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Kuo S, Ventin M, Sato H, Harrison JM, Okuda Y, Qadan M, Ferrone CR, Lillemoe KD, Fernandez-Del Castillo C. Common hepatic artery lymph node metastasis in pancreatic ductal adenocarcinoma: an analysis of actual survival. J Gastrointest Surg 2024; 28:672-678. [PMID: 38704205 DOI: 10.1016/j.gassur.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/03/2024] [Accepted: 02/08/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND The common hepatic artery lymph node (CHALN) represents a second-echelon node for tumors in the head of the pancreas. Although early studies suggested survival was comparable between the CHALN and remote metastasis in pancreatic ductal adenocarcinoma (PDAC), whether the lymph node is associated with adverse survival remains equivocal. Here, we examined a prospective cohort of patients calculating actual survival to better understand implications of this specific lymph node metastasis. METHODS We studied 215 patients with pancreatic head PDAC, who underwent pancreaticoduodenectomies at a single institution between 2010 and 2017, wherein the CHALNs were excised. We performed actual and actuarial overall survival and disease-free survival (DFS) analyses, with subsequent univariate and multivariate analyses in node-positive patients. RESULTS Of this cohort, 7.3% of patients had involvement of the CHALN, and all of them had metastatic spread to first-echelon nodes. Actual median survival of patients with no lymph node involvement was 49 months. In patients with any nodal involvement, the survival was no different when comparing the lymph node positive and negative (13 and 20 months, respectively). Univariate and multivariate analyses likewise attached no significance to the lymph node metastasis, while demonstrating worse survival with positive margin status and poorly differentiated histology. Our DFS analyses yielded similar results. CONCLUSION We found no difference in actual survival in node-positive patients regardless of the CHALN involvement and recommended against its assessment in prognosticating survival or guiding surgical treatment.
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Affiliation(s)
- Susan Kuo
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States; Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Marco Ventin
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States; Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Hiroki Sato
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Jon M Harrison
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Yusuke Okuda
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States; Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
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Conde D, Rey C, Pardo M, Recaman A, Sabogal Olarte JC. Hepatic artery lymph node relevance in periampullary tumors: A retrospective analysis of survival outcomes. Front Surg 2022; 9:963855. [PMID: 36561573 PMCID: PMC9763566 DOI: 10.3389/fsurg.2022.963855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
Background The Periampullary area comprehends a heterogeneous and complex structure with different histological tissues. Surgical standards include the peripancreatic regional lymphadenectomy, and during pancreatoduodenectomy (PD) the hepatic artery lymph node HALN(8a) is dissected. We aimed to describe the prognostic significance of the HALN(8a) lymph node metastasis in terms of disease-free survival (DFS) and overall survival (OS) in a specific cohort of patients in limited economic and social conditions. Methods A retrospective study was conducted based on a prospective database from the HPB department of patients who underwent pancreaticoduodenectomy (PD) due to periampullary tumors during 2014-2021. Overall survival (OS) and disease-free survival (DFS) were estimated to be associated with positive HALN(8a) using Kaplan-Meier analysis. Log Rank test and Cox proportional hazards regression analysis was used. Results 111 patients were included, 55,4% female. The most frequent pathology was ductal adenocarcinoma (60.3%). The positive rate of the HALN(8a) node was 21.62%. The Median OS time was 25.5 months, and the median DFS time was 13,8 months. Positive HLAN(8a) node, the cutoff of lymph node ratio resection (LNRR), and vascular invasion showed a strong association with OS. (CoxRegression p = 0.03 HR 0.5, p 0.003 HR = 1.8, p = 0.02 HR 0.4 CI 95%). In terms of DFS, lymph node ratio cutoff, tumoral size, and vascular invasion showed a statistically significant association with the outcome (p = 0.008, HR = 1.5; p = 0.04 HR = 2.1; p = 0.02 HR = 0.4 CI 95%). Conclusion In this series of PD, OS was reduced in patients with HALN(8a) compromise in patients with pancreatic cancer, however without statistical significance in DFS. In multivariate analysis, lymph node status remains an independent predictor of OS and DFS. Further studies are needed.
