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10.1245/s10434-007-9368-x
Annals of Surgical Oncology 14:1980-1990 (2007)
© 2007 Society of Surgical Oncology
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Original Article

Oncologic Results of Laparoscopic D3 Lymphadenectomy for Male Sigmoid and Upper Rectal Cancer with Clinically Positive Lymph Nodes

Jin-Tung Liang, MD, PhD1, Kuo-Chin Huang, MD, PhD2, Hong-Shiee Lai, MD, PhD1, Po-Huang Lee, MD, PhD1 and Chia-Tung Sun, MD3

1 Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan, ROC
2 Department of Family Medicine, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan, ROC
3 Department of Pathology, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan, ROC

Correspondence: Address correspondence and reprint requests to: Jin-Tung Liang, MD, PhD; E-mail: jintung{at}ntu.edu.tw


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Many Japanese surgeons routinely perform extended D3 lymph node dissection for the treatment of advanced rectosigmoid cancer with a view to achieving better tumor control. However, the application of a laparoscopic approach to perform D3 lymphadenectomy has been challenging. This phase 2 prospective study aimed to explore the oncologic results of this surgical approach.

Methods: The study was conducted during a 6-year period, in consideration of median follow-up time being >3 years. The study subjects were tumor, node, metastasis system stage III rectosigmoid cancer staged by clinical images. The extent of D3 dissection and the postoperative lymph node mapping were according to the guidelines of the Japanese Society for Cancer of the Colon and Rectum. Patients were stratified according to the histopathologically proved highest level of involved lymph nodes and placed into N0, N1, N2, and N3 groups. The primary end points of the study were the estimated time to recurrence and 5-year recurrence rate of cancer after laparoscopic D3 dissection.

Results: The estimated 5-year recurrence rate (20% in the N0 group [n = 10]; 25% in N1 [n = 44]; 33.3% in N2 [n = 30]; and 42.8% in N3 [n = 14]), time to recurrence (mean [95% confidence interval] 59.8 [42.6–76.9] months in the N0 group; 56.8 [48.3–65.2] months in N1; 46.8 [37.5–56.1] months in N2; and 43.9 [28.3–59.4] months in N3), and recurrence patterns were without significant difference (all P values >.05) among N0, N1, N2, and N3 groups. Therefore, by laparoscopic wide anatomic dissection, patients with lymph node involvement could be treated as well as those without lymph node metastasis. Laparoscopic D3 dissection facilitated the collection of more lymph nodes (mean ± standard deviation, 27.4 ± 4.2) for histopathologic examination. Mapping of dissected lymph nodes showed that 18.2% (16 of 88) patients had skip lymph node metastasis. D3 dissection facilitated upstaging of cancer (from N0 to N3) in five patients (5.1%). However, this procedure resulted in transient voiding dysfunction in 77.5% patients and loss of ejaculatory function in 91.7%. By laparoscopic approach, the D3 lymph node dissection was safely performed through small wounds, resulting in quick functional recovery and only moderate blood loss (324.8 ± 44.5 mL), but at the expense of a long operation time (294.4 ± 34.8 minutes).

Conclusions: The good short-term oncologic results and quick convalescence mean that the laparoscopic D3 dissection may be recommended for patients with stage III rectosigmoid cancer who could accept the genitourinary dysfunction.

Key Words: Laparoscopic surgery • N3 lymph node • D3 lymphadenectomy • Rectal cancer


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The role of radical lymphadenectomy in the treatment of advanced rectosigmoid cancer has been a contentious issue between Japanese and Western surgeons.1–5 Most Western surgeons argue that oncologic examples in which survival is increased by extended para-aortic lymph node dissection are few and that level 1 evidence confirming a benefit is scarce. A basic tenet of surgical oncology in Western countries is that cancerous lymph nodes are indicators, not governors, of survival.1 Moreover, the voices against radical lymphadenectomy are especially strident for those parts of the radical procedure that result in added morbidity—for example, the genitourinary dysfunction caused by pelvic lateral node dissection.6–10

