ANTICANCER RESEARCH 39: 5767-5772 (2019)

doi:10.21873/anticanres.13779

Treatment Strategy for Rectal Cancer Patients

With Inguinal Lymph Node Metastasis
KOJI UETA1, TAKERU MATSUDA1,2, KIMIHIRO YAMASHITA1, HIROSHI HASEGAWA1,
JUNKO MUKOHYAMA3, MASASHI YAMAMOTO1, YOSHIKO MATSUDA1, SHINGO KANAJI1,
TARO OSHIKIRI1, TETSU NAKAMURA1, SATOSHI SUZUKI1 and YOSHIHIRO KAKEJI1

1Division
of Gastrointestinal Surgery, Department of Surgery,
Kobe University Graduate School of Medicine, Kobe, Japan;
2Division of Minimally Invasive Surgery, Department of Surgery,

Kobe University Graduate School of Medicine, Kobe, Japan;

3Department of Pathology and Cell Biology, Columbia University, New York, NY, U.S.A.

Abstract. Background/Aim: To investigate the impact of
inguinal lymph node dissection (ILND) following neoadjuvant
chemoradiotherapy (NACRT) for rectal cancer patients with
ILN metastasis. Patients and Methods: Forty-three patients
with rectal cancer underwent NACRT followed by curative
surgery between January 2005 and December 2016. Seven
patients underwent ILND after NACRT for clinically-positive
ILN metastasis (ILND (+) group), while the remaining 36 did
not receive ILND for clinically negative ILN metastasis
(ILND (–) group). Their outcomes were retrospectively
analyzed. Results: Only one patient in the ILND (+) group
had a local recurrence at six years after surgery. The 5-year
recurrence-free survival was 100% and 65.4% in the ILND
(+) and ILND (–) groups, respectively (p=0.09), and the 5-
year overall survival was 100% and 83.2%, respectively
(p=0.32). Conclusion: ILND following NACRT seems
effective for rectal cancer patients with ILN metastasis.
Rectal cancer with inguinal lymph node (ILN) metastasis is
one of the most challenging diseases to treat and cure among
colorectal malignancies, as demonstrated by previous studies
(1-3). Although several treatment options, including
chemotherapy, radiotherapy, and lymphadenectomy have
been proposed for patients with this disease, the optimal
treatment strategy has not been yet established (4-6). Total
mesorectal excision (TME) with lateral pelvic lymph node
(LLN) dissection (LLND), but without neoadjuvant
chemoradiotherapy (NACRT), is considered a standard
treatment for locally advanced rectal cancer in Japan (7). The
results of a recent randomized study in Japan support the
validity of this combination of LLND with TME (8). On the
other hand, in Western countries, NACRT followed by TME
has been a standard treatment for locally advanced rectal
cancer since several large randomized trials demonstrated
that local recurrence was decreased to less than 10% by
using NACRT and TME without LLND (4, 9, 10). However,
these standard treatments based on evidence in either Japan
or Western countries are generally indicated for locally
advanced rectal cancer without ILN metastasis, and thus do
not apply for rectal cancer with INL metastasis.
We performed TME with selective LLND following
NACRT for locally advanced rectal cancer for over a decade
and reported that this strategy improves the oncological
outcomes of rectal cancer patients, even those with clinically
positive LLN metastasis (11, 12). We also performed TME
with ILN dissection (ILND) following NACRT for rectal
cancer patients with clinically positive ILN metastasis. This
study aimed to assess the validity of this treatment strategy
by evaluating the outcomes of rectal cancer patients with
ILN metastasis who were treated with TME and ILND
following NACRT.
Patients and Methods

Study population. We reviewed the medical files of patients with

Correspondence to: Takeru Matsuda, MD, Ph.D, Division of
Minimally Invasive Surgery, Department of Surgery, Kobe
University Graduate School of Medicine, 7-5-2 Kusunoki-cho,
Chuo-ku, Kobe 650-0017, Japan. Tel: +81 783825925, Fax: +81
783825939, e-mail: takerumatsuda@nifty.com
Kew Words: Rectal cancer, Inguinal lymph node, NACRT.
locally advanced rectal cancer who underwent NACRT followed by
curative resection at Kobe University Hospital from January 2005
to December 2016. A total of 43 patients were included in this study
and their data were retrospectively analyzed. The seven patients
with clinically positive ILN metastasis underwent ILND after
NACRT (ILND (+) group). The remaining 36 patients with
clinically negative ILNs did not receive ILND (ILND (–) group).

