Does a fine line exist between regional and metastatic pelvic lymph nodes in rectal cancer-striking discordance between national guidelines and treatment recommendations by US radiation oncologists

Jehan Behal Yahya, Daniel Herzig, Matthew Joseph Farrell, Catherine R. Degnin, Yiyi Chen, John Holland, Simon Brown, Jerry Jaboin, Vassiliki Tsikitis, Kim Lu, Charles Thomas, Timur Mitin

Research output: Contribution to journalArticle

Abstract

Background: Management of rectal cancer with involved lateral pelvic lymph nodes (LPLNs) at the time of diagnosis-the stage we refer institutionally to as Stage 3.5-is controversial. The American Joint Committee on Cancer's 7th edition classifies internal iliac lymph nodes (LNs) as regional (Stage III), but both external and common iliac LNs as metastatic (Stage IV). However, in many Asian countries all LPLNs are considered regional and patients are treated with curative intent, with literature supporting improved outcomes with LPLN dissection. Management patterns of these patients by US radiation oncologists (ROs) are unknown. Methods: American ROs completed an anonymous institutional review board-approved online questionnaire regarding rectal cancer management. Results: Among the 220 completed responses, 45% treat more than 10 patients annually and 39% work in academia. We found 10.5% and 34.2% recommend biopsy of clinically involved internal and common iliac LNs, respectively. The vast majority of responders-98.6% and 94.5%-treat involved internal and common iliac LNs with curative intent, respectively. Respondents recommend treatment intensification to involved internal iliac LNs by dissection of the nodal basin (88.2%) and radiation therapy (RT) boost (59.1%), and treatment intensification to involved common iliac LNs by LN dissection (76.4%) and RT boost (63.6%). Conclusions: Our analysis reveals that the vast majority of US ROs approach patients with involved LPLNs, both regional (internal iliac) and metastatic (common iliac), with curative intent. They recommend treatment intensification with surgical resection and/or RT boost to involved nodes. Prospective clinical trials need to determine the appropriate management of patients with Stage 3.5 rectal cancer.

Original languageEnglish (US)
Pages (from-to)441-447
Number of pages7
JournalJournal of Gastrointestinal Oncology
Volume9
Issue number3
DOIs
StatePublished - Jun 1 2018

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Rectal Neoplasms
Lymph Nodes
Guidelines
Lymph Node Excision
Radiotherapy
Therapeutics
Radiation Oncologists
Research Ethics Committees
Clinical Trials
Biopsy
Neoplasms

Keywords

  • Guideline adherence
  • Intention
  • Lymph node excision
  • Radiation oncology
  • Rectal neoplasms

ASJC Scopus subject areas

  • Oncology
  • Gastroenterology

Cite this

@article{c7857df75d4e4d398ff5abaaabf5903f,
title = "Does a fine line exist between regional and metastatic pelvic lymph nodes in rectal cancer-striking discordance between national guidelines and treatment recommendations by US radiation oncologists",
abstract = "Background: Management of rectal cancer with involved lateral pelvic lymph nodes (LPLNs) at the time of diagnosis-the stage we refer institutionally to as Stage 3.5-is controversial. The American Joint Committee on Cancer's 7th edition classifies internal iliac lymph nodes (LNs) as regional (Stage III), but both external and common iliac LNs as metastatic (Stage IV). However, in many Asian countries all LPLNs are considered regional and patients are treated with curative intent, with literature supporting improved outcomes with LPLN dissection. Management patterns of these patients by US radiation oncologists (ROs) are unknown. Methods: American ROs completed an anonymous institutional review board-approved online questionnaire regarding rectal cancer management. Results: Among the 220 completed responses, 45{\%} treat more than 10 patients annually and 39{\%} work in academia. We found 10.5{\%} and 34.2{\%} recommend biopsy of clinically involved internal and common iliac LNs, respectively. The vast majority of responders-98.6{\%} and 94.5{\%}-treat involved internal and common iliac LNs with curative intent, respectively. Respondents recommend treatment intensification to involved internal iliac LNs by dissection of the nodal basin (88.2{\%}) and radiation therapy (RT) boost (59.1{\%}), and treatment intensification to involved common iliac LNs by LN dissection (76.4{\%}) and RT boost (63.6{\%}). Conclusions: Our analysis reveals that the vast majority of US ROs approach patients with involved LPLNs, both regional (internal iliac) and metastatic (common iliac), with curative intent. They recommend treatment intensification with surgical resection and/or RT boost to involved nodes. Prospective clinical trials need to determine the appropriate management of patients with Stage 3.5 rectal cancer.",
keywords = "Guideline adherence, Intention, Lymph node excision, Radiation oncology, Rectal neoplasms",
author = "Yahya, {Jehan Behal} and Daniel Herzig and Farrell, {Matthew Joseph} and Degnin, {Catherine R.} and Yiyi Chen and John Holland and Simon Brown and Jerry Jaboin and Vassiliki Tsikitis and Kim Lu and Charles Thomas and Timur Mitin",
year = "2018",
month = "6",
day = "1",
doi = "10.21037/jgo.2018.02.05",
language = "English (US)",
volume = "9",
pages = "441--447",
journal = "Journal of Gastrointestinal Oncology",
issn = "2078-6891",
publisher = "Pioneer Bioscience Publishing Company (PBPC)",
number = "3",