However, many Japanese colorectal surgeons like to perform extended lymph node dissection.11–14 For tumor, node, metastasis system (TNM) stage II or III rectosigmoid cancers located above the pelvic peritoneal reflection, besides the high ligation of inferior mesenteric artery, Japanese surgeons additionally remove the extramesenteric lymphatic drainage along bilateral common iliac arteries and veins, inferior vena cava, and abdominal aorta upward to the level just below the duodenal third portion and left renal vein.15 For advanced rectal cancer below the peritoneal reflection, dissection of pelvic lateral nodes in the anatomic locations, including internal iliac system, obturator fossa, and the lateral vesicle tissue, was added.16–18 Japanese surgeons grouped the lymph nodes in above-mentioned anatomic regions as N3, and this method of lymphadenectomy is known as D3 lymph node dissection (Fig. 1Go). The rationale for such a complex scenario is the Japanese surgeons’ belief that extensive removal of extramesenteric lymphatic and perineural tissues results in a survival benefit.17–25 Moreover, removal of more N3 lymph nodes for detailed histopathologic examination facilitates stage migration, and a proportion of such patients would thus gain a survival advantage from postoperative adjuvant chemotherapy.26–29 However, in our institution, the radical D3 dissection was only limited to patients with the presence of clinically disease-positive nodes, as suggested by National Cancer Institute Guidelines.27


Figure 1
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  		FIG. 1. Definition of lymph node mapping for rectosigmoid cancer by Japanese Society of Colorectal Surgeons. N1, no. 241 or no. 251 within 5 cm proximal and distal to the primary tumor; N2, no. 252 and no. 242; N3, no. 253, no. 216, no. 273, no. 280, no. 270.

 
With the progress of surgical skills and instrumental technology, a laparoscopic technique has been widely adopted for the resection of colorectal malignancies. However, the application of laparoscopic technique to the N3 lymph node (D3) dissection procedure for the treatment of rectosigmoid cancer has only been sporadically reported, and the oncologic benefits of D3 dissection remain unclear.1–10,30 The scarcity for this kind of study reflects the steep learning curve of laparoscopic D3 dissection, as well as the concern about complications related to the nature of the surgery, including genitourinary dysfunction. Our previous studies have demonstrated that a laparoscopic technique could resect the colorectal malignancies along the same anatomic boundaries as conventional open surgery.10,31–33 We were inspired by these encouraging results to conduct this phase 2 prospective study to examine the oncologic results of a laparoscopic approach in performing Japanese-style extended lymph node dissection for the treatment of rectosigmoid cancer in men.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patient Selection
All consecutive patients with rectosigmoid cancer treated at Colorectal Division of National Taiwan University Hospital since June 2000 were selected for this study according to the following eligibility criteria: (1) Histopathologically proved adenocarcinoma located at upper rectum (above pelvic peritoneal reflection), rectosigmoid junction, or distal sigmoid colon (generally 10 to 25 cm above anal verge). Only rectosigmoid cancers above the peritoneal reflection were investigated because the lymphatic drainage of upper rectum and distal sigmoid colon was along the inferior mesenteric artery to the para-aortic area, and therefore the extent of surgical resection and lymph node mapping were standardized. (2) Male patients. This was because the male pelvis is narrower than the female pelvis, and thus the laparoscopic D3 lymph node dissection is technically more challenging in men. Moreover, the impairment of sexual function after para-aortic (N3) lymph node dissection is more obvious in men, and thus this procedure would have been more controversial and would have required far more justification for its use in men rather than women, with oncologic benefits weighed against functional deficit. (3) TNM stage III cancers. Because of the high prevalence of genitourinary dysfunction of D3 dissection, this procedure was reserved only for clinically staged stage III cancers in our institution. Therefore, only stage III cancers could get approval from our local ethics committee for surgical trial. (4) Curative and elective surgery. (5) American Society of Anesthesiology (ASA) class I to III patients. (6) Age between 50 and 70 years. This was because patients >50 years old are generally deemed to be over the reproductive age, and the D3 dissection was considered too aggressive for patients older than 70 years.

