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Journal of Gastrointestinal Surgery

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01-09-2015 | Original Article

Pancreatectomy with Para-Aortic Lymph Node Dissection for Pancreatic Head Adenocarcinoma: Pattern of Nodal Metastasis Spread and Analysis of Prognostic Factors

Authors: Salvatore Paiella, Giuseppe Malleo, Laura Maggino, Claudio Bassi, Roberto Salvia, Giovanni Butturini

Published in: Journal of Gastrointestinal Surgery | Issue 9/2015

Abstract

Background

This study investigated the prognostic impact of the exact location of nodal metastases in a subgroup of patients who underwent pancreatectomy with extended lymphadenectomy for head adenocarcinoma, with a special focus on station 16b1.

Methods

Clinical, pathologic, and follow-up details were extracted from our database and analyzed retrospectively. Survival analysis was performed using univariate and multivariate models. We also performed a matched case-control analysis with resected patients who did not receive extended lymphadenectomy and with locally advanced patients.

Results

The study population consisted of 67 patients. The rate of station 16b1 metastases was 20.9 %. Station 14a-b metastases (OR = 4.28), G3 tumors (OR = 4.03), and number of PLN ≥ 8 (OR = 4.46) were independently associated with station 16b1 involvement. Among pN1 patients, station 14a-b (HR = 2.60) and station 16b1 metastases (HR = 2.40) were predictors of survival. The median disease-specific survival of 16b1+ patients was 17 months (95 % CI 8.47–25.52). In the matched case-control analysis, the survival rates of resected 16b1+ patients was in between pN1/16b1− patients and locally advanced patients.

Conclusions

Metastases to station 16b1 are associated with a decreased survival in comparison with pN1/16b1− patients, yet longer than in matched locally advanced patients. Station 14 can be considered as a “junctional node” to station 16b1.

American Cancer Society. Cancer Facts & Figures 2014. Atlanta: American Cancer Society.

Sohn TA, Yeo CJ, Cameron JL, Koniaris L, Kaushal S, Abrams RA, Sauter PK, Coleman J, Hruban RH, Lillemoe KD. Resected adenocarcinoma of the pancreas—616 patients: results, outcomes, and prognostic indicators. J Gastrointest Surg 2000;4:567-579.CrossRefPubMed

Schwarz RE, Smith DD. Extent of lymph node retrieval and pancreatic cancer survival: information from a large US population database. Ann Surg Oncol 2006;13:1189-1200.CrossRefPubMed

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, doi:10.1016/j.jamcollsurg.2015.02.019

Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, Klöppel G, Dhaene K, Michelassi F. Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group. Ann Surg 1998;228:508-517.PubMedCentralCrossRefPubMed

Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, Hruban RH, Pitt HA, Lillemoe KD. Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome. Ann Surg 1999;229:613-622.

Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ; Pancreas Cancer Working Group. A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma. Surgery 2005;138:618-628.

Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, Miyagawa S, Yamaguchi A, Ishiyama S, Takeda Y, Sakoda K, Kinoshita T, Yasui K, Shimada H, Katoh H. Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial. J Hepatobiliary Pancreat Sci 2012;19:230-241.

Jang JY, Kang MJ, Heo JS, Choi SH, Choi DW, Park SJ, Han SS, Yoon DS, Yu HC, Kang KJ, Kim SG, Kim SW. A prospective randomized controlled study comparing outcomes of standard resection and extended resection, including dissection of the nerve plexus and various lymph nodes, in patients with pancreatic head cancer. Ann Surg 2014;259:656-664.CrossRefPubMed

10.

Tol JA, Gouma DJ, Bassi C, Dervenis C, Montorsi M, Adham M, Andrén-Sandberg A, Asbun HJ, Bockhorn M, Büchler MW, Conlon KC, Fernández-Cruz L, Fingerhut A, Friess H, Hartwig W, Izbicki JR, Lillemoe KD, Milicevic MN, Neoptolemos JP, Shrikhande SV, Vollmer CM, Yeo CJ, Charnley RM; International Study Group on Pancreatic Surgery. Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS). Surgery 2014;156:591-600.CrossRefPubMed

11.

Kanda M, Fujii T, Nagai S, Kodera Y, Kanzaki A, Sahin TT, Hayashi M, Yamada S, Sugimoto H, Nomoto S, Takeda S, Morita S, Nakao A. Pattern of lymph node metastasis spread in pancreatic cancer. Pancreas 2011;40:951-955.CrossRefPubMed

12.

Hirono S, Tani M, Kawai M, Okada K, Miyazawa M, Shimizu A, Uchiyama K, Yamaue H. Identification of the lymphatic drainage pathways from the pancreatic head guided by indocyanine green fluorescence imaging during pancreaticoduodenectomy. Dig Surg 2012;29:132–139.CrossRefPubMed

13.

Doi R, Kami K, Ito D, Fujimoto K, Kawaguchi Y, Wada M, et al. Prognostic implication of para-aortic lymph node metastasis in resectable pancreatic cancer. World J Surg 2007;31:147-154.CrossRefPubMed

14.

Japan Pancreas Society. Classification of pancreatic carcinoma. 2nd English ed. Tokyo: Kanehara & Co. Ltd; 2003.

15.

Sakai M, Nakao A, Kaneko T, Takeda S, Inoue S, Kodera Y, Nomoto S, Kanazumi N, Sugimoto H. Para-aortic lymph node metastasis in carcinoma of the head of the pancreas. Surgery 2005;137:606-611.CrossRefPubMed

16.

