Surgery for ductal adenocarcinoma of the pancreatic head: staging, complications, and survival after regional versus extended lymphadenectomy

Clinical value of extended lymphadenectomy in radical surgery for pancreatic head carcinoma at different T stages

BACKGROUND

As the lymph-node metastasis rate and sites vary among pancreatic head carcinomas (PHCs) of different T stages, selective extended lymphadenectomy (ELD) performance may improve the prognosis of patients with PHC.

AIM

To investigate the effect of ELD on the long-term prognosis of patients with PHC of different T stages.

METHODS

We analyzed data from 216 patients with PHC who underwent surgery at our hospital between January 2011 and December 2021. The patients were divided into extended and standard lymphadenectomy (SLD) groups according to extent of lymphadenectomy and into T1, T2, and T3 groups according to the 8^th edition of the American Joint Committee on Cancer’s staging system. Perioperative data and prognoses were compared among groups. Risk factors associated with prognoses were identified through univariate and multivariate analyses.

RESULTS

The 1-, 2- and 3-year overall survival (OS) rates in the extended and SLD groups were 69.0%, 39.5%, and 26.8% and 55.1%, 32.6%, and 22.1%, respectively (P = 0.073). The 1-, 2- and 3-year disease-free survival rates in the extended and SLD groups of patients with stage-T3 PHC were 50.3%, 25.1%, and 15.1% and 22.1%, 1.7%, and 0%, respectively (P = 0.025); the corresponding OS rates were 65.3%, 38.1%, and 21.8% and 36.1%, 7.5%, and 0%, respectively (P = 0.073). Multivariate analysis indicated that portal vein invasion and lymphadenectomy extent were risk factors for prognosis in patients with stage-T3 PHC.

CONCLUSION

ELD may improve the prognosis of patients with stage-T3 PHC and may be of benefit if performed selectively.

Importance of Nodal Metastases Location in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: Results from a Prospective, Lymphadenectomy Protocol

BACKGROUND

Implementing a prospective lymphadenectomy protocol, we investigated the nodal yields and metastases per anatomical stations and nodal echelon following upfront pancreatoduodenectomy (PD) for cancer. Next, the relationship between the extension of nodal dissection, the number of examined and positive nodes (ELN/PLN), disease staging and prognosis was assessed.

METHODS

Lymphadenectomy included stations 5, 6, 8a-p, 12a-b-p, 13, 14a-b, 17, and jejunal mesentery nodes. Data were stratified by N-status, anatomical stations, and nodal echelons. First echelon was defined as stations embedded in the main specimen and second echelon as stations sampled as separate specimens. Recurrence and survival analyses were performed by using standard statistics.

RESULTS

Overall, 424 patients were enrolled from June 2013 through December 2018. The median number of ELN and PLN was 42 (interquartile range [IQR] 34-50) and 4 (IQR 2-8). Node-positive patients were 88.2%. The commonest metastatic sites were stations 13 (77.8%) and 14 (57.5%). The median number of ELN and PLN in the first echelon was 28 (IQR 23-34) and 4 (IQR 1-7). While first-echelon dissection provided enough ELN for optimal nodal staging, the aggregate rate of second-echelon metastases approached 30%. Nodal-related factors associated with recurrence and survival were N-status, multiple metastatic stations, metastases to station 14, and jejunal mesentery nodes.

CONCLUSIONS

First-echelon dissection provides adequate number of ELN for optimal staging. Nodal metastases occur mostly at stations 13/14, although second-echelon involvement is frequent. Only station 14 and jejunal mesentery nodes involvement was prognostically relevant. This latter station should be included in the standard nodal map and analyzed pathologically.

Central vascular ligation and mesentery based abdominal surgery

In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.

Predictive factors for long-term survival after surgery for pancreatic ductal adenocarcinoma: Making a case for standardized reporting of the resection margin using certified cancer center data

Factors for overall survival after pancreatic ductal adenocarcinoma (PDAC) seem to be nodal status, chemotherapy administration, UICC staging, and resection margin. However, there is no consensus on the definition for tumor free resection margin. Therefore, univariate OS as well as multivariate long-term survival using cancer center data was analyzed with regards to two different resection margin definitions. Ninety-five patients met inclusion criteria (pancreatic head PDAC, R0/R1, no 30 days mortality). OS was analyzed in univariate analysis with respect to R-status, CRM (circumferential resection margin; positive: ≤1mm; negative: >1mm), nodal status, and chemotherapy administration. Long-term survival >36 months was modelled using multivariate logistic regression instead of Cox regression because the distribution function of the dependent data violated the requirements for the application of this test. Significant differences in OS were found regarding the R status (Median OS and 95%CI for R0: 29.8 months, 22.3–37.4; R1: 15.9 months, 9.2–22.7; p = 0.005), nodal status (pN0 = 34.7, 10.4–59.0; pN1 = 17.1, 11.5–22.8; p = 0.003), and chemotherapy (with CTx: 26.7, 20.4–33.0; without CTx: 9.7, 5.2–14.1; p < .001). OS according to CRM status differed on a clinically relevant level by about 12 months (CRM positive: 17.2 months, 11.5–23.0; CRM negative: 29.8 months, 18.6–41.1; p = 0.126). A multivariate model containing chemotherapy, nodal status, and CRM explained long-term survival (p = 0.008; correct prediction >70%). Chemotherapy, nodal status and resection margin according to UICC R status are univariate factors for OS after PDAC. In contrast, long-term survival seems to depend on wider resection margins than those used in UICC R classification. Therefore, standardized histopathological reporting (including resection margin size) should be agreed upon.

Extended lymph node resection versus standard resection for pancreatic and periampullary adenocarcinoma

BACKGROUND

Pancreatic and periampullary adenocarcinomas account for some of the most aggressive malignancies, and the leading causes of cancer-related mortalities. Partial pancreaticoduodenectomy (PD) with negative resection margins is the only potentially curative therapy. The high prevalence of lymph node metastases has led to the hypothesis that wider excision with the removal of more lymphatic tissue could result in an improvement of survival, and higher rates of negative resection margins.

OBJECTIVES

To compare overall survival following standard (SLA) versus extended lymph lymphadenectomy (ELA) for pancreatic head and periampullary adenocarcinoma. We also compared secondary outcomes, such as morbidity, mortality, and tumour involvement of the resection margins between the two procedures.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PubMed, and Embase from 1973 to September 2020; we applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCT) comparing PD with SLA versus PD with ELA, including participants with pancreatic head and periampullary adenocarcinoma.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references and extracted data from study reports. We calculated pooled risk ratios (RR) for most binary outcomes except for postoperative mortality, for which we estimated a Peto odds ratio (Peto OR), and mean differences (MD) for continuous outcomes. We used a fixed-effect model in the absence of substantial heterogeneity (I² < 25%), and a random-effects model in cases of substantial heterogeneity (I² > 25%). Two review authors independently assessed risk of bias, and we used GRADE to assess the quality of the evidence for important outcomes.