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Affiliation(s)
- Danny Conde
- Department of Hepatobiliary and Pancreatic Surgery, Hospital Universitario Mayor Méderi, Bogotá, Colombia
| | - Carlos Rey
- School of Medicine, Universidad el Rosario, Bogotá, Colombia,Correspondence: Carlos Rey
| | - Manuel Pardo
- School of Medicine, Universidad el Rosario, Bogotá, Colombia
| | - Andrea Recaman
- School of Medicine, Universidad el Rosario, Bogotá, Colombia
| | - Juan Carlos Sabogal Olarte
- Chief and Chairman of Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor Méderi, Bogotá, Colombia
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Min SK, You Y, Choi DW, Han IW, Shin SH, Yoon S, Jung JH, Yoon SJ, Heo JS. Prognosis of pancreatic head cancer with different patterns of lymph node metastasis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:1004-1013. [PMID: 35446462 DOI: 10.1002/jhbp.1159] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/19/2022] [Accepted: 03/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The nodal stage of pancreatic ductal adenocarcinoma (PDAC) is revised in the AJCC 8th edition. Studies on the prognosis of PDAC according to lymph node metastasis (LNM) are still ongoing. We attempted to find the patterns of nodal involvement and to reveal its clinical significance to overall survival (OS). METHODS We analyzed 585 patients who received pancreatic head cancer surgery diagnosed as PDAC from January 2007 to December 2016. Patients were classified into three groups: Group 1 (G1, patients without LNM), Group 2 (G2, those with LNM only in the peripancreatic area), and Group 3 (G3 those with LNM in the other area and/or peripancreatic LNM). Risk factors were analyzed by Cox-regression test and overall survival was compared by Kaplan-Meier analysis. RESULTS LNM in peripancreatic area was the most common (88.7%). In the multivariate analysis, T stage, nuclear differentiation, adjuvant treatment, and the G2 and G3 were independent risk factors for OS (G2 over G1, HR 1.384, 95% CI 1.046-1.802; P = .036 and G3 over G1, HR 2.383, 95% CI 1.378-4.103; P = .001). G3 showed worse OS than G2 (P = .006). In the N1 status, LNM to the pericholedochal (PC) and superior mesenteric artery (SMA) areas resulted in worse OS than the G2 (P = .011 and P = .019). CONCLUSIONS We found that LNM beyond the peripancreatic area significantly affects OS in pancreatic head cancer patients. Depending on the station of the LNM, different risk-stratification and treatment strategies will need to be considered.
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Affiliation(s)
- Seung Ki Min
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yunghun You
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - In Woong Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang Hyun Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sokyung Yoon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji Hye Jung
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - So Jeong Yoon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Sachs TE. Too Many or Too Few? How Many Lymph Nodes Are Enough? Ann Surg Oncol 2021; 29:1496-1497. [PMID: 34677725 DOI: 10.1245/s10434-021-10947-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Teviah E Sachs
- Section of Surgical Oncology, Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Miyata Y, Yonamine N, Fujinuma I, Tsunenari T, Takihata Y, Iwasaki T, Einama T, Tsujimoto H, Ueno H, Yamamoto J, Kishi Y. Impact of Lymph Node Metastases Around the Superior Mesenteric Artery on Postoperative Outcomes of Pancreatic Head Cancer. World J Surg 2021; 45:3668-3676. [PMID: 34406453 DOI: 10.1007/s00268-021-06276-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The neural plexus and lymph nodes around the superior mesenteric artery (LN#14), are the most frequent sites involved by pancreatic head cancer. However the influence of metastases to LN#14 on patients' prognosis has rarely been evaluated. METHODS The patients who underwent pancreatectomy for pancreatic head cancer between January 2010 and December 2018 were selected. The patients with nodal metastases were classified into an LN#14 + or LN#14-group according to LN#14 metastasis. Clinical and pathological characteristics and prognosis were compared between the two groups. RESULTS In total, 99 patients underwent pancreatectomy. Ninety-four patients were positive for lymph node metastases and 14 and 80 were classified as LN#14 + and LN#14 - , respectively. Postoperative median overall survival (OS) of the LN#14 + and LN#14 - groups was 10.2 and 31.1 months, respectively (P < 0.001). Median OS of the LN#14 + group was worse than that of patients with ≥ 4 metastatic nodes in the LN#14 - group (n = 35, 24.7 months, P = 0.002). In multivariate analysis, LN#14 + (hazard ratio [HR] = 3.89, 95% confidence interval [CI], 1.64-8.86) was one of the independent predictors of worse OS. CONCLUSION It might be feasible to recognize LN#14 metastases as an important prognostic factor independently from other regional lymph node metastases.
