Current perspectives on the management of lateral pelvic lymph nodes in rectal cancer

Significant controversies exist with regards to the optimal management of lateral pelvic lymph nodes metastases (mLLN) in patients with low rectal cancer. The differing views held by Japanese and Western clinicians on the management of mLLN have been well documented. However, the adequacy of pelvic lymph node dissection (PLND) or neoadjuvant chemoradiation (NACRT) alone in addition to total mesorectal excision (TME) have recently come into question, due to the relatively high incidence of lateral local recurrences following PLND and TME, or NACRT and TME alone. Recently, a more selective approach to PLND has been suggested, involving a combination of neoadjuvant therapy, followed by PLND only to patients in whom the oncological benefit is likely to outweigh the risk of potential adverse events. A number of studies have attempted to retrospectively identify certain nodal characteristics on preoperative imaging, such as nodal size, appearance, and size reduction following neoadjuvant therapy. However, no consensus has been reached regarding the optimal criteria for a selective approach to PLND, partly due to the heterogeneity and retrospective nature of most of these studies. This review aims to provide an overview of recent evidence with regards to the diagnostic challenges, considerations for, and outcomes of the current management strategies for mLLN in rectal cancer patients.