Surgical Roles in the Management of Metachronus Para-aortic Lymph Node Recurrence and Synchronous Para-aortic Lymph Node Metastasis in Colorectal Cancer Patients

Abd-Elaziz, Osama; Ali, Ramadan M.; Amin, Mohamed Farouk; Fahmy, Ahmed M.; Elshorbagy, Shereen; Mandour, Doaa; Hemeda, Rehab; Harb, Ola A.; Samir, Amr; El-Hendawy, Elsayed I.

doi:10.1055/s-0042-1742310

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Journal of Coloproctology (Rio de Janeiro)

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Sumário

Original Article • J. Coloproctol. (Rio J.) 42 (2) • June 2022 • https://doi.org/10.1055/s-0042-1742310 copy

Surgical Roles in the Management of Metachronus Para-aortic Lymph Node Recurrence and Synchronous Para-aortic Lymph Node Metastasis in Colorectal Cancer Patients

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background

The relative rarity of synchronous para-aortic lymph node (PALN) metastasis (SPM) and metachronous PALN recurrence (MPR) in colorectal carcinoma (CRC) patients leads to a limited number of studies on patient management, and no treatment guidelines have been established to date.

Objective

To assess the prognostic, predictive roles, and long-term outcomes of different management strategies for isolated MPR and SPM in CRC patients to establish the best one.

Materials and Methods

We included 35 CRC patients with isolated MPR and 25 patients with isolated SPM who underwent curative R0 resection. We performed PALN dissection (PALND) in 15 cases in MPR group and in 10 cases in the SPM group; all remaining patients in both groups underwent chemoradiotherapy (CRT) without further surgical intervention. During the study period of about 5 years, we compared the patients who underwent PALND and those who underwent CRT.

Results

The overall survival and recurrence-free survival rates were significantly longer in patients who underwent PALND (p = 0.049 and 0.036 respectively).

Keywords:
colorectal cancer; metachronous paraaortic lymph node recurrence; synchronous paraaortic lymph node metastasis; surgery

Variable		SPM		MPR		Total N = 60		p-value
		N = 25		N = 35		Total N = 60
		n	%	n	%	n	%
Mean age in years (range)		50 (30–65)		50 (32–68)		50 (30–68)		0.976
Histopathological subtype	Conventional adenocarcinoma	22	88.0	28	80.0	50	83.3	0.412
Histopathological subtype	Mucoid carcinoma	3	12.0	7	20.0	10	16.7	0.412
Site of the primary tumor	Ascending colon	7	28.0	20	57.1	27	45.0	0.038
	Rectosigmoid	10	40.0	4	11.4	14	23.3
	Descending colon	3	12.0	6	17.1	9	15.0
	Transverse colon	5	20.0	5	14.3	10	16.7
Duke stage	A	2	8.0	9	25.7	11	18.3	< 0.001
	B	11	44.0	0	0.0	11	18.3
	C	12	48.0	13	37.1	25	41.7
	D	0	0.0	13	37.1	13	21.7
Type of primary operation	Right hemicolectomy	10	40.0	20	57.1	30	50.0	0.075
	Left hemicolectomy	5	20.0	11	31.4	16	26.7
	Anterior resection	4	16.0	1	2.9	5	8.3
	Abdominoperineal resection	6	24.0	3	8.6	9	15.0
Mean size of largest PALN in millimeters (range)		15 (12–20)		15 (12–20)		15 (12–20)		0.655
PALND	No	15	60.0	20	57.1	35	58.3	0.825
PALND	Yes	10	40.0	15	42.9	25	41.7	0.825
Preoperative chemoradiotherapy	No	13	52.0	17	48.6	30	50.0	0.793
Preoperative chemoradiotherapy	Yes	12	48.0	18	51.4	30	50.0	0.793
Postoperative chemoradiotherapy	No	5	20.0	7	20.0	12	20.0	> 0.999
	Yes	20	80.0	28	80.0	48	80.0
	Yes –distant metastasis	1	14.3	6	46.2	7	35.0

