Diagnostic and management strategies for lateral pelvic lymph nodes in low rectal cancer—a review of the evidence

The presence of metastatic lateral pelvic lymph nodes has been shown to portend a worse prognosis for patients with low rectal cancer (1). In patients with low rectal cancer, the lymphatic drainage does not only flow along the inferior mesenteric artery, but also along the internal iliac artery, therefore its propensity to metastasize to the lateral pelvic lymph nodes. Dissection of these nodes was standard treatment in the 1980s, with literature from that period suggesting a reduction in local recurrence as well as prolonged overall survival (2,3). The advent of neoadjuvant chemoradiation therapy has however changed Western paradigms, such that there is ongoing debate about the effectiveness of lateral pelvic lymph node dissection in the era of neoadjuvant chemoradiation therapy. In contrast, the Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines continue to advocate lateral pelvic lymph node dissection for all patients who have tumours below the peritoneal reflection (4)