5767
 ANTICANCER RESEARCH 39: 5767-5772 (2019)
Although all tumors were classified according to the Union for
International Cancer Control tumor-node-metastasis system (13),
we considered the ILNs as regional lymph nodes for the purpose
of this study.
This retrospective study was conducted with approval of the
Institutional Review Board and Ethics Committee of the Graduate
School of Medicine, Kobe University School of Medicine (approval
number: B190115).
Determination of clinical inguinal lymph node metastasis. Clinical
ILN metastasis was determined based on pretreatment imaging
(computed tomography (CT), magnetic resonance imaging (MRI),
and/or positron emission tomography (PET)), as described
previously (12). ILNs that had a short-axis diameter ≥10 mm on CT
or MRI, diffusion-weighted imaging-positive on MRI, and/or
presented as a high-intensity spot on PET were considered clinically
positive for metastasis. Based on this assessment, seven patients
were diagnosed as clinically positive for ILN metastasis, while the
other 36 were diagnosed as negative.
Treatment strategy. Our treatment strategy for locally advanced
rectal cancer was described previously (12). Briefly, NACRT
consisted of a total radiation dose of 45 Gy and oral 5-fluorouracil
(5-FU)-based chemotherapy. Radiotherapy was administered in
fractions of 1.8 Gy/day, five days a week, for five weeks. The lateral
pelvic area was routinely included in the target volume. When the
ILNs were clinically suspicious for metastasis, the inguinal area was
also included in the target volume. Preventive irradiation of the
bilateral ILN was not performed because of the serious
complications that have been reported for this approach (14).
The imaging studies were repeated four to six weeks after
NACRT, and surgery was performed six to eight weeks after
completion of NACRT. TME was performed in all patients as either
open or laparoscopic surgery.
ILND was performed only for patients with clinically positive
ILN metastasis on pretreatment images. If there were suspicious
ILNs on one side only, ILND was performed unilaterally; if there
were suspicious ILNs on both sides, ILND was performed
bilaterally. LLND was performed following the same concept.
Evaluation of pathological response. The pathological tumor
response to NACRT was evaluated according to the Japanese
Society for Cancer of the Colon and Rectum guidelines (7): Grade
0: no response to treatment; Grade 1a: tumor size reduction of 1/3;
Grade 1b: tumor size reduction of 1/3-2/3; Grade 2: tumor size
reduction of > 2/3; Grade 3: complete tumor ablation, corresponding
to pathological complete response (pCR).
Statistical analysis. Statistical analysis was conducted using JMP®
11 (SAS Institute Inc., Cary, NC, USA). Fisher’s test and Bartlett’s
test were used to analyze the relationships of clinicopathological
factors and pathological response with patient outcome. Overall
survival (OS) and recurrence-free survival (RFS) were calculated
using the Kaplan–Meier method and analyzed using the log-rank
test. A p-value of <0.05 was considered statistically significant.
Results
Patient and tumor characteristics are summarized in Table I.
There were significantly more women in the ILND (+)
5768
group. No significant differences were found between the
groups in regards to oncological factors, postoperative
pathological factors, and tumor markers.
Surgical outcomes are shown in Table II. Abdominoperineal
resection was performed in all seven patients in the ILND (+)
group. With regard to the surgical approach, laparoscopic
surgery was performed in 43% and 47% of patients in the
ILND (–) and ILND (+) group, respectively (p=0.78). The
postoperative complications did not differ significantly
between the groups; however, lymphorrhea was only observed
in two patients who had ILND.
Postoperative findings of the patients in the ILND (+)
group are shown in Table III. Downstaging was achieved in
five of the seven patients, and pCR in two patients. ILN size
was reduced in all patients, and reduced accumulation in
PET-CT was observed in six patients. Pathological metastasis
of ILNs was observed in two of the seven patients.
Recurrence developed only in one patient as local recurrence
in the right pelvic area. Radiological and colonoscopy
images of case #2 in Table III, before and after NACRT, are
shown in Figure 1.
The median follow-up period was 46.0 months. Kaplan–
Meier curves of RFS and OS in the ILND (+) and ILND (–)
group showed no significant difference between the groups
in the 5-year RFS [65.4% for ILND (–) vs. 100% for ILND
(+), p=0.09] and 5-year OS [83.2% for ILND (–) vs. 100%
for ILND (+), p=0.32; Figure 2]. Overall, the oncological
outcomes tended to be better in the ILND (+) group.
Discussion
Graham et al. reported a 5-year survival rate of 0% in 32
patients with advanced rectal cancer with ILN metastases
(1). Adachi et al. found that the 3-year survival rate in
patients with advanced rectal cancer and ILN metastasis was
50%, even when ILND was performed (15). While a few
case reports showed good results (16-18), new effective
treatment strategies are needed for rectal cancer patients with
ILN metastasis. In this study, we proposed combining
NACRT and surgery with ILND for patients with ILN
metastasis and achieved 5-year OS and RFS rates of 100%.
We previously reported the effectiveness of selective LLND
following NACRT for rectal cancer patients with LLN
metastasis (12). In the present study, we used the same
criteria to determine ILN metastasis based on pretreatment
images, including CT, MRI, and PET-CT. We defined the
cut-off value of the short-axis diameter of an ILN indicating
clinical metastasis as 10 mm, and diagnosis was performed
using CT, MRI, and/or PET-CT (19, 20). Wang et al.
reported that the long-axis diameter of ILNs with metastases
was 12 mm or more (5). Among the seven patients who were
clinically positive for ILN metastasis based on our criteria,
six had swollen ILNs much larger than 12 mm. Furthermore,
 Ueta et al: Rectal Cancer With Inguinal Metastasis