Variable		PALND				Total N = 60		p-value
		Yes N = 35		No N = 25		Total N = 60
		n	%	n	%	n	%
Mean age in years (range)		50 (30–68)		54 (32–67)		50 (30–68)		0.192
Gender	Female	12	34.3	8	32.0	20	33.3	0.853
Gender	Male	23	65.7	17	68.0	40	66.7
Histopathological subtype	Conventional adeno carcinoma	29	82.9	21	84.0	50	83.3	0.907
Histopathological subtype	Mucoid carcinoma	6	17.1	4	16.0	10	16.7
Site of the primary tumor	Ascending colon	14	40.0	13	52.0	27	45.0	0.237
	Rectosigmoid	10	28.6	4	16.0	14	23.3
	Descending colon	7	20.0	2	8.0	9	15.0
	Transverse colon	4	11.4	6	24.0	10	16.7
Duke stage	A	6	17.1	5	20.0	11	18.3	0.001
	B	11	31.4	0	0.0	11	18.3
	C	8	22.9	17	68.0	25	41.7
	D	10	28.6	3	12.0	13	21.7
PALN	Synchronous metastasis	15	42.9	10	40.0	25	41.7	0.825
PALN	Meta-chronous recurrence	20	57.1	15	60.0	35	58.3
Type of primary operation	Right hemicolectomy	14	40.0	16	64.0	30	50.0	0.306
	Left hemicolectomy	11	31.4	5	20.0	16	26.7
	Anterior resection	4	11.4	1	4.0	5	8.3
	Abdominoperineal resection	6	17.1	3	12.0	9	15.0
Mean size of largest PALN in millimeters (range)		14 (12–15)		18 (17–20)		15 (12–20)		< 0.001
Response to treatment	PD	4	11.4	2	8.0	6	10.0	0.962
	SD	4	11.4	3	12.0	7	11.7
	PR	5	14.3	3	12.0	8	13.3
	CR	22	62.9	17	68.0	39	65.0
Preoperative chemoradiotherapy	No	16	45.7	14	56.0	30	50.0	0.432
Preoperative chemoradiotherapy	Yes	19	54.3	11	44.0	30	50.0
Postoperative chemoradiotherapy	No	6	17.1	6	24.0	12	20.0	0.513
Postoperative chemoradiotherapy	Yes	29	82.9	19	76.0	48	80.0
PALN	Synchronous metastasis	15	42.9	10	40.0	25	41.7	0.825
PALN	Metachronous recurrence	20	57.1	15	60.0	35	58.3

Variable		PALND				Total		p-value
		No N = 35		Yes N = 25		Total
		n	%	n	%	n	%
Recurrence pattern after PALND	Local	8	34.8%	5	50.0%	13	39.4%	0.411
Recurrence pattern after PALND	Distant	15	65.2%	5	50.0%	20	60.6%
Death	No	14	40.0%	16	64.0%	30	50.0%	0.047
Death	Yes	21	60.0%	9	36.0%	30	50.0%
Relapse^* * Calculated from patients with documented response to therapy.	No	12	44.4%	15	75.0%	27	57.4%	0.036
	Yes	15	55.6%	5	25.0%	20	42.6%

PALND	Total	Number of Events	Censored		Survival time in months				Survival rate	p-value
					Mean		Median
					Estimate ± standard error	95% confidence interval	Estimate ± standard error	95% confidence interval
Overall survival
No	35	21	14	40.0%	18.9 ± 0.8	17.4 – 20.4	18.0 ± 0.5	17.0 – 19.0	11.0%	0.049
Yes	25	9	16	64.0%	21.1 ± 1.0	19.1 – 23.1	23.0 ± 2.8	17.5 – 28.5	0.0%	0.049
Total	60	30	30	50.0%	19.8 ± 0.6	18.6 – 21.0	18.0 ± 1.5	15.0 – 21.0	41.0%
Relapse-free survival
No	27	15	12	44.4%	18.3 ± 1.0	16.2 – 20.3	17.0 ± 1.0	15.0 – 19.0	30.5%	0.036
Yes	20	5	15	75.0%	18.8 ± 0.4	17.9 – 19.6	Not reached		57.3%
Total	47	20	27	57.4%	19.6 ± 0.8	18.0 – 21.2	18.0 ± 0.6	16.8 – 19.2	8.8%