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Affiliation(s)
- Yoichi Miyata
- Department of Surgery, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Naoto Yonamine
- Department of Surgery, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Ibuki Fujinuma
- Department of Surgery, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Takazumi Tsunenari
- Department of Surgery, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Yasuhiro Takihata
- Department of Surgery, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Toshimitsu Iwasaki
- Department of Surgery, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Takahiro Einama
- Department of Surgery, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Hironori Tsujimoto
- Department of Surgery, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Junji Yamamoto
- Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Ibaraki, 309-1793, Japan
| | - Yoji Kishi
- Department of Surgery, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan.
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Perlmutter BC, Hossain MS, Naples R, Tu C, Vilchez V, McMichael J, Tullio K, Simon R, Walsh RM, Augustin T. Survival impact based on hepatic artery lymph node status in pancreatic adenocarcinoma: A study of patients receiving modern chemotherapy. J Surg Oncol 2020; 123:399-406. [PMID: 33159317 DOI: 10.1002/jso.26281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/17/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Chemotherapy for pancreatic adenocarcinoma (PDAC) has significantly improved in recent years. While the involvement of the hepatic artery lymph node (HALN; station 8a lymph node) likely represents advanced disease, a comparison to patients with metastases on modern chemotherapy is lacking. METHODS Patients who underwent pancreatoduodenectomy with HALN sent for pathologic review at a single institution from 2003 to 2018 were reviewed. Patients who presented with liver-only metastases at the time of PDAC diagnosis (Stage IV) and received chemotherapy were identified. Multivariate Cox proportional hazards regression modeling was utilized and overall survival (OS) was estimated using Kaplan-Meier analysis. RESULTS Of the 112 patients with a HALN sent for analysis, 17 (15%) were positive and 13 (76%) received chemotherapy. Ninety-four stage IV patients were identified and were significantly more likely to have received a multiagent rather than single-agent chemotherapy regimen compared to HALN positive patients (79.8% vs. 38.5%, p < .001). Median OS was significantly longer in all patients who underwent surgical resection, regardless of HALN status, compared to stage IV patients. CONCLUSIONS Patients undergoing pancreatoduodenectomy with HALN positivity have significantly improved OS compared to patients with stage IV disease. HALN involvement does not significantly alter survival among resected patients and does not warrant preoperative endoscopic ultrasound-guided biopsy.
