West Side Story.

Top Line: Local recurrence rates of rectal cancer are so low following neoadjuvant chemoradiation and total mesorectal excision (TME), some people are talking about forgoing the TME part altogether.

The Study: Quit the opposite, many Eastern countries feel surgeons should go even bigger. When local recurrences do happen, they can be predictable. Such is the case with patients with enlarged (>1 cm) obturator / internal iliac lymph nodes in the “lateral compartment,” which isn’t dissected with a standard TME. Enter Team East (including Japan) embracing lateral node dissections to effectively mitigate risk of lateral recurrence. Team West (including the US) counters that the small absolute benefit in cancer control doesn’t merit the added surgical morbidity, primarily nerve damage. When things got heated, in lieu of a dance-off—which we think everyone can agree would have been more enjoyable—the Lateral Node Study Consortium was born. Among 741 patients treated at 10 centers across hemispheres, 90 received lateral node dissection per institutional standards. Looking at all 96 patients who had a lateral node >7 mm on upfront MRI, the lateral recurrence rate was 19% versus 4% otherwise. That’s not the crux of the story. Lateral node response on pre-op, post-chemoradiation restaging MRI was the real tell: lateral recurrences happened to 0% of those whose lateral nodes shrunk below the median (≤4 mm), 10% with obturator nodes >4 mm, and over half (52%) with internal iliac nodes >4 mm. And finally, Team East will have you know that a lateral node dissection dropped that last rate from 52 → 9%.

TBL: Persistently enlarged internal iliac nodes on pre-op restaging MRI for rectal cancer may call more a more aggressive nodal dissection. | Ogura, JAMA Surg 2019