Evaluation of National Surgical Practice for Lateral Lymph Nodes in Rectal Cancer in an Untrained Setting
Authors: Sluckin Tania C. , Hazen Sanne-Marije J. A. , Horsthuis Karin , Beets-Tan Regina G. H. , Aalbers Arend G. J. , Beets Geerard L. , Boerma Evert-Jan G. , Borstlap Jaap , van Breest Smallenburg Vivian , Burger Jacobus W. A. , Crolla Rogier M. P. H. , Daniëls-Gooszen Alette W. , Davids Paul H. P. , Dunker Michalda S. , Fabry Hans F. J. , Furnée Edgar J. B. , van Gils Renza A. H. , de Haas Robbert J. , Hoogendoorn Stefan , van Koeverden Sebastiaan , de Korte Fleur I. , Oosterling Steven J. , Peeters Koen C. M. J. , Posma Lisanne A. E. , Pultrum Bareld B. , Rothbarth Joost , Rutten Harm J. T. , Schasfoort Renske A. , Schreurs Wilhelmina H. , Simons Petra C. G. , Smits Anke B. , Talsma Aaldert K. , The G. Y. Mireille , van Tilborg Fiek , Tuynman Jurriaan B. , Vanhooymissen Inge J. S. , van de Ven Anthony W. H. , Verdaasdonk Emiel G. G. , Vermaas Maarten , Vliegen Roy F. A. , Vogelaar F. Jeroen , de Vries Marianne , Vroemen Joy C. , van Vugt Sebastiaan T. , Westerterp Marinke , van Westreenen Henderik L. , de Wilt Johannes H. W. , van der Zaag Edwin S. , Zimmerman David D. E. , Marijnen Corrie A. M. , Tanis Pieter J. , Kusters Miranda ,   Dutch Snapshot Research Group, van Aalten Susanna M. , Amelung Femke J. , Ankersmit Marjolein , Antonisse Imogeen E. , Ashruf Jesse F. , Aukema Tjeerd S. , Avenarius Henk , Bahadoer Renu R. , Bakers Frans C. H. , Bakker Ilsalien S. , Bangert Fleur , Barendse Renée M. , Beekhuis Heleen M. D. , Bemelman Willem A. , Berbée Maaike , de Bie Shira H. , Bisschops Robert H. C. , Blok Robin D. , van Bockel Liselotte W. , Boer Anniek H. , Boer Frank C.den , Boogerd Leonora S. F. , Borstlap Wernard A. A. , Bouwman Johanna E. , Braak Sicco J. , Braat Manon N. G. J. A. , Bradshaw Jennifer , Brandsma Amarins T. A. , van den Broek Wim T. , van der Burg Sjirk W. , Burghgraef Thijs A. , Cate David W. G. ten , Ceha Heleen M. , Cnossen Jeltsje S. , van den Braak Robert R. J. Coebergh , Consten Esther C. J. , Corver Maaike , Curutchet Sam , Dekker Emmelie N. , Dekker Jan Willem T. , Demirkiran Ahmet , Derksen Tyche , Diederik Arjen L. , Dinaux Anne M. , Dogan Kemal , van Dop Ilse M. , Greve Kitty E. Droogh-de , Duijsens Hanneke M. H. , Duyck Johan , van Duyn Eino B. , van Egdom Laurentine S. E. , Eijlers Bram , El-Massoudi Youssef , van Elderen Saskia , Emmen Anouk M. L. H. , Engelbrecht Marc , van Erp Anne C. , van Essen Jeroen A. , Fassaert Thomas , Feitsma Eline A. , Feshtali Shirin S. , Frietman Bas , van Geel Anne M. , Geijsen Elisabeth D. , van Geloven Anna A. W. , Gerhards Michael F. , Gielkens Hugo , Goense Lucas , Govaert Marc J. P. M. , van Grevenstein Wilhelmina M. U. , de Groof E. Joline , de Groot Irene , Hakkenbrak Nadia A. G. , Hartogh Mariska D.den , Heesink Vera , Heikens Joost T. , Hendriksen Ellen M. , van den Hoek Sjoerd , van der Hoeven Erik J. R. J. , Hoff Christiaan , Hogewoning Anna , Hogewoning Cornelis R. C. , Hompes Roel , van Hoorn Francois , van der Hul René L. , van Hulst Rieke , Imani Farshad , Inberg Bas , Intven Martijn P. W. , Janssen Pedro , de Jong Chris E. J. , Jonkers Jacoline , Jou-Valencia Daniela , Keizers Bas , Ketelaers Stijn H. J. , Knöps Eva , Kok Sylvia , Kolderman Stephanie E. M. , Kortekaas Robert T. J. , Korving Julie C. , Koster Ingrid M. , Krdzalic Jasenko , Krielen Pepijn , Kroese Leonard F. , Krul Eveline J. T. , Lahuis Derk H. H. , Lamme Bas , van Landeghem An A. G. , Leijtens Jeroen W. A. , Leseman-Hoogenboom Mathilde M. , de Lijster Manou S. , Marsman Martijn S. , Martens Milou.H. , Masselink Ilse , van der Meij Wout , Meijnen Philip , Melenhorst Jarno , de Mey Dietrich J. L. , Moelker-Galuzina Julia , Morsink Linda , Mulder Erik J. , Muller Karin , Musters Gijsbert D. , Nederend Joost , Neijenhuis Peter A. , de Nes Lindsey C. F. , Nielen M. , van den Nieuwboer Jan B. J. , Nieuwenhuis Jonanne F. , Nonner Joost , Noordman Bo J. , Nordkamp Stefi , Olthof Pim B. , Ootes Daan , Oppedijk Vera , Ott Pieter , Paulusma Ida , Pereboom Ilona T. A. , Peringa Jan , Pironet Zoë , Plate Joost D. J. , Polat Fatih , Poodt Ingrid G. M. , Prette Jeroen F. , Qaderi Seyed M. , van Rees Jan M. , Renger Rutger-Jan , Rombouts Anouk J. M. , Roosen Lodewijk J. , Brinke Ellen A. Roskott-ten , Rouw Dennis B. , Rozema Tom , Rütten Heidi , van der Sande Marit E. , Schaafsma Boudewijn E. , Scheurkogel Merel M. , van der Velden Arjan P. Schouten , Schuivens Puck M. E. , Sietses Colin , Slob Marjan J. , Slooter Gerrit D. , van der Sluis Martsje , Smalbroek Bo P. , Spillenaar-Bilgen Ernst J. , Spruit Patty H. , Stam Tanja C. , Temmink Sofieke J. D. , Tielbeek Jeroen A. W. , van Tilborg Aukje A. J. M. , van Trier Dorothée , van der Valk Maxime J. M. , Vasbinder G. Boudewijn C. , Veeken Cornelis J. , Velema Laura A. , Verduin Wouter M. , Verhagen Tim , Verheijen Paul M. , Verrijssen An-Sofie E. , Verschuur Anna V. D. , Schaik Harmke Verwoerd-van , Voets Sophie , Vogelij Clementine L. A. , Vos-Westerman Johanna , Wegdam Johannes A. , van Wely Bob J. , van Westerveld Paul P. , Wijma Allard G. , de Wit Bart W. K. , Wit Fennie , Woensdregt Karlijn , van Woerden Victor , van der Wolf Floor S. W. , van der Wolk Sander , Wybenga Johannes M. , Zamaray Bobby , Zandvoort Herman J. A. , van der Zee Dennis , Zeilstra Annette , Zheng Kang J. , Zorgdrager Marcel 
Published: June 2023