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Affiliation(s)
- Breanna C Perlmutter
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mir Shanaz Hossain
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert Naples
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Chao Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Valery Vilchez
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - John McMichael
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Katherine Tullio
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Malleo G, Maggino L, Nobile S, Casciani F, Cacciatori N, Paiella S, Luchini C, Rusev B, Capelli P, Marchegiani G, Bassi C, Salvia R. Reappraisal of nodal staging and study of lymph node station involvement in distal pancreatectomy for body-tail pancreatic ductal adenocarcinoma. Eur J Surg Oncol 2020; 46:1734-1741. [PMID: 32327367 DOI: 10.1016/j.ejso.2020.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The pattern of nodal spread in body-tail pancreatic ductal adenocarcinoma (PDAC) has been poorly investigated. This study analyzed the characteristics of lymph node (LN) involvement and the prognostic role of nodal metastases stratified by LN stations. METHODS All upfront distal pancreatectomies (DPs) for PDAC (2000-2017) with complete information on station 8,10,11, and 18 were included. Clinico-pathological correlates and survival were investigated using uni- and multivariable analyses. RESULTS Among 100 included patients, 28 were N0, 42 N1 and 30 N2. The median number of examined LN was 32 (IQR 26-44). Tumor size at preoperative imaging increased across N-classes. Preoperative size >27.5 mm was associated with N2 status. The frequency of nodal metastases at stations 8, 9, 10, 11, and 18 was 12.0%, 10.9%, 3.0%, 71.0%, and 19%, respectively. The pattern of LN spread was independent from primary tumor location (with tail tumors metastasizing to station 8/9 and body tumors to station 10), while it was highly associated with N-class. At multivariable analysis, tumor grading, adjuvant treatment, station 9 and 10 metastases were independent prognostic factors in node-positive patients. CONCLUSIONS In patients undergoing upfront DP for PDAC preoperative tumor size is associated with the degree of nodal spread. While station 11 was the most frequently involved, only station-9 and 10 metastases were independent prognostic factors. The site of nodal metastases was somewhat unpredictable based on tumor location. This data has potential implications for allocating patients to neoadjuvant treatment and supports the performance of routine splenectomy during DP for PDAC.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy.
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Sara Nobile
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Nicolò Cacciatori
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Borislav Rusev
- ARC-Net Research Center, University of Verona, Verona, Italy
| | - Paola Capelli
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
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Rodrigues V, Dopazo C, Pando E, Blanco L, Caralt M, Gómez-Gavara C, Bilbao I, Salcedo MT, Balsells J, Charco R. Is the involvement of the hepatic artery lymph node a poor prognostic factor in pancreatic adenocarcinoma? Cir Esp 2019; 98:204-211. [PMID: 31839175 DOI: 10.1016/j.ciresp.2019.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 09/18/2019] [Accepted: 09/29/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The aim of this study is to analyze the impact of hepatic artery lymph node (HALN) involvement on the survival of patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). METHODS A single-center retrospective study analyzing patients who underwent PD for PA. Patients were included if, during PD, the HALN was submitted for pathologic evaluation. Patients were stratified by node status: PPLN- (peripancreatic lymph node)/HALN-, PPLN+/HALN- and PPLN+/HALN+. Survival analysis was estimated by the Kaplan-Meier method, and Cox regression was used for risk factors analyses. RESULTS Out of the 118 patients who underwent PD for PA, HALN status was analyzed in 64 patients. The median follow-up was 20months (r: 1-159months). HALN and PPLN were negative in 12patients (PPLN-/HALN-, 19%), PPLN was positive and HALN negative in 40patients (PPLN+/HALN-, 62%), PPLN and HALN were positive in 12 patients (PPLN+/HALN+, 19%) and PPLN was negative and HALN positive in 0 patients (PPLN-/HALN+, 0%). The overall 1, 3 and 5-year survival rates were statistically better in the PPLN-/HALN- group (82%, 72%, 54%) than in the PPLN+/HALN- group (68%, 29%, 21%) and the PPLN+/HALN+ group (72%, 9%, 9%, respectively) (P=.001 vs P=.007). The 1, 3 and 5-year probabilities of cumulative recurrence were also statistically better in the PPLN-/HALN- group (18%, 46%, 55%) than in the PPLN+/HALN- group (57%, 80%, 89%) and the PPLN+/HALN+ group (46%, 91%, 100%, respectively) (P=.006 vs P=.021). In the multivariate model, the main risk factor for overall survival and recurrence was lymphatic invasion, regardless of HALN status. CONCLUSIONS In pancreatic adenocarcinoma patients with lymph node disease, survival after PD is comparable regardless of HALN status.