Sho M, Murakami Y, Motoi F, Satoi S, Matsumoto I, Kawai M, Honda G, Uemura K, Yanagimoto H, Kurata M, Fukumoto T, Akahori T, Kinoshita S, Nagai M, Nishiwada S, Unno M, Yamaue H, Nakajima Y. Postoperative prognosis of pancreatic cancer with para-aortic lymph node metastasis: a multicenter study on 822 patients. J Gastroenterol 2015;50:694-702.CrossRefPubMed

17.

Edge, S., Byrd, D.R., Compton, C.C., Fritz, A.G., Greene, F.L., Trotti, A. (Eds.) AJCC Cancer Staging Manual 7th ed. 2010, Springer-Verlag, NY, USA.

18.

Zhang Y, Li R, Tsai CL. Regularization parameter selections via generalized information criterion. J Am Stat Assoc. 2010 Mar 1;105(489):312-323.

19.

Iacus SM, King G, Porro G. Multivariate matching methods that are monotonic imbalance bounding. J Am Stat Assoc 2011;106:345-361CrossRef

20.

Murakami Y, Uemura K, Sudo T, Hashimoto Y, Yuasa Y, Sueda T. Prognostic impact of para-aortic lymph node metastasis in pancreatic ductal adenocarcinoma. World J Surg 2010;34:1900-1907.CrossRefPubMed

21.

Shimada K, Sakamoto Y, Sano T, Kosuge T. The role of paraaortic lymph node involvement on early recurrence and survival after macroscopic curative resection with extended lymphadenectomy for pancreatic carcinoma. J Am Coll Surg 2006;203:345-352.CrossRefPubMed

22.

Yoshida T, Matsumoto T, Sasaki A, Shibata K, Aramaki M, Kitano S. Outcome of paraaortic node-positive pancreatic head and bile duct adenocarcinoma. Am J Surg 2004;187:736-740.CrossRefPubMed

23.

Schwarz L, Lupinacci RM, Svrcek M, Lesurtel M, Bubenheim M, Vuarnesson H, Balladur P, Paye F. Para-aortic lymph node sampling in pancreatic head adenocarcinoma. Br J Surg 2014;101:530-538.CrossRefPubMed

24.

Yamada S, Nakao A, Fujii T, Sugimoto H, Kanazumi N, Nomoto S, Kodera Y, Takeda S. Pancreatic cancer with paraaortic lymph node metastasis: a contraindication for radical surgery? Pancreas. 2009;38(1):e13-17.CrossRefPubMed

25.

Connor S, Bosonnet L, Ghaneh P, Alexakis N, Hartley M, Campbell F, Sutton R, Neoptolemos JP. Survival of patients with periampullary carcinoma is predicted by lymph node 8a but not by lymph node 16b1 status. Br J Surg 2004;91:1592-1599.CrossRefPubMed

26.

Kurahara H, Takao S, Shinchi H, Maemura K, Mataki Y, Sakoda M, et al. Significance of lymphangiogenesis in primary tumor and draining lymph nodes during lymphatic metastasis of pancreatic head cancer. J Surg Oncol. 2010;102(7):809-815.CrossRefPubMed

27.

Chauffert B, Mornex F, Bonnetain F, Rougier P, Mariette C, Bouche O, et al. Phase III trial comparing intensive induction chemoradiotherapy (60 Gy, infusional 5-FU and intermittent cisplatin) followed by maintenance gemcitabine with gemcitabine alone for locally advanced unresectable pancreatic cancer. Definitive results of the 2000-01 FFCD/SFRO study. Ann Oncol. 2008;19(9):1592-1599.CrossRefPubMed

28.

Loehrer PJ, Sr., Feng Y, Cardenes H, Wagner L, Brell JM, Cella D, et al. Gemcitabine alone versus gemcitabine plus radiotherapy in patients with locally advanced pancreatic cancer: an Eastern Cooperative Oncology Group trial. J Clin Oncol. 2011;29(31):4105-4112.PubMedCentralCrossRefPubMed

29.

Nagakawa T, Kobayashi H, Ueno K, Ohta T, Kayahara M, Miyazaki I. Clinical study of lymphatic flow to the paraaortic lymph nodes in carcinoma of the head of the pancreas. Cancer. 1994;73(4):1155-1162.CrossRefPubMed

30.

Nagai H. An anatomic and pathologic study of autopsy material on metastasis of pancreatic cancer to para-aortic lymph nodes. Jpn J Surg 1987;88:308-17.

31.

Kayahara M, Nagakawa T, Kobayashi H, Mori K, Nakano T, Kadoya N, et al. Lymphatic flow in carcinoma of the head of the pancreas. Cancer. 1992;70(8):2061-2066.CrossRefPubMed

32.

Karmazanovsky G, Fedorov V, Kubyshkin V, Kotchatkov A. Pancreatic head cancer: accuracy of CT in determination of resectability. Abdom Imaging 2005; 30: 488–500.CrossRefPubMed

Title: Pancreatectomy with Para-Aortic Lymph Node Dissection for Pancreatic Head Adenocarcinoma: Pattern of Nodal Metastasis Spread and Analysis of Prognostic Factors
Authors: Salvatore Paiella
Giuseppe Malleo
Laura Maggino
Claudio Bassi
Roberto Salvia
Giovanni Butturini
Publication date: 01-09-2015
Publisher: Springer US
Published in: Journal of Gastrointestinal Surgery / Issue 9/2015
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-015-2882-4

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Springer Medicine

Pancreatectomy with Para-Aortic Lymph Node Dissection for Pancreatic Head Adenocarcinoma: Pattern of Nodal Metastasis Spread and Analysis of Prognostic Factors

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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