The exclusion criteria were as follows: (1) tumors located at other anatomic positions; (2) emergency or palliative surgery; (3) evidence of disseminated disease or adjacent organ invasion; (4) primary tumor mass >8 cm in diameter; (5) morbidly obese patients (body mass index ≥40 kg/m2); (6) previous major surgery of lower abdomen; (7) preoperative radiotherapy, because the subjects of the present study were sigmoid and upper rectal cancers, which are usually beyond the scope of radiotherapy.

Before patients were enrolled onto the study, they were informed of the advantages and disadvantages of laparoscopic versus traditional open surgery and were given a choice of laparoscopy or laparotomy. This study was approved by ethics committee of the National Taiwan University Hospital. The final patient accrual for the present interim analysis was in June 2006. This was because the recent report from Sargent et al.34 has shown that 3-year disease-free survival is an appropriate end point to replace 5-year overall survival as an end point in adjuvant colon cancer clinical trials of fluorouracil-based regimens. Because the present study was started in June 2000, it was not until June 2006 that the median time of follow-up would reach 3 years and the oncologic results could act as the surrogate for the outcomes of 5-year follow-up. All patients were prospectively followed until August 2006.

The primary end point of this study was time to recurrence of cancer after curative resection. The secondary end points included the number and distribution of dissected lymph nodes, functional recovery and disability of patients, surgical efficiency, and overall costs of laparoscopic approach. Patients who died without reported recurrence of disease were assumed to have had a recurrence at death unless it was clearly documented otherwise, in which case the patient’s data were censored on the date of death in the analysis of the time to recurrence.

Preoperative Staging Work-up
All patients first underwent colonoscopy with biopsy to confirm the diagnosis, followed by a barium enema, abdominal ultrasonography, computed tomographic (CT) scans of the abdomen and pelvis, and a chest radiograph to fully stage the extent of tumor before surgery. Whole-body magnetic resonance imaging, multislice spiral CT, and positron emission tomography (PET) scanning were selectively used in some patients (Fig. 2Go). Patients were considered to have clinically disease-positive lymph nodes when preoperative imaging showed the presence of mesenteric lymph nodes >4 mm in size and/or the presence of lymph nodes with a spiculated or indistinct border or a mottled, heterogeneous appearance.35 Additionally, serum levels of carcinoembryonic antigen were routinely quantified before surgery.


Figure 2
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  		FIG. 2. Imaging studies of a typical case in this clinical trial. (A) Barium enema showed an apple-core lesion at the upper rectum. (B) Magnetic resonance imaging showed the lower margin of tumor was just above the pelvic peritoneal reflection. (C) Multislice spiral computed tomographic scan showed a cauli-flower mass just above the peritoneal reflection with a positive mesorectal lymph node >4 mm in size (arrow). (D) Positron emission tomographic scan showed an upper rectal cancer with a positive mesorectal lymph node.

 
Operative Strategy
The operation procedures are shown in Fig. 3Go and have been described by us previously.10,31,32 The extent of mesenteric dissection included paracolic (N1) lymph nodes, intermediate (N2) lymph nodes, and lymph nodes in the root of inferior mesenteric artery (N3).15 The scope of extramesenteric dissection included the clearance of lymph nodes along common iliac artery and vein, to abdominal aorta, upward to the level of duodenal third portion, and to the left renal vein (Fig. 1Go).15


Figure 3
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  		FIG. 3. Extent of D3 lymph node dissection. (A) Define the upper margin of D3 lymph node dissection. (B) The lymph node dissection commences from the trigone area of abdominal aortic bifurcation. (C) The inferior mesenteric artery (arrow) was clipped and transected. (D) Dissection along the plane between Gerota fascia and sigmoid mesentery (arrow). (E) Complete skeletonization of abdominal aorta. (F) Complete skeletonization of common iliac artery and vein.