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Affiliation(s)
- Victor Rodrigues
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Cristina Dopazo
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España.
| | - Elizabeth Pando
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Laia Blanco
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Mireia Caralt
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Concepción Gómez-Gavara
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Itxarone Bilbao
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - María Teresa Salcedo
- Servicio de Anatomía Patológica, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Joaquim Balsells
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Ramon Charco
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
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Wennerblom J, Saksena P, Jönsson C, Thune A. Lymph node 8a as a prognostic marker for poorer prognosis in pancreatic and periampullary carcinoma. Scand J Gastroenterol 2018; 53:225-230. [PMID: 29262727 DOI: 10.1080/00365521.2017.1417474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES An investigation of patients with pancreatic carcinoma aims to identify those who will benefit from surgery. Physical examination, radiology and laboratory findings are helpful. Most prognostic markers, such as lymph node status, micro metastasis and tumour differentiation, are not preoperatively accessible. Metastatic disease in lymph node 8a (Ln8a) in patients operated for pancreatic carcinoma has been reported to be a predictor of shorter overall survival (OS). This lymph node can be assessed preoperatively through resection (possibly even with laparoscopy) and subsequent histopathology. The value of the procedure is disputed. The aim of this study is to investigate whether metastatic disease in Ln8a is a predictor of decreased OS. MATERIALS AND METHODS In patients with suspected pancreatic or periampullary carcinoma, who were operated with pancreatoduodenectomy (PD), Ln8a was separately resected and analysed with standard and immuno-histochemical methods. Patients with or without metastasis in Ln8a were compared regarding OS. RESULTS Between 2008 and 2011, 122 consecutive patients were eligible and 87 were resected and had LN8a analysed separately. Sixteen patients were Ln8a + and 71 were Ln8a-. Patients with Ln8a + had a significantly reduced median OS as compared to patients with Ln8a- (0.74 (95% CI 0.26-1.26) versus 5.91 years (95% CI 2.91-), p < .001). CONCLUSION Ln8a + was associated with a marked reduction of OS, indicating a possible role in the future preoperative workup in patients with a suspicion of pancreatic cancer.
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Affiliation(s)
- Johanna Wennerblom
- a Department of Surgery, Institute of Clinical Sciences , Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden
| | - Pushpa Saksena
- b Department of Clinical Pathology and Genetics , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Claes Jönsson
- a Department of Surgery, Institute of Clinical Sciences , Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden
| | - Anders Thune
- a Department of Surgery, Institute of Clinical Sciences , Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden
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10
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van Rijssen LB, Narwade P, van Huijgevoort NC, Tseng DS, van Santvoort HC, Molenaar IQ, van Laarhoven HW, van Eijck CH, Busch OR, Besselink MG. Prognostic value of lymph node metastases detected during surgical exploration for pancreatic or periampullary cancer: a systematic review and meta-analysis. HPB (Oxford) 2016; 18:559-66. [PMID: 27346135 PMCID: PMC4925793 DOI: 10.1016/j.hpb.2016.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/28/2016] [Accepted: 05/06/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatic-artery and para-aortic lymph node metastases (LNM) may be detected during surgical exploration for pancreatic (PDAC) or periampullary cancer. Some surgeons will continue the resection while others abort the exploration. METHODS A systematic search was performed in PubMed, EMBASE and Cochrane Library for studies investigating survival in patients with intra-operatively detected hepatic-artery or para-aortic LNM. Survival was stratified for node positive (N1) disease. RESULTS After screening 3088 studies, 13 studies with 2045 patients undergoing pancreatoduodenectomy were included. No study reported survival data after detection of LNM and aborted surgical exploration. In 110 patients with hepatic-artery LNM, median survival ranged between 7 and 17 months. Estimated pooled mean survival in 84 patients with hepatic-artery LNM was 15 [95%CI 12-18] months (13 months in PDAC), compared to 19 [16-22] months in 270 patients with N1-disease without hepatic-artery LNM (p = 0.020). In 192 patients with para-aortic LNM, median survival ranged between 5 and 32 months. Estimated pooled mean survival in 169 patients with para-aortic LNM was 13 [8-17] months (11 months in PDAC), compared to 17 (6-27) months in 506 patients with N1-disease without para-aortic LNM (p < 0.001). Data on the impact of (neo)adjuvant therapy on survival were lacking. CONCLUSION Survival after pancreatoduodenectomy in patients with intra-operatively detected hepatic-artery and especially para-aortic LNM is inferior to patients undergoing pancreatoduodenectomy with other N1 disease. It remains unclear what the consequence of this should be since data on (neo-)adjuvant therapy and survival after aborted exploration are lacking.
