69 (10) 613-616
    CrossrefPubMedGoogle Scholar
  • 25 Kanemitsu Y, Shida D, Tsukamoto S, Moritani K, Sakamoto R. Japanese evidences on nerve-preserving lateral pelvic lymph node dissection for rectal cancer: major historical milestones and clinical impact: the past, present and future. Clin Colon Rectal Surg 2020; 33 (06) 349-354
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Kusters M, Uehara K, Velde CJHV, Moriya Y. Is there any reason to still consider lateral lymph node dissection in rectal cancer? Rationale and technique. Clin Colon Rectal Surg 2017; 30 (05) 346-356
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Ogura A, van Oostendorp S, Kusters M. Neoadjuvant (chemo)radiotherapy and lateral node dissection: is it mutually exclusive?. Clin Colon Rectal Surg 2020; 33 (06) 355-360
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Akiyoshi T, Watanabe T, Miyata S, Kotake K, Muto T, Sugihara K. Japanese Society for Cancer of the Colon and Rectum. Results of a Japanese nationwide multi-institutional study on lateral pelvic lymph node metastasis in low rectal cancer: is it regional or distant disease?. Ann Surg 2012; 255 (06) 1129-1134
    CrossrefPubMedGoogle Scholar
  • 29 Kusters M, Beets GL, van de Velde CJ. et al. A comparison between the treatment of low rectal cancer in Japan and the Netherlands, focusing on the patterns of local recurrence. Ann Surg 2009; 249 (02) 229-235
    CrossrefPubMedGoogle Scholar
  • 30 Emile SH, Elfeki H, Shalaby M, Sakr A, Kim NK. Outcome of lateral pelvic lymph node dissection with total mesorectal excision in treatment of rectal cancer: a systematic review and meta-analysis. Surgery 2021; 169 (05) 1005-1015
    CrossrefPubMedGoogle Scholar
  • 31 Nagawa H, Muto T, Sunouchi K. et al. Randomized, controlled trial of lateral node dissection vs. nerve-preserving resection in patients with rectal cancer after preoperative radiotherapy. Dis Colon Rectum 2001; 44 (09) 1274-1280
    CrossrefPubMedGoogle Scholar
  • 32 Akiyoshi T, Ueno M, Matsueda K. et al. Selective lateral pelvic lymph node dissection in patients with advanced low rectal cancer treated with preoperative chemoradiotherapy based on pretreatment imaging. Ann Surg Oncol 2014; 21 (01) 189-196
    CrossrefPubMedGoogle Scholar
  • 33 Ishihara S, Kawai K, Tanaka T. et al. Oncological outcomes of lateral pelvic lymph node metastasis in rectal cancer treated with preoperative chemoradiotherapy. Dis Colon Rectum 2017; 60 (05) 469-476
    CrossrefPubMedGoogle Scholar
  • 34 Ogura A, Konishi T, Cunningham C. et al; Lateral Node Study Consortium. Neoadjuvant (chemo)radiotherapy with total mesorectal excision only is not sufficient to prevent lateral local recurrence in enlarged nodes: results of the multicenter lateral node study of patients with low cT3/4 rectal cancer. J Clin Oncol 2019; 37 (01) 33-43
    CrossrefPubMedGoogle Scholar
  • 35 Yang X, Yang S, Hu T. et al. What is the role of lateral lymph node dissection in rectal cancer patients with clinically suspected lateral lymph node metastasis after preoperative chemoradiotherapy? A meta-analysis and systematic review. Cancer Med 2020; 9 (13) 4477-4489
    CrossrefPubMedGoogle Scholar
  • 36 Kroon HM, Hoogervorst LA, Hanna-Rivero N. et al. Systematic review and meta-analysis of long-term oncological outcomes of lateral lymph node dissection for metastatic nodes after neoadjuvant chemoradiotherapy in rectal cancer. Eur J Surg Oncol 2022; 48 (07) 1475-1482
    CrossrefPubMedGoogle Scholar
  • 37 Oh HK, Kang SB, Lee SM. et al. Neoadjuvant chemoradiotherapy affects the indications for lateral pelvic node dissection in mid/low rectal cancer with clinically suspected lateral node involvement: a multicenter retrospective cohort study. Ann Surg Oncol 2014; 21 (07) 2280-2287
    CrossrefPubMedGoogle Scholar
  • 38 Kim HJ, Choi GS, Park JS. et al. Optimal treatment strategies for clinically suspicious lateral pelvic lymph node metastasis in rectal cancer. Oncotarget 2017; 8 (59) 100724-100733
    CrossrefPubMedGoogle Scholar
  • 39 Stewart CL, Warner S, Ito K. et al. Cytoreduction for colorectal metastases: liver, lung, peritoneum, lymph nodes, bone, brain. When does it palliate, prolong survival, and potentially cure?. Curr Probl Surg 2018; 55 (09) 330-379