 
The surgical procedures were performed by a single surgeon (J.-T.L.). Before the present study began, the surgeon had performed approximately 300 laparoscopic resections of rectosigmoid cancer and more than 20 N3 lymph node dissection procedures.

Evaluation of Surgical Efficacy
The surgical efficacy was evaluated by the number of regional lymph node collected and time to recurrence of cancer after surgery. The experienced pathologist, blinded to surgical procedures, was in charge of the evaluation of preoperative and postoperative surgical histopathology, as well as the determination of the final TNM stage of the resected tumor. The collected lymph nodes were mapped according to the definition of the Japanese Society of Colorectal Surgeons (Fig. 1Go). Patients were grouped according to the histopathologically proved highest level of lymph nodes involvement by cancer; these groups were designated as N0, N1, N2, and N3 groups. The treatment efficacy among groups was compared. Adjuvant chemotherapy with Mayo regimens and selective use of oxaliplatin was provided to all patients with pathologic stage III cancer according to National Cancer Institute guidelines.27 No patients underwent preoperative adjuvant radiotherapy. All patients were prospectively followed.

Detection of Tumor Recurrence
Tumor recurrence was determined by various diagnostic modalities, including simple history and physical examination, digital examination, stool occult blood test, quantification of carcinoembryonic antigen levels and liver function tests at 1-month intervals, chest radiography and abdominal ultrasonography at 3-month intervals, and colonoscopy or barium enema examination every 6 months. Suspected recurrent lesions were further assessed by selective use of traditional CT, multislice spiral CT, magnetic resonance imaging, bone scan, intravenous pyelography, endoscopic ultrasonography, and PET scan. In equivocal cases, endoscopic biopsy, ultrasonogram-guided biopsy, and exploratory laparotomy were selectively used to confirm the diagnosis of a recurrent tumor.

Evaluation of Surgical Efficiency
We assessed the surgical efficiency by using parameters that included length of operation time (counted from the beginning of skin incision to the final skin closure), blood loss (measured by the amount of blood in the suction bottle and the number of blood-soaked gauzes), intraoperative and postoperative complications, and wound size. The wound size was measured by adding together the length of one major wound (generally 5 cm in size) for tumor retrieval and four working ports (5 to 12 mm in diameter). The operative complications, if present, were individually listed.

Evaluation of Functional Recovery
Functional recovery was compared by length of postoperative restoration of flatus passage, hospitalization, degree of postoperative pain, and disability. The visual analog scale was used to assess postoperative pain on the first postoperative day. A subjective-response standardized questionnaire was given to patients to assess disability, which included the number of days until return to partial activity, full activity, and work.

Evaluation of Genitourinary Function
Before surgery, the genitourinary function of all patients was assessed by a questionnaire-based interview. Patients with abnormal preoperative baseline functional data were excluded from further postoperative assessment of sexual or urinary function. Male sexual function was evaluated by potency and ejaculation. The evaluation of sexual function was performed 6 months after the operation, when the temporary colostomy, if present, has been closed and the patients were completely recovered from surgical disability. In evaluating the urinary function, the duration between initial voiding trial and spontaneous voiding was recorded. The questionnaire used for the assessment of urinary dysfunction was based on International Prostate Symptom Score,10 the parameters of which included incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia. Any voiding problems recovered within 3 months after operation were considered to be transient bladder voiding dysfunction; otherwise, such problems were deemed persistent. The genitourinary function was ranked as good, fair (decreased), and poor (impaired).

Calculation of Overall Costs
The overall costs of the laparoscopic surgery were calculated by adding together the operation fee, anesthesia fee, surgical equipment costs, the price of disposable laparoscopic instruments, hospital stay and pharmacy costs, and miscellaneous expenses.