Table I. Patient and tumor characteristics. Table II. Operative and postoperative outcomes.

ILND (–) ILND (+) p-Value ILND (–) ILND (+) p-Value
(n=36) (n=7) (n=36) (n=7)

Age, median (range) 74 (42-86) 74 (57-96) 0.94 Operative approach,

Gender, n (%) 0.03 n (%) 0.78
Male 29 (80.6) 2 (28.6) Open 19 (52.8) 4 (57.1)
Female 7 (19.4) 5 (71.4) Laparoscopic 17 (47.2) 3 (42.9)
Tumor location, Operative type, n (%) <0.01
n (%) 0.89 LAR 10 (27.8) 0 (0)
Rs 1 (2.8) 0 (0) APR 26 (72.2) 7 (100)
Ra 5 (13.9) 0 (0) LLND, n (%) 0.52
Rb 30 (83.3) 5 (71.4) Yes 27 (75) 6 (85.7)
P 0 (0) 2 (28.6) No 9 (25) 1 (14.3)
cT*, n (%) 0.91 Operative time,
cT2 2 (5.6) 0 (0) min (range) 528 (329-952) 603 (394-1138) 0.35
cT3 23 (63.9) 4 (57.1) Blood loss, g (range) 902 (10-5345) 765 (55-1686) 0.77
cT4 11 (30.5) 3 (42.9) Postoperative
cN*, n (%) 0.21 complications, n (%)
cN0 9 (25) 0 (0) Surgical site infection 17 (47.2) 4 (57.1) 0.78
cN1 9 (25) 3 (42.9) Paralytic ileus 7 (19.4) 1 (14.3) 0.60
cN2 18 (50) 4 (57.1) Urinary retention 11 (30.6) 2 (28.9) 0.92
cStage*, n (%) 0.01
I 1 (2.8) 0 (0) LAR: Low anterior resection; APR: abdominoperineal resection; LLND:
II 11 (30.5) 0 (0) lateral pelvic lymph node dissection.
III 24 (66.7) 0 (0)
IV 0 (0) 7 (100)
ypT*, n (%) 0.43
pT0 2 (5.6) 2 (28.6)
pT1 0 (0) 0 (0) six of them showed a significant decrease in PET-
pT2 7 (19.4) 3 (42.8) accumulation after NACRT. These findings strongly
pT3 26 (72.2) 2 (28.6) suggested that our patients in the ILND (+) group indeed had
pT4 1 (2.8) 0 ILN metastasis before NACRT. After treatment, only two of
ypN*, n (%) 0.94
them had pathological ILN metastasis. One of these patients
pN0 22 (61.2) 4 (57.1)
pN1 7 (19.4) 2 (28.6) had local recurrence six years after surgery in the pelvis, but
pN2 7 (19.4) 1(14.3) not in the inguinal area. The other five patients who achieved
ypStage*, n (%) 0.33 downstaging after NACRT had pathologically negative INL.
0 2 (5.6) 2 (28.6) Importantly, no recurrence was observed in the inguinal area
I 3 (8.3) 2 (28.6)
in the ILND (–) group without radiation in that area. Based
II 17 (47.2) 0 (0)
III 14 (38.9) 1 (14.3) on our results, our criteria for clinical diagnosis of ILN
IV 0 (0) 2 (28.6) metastasis seem valid and reliable. Furthermore, even INLs
Lymphatic invasion, with metastases could be successfully treated by ILND
n (%) 0.52 following NACRT.
Negative 9 (25) 8 (40) In case of swollen ILNs on one side only, ILND was
Positive 27 (75) 12 (60)
Venous invasion,
performed only on this side. When the swollen ILNs were
n (%) 0.03 observed on both sides, bilateral ILND was performed.
Negative 20 (55.6) 1 (14.3) ILND was confined to the dissection of superficial ILNs, and
Positive 16 (44.4) 6 (85.7) it was performed at the beginning of surgery to account for
preCRT CEA(μg/l), the risk of wound infection. Additional ILND did not
n (%) 0.84
significantly increase intraoperative bleeding or operation
≤5 14 (38.9) 1 (14.3)
>5 22 (61.1) 6 (85.7) time. However, lymphorrhea was observed in two patients of
preCRT CA19-9(U/ml), the ILND (+) group. Although they could be treated
n (%) 0.85 conservatively, meticulous ligation of small lymphatic
≤37 27 (75) 3 (42.9) vessels is recommended to prevent this complication.
>37 9 (25) 4 (57.1)
The effect of ILND following NACRT on the local control
*Tumors were classified according to the Union for International Cancer of rectal cancer with clinically positive INLs was greater
Control tumor-node-metastasis system. than we expected. Also, their oncological outcomes seemed