MAIN RESULTS

We included seven studies with 843 participants (421 ELA and 422 SLA). All seven studies included Kaplan-Meier curves for overall survival. There was little or no difference in survival between groups (log hazard ratio (log HR) 0.12, 95% confidence interval (CI) -3.06 to 3.31; P = 0.94; seven studies, 843 participants; very low-quality evidence). There was little or no difference in postoperative mortality between the groups (Peto odds ratio (OR) 1.20, 95% CI 0.51 to 2.80; seven studies, 843 participants; low-quality evidence). Operating time was probably longer for ELA (mean difference (MD) 50.13 minutes, 95% CI 19.19 to 81.06 minutes; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 88%; P < 0.00001). There may have been more blood loss during ELA (MD 137.43 mL, 95% CI 11.55 to 263.30 mL; two studies, 463 participants; very low-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P = 0.02). There may have been more lymph nodes retrieved during ELA (MD 11.09 nodes, 95% CI 7.16 to 15.02; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P < 0.00001). There was little or no difference in the incidence of positive resection margins between groups (RR 0.81, 95% CI 0.58 to 1.13; six studies, 783 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

There is no evidence of an impact on survival with extended versus standard lymph node resection. However, the operating time may have been longer and blood loss greater in the extended resection group. In conclusion, current evidence neither supports nor refutes the effect of extended lymph lymphadenectomy in people with adenocarcinoma of the head of the pancreas.

Complete Lymphadenectomy Around the Entire Superior Mesenteric Artery Improves Survival in Artery-First Approach Pancreatoduodenectomy for T3 Pancreatic Ductal Adenocarcinoma

BACKGROUND

Artery-first approach pancreatoduodenectomy (AFA-PD) is an important technique for treating pancreatic ductal adenocarcinoma (PDAC). However, it remains unknown whether performing complete lymphadenectomy around the entire superior mesenteric artery (SMA) is associated with better outcomes. In this retrospective study, we aimed to investigate whether this approach improved overall and recurrence-free survival in patients with PDAC.

METHODS

We identified 88 patients with T3 PDAC who underwent PD at St. Marianna University School of Medicine, Kawasaki, Japan, between April 2005 and October 2017. Two groups were defined: an "AFA-PD group" (n = 45) who had undergone AFA-PD in addition to complete lymphadenectomy around the entire SMA, and a "conventional PD group" (n = 43) in whom complete lymphadenectomy had not been performed (conventional group). Univariate and multivariate survival analyses were performed to identify risk factors for overall and disease-free survival.

RESULTS

The AFA-PD group had a longer median survival time (40.3 vs. 22.6 months; p = 0.0140) and a higher 5-year survival rate (40.3% vs. 5.9%, p = 0.005) than the conventional PD group. Multivariate analysis showed that AFA-PD with complete lymphadenectomy around the entire SMA was an independent factor for improved overall survival (p = 0.022). Recurrences around the SMA were significantly less frequent in the AFA-PD group than in the conventional group (22.2% vs. 44.2%, p = 0.041).

CONCLUSIONS

AFA-PD with complete lymphadenectomy around the entire SMA can prevent recurrences around the SMA and may prolong overall survival in patients with PDAC.

Margin Status Impacts Survival after Pancreaticoduodenectomy but Negative Margins Should Not be Pursued

Negative margins are the goal with pancreaticoduodenectomy for pancreatic adenocarcinoma. Thereby, margins are assessed intraoperatively with frozen section analysis and negative margins are pursued. This study was undertaken to determine the impact of margin status with pancreaticoduodenectomy for pancreatic adenocarcinoma and the value of extending resections to achieve negative margins. The intraoperative frozen section analysis and final margins for 448 patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma were assessed and their impact on survival was determined. Median data are presented. Two hundred ninety-eight (67%) patients had negative margins (R0), an additional 110 (25%) patients had microscopically positive and macroscopically negative margins (R1), and an additional 40 (9%) patients had initially positive microscopic margins, which became negative with further resection (R1 å R0). R0 resections were more likely to have smaller tumors, earlier T grade, earlier N grade, lower American Joint Committee on Cancer stage, and less frequent extrapancreatic extension ( P ≤ 0.03 for each). Survival was better with R0 resections than R1 resections (20 vs 12 months, P < 0.001); extending resections to achieve negative margins (i.e., R1 ! R0) did not improve survival beyond R1 resections (14 vs 12 months, P = 0.19). Survival after pancreaticoduodenectomy is disappointing. Patients with initial negative margins do best. Positive microscopic margins reflect more aggressive tumor-specific factors and lead to abbreviated survival even with extended resections to achieve negative margins (i.e., R1 ! R0). With an initial positive margin, pursuing negative margins does not improve survival and, thereby, negative margins should not be “chased.”

Pancreatic Cancer: 80 Years of Surgery-Percentage and Repetitions

Objective. The incidence of pancreatic cancer is estimated to be 48,960 in 2015 in the US and projected to become the second and third leading causes of cancer-related deaths by 2030. The mean costs in 2015 may be assumed to be $79,800 per patient and for each resection $164,100. Attempt is made to evaluate the results over the last 80 years, the number of survivors, and the overall survival percentage. Methods. Altogether 1230 papers have been found which deal with resections and reveal survival information. Only 621 of these report 5-year survivors. Reservation about surgery was first expressed in 1964 and five-year survival of nonresected survivors is well documented. Results. The survival percentage depends not only on the number of survivors but also on the subset from which it is calculated. Since the 1980s the papers have mainly reported the number of resections and survival as actuarial percentages, with or without the actual number of survivors being reported. The actuarial percentage is on average 2.75 higher. Detailed information on the original group (TN), number of resections, and actual number of survivors is reported in only 10.6% of the papers. Repetition occurs when the patients from a certain year are reported several times from the same institution or include survivors from many institutions or countries. Each 5-year survivor may be reported several times. Conclusion. Assuming a 10% resection rate and correcting for repetitions and the life table percentage the overall actual survival rate is hardly more than 0.3%.

The Standardization of Pancreatoduodenectomy: Where Are We?

Pancreaticoduodenectomy (PD) represents an important challenge for surgeons due to the complexity of the operation, requirement for technical skills and experience, and postoperative management involving important and life-threatening complications. Despite efforts to reduce mortality in high-volume centers, the morbidity rate is still high (approximately 40-50%). The PD standardization process of surgical aspects and preoperative and postoperative settings is essential to permit pancreatic surgeons to communicate in the same language, compare experiences and results, and to improve the short- and long-term outcomes. The aim of this article is to assess the state of the art practices for important matters of debate for PD (the role of mini invasive approach, the definition and the role of mesopancreas, the extent of lymphadenectomy, the different methods of reconstructions, the prophylactic drainage of the abdominal cavity), and to suggest possible future studies.