    CrossrefPubMedGoogle Scholar
  • 40 Zhao P, Yang X, Yan Y, Yang J, Li S, Du X. Effect of radical lymphadenectomy in colorectal cancer with para-aortic lymph node metastasis: a systematic review and meta-analysis. BMC Surg 2022; 22 (01) 181
    CrossrefPubMedGoogle Scholar
  • 41 Gagnière J, Dupré A, Chabaud S, Peyrat P, Meeus P, Rivoire M. Retroperitoneal nodal metastases from colorectal cancer: curable metastases with radical retroperitoneal lymphadenectomy in selected patients. Eur J Surg Oncol 2015; 41 (06) 731-737
    CrossrefPubMedGoogle Scholar
  • 42 Sasaki K, Nozawa H, Kawai K. et al. Management of isolated para-aortic lymph node recurrence of colorectal cancer. Surg Today 2020; 50 (09) 947-954
    CrossrefPubMedGoogle Scholar
  • 43 Sahara K, Watanabe J, Ishibe A. et al. Long-term outcome and prognostic factors for patients with para-aortic lymph node dissection in left-sided colorectal cancer. Int J Colorectal Dis 2019; 34 (06) 1121-1129
    CrossrefPubMedGoogle Scholar
  • 44 Zizzo M, Dorma MPF, Zanelli M. et al. Long-term outcomes of surgical resection of pathologically confirmed isolated para-aortic lymph node metastases in colorectal cancer: a systematic review. Cancers (Basel) 2022; 14 (03) 661
    CrossrefPubMedGoogle Scholar
  • 45 Grinnell RS. The lymphatic and venous spread of carcinoma of the rectum. Ann Surg 1942; 116 (02) 200-216
    CrossrefPubMedGoogle Scholar
  • 46 Graham RA, Hohn DC. Management of inguinal lymph node metastases from adenocarcinoma of the rectum. Dis Colon Rectum 1990; 33 (03) 212-216
    CrossrefPubMedGoogle Scholar
  • 47 Taylor N, Crane C, Skibber J. et al. Elective groin irradiation is not indicated for patients with adenocarcinoma of the rectum extending to the anal canal. Int J Radiat Oncol Biol Phys 2001; 51 (03) 741-747
    CrossrefPubMedGoogle Scholar
  • 48 Yeo SG, Lim HW, Kim DY. et al. Is elective inguinal radiotherapy necessary for locally advanced rectal adenocarcinoma invading anal canal?. Radiat Oncol 2014; 9: 296
    CrossrefPubMedGoogle Scholar
  • 49 Shiratori H, Nozawa H, Kawai K. et al. Risk factors and therapeutic significance of inguinal lymph node metastasis in advanced lower rectal cancer. Int J Colorectal Dis 2020; 35 (04) 655-664
    CrossrefPubMedGoogle Scholar
  • 50 Wang R, Wu P, Shi D. et al. Risk factors of synchronous inguinal lymph nodes metastasis for lower rectal cancer involving the anal canal. PLoS One 2014; 9 (11) e111770
    CrossrefPubMedGoogle Scholar
  • 51 Tocchi A, Lepre L, Costa G. et al. Rectal cancer and inguinal metastases: prognostic role and therapeutic indications. Dis Colon Rectum 1999; 42 (11) 1464-1466
    CrossrefPubMedGoogle Scholar
  • 52 Hagemans JAW, Rothbarth J, van Bogerijen GHW. et al. Treatment of inguinal lymph node metastases in patients with rectal adenocarcinoma. Ann Surg Oncol 2019; 26 (04) 1134-1141
    CrossrefPubMedGoogle Scholar
  • 53 Tanabe T, Shida D, Komukai S, Nakamura Y, Tsukamoto S, Kanemitsu Y. Long-term outcomes after surgical dissection of inguinal lymph node metastasis from rectal or anal canal adenocarcinoma. BMC Cancer 2019; 19 (01) 733
    CrossrefPubMedGoogle Scholar
  • 54 Sato H, Maeda K, Kinugasa Y. et al. Management of inguinal lymph node metastases from rectal and anal canal adenocarcinoma. Colorectal Dis 2022; 24 (10) 1150-1163
    CrossrefPubMedGoogle Scholar
  • 55 Chen M, Liu S, Xu M, Yi HC, Liu Y, He F. Radiation boost for synchronous solitary inguinal lymph node metastasis during neoadjuvant chemoradiotherapy for locally advanced rectal cancer. Discov Oncol 2021; 12 (01) 59
    CrossrefPubMedGoogle Scholar
  • 56 Alzahrani AM, Alshehri A. Synchronous colon adenocarcinoma with right inguinal lymph node metastasis: a case report and brief literature review. Cureus 2020; 12 (11) e11501
    PubMedGoogle Scholar
  • 57 Kitano Y, Kuramoto M, Masuda T. et al. Ascending colon cancer with synchronous external iliac and inguinal lymph node metastases but without regional lymph node metastasis: a case report and brief literature review. Surg Case Rep 2017; 3 (01) 32