Statistical Analysis
The patients were analyzed according to the intent-to-treat statistical principle. Kaplan-Meier curves were constructed to estimate the distribution of the disease-free survival. The log rank test was used to compare time to recurrence in the allocated groups. In evaluating secondary end points, two-tailed Fisher exact test, or {chi}2 test with or without Yates correction was used, as appropriate, to analyze the categorical data; continuous data were compared by analysis of variance. The significance level of all tests was set at P < 0.05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
A total of 98 men completed the treatment protocol and could be assessed (Fig. 4Go). Ten patients were placed into the N0 group. This means that with the current imaging technology, the preoperative diagnosis of patients as having clinically disease-positive lymph nodes was subject to false-positive findings 10.2% of the time. There was no statistically significant difference (P > 0.05) of various demographic and clinicopathologic parameters between groups of patients stratified by the final pathologic nodal status, except that the tumor location was a little higher above the anal verge in N2 group compared with the N3 group (Table 1Go).


Figure 4
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  		FIG. 4. Trial profile.

 

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  		TABLE 1. Comparison of demographic and clinicopathologic data stratified by pathologic nodal status in 98 patients with advanced rectosigmoid cancer
 
During the follow-up periods (median, 38 months; range, 2–74 months), the oncologic results of this case series were acceptable, with the estimated overall recurrence rate of 28.6% (n = 28). The mean estimated time to recurrence (95% confidence interval) was 59.8 (42.6–76.9) months in the N0 group (n = 10); 56.8 (48.3–65.2) months in N1 (n = 44); 46.8 (37.5–56.1) months in N2 (n = 30); and 43.9 (28.3–59.4) months in N3 (n = 14). The estimated 2-, 3-, and 5-year recurrence rate were 20%, 20%, and 20% in the N0 group; 18.8%, 20.5%, and 25% in N1; 13.3%, 30%, and 33.3% in N2; and 35.7%, 42.8%, and 42.8% in N3. Although these data indicate that the estimated time to recurrence was shorter and the 5-year estimated recurrence rate sequentially increased from N0, N1, N2, to N3 disease, the differences in these two parameters were statistically insignificant (P > 0.05, log rank test) among these four groups (Fig. 5Go). Furthermore, we found that the recurrence patterns were without significant difference (P = 0.9903) among the N0, N1, N2, and N3 groups (Table 2Go). Most recurrences occurred within 3 years after surgery and were distant metastases. The present data suggest that laparoscopic D3 dissection could achieve good locoregional control in patients with N1, N2, and N3 disease as well as in patients with N0 disease.


Figure 5
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  		FIG. 5. Time to recurrence and cumulative incidence of tumor recurrence after standardized laparoscopic D3 lymph node dissection in patients stratified by pathologic nodal status (N3 vs. N2: P = .5290, N3 vs. N1: P = .1763, N3 vs. N0: P = .2941, N2 vs. N1: P = .3417, N2 vs. N0: P = .4167, N1 vs. N0: P = .7912, log rank test).

 

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  		TABLE 2. Comparison of recurrence patterns in 98 patients with advanced rectosigmoid cancer treated by laparoscopic D3 lymph node dissection
 
Laparoscopic D3 dissection facilitated the collection of more lymph nodes for histopathologic examination. The mapping of nodal status for this case series is listed in Table 3Go. There were 14 patients (14.3%) with N3 disease-positive lymph nodes. This finding indicated that D3 dissection provided the chance of R0 surgery for patients with disease-positive N3 lymph nodes, which were located outside of the conventional margins of D2 dissection. The detailed mapping of dissected lymph nodes showed that five patients had a positive N3 lymph node but without N1 or N2 involvement, eight patients had a positive N2 lymph node but without N1 involvement, one patient had positive N3 plus N1 nodes but without N2 involvement, and two patients had positive N3 plus N2 nodes without N1 involvement. This means that 16 (18.2%) of 88 patients had skip lymph node metastases. Furthermore, we found in five patients (5.1%) that D3 dissection led to upstaging of disease (from N0 to N3); these patients would have otherwise been classified as having N0 lesions after conventional D2 dissection.