Abstract
Background
Involved lateral lymph nodes (LLNs) have been associated with increased local recurrence (LR) and ipsi-lateral LR (LLR) rates. However, consensus regarding the indication and type of surgical treatment for suspicious LLNs is lacking. This study evaluated the surgical treatment of LLNs in an untrained setting at a national level.

Methods
Patients who underwent additional LLN surgery were selected from a national cross-sectional cohort study regarding patients undergoing rectal cancer surgery in 69 Dutch hospitals in 2016. LLN surgery consisted of either ‘node-picking’ (the removal of an individual LLN) or ‘partial regional node dissection’ (PRND; an incomplete resection of the LLN area). For all patients with primarily enlarged (≥7 mm) LLNs, those undergoing rectal surgery with an additional LLN procedure were compared to those undergoing only rectal resection.

Results
Out of 3057 patients, 64 underwent additional LLN surgery, with 4-year LR and LLR rates of 26% and 15%, respectively. Forty-eight patients (75%) had enlarged LLNs, with corresponding recurrence rates of 26% and 19%, respectively. Node-picking (n = 40) resulted in a 20% 4-year LLR, and a 14% LLR after PRND (n = 8; p = 0.677). Multivariable analysis of 158 patients with enlarged LLNs undergoing additional LLN surgery (n = 48) or rectal resection alone (n = 110) showed no significant association of LLN surgery with 4-year LR or LLR, but suggested higher recurrence risks after LLN surgery (LR: hazard ratio [HR] 1.5, 95% confidence interval [CI] 0.7–3.2, p = 0.264; LLR: HR 1.9, 95% CI 0.2–2.5, p = 0.874).

Conclusion
Evaluation of Dutch practice in 2016 revealed that approximately one-third of patients with primarily enlarged LLNs underwent surgical treatment, mostly consisting of node-picking. Recurrence rates were not significantly affected by LLN surgery, but did suggest worse outcomes. Outcomes of LLN surgery after adequate training requires further research.