5769
 ANTICANCER RESEARCH 39: 5767-5772 (2019)

Figure 1. Radiological and colonoscopy images of case #2 in Table III. (A) CT-scan, (B) MRI, (C) PET-CT, (D) colonoscopy, before NACRT, (E)
CT-scan, (F) MRI, (G) PET-CT, (H) colonoscopy, after NACRT.

Figure 2. Comparison of Kaplan–Meier curves for recurrence-free survival and overall survival between the ILND (+) and ILND (–) groups. A:
No significant difference in the 5-year recurrence-free survival between the groups. B: No significant difference in the 5-year overall survival
between the groups.

Table III. Cases with inguinal lymph node dissection.

Case Age/ Location Histology cStage ILN PET-CT pT ypN ypStage Operative Recurrence Follow-up Outcome
Gender size type (y)
Before After Before After M L I

1 41 F Rb tub2 IV 13.9 → 9.1 mm Positive → Low 2 – – – I APR - 11.46 Alive

2 66 F Rb por IV 24.8 → 10.3 mm Positive → Low 0 – – – 0 APR - 8.76 Alive
3 78 F RbaP tub2 IV 20.6 → 18.0 mm NA High 2 – – + IV APR local* 5.74 Alive
4 71 M RbP tub1 IV 10.7 → 9.5 mm Positive → Low 0 – – – 0 APR - 7.39 Alive
5 62 M RbP tub2 IV 12.6 → 11.8 mm Positive → Low 3 + + – III APR - 1.73 Alive
6 64 F RbP tub1 IV 14.6 → 7.8 mm Positive → Low 2 – – – I APR - 0.63 Alive
7 70 F RbP tub1 IV 21.0 → 18.8 mm Positive → Low 3 – – + IV APR - 0.66 Alive

ILN: Inguinal lymph node; M: mesorectal lymph node; L: lateral lymph node; I: inguinal lymph node; APR: abdominoperineal resection; NA: not
applicated. *Local recurrence developed in the right pelvic area.

