How would you manage a patient with distal rectal adenocarcinoma involving the anal canal and a single non-bulky inguinal nodal metastasis?

Patients with low rectal cancer and inguinal involvement at presentation should obviously be treated with curative intent because inguinal lymph nodes are first echelon drainage from the low rectum and anal canal. Standard dose neoadjuvant chemoradiation and limited surgical excision of the involved gross disease is the preferred treatment in my view. I would not recommend a radical inguinal dissection after preoperative radiation if that can be avoided. Doing so with risk lymphedema in that extremity. Definitive chemoradiation for the groin without surgical excision is also a consideration. I have used IMRT with a simultaneous integrated boost of 63-70 Gy in 28 fractions within a microscopic dose of 50.4Gy.

The worst option is initial ingu...

For consideration: Tattoo the site of the primary with a 1.0cm margin before beginning neo-adjuvant chemotherapy. This should be followed by chemopotentiated IMRT to the rectal-anal tumor, including first and second station nodes in pelvic and and inguinal- fémoral sites.Then, using the Papillon technique, boost the tattooed rectal-anal primary site, raising the dose at that site to approximately 8000 cGy at a depth of 1.5 to 2cm depth. Surgery (A-P resection) would be reserved for persistent or local recurrence, or unmanageable local ano-rectal complications. Anyone can google to find where in the world the Papillon technique is available, or e-mail me at the address that accompanies this proposal.

Sid Sobel, M.D., FACR, Rochester, New Yor...

I agree with starting with chemo in cases of extensive LAD and would advocate for preop does of radiation followed by surgery. If after discussion with the surgeon I learned that these nodes could not be resected, I would use IMRT with SIB to 63-70Gy depending on OAR considerations.

The intent would be curative as inguinal nodes are regional spread and the plan would be preoperative chemo RT followed by surgery.