Covariate	Relapse-free survival
	Univariate		Multivariate
	p-value	Hazard ratio (95% confidence interval)	p-value	Hazard rastio (95% confidence interval)
Age (years)	0.87	1.00 (0.95–1.04)
Gender	0.033	1.63 (1.04–2.56)	0.034	1.62 (1.04–2.52)
Histopathological subtype	0.339	0.49 (0.11–2.12)
Site of the primary tumor
Ascending colon	0.824	0.86 (0.23–3.25)
Rectosigmoid	0.948	1.05 (0.25–4.39)
Descending colon	0.087	3.79 (0.82–17.40)
Duke stage
A	0.375	1.89 (0.46–7.70)
B	0.667	0.75 (0.20–2.83)
C	0.16	0.41 (0.12–1.42)
SPM and MPR	0.04	2.72 (1.05–7.10)
Size of the largest PALN (mm)	0.043	0.83 (0.68–0.99)	0.145	0.86 (0.70–1.05)
Type of primary operation
Right hemicolectomy	0.653	1.43 (0.30–6.72)
Left hemi-colectomy	0.08	4.11 (0.85–20.00)
Anterior resection	0.081	4.94 (0.82–29.71)
PALND	0.062	0.38 (0.14–1.05)
Preoperative chemoradiotherapy	< 0.001	7.32 (2.43–21.99)	0.001	6.16 (2.02–18.78)
Postoperative chemoradiotherapy	0.108	32.28 (0.46–2240.74)

Covariate	Overall survival
	Univariate		Multivariate
	p-value	Hazard ratio (95% confidence interval)	p-value	Hazard ratio (95% confidence interval)
Age (years)	0.199	1.03 (0.99–1.07)
Gender	0.792	0.88 (0.35–2.23)
Histopathological subtype	0.978	1.01 (0.41–2.52)
Site of the primary tumor
Ascending colon	0.458	1.52 (0.50–4.63)
Recto-sigmoid	0.896	1.09 (0.31–3.87)
Descending colon	0.076	3.39 (0.88–13.03)
Duke stage
A	0.998	1.00 (0.30–3.32)	0.959	1.04 (0.25–4.32)
B	0.173	0.47 (0.16–1.39)	0.961	1.04 (0.23–4.66)
C	0.031	0.35 (0.13–0.91)	0.229	0.52 (0.18–1.51)
SPM and MPR	0.029	2.61 (1.10–6.17)	0.079	2.48 (0.90–6.82)
Size of the largest PALN (mm)	0.211	0.91 (0.79–1.05)
Type of primary operation
Right hemicolectomy	0.506	1.45 (0.48–4.38)
Left hemicolectomy	0.264	1.99 (0.59–6.67)
Anterior resection	0.631	1.52 (0.27–8.44)
PALND	0.204	1.66 (0.76–3.63)
Preoperative chemoradiotherapy	0.002	0.21 (0.08–0.57)	0.003	0.01 (0.00–0.23)
Postoperative chemoradiotherapy	0.037	4.65 (1.10–19.62)	0.205	2.72 (0.58–12.76)
Relapse	0.011	3.37 (1.32–8.63)	0.004	0.01 (0.001–0.26)
Response to treatment	< 0.001	0.54 (0.39–0.75)	0.023	0.59 (0.38–0.93)

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[1] Address for correspondence Ola A. Harb, MD, PhD, Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt, 44519 (e-mail: olaharb2015@gmail.com).