The lymphatic system and pancreatic cancer

This review summarizes current knowledge of the biology, pathology and clinical understanding of lymphatic invasion and metastasis in pancreatic cancer. We discuss the clinical and biological consequences of lymphatic invasion and metastasis, including paraneoplastic effects on immune responses and consider the possible benefit of therapies to treat tumors that are localized to lymphatics. A review of current techniques and methods to study interactions between tumors and lymphatics is presented.

Meta-analysis of the efficacies of extended and standard pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas

BACKGROUND

The purpose of the present study was to evaluate the efficacy of extended pancreatoduodenectomy (EPD) and standard pancreatoduodenectomy (SPD) for ductal adenocarcinoma of the head of the pancreas via meta-analysis.

METHODS

Relevant articles (published between 1995 and 2012) were compiled from online data sources. A total of nine studies satisfied the selection criteria, including a total of 973 patients (478 in the SPD group and 495 in the EPD group). Evaluation parameters included 1-, 3-, and 5-year survival, as well as mortality, morbidity, and specific morbidity outcomes.

RESULTS

Meta-analysis revealed (1) differences in morbidity (Odds ratio [OR] = 1.740; 95 % confidence interval [CI], 0.840-3.600; P = 0.140), mortality (OR = 0.890; 95 % CI, 0.560-1.400; P = 0.620), 1-year overall survival (OS) rate (OR = 1.20; 95 % CI, 0.490-2.930; P = 0.69), 3-year OS rate (OR = 0.770; 95 % CI, 0.460-1.280; P = 0.190), and 5-year OS rate (OR = 1.12; 95 % CI, 0.690-1.810; P = 0.560) were not significant between EPD and SPD. (2) For bile leak (OR = 2.640; 95 % CI, 1.040-6.700; P = 0.040), pancreatic leak (OR = 1.740; 95 % CI, 1.040-2.91; P = 0.030), delayed gastric emptying (OR = 2.090; 95 % CI, 1.240-3.520; P = 0.006), and lymphatic fistula (OR = 6.120; 95 % CI, 1.06-35.320; P = 0.040) differences between EPD and SPD were significant, whereas other specific morbidities were not significantly different.

CONCLUSIONS

Extended pancreatoduodenectomy does not improve 1-, 3-, 5-year OS rates compared to SPD and there is a trend toward increased bile leak, pancreatic leak, delayed gastric emptying, and lymphatic fistula after EPD.

[Neoadjuvant treatment for unresectable pancreatic tumors: Against!]

Should we consider surgery for pancreatic cancer when resectability seems initially uncertain? The answer is no consensual as illustrated by the controversy presented here. This article presents the key arguments against surgery.

Role of extended lymphadenectomy in the treatment of pancreatic head adenocarcinoma: review and meta-analysis

BACKGROUND

Extended lymph node dissection has been established as the method of choice in the treatment of many digestive malignancies, but its role in the treatment of adenocarcinoma of the pancreas remains controversial.

OBJECTIVES

The goal is to evaluate the role of extended lymph node dissection in pancreatic head adenocarcinoma and to review how it affects survival, morbidity, mortality and post-operative quality of life.

METHODS

A computerized search was made of the Medline database from January 1973 to October 2012. Fifteen non-duplicated studies, four randomized and 11 non-randomized, comparing extended radical pancreaticoduodenectomy (ERP) and standard pancreaticoduodenectomy were reviewed. Five-year overall survivals were compared using the MetaXL software in eight of these studies, where the necessary data were available.

RESULTS

The 5-year survival after ERP ranged from 6 to 33.4% and the local recurrence incidence from 8 to 36.1%, while the incidence of severe diarrhoea, one of the main complications, ranged from 10.8 to 42.4%. Meta-analysis showed that there was no significant difference in the 5-year overall survival (95% confidence interval (CI): -0.21-0.20, Z=0.07, P=0.94) for randomized control trials, (95% CI: -0.51-0.02, Z=1.85, P=0.07) for non-randomized control trials and (95% CI: -0.26-0.06, Z=1.20, P=0.23) for all the studies.

CONCLUSIONS

Although ERP is a safe procedure, it did not offer a significant improvement in survival, while at the same time leading to an increased incidence of severe diarrhoea for at least 1 year, thus leaving the standard pancreaticoduodenectomy as the surgical method of choice for the treatment of pancreatic head adenocarcinoma.

Tricks and tips in pancreatoduodenectomy

Pancreaticoduodenectomy (PD) is the standard surgical treatment for tumors of the pancreatic head, proximal bile duct, duodenum and ampulla, and represents the only hope of cure in cases of malignancy. Since its initial description in 1935 by Whipple et al, this complex surgical technique has evolved and undergone several modifications. We review three key issues in PD: (1) the initial approach to the superior mesenteric artery, known as the artery-first approach; (2) arterial complications caused by anatomic variants of the hepatic artery or celiac artery stenosis; and (3) the extent of lymphadenectomy.

Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS)

BACKGROUND

The lymph node (Ln) status of patients with resectable pancreatic ductal adenocarcinoma is an important predictor of survival. The survival benefit of extended lymphadenectomy during pancreatectomy is, however, disputed, and there is no true definition of the optimal extent of the lymphadenectomy. The aim of this study was to formulate a definition for standard lymphadenectomy during pancreatectomy.

METHODS

During a consensus meeting of the International Study Group on Pancreatic Surgery, pancreatic surgeons formulated a consensus statement based on available literature and their experience.

RESULTS

The nomenclature of the Japanese Pancreas Society was accepted by all participants. Extended lymphadenectomy during pancreatoduodenectomy with resection of Ln's along the left side of the superior mesenteric artery (SMA) and around the celiac trunk, splenic artery, or left gastric artery showed no survival benefit compared with a standard lymphadenectomy. No level I evidence was available on prognostic impact of positive para-aortic Ln's. Consensus was reached on selectively removing suspected Ln's outside the resection area for frozen section. No consensus was reached on continuing or terminating resection in cases where these nodes were positive.

CONCLUSION

Extended lymphadenectomy cannot be recommended. Standard lymphadenectomy for pancreatoduodenectomy should strive to resect Ln stations no. 5, 6, 8a, 12b1, 12b2, 12c, 13a, 13b, 14a, 14b, 17a, and 17b. For cancers of the body and tail of the pancreas, removal of stations 10, 11, and 18 is standard. Furthermore, lymphadenectomy is important for adequate nodal staging. Both pancreatic resection in relatively fit patients or nonresectional palliative treatment were accepted as acceptable treatment in cases of positive Ln's outside the resection plane. This consensus statement could serve as a guide for surgeons and researchers in future directives and new clinical studies.