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  		TABLE 3. Nodal status of this case series (n = 98)
 
The surgical outcomes are listed in Table 4Go. Briefly, the laparoscopic D3 lymph node dissection was safely and efficiently performed through five small wounds with an acceptable morbidity rate and no deaths, long but tolerable (for both the patients and the surgeon) operative time, and moderate blood loss. Anastomotic leakage occurred in two patients. However, four patients were protected by a diverting ileostoma because of comorbidity (poorly controlled diabetes mellitus) in one, edematous bowel in one, and technical insecurity of stapling in two. The patients had short convalescences, as assessed by the length of postoperative restoration of flatus passage, hospitalization, degree of postoperative pain, and disability. However, the overall costs of laparoscopic approach were higher than those of conventional open surgery. In Taiwan, the disposable instrument costs are borne by the patients themselves. Besides the expenses covered by Taiwan’s National Bureau of Health Insurance, patients undergoing laparoscopic resection of rectosigmoid cancer in the present study had to pay, on average, an extra US$2031.30.


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  		TABLE 4. Surgical outcomes for 98 patients with advanced rectosigmoid cancer treated by laparoscopic D3 lymphadenectomya
 
Laparoscopic D3 lymph node dissection resulted in voiding dysfunction in 75.5% of patients, and in 14.8% of these, the bladder dysfunction was permanent. The incidence of sexual dysfunction was even greater, with 91.7% of patients experiencing complete loss of ejaculatory function or retrograde ejaculation and 47.7% of patients with a decrease in or loss of penile erection (Table 5Go).


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  		TABLE 5. Genitourinary dysfunction after laparoscopic D3 dissection of rectosigmoid cancer
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The present study demonstrated that with the current of laparoscopic technology, D3 lymph node dissection for TNM stage III rectosigmoid cancer could be performed by laparoscopic approach with acceptable oncologic results and quick postoperative recovery for the patients, but at the sacrifice of normal genitourinary function. D3 lymph node dissection for rectosigmoid cancer, either performed by conventional open surgery or by a laparoscopic approach, has created controversies that remain unsolved. It has been generally accepted that a progressive increase in recurrence rate is observed in parallel with a higher level and number of involved nodes.36

However, the present study showed that the recurrence of tumor was not statistically different among patient groups with N3, N2, N1, and N0 node involvement after laparoscopic D3 dissection. These data suggest that disease-free survival of patients with node involvement was enhanced by laparoscopic wide anatomic resection. The oncologic results of the present study were better than those from several Japanese case series, in which extended lymphadenectomy was routinely performed.9,11–14,16–25 Our explanations for these encouraging results are as follows. First, extended D3 lymph node dissection provided a better chance for R0 surgery in TNM stage III rectosigmoid cancer. In the present study, 14 patients (14.3%) had a positive N3 lymph node. This subset of patients would have a residual tumor (R1) with conventional D2 dissection. However, whether the removal of more negative nodes by wide D3 dissection would have translated into a disease-free advantage in N2 and N1 groups of patients is thought-provoking. Because most recurrences occurred within 3 years after surgery and were almost distant metastases in N0, N1, N2, and N3 patients, we postulated that D3 dissection would provide good and similar locoregional controls of tumors among patients with and without lymph node metastasis. These distant metastases would have gradually developed from systemic occult cancer nidi, which had been present before and after surgery and which were beyond the scope of radical excision. To further clarify this issue, recruitment of more cases for a randomized controlled prospective study will be necessary.