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Affiliation(s)
| | - Poorvi Narwade
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | | | | | - Hjalmar C. van Santvoort
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands,Department of Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | | | | | | | | | - Marc G.H. Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands,Correspondence: Marc G. Besselink, Academic Medical Center Amsterdam, Department of Surgery, G4.196, PO Box 22660, 1100 DD Amsterdam, The Netherlands. Tel: +31 20 5662666.Academic Medical Center AmsterdamDepartment of SurgeryG4.196, PO Box 22660Amsterdam1100 DDThe Netherlands
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Nappo G, Borzomati D, Perrone G, Valeri S, Amato M, Petitti T, Coppola R. Incidence and prognostic impact of para-aortic lymph nodes metastases during pancreaticoduodenectomy for peri-ampullary cancer. HPB (Oxford) 2015; 17:1001-8. [PMID: 26335256 PMCID: PMC4605339 DOI: 10.1111/hpb.12497] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/16/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Standard lymphadenectomy during pancreaticoduodenectomy (PD) for peri-ampullary cancer does not include the routine removal of para-aortic lymph nodes (PALN) (station 16, according to the JPS staging system). The aim of this study was to report the incidence and the prognostic value of PALN metastases in patients undergoing PD for peri-ampullary cancer. MATERIALS AND METHODS One hundred thirty-five consecutive patients who underwent PD and PALN dissection for peri-ampullary cancer were prospectively evaluated. The relationship between clinicopathological factors, including PALN metastases and survival was evaluated at univariate and multivariate analysis. RESULTS PALN metastases (N16+) were found in 11.1% of cases. At univariate analysis, R1 resection, metastatic nodes different from para aortic (N1) and N16+ significantly affected patients' prognosis. Compared with N16+, the median overall survival (OS) of N0 patients was significantly longer (32 versus 69 months, respectively; P < 0.05), whereas no difference was found between N16+ and N1 patients (32 versus 34 months, respectively) (P > 0.05). At multivariate analysis, only R1 resection reached statistical significance and was confirmed an independent prognostic factor. CONCLUSIONS Neoplastic involvement of PALN in peri-ampullary cancer is frequent and, so, their removal during PD could be justified. Moreover, PALN metastases should be not considered an absolute contraindication to radical surgery.
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Affiliation(s)
- Gennaro Nappo
- Department of General Surgery, Campus Bio-Medico University of RomeRome, Italy
| | - Domenico Borzomati
- Department of General Surgery, Campus Bio-Medico University of RomeRome, Italy
| | - Giuseppe Perrone
- Unit of Pathology, Campus Bio-Medico University of RomeRome, Italy
| | - Sergio Valeri
- Department of General Surgery, Campus Bio-Medico University of RomeRome, Italy
| | - Michela Amato
- Unit of Pathology, Campus Bio-Medico University of RomeRome, Italy
| | | | - Roberto Coppola
- Department of General Surgery, Campus Bio-Medico University of RomeRome, Italy
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Abstract
Surgical resection remains the only potentially curative therapy for pancreatic cancer, despite a high rate of systemic recurrence. Because of local invasion or distant spread, a minority of patients presenting with pancreatic cancer are candidates for surgery. Although perioperative mortality is low in high-volume settings, pancreatic surgery remains associated with considerable morbidity. Minimally invasive and robotic surgical techniques are increasingly used for pancreatic resection, although not always applicable to all patients. Strategies to extend the benefits of margin-negative surgical resection to more patients include surgery with vascular resection and reconstruction for locally invasive tumors, and resection after neoadjuvant therapy.
