The incidence of lateral pelvic side-wall nodal involvement in low rectal cancer may be similar in Japan and the West

BACKGROUND: There is an East-West divide with regard to the frequency, significance and management of lateral pelvic side-wall nodes associated with low rectal cancer. In Japan, removal of nodes is considered essential in curative treatment of selected patients. In the West, involved nodes are generally considered as metastatic disease. There may be international differences in rectal cancer behaviour. METHODS: A review of relevant studies was undertaken using PubMed, Cochrane Library and personal archives of references; further cross-referencing was conducted. Historical developments, relevant anatomy and reports on lateral pelvic lymphadenectomy (LPLD) were identified. Outcomes following LPLD were assessed. RESULTS: The low rectum has lateral lymphatic drainage. Enhanced pelvic imaging techniques suggest that some patients with low rectal cancer have lateral pelvic lymph node involvement. However, there is no universal agreement on the definition of either the rectum or low rectal cancer. Selective use of LPLD has led to good outcomes in Japan. An alternative strategy might be neoadjuvant therapy for involved lateral nodes. CONCLUSION: Pelvic imaging and correlation with pathological findings are crucial in the assessment of lateral pelvic side-wall nodes. East and West should combine their experience of preoperative staging, surgical treatment and pathological assessment of low rectal cancer.