Second, during the present surgical trial, the negative nodes would probably have been subjected to more detailed histopathologic scrutiny, and the pathologic staging would have been more precise. The present study shows that extensive D3 dissection could result in stage migration in five patients (5.1%). These upstaged patients would have benefited from more aggressive chemotherapy. Andre et al.28 reported that oxaliplatin plus 5-fluorouracil–based chemotherapy could provide a marked decrease of recurrence rate in up to 7% of patients with TNM stage III disease. In the present series, the N2 and N3 patients (n = 44, 44.9%) underwent postoperative adjuvant chemotherapy with oxaliplatin, in contrast to the N1 patients, who received the traditional Mayo chemotherapeutic regimens. This might partly explain the better oncologic results of our patient series, as compared with some Japanese case series, in which extended D3 dissection was provided, but without aggressive chemotherapy with oxaliplatin.

Third, the D3 dissection in the present case series was performed by a laparoscopic approach. Most colorectal surgeons believe that this approach results in less operative stress than traditional open laparotomy.31,33 Previous studies have indicated that surgical stress would result in immunocompromise and thus poorer oncologic results in cancer patients.37 It is therefore our speculation that the lower recurrence rate in the present study might be related to the minimally invasive nature of the surgery. However, a recent meta-analysis by Reza et al.38 did not mention that the laparoscopic approach was associated with better overall survival of patients. In the current study, the small number of patients in each stratified subgroup means that more cases will need to be recruited before this question can be answered more definitely.

The current study provided some new insights into the clinical applicability of sentinel node navigation surgery for the treatment of rectosigmoid cancer. Sixteen (18.2%) of 88 patients with positive lymph node involvement had skip lymph node metastasis. Lymphatic mapping in melanoma and breast cancer is based on the reproducibility of and orderly drainage of the lymphatics from the primary tumor first, then to a sentinel node. However, the higher rate of skip metastasis in the present study indicated that the concept of sentinel node may not be reliable in colon cancer. The lymphatic drainage in colon cancer can be likened more to a watershed than a more direct line, as in skin and breast cancer. The lymphatic drainage could therefore be on one or the other side of the mesentery; either proximal or distal to the tumor; or even at the center of a fat mesentery in obese patients, which would make identification difficult.

In addition, there is evidence in the literature that the success of sentinel node identification differs between right and left colon cancers, suggesting that the complexity and variability of lymphatic drainage may be major factors. There is some evidence that more locally advanced colon cancers may have a higher false-negative rate by blocking lymphatics and altering the routing of tumor cells. Several researchers attempting to translate the sentinel node mapping to clinical use also showed considerable variability in sensitivity, which was particularly influenced by the technical variability between different studies.39–43 Given the limitation of anatomic characteristics and technical variability, it is thus our opinion that clinical applicability of sentinel node mapping is limited. Interestingly, PET scan could demonstrate the N3 lymph node metastasis in 4 (44.4%) of 9 patients with a positive N3 lymph node in the present case series. Therefore, the PET-guided lymphadenectomy may be potentially applicable and deserves further investigation.

Laparoscopic resection for colon cancer may be performed, but laparoscopic resection of rectal cancer is much less accepted.44 On the basis of the present study, and with reference to our previous standard laparotomy statistics,33 the technique of laparoscopic approach for radical D3 lymph node dissection for stage III rectosigmoid cancer has become well established in our institution. It was therefore our thought that the maturation of laparoscopic procedures would facilitate further feasibility studies regarding the application of laparoscopic techniques to the dissection of pelvic lateral nodes for the treatment of lower rectal cancer (below the peritoneal reflection), and that the standardization of laparoscopic D3 lymph node dissection would inspire further recruitment of more cases for a randomized prospective controlled trial to provide level 1 evidence regarding the efficacy of extended N3 lymph node dissection for rectosigmoid cancer.

Received for publication November 26, 2006. Accepted for publication January 5, 2007.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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S. Yamamoto, K. Yoshimura, F. Konishi, and M. Watanabe
Phase II Trial to Evaluate Laparoscopic Surgery for Stage 0/I Rectal Carcinoma
Jpn. J. Clin. Oncol., July 1, 2008; 38(7): 497 - 500.
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