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Affiliation(s)
- Thomas E Clancy
- Division of Surgical Oncology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Pancreas and Biliary Tumor Center, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA 02115-5450, USA; Harvard Medical School, Boston, MA 02115, USA.
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Malleo G, Maggino L, Capelli P, Gulino F, Segattini S, Scarpa A, Bassi C, Butturini G, Salvia R. Reappraisal of Nodal Staging and Study of Lymph Node Station Involvement in Pancreaticoduodenectomy with the Standard International Study Group of Pancreatic Surgery Definition of Lymphadenectomy for Cancer. J Am Coll Surg 2015; 221:367-79.e4. [PMID: 26081176 DOI: 10.1016/j.jamcollsurg.2015.02.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/31/2015] [Accepted: 02/10/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prognostic role of lymph node (LN) dissection in pancreatic head ductal adenocarcinoma is still unclear. This study reappraised the value of the number of positive LNs and LN ratio in patients undergoing pancreaticoduodenectomy with standard lymphadenectomy according to the recent International Study Group of Pancreatic Surgery definition. In addition, the impact of nodal metastases stratified by LN stations was investigated. STUDY DESIGN After reviewing retrospectively clinical and pathologic data of 758 pancreaticoduodenectomies for pancreatic head ductal adenocarcinoma performed from 2002 through 2011, we extracted patients in whom the LN stations included in the International Study Group of Pancreatic Surgery definition had been sampled. Survival analysis was performed using univariate and multivariate models. RESULTS The study population consisted of 255 patients. Mean number of harvested LNs was 30.8. Factors with a significant prognostic impact on multivariate analysis were tumor grade, adjuvant therapy, number of positive LNs, LN metastases along station 14a-b (proximal superior mesenteric artery), and the number of metastatic LN stations. Patients with involvement of station 14a-b exhibited worse pathologic features, indicating more aggressive disease. CONCLUSIONS In patients receiving a uniform LN dissection, the number of positive LNs is superior to LN ratio for predicting survival. Lymph node metastases along the proximal superior mesenteric artery have a significant prognostic value, and an increasing number of metastatic stations are associated with a sharp decrease in survival. In future studies, clarification of the pattern of LN metastasis spread could offer valuable insight into the optimal treatment strategies, including selection of patients for neoadjuvant therapies.
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Affiliation(s)
- Giuseppe Malleo
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Laura Maggino
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Paola Capelli
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Francesco Gulino
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Silvia Segattini
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy; ARC-NET Research Centre, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Butturini
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Philips P, Dunki-Jacobs E, Agle SC, Scoggins C, McMasters KM, Martin RCG. The role of hepatic artery lymph node in pancreatic adenocarcinoma: prognostic factor or a selection criterion for surgery. HPB (Oxford) 2014; 16:1051-5. [PMID: 25123504 PMCID: PMC4253326 DOI: 10.1111/hpb.12306] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 05/30/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatic artery lymph node (HALN) metastasis in pancreatic adenocarcinoma reportedly confers a survival disadvantage. This has led some authors to propose it as an indicator against pancreaticoduodenectomy (PD). METHODS Consecutive patients who underwent PD during 2002-2012 were identified from the University of Louisville prospective hepatopancreaticobiliary database. Overall survival (OS) and disease-free survival (DFS) were estimated using Kaplan-Meier analysis. The log-rank test and multivariate Cox proportional hazards regression were used in further analyses. RESULTS A total of 420 patients underwent PD during the period of study, of whom 197 had lymph node (LN) metastasis. Among these, 41 (20.8%) patients had disease-positive HALNs. The HALN was the only site of LN metastasis in only three of the 247 patients (1.2%). Median follow-up was 18.5 months (interquartile range: 4.1-28.2 months). Median OS and DFS were 22.7 months [95% confidence interval (CI) 19.0-26.3] and 12.6 months (95% CI 10.2-15.2). There was no significant difference in median OS between HALN-positive patients (18.4 months, 95% CI 12.3-24.0) and HALN-negative patients (19.7 months, 95% CI 16.7-22.6) (P = 0.659). On multivariate analysis, the hazard ratio (HR) of death was highest among patients with an LN ratio of >0.2 (HR 1.2, 95% CI 1.1-1.29; P = 0.012) followed by those with poorly differentiated histology (HR 1.09, 95% CI 1.04-1.11; P = 0.029). CONCLUSIONS In pancreatic adenocarcinoma patients with LN disease, survival after PD is comparable regardless of HALN status. Therefore, HALN-positive disease should not preclude the performance of PD.