Extended lymphadenectomy in pancreatic cancer is crucial

Lymph node metastasis is considered one of the most significant factors associated with postoperative prognosis in patients with pancreatic cancer. Some prospective studies found no significant differences in survival between patients who underwent pancreatic cancer surgery with extended lymphadenectomy and those who underwent surgery with standard lymphadenectomy. However, recent reports, such as those describing the significance of the metastatic to examined lymph node ratio, suggest the need for some degree of lymphadenectomy. This review describes the findings of published studies and discusses the usefulness of LN dissection in patients with pancreatic cancer.

Lymph node involvement beyond peripancreatic region in pancreatic head cancers: when results belie expectations

OBJECTIVES

Surgery remains the standard therapy for curative management of pancreatic duct adenocarcinoma (PDA) involving the head of pancreas. This study aimed to report our experience in PDA about the prognostic value of lymph node (LN) invasion (N⁺) at the root of the superior mesenteric artery (SMA) and in N2 subgroup.

METHODS

From January 2005 to September 2009, 110 patients were included for pancreaticoduodenectomy or total pancreatectomy.

RESULTS

Etiologies were PDA (n = 87) or ampullary carcinomas (n = 23). Sixty-five percent of patients were N⁺, with N1/N2/N3 location, respectively, 63.6%, 9.1%, and 2.7%. Forty-four percent had a LN identified intraoperatively at the origin of the SMA, of whom only 12% were N⁺. In multivariate analysis (whole series), complication grade greater than II, location of positive LN (N1 to N3) and vascular resection were associated with a poorer survival. In the exocrine PDA subgroup, only location of positive LN and vascular resection were associated with a poorer survival. N⁺ SMA was not statistically correlated with survival, recurrence, or disease-free survival.

CONCLUSIONS

N⁺ at the origin of the SMA was not a significant prognostic factor for PDA and should no longer be considered as a formal contraindication for curative surgery. Conversely, N2 invasion remains an unfavorable prognostic.

Gemcitabine adsorbed onto carbon particles increases drug concentrations at the injection site and in the regional lymph nodes in an animal experiment and a clinical study

This study investigated whether gemcitabine, adsorbed onto activated carbon particles (GEM-AC), increased the concentration of gemcitabine at the injection site and in the regional lymph nodes in an experimental animal model and a clinical study. The adsorption isotherm for GEM-AC was defined, and the concentration and distribution of gemcitabine in rats (n = 50) and in patients with pancreatic cancer (n = 8) was investigated. Drug concentrations in plasma, tumour samples, lymph nodes and at the injection site were measured after GEM-AC or gemcitabine solution (GEM-Sol) were subcutaneously injected into the left hind foot pad in rats, or into pancreatic tumours in patients. These experiments showed that GEM-AC was selectively delivered to the regional lymph nodes and the injection site, from which it slowly released greater amounts of gemcitabine to maintain the free concentration of gemcitabine at a relatively high level for a long period of time. The administration of GEM-AC might enhance the anticancer effects of gemcitabine.

Unique patterns of metastases in common and rare types of malignancy

This review on the unique patterns of metastases by common and rare types of cancer addresses regional lymphatic metastases but also demonstrates general principles by consideration of vital organ metastases. These general features of successfully treated metastases are relationships to basic biological behavior as illustrated by disease-free interval, organ-specific behavior, oligo-metastatic presentation, genetic control of the metastatic pattern, careful selection of patients for surgical resection, and the necessity of complete resection of the few patients eligible for long-term survival after resection of vital organ metastasis. Lymph node metastases, while illustrating these general features, are not related to overall survival because lymph node metastases themselves do not destroy a vital organ function, and therefore have no causal relationship to overall survival. When a cancer cell spreads to a regional lymph node, does it also simultaneously spread to the systemic site or sites? Alternatively, does the cancer spread to the regional lymph node first and then it subsequently spreads to the distant site(s) after an incubation period of growth in the lymph node? Of course, if the cancer is in its incubation stage in the lymph node, then removal of the lymph node in the majority of cases with cancer cells may be curative. The data from the sentinel lymph node era, particularly in melanoma and breast cancer, is consistent with the spectrum theory of cancer progression to the sentinel lymph node in the majority of cases prior to distant metastasis. Perhaps, different subsets of cancer may be better defined with relevant biomarkers so that mechanisms of metastasis can be more accurately defined on a molecular and genomic level.

The Natural History of Resected Pancreatic Cancer without Adjuvant Chemotherapy

Diagnostic imaging, surgical care, and perioperative morbidity and mortality have significantly improved for patients undergoing resections for pancreatic adenocarcinoma. This study was undertaken to define the natural history and patterns of recurrence of resected pancreatic cancer without neoadjuvant or adjuvant therapies using current standards of care. Sixty-one patients underwent pancreatectomy without neoadjuvant or adjuvant therapy. Tumors were staged according to the American Joint Committee on Cancer (AJCC) classification system. CT scans were obtained every 3 months and recurrence categorized as: liver only, local, distant, multiple sites, or clinical. Median survival after pancreatectomy was 12 months. Cancer recurred in 51 (84%) patients. The radiographic site of initial recurrence did not generally impact survival; patients initially recurring at multiple sites had significantly abbreviated median survival of 5.6 months. AJCC stage was found to correlate with disease-free and overall survival, although tumor size alone did not. The presence of lymphatic metastasis correlated with disease-free but not overall survival. Overall survival after pancreaticoduodenectomy remains poor in the absence of neoadjuvant or adjuvant therapy. AJCC stage is the best predictor of disease-free and overall survival; tumor size, lymph node status, and site of recurrence alone do not impact survival in a meaningful way.

Extended pancreatic resections and lymphadenectomy: An appraisal of the current evidence

Surgery remains the mainstay of treatment for pancreatic ductal adenocarcinoma and complete removal of the cancer confers a definite survival advantage, especially in early disease. However, the majority of patients do not present with early disease, thus precluding the chance of a cure by standard pancreatoduodenectomy (PD), distal pancreatectomy or total pancreatectomy. For this reason, pancreatic surgeons have attempted to push the limits of resection over the last three decades. The aim of these resections has been to determine whether obtaining a complete resection by extending the limits of conventional resection in patients with advanced disease will yield the results seen with PD alone in early disease. This article revisits the data from such studies in an attempt to determine if the available literature supports the performance of extended resections for pancreatic cancer in terms of improvement of survival.

Survival after pancreaticoduodenectomy is not improved by extending resections to achieve negative margins

OBJECTIVE

This study was undertaken to determine the survival benefit of extending resections to obtain microscopically negative margins after positive intraoperative frozen sections.

SUMMARY BACKGROUND DATA

The impact of residual microscopic disease after pancreaticoduodenectomy is currently a point of controversy. It is, however, generally believed that microscopically positive margins negatively impact survival and this may be improved by ultimately achieving negative margins.

