Cueto Mary Anne Carol A, Cajucom Carlo Angelo C
Jose R. Reyes Memorial Medical Center, Section of Colorectal Surgery, Department of Surgery, Manila, Philippines.
Jose R. Reyes Memorial Medical Center, Section of Colorectal Surgery, Department of Surgery, Manila, Philippines.
Int J Surg Case Rep. 2021 Dec;89:106637. doi: 10.1016/j.ijscr.2021.106637. Epub 2021 Nov 30.
Total mesorectal excision (TME) with lateral pelvic node dissection was routinely done in low clinical T3 rectal tumors below the peritoneal reflection as stated in the Japanese guidelines for colorectal cancer. Our institution follows the same practice in selected patients. This is our first reported case wherein a patient with rectal cancer underwent total mesorectal excision with lateral lymphadenectomy after neoadjuvant treatment with a positive lateral node on histopathology.
A 49 year old female rectal had rectal adenocarcinoma 4 cm FAV. Pelvic MRI revealed a low rectal tumor abutting the mesorectal fascia anteriorly, anal sphincters not involved, and confluent enlarged right iliac nodes. After neoadjuvant treatment, interval decrease in size of the rectal lesion and the right iliac nodes were noted. Patient underwent partial intersphincteric resection, lateral pelvic node dissection and protective loop ileostomy.
Histopathology revealed a rectal adenocarcinoma with one right internal iliac lymph node was positive for tumor involvement. Circumferential resection margin was 4.0 mm. Patient is currently on 4th cycle of adjuvant chemotherapy. Preoperative chemoradiation could not completely eradicate lateral pelvic node metastasis. Therefore, lateral pelvic node dissection should be considered if lateral pelvic lymph node metastasis is suspected even after neoadjuvant therapy.
Unlike TME, performance of a routine lateral lymphadenectomy in rectal cancer surgery varies by geographic location. Reports from Asian countries and our practice in our institution shows that it can be performed safely. This could improve the oncologic outcomes of patients especially if combined with neoadjuvant chemoradiotherapy.
按照日本结直肠癌指南所述，对于腹膜返折以下临床分期为T3的低位直肠肿瘤，常规行全直肠系膜切除术（TME）并加行侧方盆腔淋巴结清扫。我们机构在部分患者中也采用同样的做法。这是我们首次报告的1例病例，该直肠癌患者在新辅助治疗后组织病理学检查发现侧方淋巴结阳性，随后接受了全直肠系膜切除术并加行侧方淋巴结清扫。
一名49岁女性患有4 cm大小的直肠腺癌。盆腔磁共振成像（MRI）显示低位直肠肿瘤，前方紧邻直肠系膜筋膜，未累及肛门括约肌，右侧髂淋巴结融合增大。新辅助治疗后，直肠病变及右侧髂淋巴结大小均有缩小。患者接受了部分括约肌间切除术、侧方盆腔淋巴结清扫及保护性回肠造口术。
组织病理学检查显示直肠腺癌，右侧髂内淋巴结1枚有肿瘤转移。环周切缘为4.0 mm。患者目前正在接受第4周期辅助化疗。术前放化疗未能完全清除侧方盆腔淋巴结转移。因此，即使在新辅助治疗后怀疑有侧方盆腔淋巴结转移，也应考虑行侧方盆腔淋巴结清扫。
与TME不同，直肠癌手术中常规行侧方淋巴结清扫的情况因地理位置而异。来自亚洲国家的报告以及我们机构的实践表明，该手术可以安全实施。这可能会改善患者的肿瘤学预后，尤其是与新辅助放化疗联合应用时。
