Abstract
BACKGROUND: Lateral lymph node dissection (LLND) can decrease local recurrence to lateral compartments in middle-low rectal cancer, but pathological evidence for optimal surgical indications, especially after neoadjuvant (chemo)radiotherapy (nCRT), is lacking. This study aimed to identify the predictive factors and oncological outcomes for different LLN locations associated with pathological metastasis. METHOD: In this multicenter study, patients from 19 centers who underwent total mesorectal excision (TME) with LLND for locally advanced mid-/low rectal cancer from January 2012 to December 2021 were included. RESULTS: All 566 included patients underwent TME with LLND surgery; 241 (37.4%) of the largest LLNs were located in the obturator area, and 403 (62.6%) of the largest LLNs were located in the internal iliac area. Multivariate analysis revealed that a short-axis size of 9 mm for the obturator area and 6 mm for internal iliac nodes constituted a reliable indicator of pathological LLN metastasis in non-CRT patients. In nCRT patients, a short-axis node size of 7 mm for obturator nodes and 4 mm for internal iliac nodes could be used to accurately predict pathological LLN metastasis. In contrast to pathological internal iliac node metastasis, pathological obturator node metastasis was associated with lower distant metastasis-free survival (DMFS) (P = 0.001), cancer-specific survival (CSS) (P = 0.043), and overall survival (OS) (P = 0.009), but lower lateral local recurrence-free survival (LRFS) (P > 0.05) was not statistically significant. CONCLUSIONS: The obturator and internal iliac nodes may be two completely different types of LLNs, and the optimal cutoff value for predicting pathological LLN metastasis is inconsistent regardless of nCRT. Clinical trial registration The protocol of the current study was registered on ClinicalTrials.gov (NCT04850027), and the protocols were in accordance with the standards set by the World Medical Association Declaration of Helsinki.