METHODS

Since 1995, patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma have been prospectively followed. Margin status has been codified as macro/microscopically negative (R0) or macroscopically negative/microscopically positive (R1). The impact of margin status on survival was evaluated utilizing survival curve analysis. Data are presented as median, mean +/- SD where appropriate.

RESULTS

For pancreatic adenocarcinoma, 202 patients underwent pancreaticoduodenectomy. R0 resections were achieved in 158 patients, 17 of whom required extended resections to achieve complete tumor extirpation after an initially positive intraoperative frozen section (R1 --> R0). R1 resections were undertaken in 44 patients. Median survival for patients undergoing R0 resections was 21 months, 26 +/- 23.4 months versus 13 months, 17 +/- 21.0 months for patients undergoing R1 resections (P = 0.02). Median survival for patients undergoing R1 --> R0 resections was 11 months, 16 +/- 17.3, (P = 0.001). Margin status had a significant correlation with "N" stage and AJCC stage but not "T" stage.

CONCLUSION

Survival after pancreaticoduodenectomy is not improved by extending pancreatic resections to achieve negative margins after initially positive intraoperative frozen sections. Tumor-specific factors beyond the presence of disease at a surgical margin are responsible for the abbreviated survival seen in patients undergoing R1 resections.

Advances in the treatment of pancreatic cancer: limitations of surgery and evaluation of new therapeutic strategies

Pancreatic ductal carcinoma is one of the most dismal malignancies of the gastrointestinal system. Even after curative resection, the actual 5-year survival is only 10%-20%. Of all the treatments used against pancreatic cancer, surgery is still the only one that can achieve complete cure. Pancreatic cancer spreads easily to the adjacent tissues and distant metastasis is common. Typically, this cancer invades the retropancreatic neural tissue, duodenum, portal vein (PV), and superior mesenteric vein (SMV), or regional lymph nodes. For this reason, aggressive surgery that removes the cancerous lesion completely is recommended. Several retrospective and prospective studies have been conducted to validate the usefulness of aggressive surgery for pancreatic cancer in the past few decades. Surprisingly, the survival benefits of aggressive surgery have been denied by most randomized controlled trials (RCTs). This implies that surgery alone is not enough. Thus, adjuvant therapy, such as radiotherapy and chemotherapy, has been given in combination with surgery to improve survival. Although the benefits of radiotherapy alone are limited, the results of chemotherapy are promising. Other newly evolving molecular targeting drugs may also improve the treatment outcomes of pancreatic cancer.

Does lymph node ratio impact survival in resected periampullary malignancies?

BACKGROUND

Lymph node ratio (LNR) has been associated with long-term survival in patients with pancreatic adenocarcinoma; however, this has not been demonstrated in other periampullary malignancies. The purpose of this study was to determine if LNR is associated with survival in other periampullary malignancies.

METHODS

A retrospective review of a prospective database of 522 pancreaticoduodenectomies (PDs) performed between 1988 and 2007 was undertaken. Clinicopathologic data were collected, and LNR was calculated. Patients with positive lymph node (LN) status were placed into the following groups: (1) LNR = 0; (2) LNR < or =0.2; (3) LNR < or =0.4; and (4) LNR >0.4.

RESULTS

Of the 364 malignancies identified, there were 219 (60%) pancreatic adenocarcinomas, 36 (10%) duodenal adenocarcinomas, 75 (21%) ampullary adenocarcinomas, and 35 (10%) cholangiocarcinomas. Positive LN status affected patient survival in all malignancies studied. Increasing LNR is associated with decreased survival in PA (P = .03) and AA (P = .04).

CONCLUSIONS

Positive LN status in all patients with periampullary malignancies is associated with worse survival rates than in those with no evidence of disease. LNR is inversely associated with survival rates in pancreatic and ampullary adenocarcinoma patients.

Does lymph node ratio impact survival in resected periampullary malignancies?

BACKGROUND

Lymph node ratio (LNR) has been associated with long-term survival in patients with pancreatic adenocarcinoma; however, this has not been demonstrated in other periampullary malignancies. The purpose of this study was to determine if LNR is associated with survival in other periampullary malignancies.

METHODS

A retrospective review of a prospective database of 522 pancreaticoduodenectomies (PDs) performed between 1988 and 2007 was undertaken. Clinicopathologic data were collected, and LNR was calculated. Patients with positive lymph node (LN) status were placed into the following groups: (1) LNR = 0; (2) LNR < or =0.2; (3) LNR < or =0.4; and (4) LNR >0.4.

RESULTS

Of the 364 malignancies identified, there were 219 (60%) pancreatic adenocarcinomas, 36 (10%) duodenal adenocarcinomas, 75 (21%) ampullary adenocarcinomas, and 35 (10%) cholangiocarcinomas. Positive LN status affected patient survival in all malignancies studied. Increasing LNR is associated with decreased survival in PA (P = .03) and AA (P = .04).

CONCLUSIONS

Positive LN status in all patients with periampullary malignancies is associated with worse survival rates than in those with no evidence of disease. LNR is inversely associated with survival rates in pancreatic and ampullary adenocarcinoma patients.

An exploration of the extended lymph node dissection and skeletonization of the vasculature for pancreatic adenocarcinoma

About 50%-90% of patients with pancreas carcinoma are found to have metastatic tumors when diagnosis is confirmed. The metastasis routes include via circulation system, lymph-node, and invasion to solar nerve plexus which usually occurs in 70% of patients. Pancreatoduodenectomy (PD) is the routine operation performed for pancreas carcinoma. There is also operation plan suggesting the resection of the nerve plexus and soft tissue distributing along the artery vessels, and the nerve fiber bat around the pancreas. This operation is also named as skeletonization of the vasculature. There have been different point-views from different surgery groups, on whether the extended lymphadenectomy (ELND) can extend the survival length and improve life quality of patients or not. However, ELND is considered to be possible to prolong the survival time for the patients with positive nodal metastasis.

Pancreatic cancer with paraaortic lymph node metastasis: a contraindication for radical surgery?

OBJECTIVES

The purpose of this study was to determine the operative indications for pancreatic cancer with paraaortic lymph node metastases (No. 16 [+]).

METHODS

Between July 1981 and March 2007, 335 patients with pancreatic cancer including 45 No. 16 (+) patients underwent extended radical surgery at the Department of Surgery II, Nagoya University. The overall survival rates and clinicopathological parameters were analyzed using univariate and multivariate analyses.

RESULTS

Although there was no significant difference in survival between the No. 16 (+) patients and the unresectable cases, there were some long-term survivors among the No. 16 (+) patients. Multivariate analysis of the No. 16 (+) patients identified age (59 years or younger), tumor size (>4 cm), and pathologically confirmed portal invasion (pPV[+]) as independent prognostic factors. The survival of No. 16 (+) patients without these factors was significantly better than the unresectable cases. The survival of patients with only 1 metastatic paraaortic lymph node also was significantly better than the unresectable cases, and tended to be better than those with more than 2 metastatic nodes.