    CrossrefPubMedGoogle Scholar
  • 58 Iwata Y, Matsuhashi N, Takahashi T. et al. Ascending colon cancer with synchronous right external iliac lymph node metastasis. Int Cancer Conf J 2020; 9 (03) 162-167
    CrossrefPubMedGoogle Scholar
  • 59 Hakeem A, Khan M, Dugar N, Muzaffar M, Robinson J. Inguinal lymphadenopathy secondary to adenocarcinoma of caecum: a case report. Open Med 2009; 4 (01) 131-133
    CrossrefPubMedGoogle Scholar
  • 60 Wu YY, Xing CG, Jiang JX, Lu XD, Feng YZ, Wu HR. Carcinoma of the right side colon accompanied by Sister Mary Joseph's nodule and inguinal nodal metastases: a case report and literature review. Chin J Cancer 2010; 29 (02) 239-241
    CrossrefPubMedGoogle Scholar
  • 61 Tanabe T, Shida D, Tsukamoto S, Morizono G, Taniguchi H, Kanemitsu Y. Metachronous metastasis to inguinal lymph nodes from sigmoid colon adenocarcinoma with abdominal wall metastasis: a case report. BMC Cancer 2019; 19 (01) 180
    CrossrefPubMedGoogle Scholar
  • 62 Pisanu A, Deplano D, Reccia I, Parodo G, Uccheddu A. Unusual metachronous isolated inguinal lymph node metastasis from adenocarcinoma of the sigmoid colon. World J Surg Oncol 2011; 9: 128
    CrossrefPubMedGoogle Scholar
  • 63 Uehara M, Yamamoto S, Fujita S, Akasu T, Moriya Y, Morisue A. Isolated right external iliac lymph node recurrence from a primary cecum carcinoma: report of a case. Jpn J Clin Oncol 2007; 37 (03) 230-232
    CrossrefPubMedGoogle Scholar
  • 64 Terada I, Terai S, Watanabe T. et al. A case of ascending colon cancer with extra iliac lymph node metastases [in Japanese]. Gan To Kagaku Ryoho 2015; 42 (12) 2115-2117
    PubMedGoogle Scholar
  • 65 Hara M, Takahashi H, Sato M, Takayama S, Nagasaki T, Takeyama H. Curatively resected isolated inguinal lymph node metastasis from cecum cancer: report of a case. Surg Today 2013; 43 (01) 88-90
    CrossrefPubMedGoogle Scholar
  • 66 Iwamoto M, Kawada K, Hida K, Hasegawa S, Sakai Y. Adenocarcinoma arising at a colostomy site with inguinal lymph node metastasis: report of a case. Jpn J Clin Oncol 2015; 45 (02) 217-220
    CrossrefPubMedGoogle Scholar
  • 67 Xie TH, Su P, Hong JG, Zhang H. Cervical lymph node enlargement as the initial manifestation of rectal cancer. BMC Gastroenterol 2021; 21 (01) 57
    CrossrefPubMedGoogle Scholar
  • 68 Maslov D, Bragg J. Left cervical lymphadenopathy presentation of metastatic colorectal adenocarcinoma. Ochsner J 2019; 19 (04) 410-412
    CrossrefPubMedGoogle Scholar
  • 69 Yang JQ, Shang L, Li LP. et al. Isolated synchronous Virchow lymph node metastasis of sigmoid cancer: a case report. World J Clin Cases 2021; 9 (32) 9917-9925
    CrossrefPubMedGoogle Scholar
  • 70 Aksel B, Doğan L, Karaman N, Demirci S. Cervical lymphadenopathy as the first presentation of sigmoid colon cancer. Middle East J Cancer 2013; 4: 185-188
    PubMedGoogle Scholar
  • 71 Suliman MS, Singh M, Ajmeri AN, Stuart DL, Teka ST. Virchow's node: a case report of an extremely rare presentation of metastasis of adenocarcinoma with mucinous features from the colon. Int J Gen Med 2019; 12: 137-140
    CrossrefPubMedGoogle Scholar
  • 72 Kurebayashi H, Goi T, Morikawa M. et al. Long-term survival in a patient with Virchow's lymph node metastasis of cecal cancer. Int Cancer Conf J 2017; 7 (01) 1-5
    PubMedGoogle Scholar
  • 73 Ohchi T, Akagi Y, Kinugasa T. et al. Virchow lymph node metastatic recurrence of sigmoid colon cancer with severe lymph node metastases successfully treated using systemic chemotherapy combined with radiotherapy. Anticancer Res 2013; 33 (07) 2935-2940
    PubMedGoogle Scholar
  • 74 Imamura H, Iino S, Sakamoto A. et al. A case of rectal cancer which showed complete response to chemotherapy for para-aortic lymph node metastases remaining after surgery, for which resection of Virchow's lymph node recurrence led to long-term survival [in Japanese]. Gan To Kagaku Ryoho 2013; 40 (09) 1233-1236
    PubMedGoogle Scholar
  • 75 Min Kim H, Hasegawa J, Hirota M. et al. A case of sigmoid colon cancer with Virchow's lymph node metastasis successfully treated with chemotherapy [in Japanese]. Gan To Kagaku Ryoho 2012; 39 (12) 2249-2251
    PubMedGoogle Scholar