Total mesorectal excision with and without lateral lymph node dissection: a systematic review of the literature

Treatment of lateral lymph node metastasis in rectal cancer is still under debate. While these nodes are routinely resected by Japanese teams, neoadjuvant radiochemotherapy alone is performed in Western countries. We aimed to systematically report the current literature assessing the overall and disease-free survivals of patients with rectal cancer treated with total mesorectal resection (TME) with or without lateral lymph node dissection (LLND).

MEDLINE/Pubmed, Embase, Cochrane, and Web of Science were searched from database implementation until 19 January 2019. Studies reporting overall survival or recurrence-free survival in patients with LLND for rectal cancer were included. We excluded studies including patients with recurrent rectal cancer, multivisceral resection, and/or without control group (patients with rectal surgery without LLND).

Eleven studies were included, accounting for a total of 4159 patients. Overall survival ranged between 55.6 and 92.6% for TME with LLND versus 49.2 and 90.2% for TME alone, with one study reporting statistically significant benefit of LLND. Recurrence-free survival ranged between 58.3 and 74.1% for TME with LLND versus 39.5 and 76.5% for TME alone. Two studies showed statistically significant differences between the two strategies, one randomized controlled trial showed improved recurrence-free survival in TME alone group (74.5% versus 74.1% with LLND at 5 years) and one observational retrospective study reported increased recurrence-free survival with more extensive resection (65.4% versus 39.5% without LLND, at 5 years).

Benefits of LLND are not clear and further randomized controlled trials should be performed to determine which strategy would allow improving survival in rectal cancer patients.

The study protocol was registered in PROSPERO prior to study screening (CRD42019123181) and published in September 2019.