CONCLUSIONS

No. 16 (+) pancreatic cancer patients with age 60 years or older, tumor size 4 cm or less, and pPV(-) may benefit from resection.

[Not Available]

A. Sauvanet Several factors argue for extended lymphadenectomy in surgery for pancreatic adenocarcinoma: 1) lymph node extension is an adverse prognostic factor; 2) some tumor recurrences are only loco-regional suggesting that initial resection was insufficient; 3) some retrospective studies suggest that extension of lymphadenectomy improves post-resection survival. Extended lymphadenectomy, including circumferential dissection of both the celiac axis and the superior mesenteric artery and resection of para-aortic nodes, was evaluated by 4 randomized trials; globally there was no survival benefit. Extended lymphadenectomy increases, at least transiently, the risk of post-operative diarrhea. Its influence on the rate of loco-regional recurrences has not been evaluated. However, this technique should not be definitively and globally precluded since a more radical resection was associated with a trend toward better long-term survival in the trial with the largest number of patients.

[Not Available]

A. Sauvanet Several factors argue for extended lymphadenectomy in surgery for pancreatic adenocarcinoma: 1) lymph node extension is an adverse prognostic factor; 2) some tumor recurrences are only loco-regional suggesting that initial resection was insufficient; 3) some retrospective studies suggest that extension of lymphadenectomy improves post-resection survival. Extended lymphadenectomy, including circumferential dissection of both the celiac axis and the superior mesenteric artery and resection of para-aortic nodes, was evaluated by 4 randomized trials; globally there was no survival benefit. Extended lymphadenectomy increases, at least transiently, the risk of post-operative diarrhea. Its influence on the rate of loco-regional recurrences has not been evaluated. However, this technique should not be definitively and globally precluded since a more radical resection was associated with a trend toward better long-term survival in the trial with the largest number of patients.

The impact of lymph node number on survival in patients with lymph node-negative pancreatic cancer

OBJECTIVES

The role of lymph node (LN) dissection for pancreatic cancer remains uncertain, and guidelines for a minimum LN number have not been established. We hypothesized that LN number in node-negative (N0) pancreatic cancer influences survival.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients undergoing resection for N0 pancreatic adenocarcinoma between 1988 and 2003. Lymph node number was categorized as 1-10, 11-20, and >20.

RESULTS

In a cohort of 1915 patients, the median LN number was 7 (range 1-57); 1365 (71%) patients had <11 LN. Survival was significantly better in the 11 to 20 compared with the 1-10 group (median, 20 vs 15 months, respectively, P < 0.0001); no difference was observed between the 11-20 and >20 groups (median, 20 vs 23 months, respectively, P = 0.14). Multivariate analysis demonstrated the prognostic significance of LN number for determining overall survival (hazard ratio 0.98, 95% confidence interval: 0.97-0.99; P<0.0001).

CONCLUSIONS

Pancreatic cancer lymphadenectomy with examination of >10 LN is associated with improved survival in N0 disease and should be considered a benchmark for adequacy of surgery and/or pathology. Currently, only a minority of patients are assessed by this measure. The variation in LN number may be indicative of diverse surgical technique and/or pathologic analysis and warrants further investigation.

Portal vein resection in surgery for cancer of biliary tract and pancreas: special reference to the relationship between the surgical outcome and site of primary tumor

BACKGROUND

Early and late outcomes after superior mesenteric-portal vein resection (VR) combined with pancreaticoduodenectomy, major hepatectomy, or both for pancreaticobiliary carcinoma were retrospectively evaluated. VR is the most frequently used vascular procedure in this field, but an exact role of VR has not been compared according to the primary site of tumor.

MATERIALS AND METHODS

Postoperative outcomes were compared between surgery with and without VR in each of the three disease-based groups: hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma with hilar extension (HIC, 56), middle and distal cholangiocarcinoma and gallbladder carcinoma (DGC, 118), and pancreatic head adenocarcinoma (PHC, 77).

RESULTS

VR was performed in 19.6% of HIC, 8.5% of DGC, and 45.5% of PHC. In-hospital death was 7.1% (4 of 56) patients with VR (3 of DGC and 1 of PHC). Operations with VR in DGC showed a larger amount of blood loss and more increased ratio of R1operation than those with no VR. In HIC, DGC, and PHC, median survival time of patients with VR was 37, 6.8, and 20 months and that of patients without VR was 42.9, 28.6, and 20.3 months, respectively. VR did not affect survival either in HIC or in PHC; however, in DGC, VR was accompanied with dismal outcome compared with no VR (p=0.001).

CONCLUSIONS

Aggressive surgery with VR can be justified both in HIC and in PHC but should not be recommended for DGC. Surgical outcomes of VR differed considerably, depending on the sites of the primary tumor.

Surgical management of carcinoma of the head of pancreas: extended lymphadenectomy or modified en bloc resection?

Pancreatoduodenectomy for the treatment of periampullary cancer was described over 70 years ago. The technique has evolved in an attempt to improve the dismal prognosis for patients with pancreatic cancers. Radical regional resection has been proposed to decrease the incidence of local recurrence as well as to improve survival. These extended resections have failed to show a significant survival benefit in prospective randomized controlled studies. Furthermore, extended pancreatic resections may be associated with increased morbidity. The concept of modified en bloc resection has been advocated and is soundly based on anatomical and pathological principals. This procedure is a modification of the radical regional resection previously described. It involves resection of the peripancreatic retroperitoneal tissue and lymph nodes en bloc with the head of pancreas, in order to achieve an R0 resection but without the morbidity associated with an extended lymphadenectomy. Conceptually, this procedure may be the most appropriate technique for the management of pancreatic head cancers although the ultimate effect on long-term survival can only be judged after further clinical studies.

Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer

BACKGROUND

The purpose of this study was to evaluate the significance of pathologic nodal assessment and extent of nodal metastases on patient outcome in patients with pancreatic adenocarcinoma.

MATERIALS AND METHODS

A prospectively maintained pancreatic cancer database was reviewed, and 696 consecutive patients were identified who underwent resection for pancreatic adenocarcinoma between 1995 and 2005. Overall survival was compared to lymph node (LN) status, absolute number of pathologically assessed LN, and LN ratio expressed as the number of positive LN to the total LN assessed.