}

TY - JOUR

T1 - Does a fine line exist between regional and metastatic pelvic lymph nodes in rectal cancer-striking discordance between national guidelines and treatment recommendations by US radiation oncologists

AU - Yahya, Jehan Behal

AU - Herzig, Daniel

AU - Farrell, Matthew Joseph

AU - Degnin, Catherine R.

AU - Chen, Yiyi

AU - Holland, John

AU - Brown, Simon

AU - Jaboin, Jerry

AU - Tsikitis, Vassiliki

AU - Lu, Kim

AU - Thomas, Charles

AU - Mitin, Timur

PY - 2018/6/1

Y1 - 2018/6/1

N2 - Background: Management of rectal cancer with involved lateral pelvic lymph nodes (LPLNs) at the time of diagnosis-the stage we refer institutionally to as Stage 3.5-is controversial. The American Joint Committee on Cancer's 7th edition classifies internal iliac lymph nodes (LNs) as regional (Stage III), but both external and common iliac LNs as metastatic (Stage IV). However, in many Asian countries all LPLNs are considered regional and patients are treated with curative intent, with literature supporting improved outcomes with LPLN dissection. Management patterns of these patients by US radiation oncologists (ROs) are unknown. Methods: American ROs completed an anonymous institutional review board-approved online questionnaire regarding rectal cancer management. Results: Among the 220 completed responses, 45% treat more than 10 patients annually and 39% work in academia. We found 10.5% and 34.2% recommend biopsy of clinically involved internal and common iliac LNs, respectively. The vast majority of responders-98.6% and 94.5%-treat involved internal and common iliac LNs with curative intent, respectively. Respondents recommend treatment intensification to involved internal iliac LNs by dissection of the nodal basin (88.2%) and radiation therapy (RT) boost (59.1%), and treatment intensification to involved common iliac LNs by LN dissection (76.4%) and RT boost (63.6%). Conclusions: Our analysis reveals that the vast majority of US ROs approach patients with involved LPLNs, both regional (internal iliac) and metastatic (common iliac), with curative intent. They recommend treatment intensification with surgical resection and/or RT boost to involved nodes. Prospective clinical trials need to determine the appropriate management of patients with Stage 3.5 rectal cancer.

AB - Background: Management of rectal cancer with involved lateral pelvic lymph nodes (LPLNs) at the time of diagnosis-the stage we refer institutionally to as Stage 3.5-is controversial. The American Joint Committee on Cancer's 7th edition classifies internal iliac lymph nodes (LNs) as regional (Stage III), but both external and common iliac LNs as metastatic (Stage IV). However, in many Asian countries all LPLNs are considered regional and patients are treated with curative intent, with literature supporting improved outcomes with LPLN dissection. Management patterns of these patients by US radiation oncologists (ROs) are unknown. Methods: American ROs completed an anonymous institutional review board-approved online questionnaire regarding rectal cancer management. Results: Among the 220 completed responses, 45% treat more than 10 patients annually and 39% work in academia. We found 10.5% and 34.2% recommend biopsy of clinically involved internal and common iliac LNs, respectively. The vast majority of responders-98.6% and 94.5%-treat involved internal and common iliac LNs with curative intent, respectively. Respondents recommend treatment intensification to involved internal iliac LNs by dissection of the nodal basin (88.2%) and radiation therapy (RT) boost (59.1%), and treatment intensification to involved common iliac LNs by LN dissection (76.4%) and RT boost (63.6%). Conclusions: Our analysis reveals that the vast majority of US ROs approach patients with involved LPLNs, both regional (internal iliac) and metastatic (common iliac), with curative intent. They recommend treatment intensification with surgical resection and/or RT boost to involved nodes. Prospective clinical trials need to determine the appropriate management of patients with Stage 3.5 rectal cancer.

KW - Guideline adherence

KW - Intention

KW - Lymph node excision

KW - Radiation oncology

KW - Rectal neoplasms

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U2 - 10.21037/jgo.2018.02.05

DO - 10.21037/jgo.2018.02.05

M3 - Article

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JO - Journal of Gastrointestinal Oncology

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SN - 2078-6891

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