5770
 Ueta et al: Rectal Cancer With Inguinal Metastasis
better than those of patients without ILN metastasis.
Although metastasis into ILNs is generally considered distant
metastatic disease for lower rectal cancer, our results suggest
that ILN metastasis may actually be regarded as regional
metastasis.
This study has several limitations. First, this is a
retrospective study including a small number of patients.
Second, the metastatic status of ILNs before treatment was
assessed by pretreatment images only. Aspiration biopsy
might be more suitable for accurate diagnosis of the
pathological status of ILNs.
In conclusion, ILND following NACRT and MRT was
shown to be an effective treatment for rectal cancer patients
with ILN metastasis. Further analysis in a larger patient
population is warranted to prove its effectiveness in
advanced rectal cancer with ILN metastasis.
Conflicts of Interest
The Authors have no conflicts of interest to declare regarding this
study.
Authors’ Contributions
KU and TM designed the study. KU, TM, KY, HH, JM, MY and
MY performed operation and collected data. KU wrote the initial
draft of the manuscript. SK, TO, TN and SS contributed to the
analysis and interpretation of data. TM and YK critically reviewed
the manuscript. All Authors approved the final version of the
manuscript.
References
1 Graham RA and Hohn DC: Management of inguinal lymph node
metastases from adenocarcinoma of the rectum. Dis Colon Rectum
33: 212-216, 1990. PMID: 2311465. DOI: 10.1007/bf02134182
2 Luna-Perez P, Corral P, Labastida S, Rodriguez-Coria D and
Delgado S: Inguinal lymph node metastases from rectal
adenocarcinoma. J Surg Oncol 70: 177-180, 1999. PMID:
10102348. DOI: 10.1002/(sici)1096-9098(199903)70:3<177::aid-
jso6>3.0.co;2-0
3 Tocchi A, Lepre L, Costa G, Liotta G, Mazzoni G, Agostini N and
Miccini M: Rectal cancer and inguinal metastases: prognostic role
and therapeutic indications. Dis Colon Rectum 42: 1464-1466,
1999. PMID: 10566535. DOI: 10.1007/bf02235048
4 Bosset JF, Collette L, Calais G, Mineur L, Maingon P,
Radosevic-Jelic L, Daban A, Bardet E, Beny A and Ollier JC;
EORTC Radiotherapy Group Trial 22921: Chemotherapy with
preoperative radiotherapy in rectal cancer. N Engl J Med 355:
1114-23, 2006. PMID: 16971718. DOI: 10.1056/NEJMoa060829
5 Wang R, Wu P, Shi D, Zheng H, Huang L, Gu W, Xu Y, Cai S and
Cai G: Risk factors of synchronous inguinal lymph nodes metastasis
for lower rectal cancer involving the anal canal. PLoS One 9:
e111770, 2014. PMID: 25409168. DOI: 10.1371/journal.pone.
0111770
6 Bardia A, Greeno E, Miller R, Alberts S, Dozois E, Haddock M
and Limburg P: Is a solitary inguinal lymph node metastasis
from adenocarcinoma of the rectum really a metastasis?
Colorectal Dis 12: 312-315, 2010. PMID: 19250258. DOI:
10.1111/j.1463-1318.2009.01821.x
7 Watanabe T, Muro K, Ajioka Y, Hashiguchi Y, Ito Y, Saito Y,
Hamaguchi T, Ishida H, Ishiguro M, Ishihara S, Kanemitsu Y,
Kawano H, Kinugasa Y, Kokudo N, Murofushi K, Nakajima T,
Oka S, Sakai Y, Tsuji A, Uehara K, Ueno H, Yamazaki K,
Yoshida M, Yoshino T, Boku N, Fujimori T, Itabashi M,
Koinuma N, Morita T, Nishimura G, Sakata Y, Shimada Y,
Takahashi K, Tanaka S, Tsuruta O, Yamaguchi T, Yamaguchi N,
Tanaka T, Kotake K and Sugihara K; Japanese Society for
Cancer of the Colon and Rectum: Japanese Society for Cancer
of the Colon and Rectum (JSCCR) guidelines 2016 for the
treatment of colorectal cancer. Int J Clin Oncol 23: 1-34, 2018.
PMID: 28349281. DOI: 10.1007/s10147-017-1101-6
8 Fujita S, Akasu T, Mizusawa J, Saito N, Kinugasa Y, Kanemitsu
Y, Ohue M, Fujii S, Shiozawa M, Yamaguchi T and Moriya Y;
Colorectal Cancer Study Group of Japan Clinical Oncology
Group: Postoperative morbidity and mortality after mesorectal
excision with and without lateral lymph node dissection for
clinical stage II or stage III lower rectal cancer (JCOG0212):