RESULTS

Of the 696 patients, 598 (86%) had pancreaticoduodenectomy (PD), and 96 (14%) had distal pancreatectomy (DP). For all patients, median follow-up was 13 months (range, 0-122 months), and estimated 5-year survival was 16%. A total of 243 (35%) patients were LN-negative (N0) and had a median survival of 27 months. When assessed as a continuous variable, the number of pathologically assessed LN did not correlate with survival for N0 patients undergoing either PD or DP. The median survival for the 453 patients with node-positive (N1) disease was 16 months. When analyzed as a continuous variable, the absolute number of positive LNs was a significant predictor of survival for N1 patients with a linear relationship up to eight positive LNs. LN ratio, as a continuous variable, also predicted survival with a linear relationship up to a ratio of 0.35. A ratio of 0.18 was associated with a 19-month median survival and served as the best cutoff, p < 0.01.

CONCLUSIONS

The absolute number of positive LNs and LN ratio are strong predictors of survival for patients with node-positive pancreatic adenocarcinoma. Inadequate surgical lymphadenectomy or pathologic LN assessment understages node-negative patients.

Technical limitations of lymph node mapping in pancreatic cancer

AIM

The high incidence of lymphatic and peri-neural invasion in pancreatic cancer results in poor loco-regional control. Radical pancreatico-duodenectomy may achieve better loco-regional control, but is accompanied by increasing morbidity. Our hypothesis was that if intra-operative mapping of pathological lymph nodes (LN) is technically feasible in pancreatic cancer, it would allow for selective radical resection.

METHODS

In an ethically approved and statistically powered feasibility study of 72 (stopped after 20% enrollment) patients with suspected pancreatic cancer undergoing resection, we injected methylene blue dye peri- and intra-tumorally and studied its progress to identify putative 'sentinel lymph node(s)'. The Kausch-Whipple procedure (or total pancreatectomy, if required) was carried out in addition to radical LN dissection, which was evaluated histopathologically according to the Japanese criteria.

RESULTS

Over 18 months, 14/16 patients prospectively recruited underwent lymph node mapping and a mean of 20 (range 11-37) LNs per patient were harvested. Methylene blue dye injection identified blue LN(s) in 4/14 patients, none of which were positive for malignant deposits, whilst 10/14 patients had LN metastases. The commonest stations for LN metastasis were 17A or B (9/10), 8A (2/10) and 6 (3/10). The median survival for the 13 patients with cancer was 22.3 months (IQR: 10.4-30 months).

CONCLUSION

Sentinel lymph node mapping is not technically feasible in pancreatic cancer.

Use of the left renal vein as a practical conduit in superior mesenteric vein reconstruction

PURPOSE

Invasion of the superior mesenteric vein (SMV) or superior mesenteric-portal vein (SMPV) confluence, in pancreatic adenocarcinoma of the head and uncinate process, is the most common unexpected finding at the time of pancreaticoduodenectomy. Resection of the SMV or SMPV with reconstruction using autologous and synthetic conduits is well established. We describe the use of the left renal vein as a practical, easy, and durable alternative as an interposition graft after pancreaticoduodenectomy with en bloc segmental resection of the SMV.

METHODS AND RESULTS

Involvement of the SMV by a pancreatic mass is resected en bloc with a standard pancreaticoduodenectomy. The left renal vein is then harvested from the junction with the IVC and proximal to the adrenal vein. This is then used as a vein graft for the resected portion of the SMV.

DISCUSSION

Complete pancreatic cancer resection with grossly tumor-free margins provides the only chance for long-term cure. Isolated tumor involvement of the SMV or SMPV confluence is not associated with histopathological variables predictive of a poor prognosis and appears to be a function of tumor location rather than an indicator of biological aggressiveness. Recurrence and long-term survival following pancreaticoduodenectomy with and without vein resection are equivalent, provided grossly negative margins are achieved. We describe the use of the left renal vein as a technically feasible, easy, and durable conduit for SMV reconstruction in pancreaticoduodenectomy. After resection of the left renal vein, significant increase in postoperative serum creatinine has not been reported; collateral flow has been confirmed by radiological methods and severe renal dysfunction perioperatively, postoperatively, and during long-term follow-up has not been observed.

Extended Resection for Pancreatic Adenocarcinoma

Adenocarcinoma of the pancreas presents a number of therapeutic challenges. Given the poor long-term outcomes after pancreaticoduodenectomy (PD), many surgeons have sought to improve survival via a radical or "extended" pancreatectomy which may include (a) total pancreatectomy (TP), (b) extended lymph node dissection (ELND), and (c) portal/mesenteric vascular resections. These themes of "extended" resection are addressed in this review. TP should not be performed for most cases of adenocarcinoma of the pancreatic head because of the nominal incidence of lymph node involvement along the body and tail of the pancreas, the scarcity of multicentric disease, and the better management of pancreatic leaks after PD. Most studies show no difference in long-term survival and demonstrate greater postoperative morbidity after TP than after PD. Performing ELND in addition to PD is not worthwhile because most studies do not demonstrate any long-term benefits from ELND and the circumferential dissection around the mesenteric vessels required to harvest distant lymph nodes increases postoperative morbidity. Major arterial resection increases postoperative morbidity after PD and worsens long-term survival as the need for arterial resection to achieve negative resection margins indicates more aggressive disease. In contrast, portal and/or mesenteric venous resection does not increase the morbidity after PD or impact long-term survival as venous resection is often performed because of tumor location and not extent of disease. The disappointing experience with extended resections underscores the need for better adjuvant systemic strategies and the interdisciplinary care of patients with pancreatic adenocarcinoma.

Significance of Common Hepatic Artery Lymph Node Metastases During Pancreaticoduodenectomy for Pancreatic Head Adenocarcinoma

BACKGROUND

Common hepatic artery lymph nodes (CHALN) are frequently sampled during pancreaticoduodenectomy for adenocarcinomas of the head of the pancreas. In some institutions, if metastatic disease is detected intraoperatively in these lymph nodes, the tumor is considered unresectable and a curative operation is not performed. No solid data exist to support this practice.

METHODS

A retrospective review of a prospectively collected database was conducted of the records of all patients who underwent a pancreaticoduodenectomy for pancreatic adenocarcinoma between September 1991 and April 2005. Clinical and pathologic factors were analyzed to determine their influence on survival.

RESULTS

Fifty-five of 175 patients had CHALN separately identified and evaluated; these patients constituted the study population. Thirty-eight patients (69%) had one or more lymph nodes with metastatic involvement; 10 of these had disease in CHALN. The median overall survival for patients with node-negative, node-positive (but CHALN-negative), and CHALN-positive disease were 22.9, 16.1, and 14.7 months, respectively. The 5-year overall survival rates for the respective groups were 22%, 17%, and 0%.

CONCLUSIONS

CHALN metastases correlate with poor prognosis and no long-term survival. Further studies examining CHALN status are indicated and could lead to modifications of pancreatic cancer staging and management.

Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer

BACKGROUND

The presence or absence of lymph node metastases is known to be an important prognostic factor for patients with pancreatic cancer. Few studies have investigated the ratio of the number of lymph nodes harboring metastatic cancer to the total number of lymph nodes examined (lymph node ratio [LNR]) with regard to outcome after pancreaticoduodenectomy for ductal cancer of the pancreas.

METHODS

Between 1995 and 2005, a total of 905 patients underwent pancreaticoduodenectomy for pancreatic adenocarcinoma. Demographics, operative data, number of lymph nodes evaluated, number of lymph nodes with metastatic carcinoma, LNR, pathologic margin status, and long-term survival were analyzed.

RESULTS

There were 187 (20.7%) of the 905 patients who had negative peripancreatic lymph nodes (N0), whereas 718 (79.3%) of the 905 patients had lymph node metastases (N1). The median number of lymph nodes evaluated in the N0 group was 15 versus 18 in the N1 group (P = .12). At median follow-up of 24 months, the median survival for all patients was 17.4 months, and the 5-year actuarial survival rate was 16.1%. Patients with lymph node metastases had a shorter median overall survival (16.5 months) compared with patients with negative lymph nodes (25.3 months; P = .001). Compared with the total number of lymph nodes examined or total number of lymph node metastases, LNR was the most compelling predictor of survival. As the LNR increased, median overall survival decreased (LNR = 0, 25.3 months; LNR > 0 to 0.2, 21.7 months; LNR > 0.2 to 0.4, 15.3 months; LNR > 0.4, 12.2 months; P = .001). After adjusting for other factors associated with survival, LNR remained an independent predictor of overall survival (P < .001).

CONCLUSIONS

After pancreaticoduodenectomy for adenocarcinoma of the pancreas, LNR was one of the most powerful predictors of survival. LNR should be considered when stratifying patients in future clinical trials.

Pancreaticoduodenectomy with extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma

Surgical resection provides the only chance for long-term survival for patients diagnosed with pancreatic and other associated periampullary adenocarcinomas. In the past, it had been suggested that the performance of an extended lymphadenectomy in association with a pancreaticoduodenal resection might have improved long-term survival for some patients. In response, six prospective trials have been performed and reported addressing this issue. These studies, including a large randomized trial of 280 patients from Johns Hopkins University, indicate that there is no demonstrable survival benefit to extended lymphadenectomy for periampullary cancer.

Resection of the mesopancreas (RMP): a new surgical classification of a known anatomical space

Background

Prognosis after surgical therapy for pancreatic cancer is poor and has been attributed to early lymph node involvement as well as to a strong tendency of cancer cells to infiltrate into the retropancreatic tissue and to spread along the peripancreatic neural plexuses. The objective of our study was to classify the anatomical-surgical layer of the mesopancreas and to describe the surgical principles relevant for resection of the mesopancreas (RMP). Immunohistochemical investigation of the mesopancreatic-perineural lymphogenic structures was carried out with the purpose of identifying possible routes of metastatic spread.

Methods

Resection of the mesopancreas (RMP) was performed in fresh corpses. Pancreas and mesopancreas were separated from each other and the mesopancreas was immunohistochemically investigated.

Results

The mesopancreas strains itself dorsally of the mesenteric vessels as a whitish-firm, fatty tissue-like layer. Macroscopically, in the dissected en-bloc specimens of pancreas and mesopancreas nerve plexuses were found running from the dorsal site of the pancreatic head to the mesopancreas to establish a perineural plane. Immunohistochemical examinations revealed the lymphatic vessels localized in direct vicinity of the neuronal plexuses between pancreas and mesopancreas.

Conclusion

The mesopancreas as a perineural lymphatic layer located dorsally to the pancreas and reaching beyond the mesenteric vessels has not been classified in the anatomical or surgical literature before. The aim to ensure the greatest possible distance from the retropancreatic lymphatic tissue which drains the carcinomatous focus can be achieved in patients with pancreatic cancer only by complete resection of the mesopancreas (RMP).

Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer

BACKGROUND

Although some retrospective studies of extended radical lymphadenectomy for pancreatic cancer have suggested a survival advantage, this is controversial.

METHODS

A literature search identified randomized controlled trials comparing extended with standard lymphadenectomy in pancreatic cancer surgery. Overall survival was analysed using hazard ratios and standard errors. Pooled estimates of overall treatment effects were calculated using a random effects model (odds ratio and 95 per cent confidence interval).

RESULTS

Of four randomized trials identified for systematic review, three were included in a meta-analysis of survival. The log hazard ratios (standard errors) for survival for the three trials were 0.36 (0.22), - 0.15 (0.17) and - 0.21 (0.15); the weighted mean log hazard ratio for survival overall was 0.93 (95 per cent confidence interval 0.77 to 1.13), revealing no significant differences between the standard and extended procedure (P = 0.480). Morbidity and mortality rates were also comparable, with a trend towards higher rates of delayed gastric emptying for extended lymphadenectomy. The number of resected lymph nodes was significantly higher in the extended lymphadenectomy groups (P < 0.001).

CONCLUSION

The extended procedure does not benefit overall survival, and there may even be a trend towards increased morbidity. Therefore extended lymphadenectomy should be performed only within adequately powered controlled trials, if at all.

Tumour characteristics predictive of survival following resection for ductal adenocarcinoma of the head of pancreas

AIMS

We have maintained a highly conservative policy in selecting patients with carcinoma of the head of pancreas for resection. This has been based on tumour size, evidence of lymph node involvement or local invasion outside of the gland at laparotomy, laparoscopy or CT imaging. This study investigated our survival rates following pancreatic resection and examined clinicopathological predictors of survival.

METHODS

Sixty-two consecutive patients undergoing pancreatic resections for malignancy were identified from 1999 onwards. Thirty-three underwent resection for pancreatic ductal adenocarcinoma and were included in our analysis, the remainder included resections for ampullary adenocarcinoma (n=20) or other malignancies (n=9). Patient, tumour and operative characteristics were analysed to assess predictors of survival following resection (Kaplan-Meier survival curves).

RESULTS

Median survival following resection for ductal pancreatic adenocarcinoma was 54 months (ampullary adenocarcinomas achieved a median survival of 62 months) and thirty-day mortality was 2.7% (n=1). Survival was not associated with any demographic or intraoperative factors, such as blood loss, operative duration or anaesthetic technique. Survival curves were significantly worse when perineural or vascular invasion was evident histologically (p=0.023 and 0.0023 respectively). Patients with positive lymph nodes had a significantly shorter survival (p=0.0030) especially when lymph node status was expressed as a percentage of total lymph node yield. If more than 20% of retrieved lymph nodes were positive for tumour, this was a clear predictor of survival (p<0.0001). A positive resection margin was also associated with shortened survival (p=0.0291).

CONCLUSION

Despite the advances made in the management of pancreatic cancer, tumour biology still dictates long-term survival. A highly selective surgical approach to the management of these patients results in good long-term survival.