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Affiliation(s)
- Prejesh Philips
- Correspondence Prejesh Philips, Department of Surgery, Division of Surgical Oncology, University of Louisville, 315 East Broadway Street, Suite 312, Louisville, KY 40202, USA. Tel: +1 502 629 6950. Fax: +1 502 629 3183. E-mail:
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Spanheimer PM, Cyr AR, Liao J, Johlin FC, Hoshi H, Howe JR, Mezhir JJ. Complications and survival associated with operative procedures in patients with unresectable pancreatic head adenocarcinoma. J Surg Oncol 2014; 109:697-701. [PMID: 24395080 DOI: 10.1002/jso.23560] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 12/17/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Unresectable tumors of the pancreatic head are encountered in up to 20% of patients taken for resection. The objective of this study was to evaluate the complications and outcome associated with palliative surgical procedures to help guide management decisions in these patients. METHODS Patients with pancreatic head adenocarcinoma taken to the operating room with curative intent who did not undergo pancreatectomy were evaluated. RESULTS From 1997 to 2013, 50 patients were explored and found be unresectable due to M1 disease (n = 27, 54.0%) or vascular invasion (n = 23, 46.0%). Among unresectable patients, 34 (68.0%) had a palliative procedure performed including double bypass (n = 13), biliary bypass (n = 7), gastrojejunostomy (n = 5), or cholecystectomy (n = 9). Complications occurred in 22 patients (44.0%), and patients who had a palliative operation had a longer hospital stay and more major complications. Overall survival was reduced in patients treated with a palliative operation. CONCLUSIONS Despite advancements in endoscopic palliation, operative bypasses are still commonplace in patients with unresectable pancreatic head cancer. In this study, patients treated with operative procedures had a high rate of complications without a notable improvement in outcome. These findings highlight the importance of identifying unresectable disease prior to surgery and support a selective approach to palliative operations.
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Affiliation(s)
- Philip M Spanheimer
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Iowa Hospitals, Clinics, Iowa City, Iowa
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Accurate prediction of nodal status in preoperative patients with pancreatic ductal adenocarcinoma using next-gen nanoparticle. Transl Oncol 2013; 6:670-5. [PMID: 24466369 DOI: 10.1593/tlo.13400] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/21/2013] [Accepted: 08/23/2013] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The objective of this study is to assess lymphotropic nanoparticle-enhanced magnetic resonance imaging (LNMRI) in identifying malignant nodal involvement in patients with pancreatic ductal adenocarcinoma. METHODS Magnetic resonance imaging was performed in 13 patients with known or high index of suspicion of pancreatic cancer and who were scheduled for surgical resection. Protocols included T2*-weighted imaging before and after administration of Ferumoxytol (Feraheme) for the evaluation of lymph node involvement. Eleven of the 13 patients underwent a Whipple procedure and lymph node dissection. Nodes that lacked contrast uptake were deemed malignant, and those that demonstrated homogeneous uptake were deemed benign. RESULTS A total of 264 lymph nodes were resection, of which 17 were malignant. The sensitivity and specificity of LNMRI was 76.5% and 98.4% at a nodal level and 83.3% and 80% at a patient level. CONCLUSION LNMRI demonstrated high sensitivity and specificity in patients with pancreatic ductal adenocarcinoma.
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