LAUSR

To the Editor: We read with interest the article of Fujita et al ‘‘Mesorectal Excision With or Without Lateral Lymph Node Dissection for Clinical Stage II/III Lower Rectal Cancer (JCOG0212). A Multicenter, Randomized Controlled, Noninferiority Trial’’ published in Annals of Surgery. The guidelines of Japanese Society for Cancer of the Colon and Rectum (JSCCR) recommend lateral lymph node dissection (LLND) for clinical stage II/III low rectal cancer: ‘‘Lateral lymph node dissection is indicated, when the lower border of the tumor is located distal to the peritoneal reflection and the tumor has invaded beyond the muscularis propria.’’ Actually, according to JSCCR ‘‘the incidence of lateral lymph node metastasis was 20.1% among patients whose lower rectal tumor border was located distal to the peritoneal reflection and whose cancer invaded beyond the muscularis propria.’’ After performing LLND for this indication, it is expected that the risk of intrapelvic recurrence decreases by 50%, and 5-year survival improves by 8 to 9%. In contrast, the Western practice does not warrant the LLND in the absence of clinically suspected lateral lymph node metastasis (LLNM), due to the few number of LLNM, the negligible survival impact of LLDN over CRT, and high postoperative morbidity. The initial answer to this unresolved dilemma was reported in 2012, when the authors published the postoperative morbidity and mortality results of the same trial (JCOG0212). Currently, they reported the oncological results after a minimum followup of 5 years. Fujita et al included only patients with T3–T4 lower rectal cancer, who due to the high frequency of positive LLNM (16.7% in T3 and 34% in T4) were included in the trial. This selection parameter reduced the bias of the Dutch trial, which included 30% of stage I rectal cancers and reported with local recurrences in 6% in the