Recent anatomic-surgical research [17, 26], together with clinical experience [17,41,42], has reaffirmed the importance of the lateral lymphatic spread in cases of neoplasia of the lower rectum (within 5 cm of the pectinate line) [17], which may still be considered in some cases as a surgically curable illness [17,41,42].

It is still not definitely clear whether involvement of lateral lymph nodes is an indicator of a severe prognosis, or of the opportunity to perform an LPLD [48], nor has the most suitable therapeutic strategy been clarified [32,42,49].

Selected subgroups of patients (exclusive metastases of lateral lymph nodes, involvement of only one group of lymph nodes of the lateral compartment, fewer than 4 lymph nodes involved) may avail themselves of an LPLD [41,42], considering that also TME offers suboptimal results in very low and advanced rectum localisations [17,44].

The difficulty which has not yet been overcome is the pre-operative selection of these patients, representing 6-15% of all cases of lower rectal cancer [4,42].

Recent remarks [48] suggest reinvestigating the role of extended but selective lymphadenectomy employing the technique of lymphatic intraoperative mapping with sentinel node [25, 26].

Pre-operative radiotherapy, in concurrence with an exeresis following TME's principles, was shown to be equally as effective as LPLD [47].

In 2001 in Japan a "TME vs. LPLD-NSS" randomised clinical trial for stage II or III lower rectal cancer was started, to clarify how to treat lateral lymph nodal metastases and which patients ought to be treated with LPLD [32].

Moriya [49] emphasises though that so far in Japan adjuvant treatments have been considered less often, and that there is a need for controlled studies testing TME+RT vs. LPLD-NSS.

At the moment diagnostic imaging tests do not allow prediction of the behaviour of a malignant tumour of the rectum as regards its lymphatic spread. In the near future a more accurate pre-intra-operative staging as well as molecular biology meth ods will be able to confirm, on the basis of a more thorough assessment of lymphatic spread, which patients need a local exeresis or a wide resection, performed alone or in combination with (neo)adjuvant therapies [25].

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