results from a multicentre, randomised controlled, non-inferiority
trial. Lancet Oncol 13: 616-621, 2012. PMID: 22591948. DOI:
10.1016/S1470-2045(12)70158-4
9 Gerard JP, Conroy T, Bonnetain F, Bouche O, Chapet O, Closon-
Dejardin MT, Untereiner M, Leduc B, Francois E, Maurel J,
Seitz JF, Buecher B, Mackiewicz R, Ducreux M and Bedenne L:
Preoperative radiotherapy with or without concurrent
fluorouracil and leucovorin in T3-4 rectal cancers: results of
FFCD 9203. J Clin Oncol 24: 4620-4625, 2006. PMID:
17008704. DOI: 10.1200/JCO.2006.06.7629
10 Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C,
Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens
JH, Liersch T, Schmidberger H and Raab R; German Rectal
Cancer Study Group: Preoperative versus postoperative
chemoradiotherapy for rectal cancer. N Engl J Med 351: 1731-
1740, 2004. PMID: 15496622. DOI: 10.1056/NEJMoa040694
11 Tomono A, Yamashita K, Kanemitsu K, Sumi Y, Yamamoto M,
Kanaji S, Imanishi T, Nakamura T, Suzuki S, Tanaka K and
Kakeji Y: Prognostic significance of pathological response to
preoperative chemoradiotherapy in patients with locally
advanced rectal cancer. Int J Clin Oncol 21: 344-349, 2016.
PMID: 26338272. DOI: 10.1007/s10147-015-0900-x
12 Matsuda T, Sumi Y, Yamashita K, Hasegawa H, Yamamoto M,
Matsuda Y, Kanaji S, Oshikiri T, Nakamura T, Suzuki S and
Kakeji Y: Outcomes and prognostic factors of selective lateral
pelvic lymph node dissection with preoperative chemo-
radiotherapy for locally advanced rectal cancer. Int J Colorectal
Dis 33: 367-374, 2018. PMID: 29442155. DOI: 10.1007/s00384-
018-2974-1
13 Sobin LH, Gospodarowicz MK and Qittekind C: International
Union Against Cancer (UICC) classification of malignant
tumours. New York: Wiley-Liss, 2010.
14 Gerard JP, Chapet O, Samiei F, Morignat E, Isaac S, Paulin C,
Romestaing P, Favrel V, Mornex F and Bobin JY: Management of
inguinal lymph node metastases in patients with carcinoma of the
anal canal: experience in a series of 270 patients treated in Lyon
and review of the literature. Cancer 92: 77-84, 2001. PMID:
11443612. DOI: 10.1002/1097-0142(20010701)92:1<77::aid-
cncr1294>3.0.co;2-p
5771
 ANTICANCER RESEARCH 39: 5767-5772 (2019)
15 Adachi T, Hinoi T, Egi H and Ohdan H: Surgical treatment for
isolated inguinal lymph node metastasis in lower rectal
adenocarcinoma patients improves outcome. Int J Colorectal Dis
28: 1675-1680, 2013. PMID: 23836116. DOI: 10.1007/s00384-
013-1746-1
16 Avill R: Carcinoma of the rectum and anal canal with inguinal
lymph node metastases--long term survival. Br J Clin Pract 38:
324-325, 1984. PMID: 6477814.
17 Sarid D, Wigler N, Gutkin Z, Merimsky O, Leider-Trejo L and
Ron IG: Cutaneous and subcutaneous metastases of rectal
cancer. Int J Clin Oncol 9: 202-205, 2004. PMID: 15221607.
DOI: 10.1007/s10147-004-0389-1
18 Kanoh T, Ohnishi T, Danno K, Watanabe A, Nakamura H,
Tsukao Y, Inatome J, Kim C, Kagara N, Taniguchi H, Kimura Y,
Tono T, Nakano Y, Monden T and Imaoka S: A case of
successfully treated lower rectal cancer with both inguinal lymph
nodes by chemoradiotherapy. Gan To Kagaku Ryoho 37: 2611-
2613, 2010. PMID: 21224655.
5772
19 Akiyoshi T, Matsueda K, Hiratsuka M, Unno T, Nagata J,
Nagasaki T, Konishi T, Fujimoto Y, Nagayama S, Fukunaga Y
and Ueno M: Indications for lateral pelvic lymph node dissection
based on magnetic resonance imaging before and after
preoperative chemoradiotherapy in patients with advanced low-
rectal cancer. Ann Surg Oncol 22: S614-20, 2015. PMID:
25896145. DOI: 10.1245/s10434-015-4565-5
20 Kim JH, Beets GL, Kim MJ, Kessels AG and Beets-Tan RG:
High-resolution MR imaging for nodal staging in rectal cancer:
are there any criteria in addition to the size? Eur J Radiol 52:
78-83, 2004. PMID: 15380850. DOI: 10.1016/j.ejrad.2003.
12.005
Received July 27, 2019
Revised September 9, 2019
Accepted September 10, 2019