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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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Elshami M, Ammoun AK, Mneimneh WS, Stitzel HJ, Hue JJ, Wu VS, Kyasaram RK, Shanahan J, Musonza T, Ammori JB, Hardacre JM, Winter JM, ElHag M, Ocuin LM. Discordance Between Conventional and Detailed Lymph Node Analysis in Resected, Node-negative Pancreatic or Ampullary Adenocarcinomas and Association With Adverse Survival Outcomes: A Single-institution Analysis. Ann Surg 2023; 278:e1204-e1209. [PMID: 37051926 DOI: 10.1097/sla.0000000000005870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVE To assess the frequency of occult metastases (OM) in patients with resected pancreatic ductal adenocarcinoma (PDAC) or ampullary adenocarcinoma (AA) discovered on detailed pathologic examination on lymph nodes (LNs) previously considered negative by conventional analysis and to examine the association between OM and overall survival (OS). BACKGROUND Poor prognosis of patients with no pathologic evidence of LN metastases may be due to OM that is not detected on conventional LN analysis. METHODS Patients with LN-negative resected PDAC or AA (2010-2020) were identified from our institutional database. Original hematoxylin and eosin ( H and E ) slides were reanalyzed. In addition, selected LN were analyzed by H and E (3 sections/LN) and pan-cytokeratin (AE1-AE3/PCK26) immunohistochemistry. RESULTS A total of 598 LNs from 74 LN-negative patients were reexamined. Nineteen patients (25.7%) had OM; 9 (47.4%) were found with immunohistochemistry but not on H and E . The number of positive LNs ranged from 1 to 3. No clinicodemographic, pathologic, or treatment-related factors were associated with OM. On conventional LN analysis, 3/19 patients (15.8%) had stage IA, 9/34 (26.5%) had stage IB, and 7/19 (36.8%) had stage IIA. On detailed LN analysis, 11/19 patients (57.9%) were upstaged to IIB, whereas 8/19 (42.1%) had isolated tumor cells only (N0i+). OM was associated with shorter OS (median OS: 22.3 vs 50.5 months; hazard ratio=3.95, 95% CI: 1.58-9.86). CONCLUSIONS There is a 26% discordance rate between conventional and detailed LN pathologic analysis in resected PDAC and AA. The presence of OM is associated with shorter OS.
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Affiliation(s)
- Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Alwalid K Ammoun
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Wadad S Mneimneh
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Henry J Stitzel
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jonathan J Hue
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Victoria S Wu
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ravi K Kyasaram
- Department of Cancer Informatics, University Hospitals Cleveland Medical Center/Seidman Cancer Center, Cleveland, OH
| | - John Shanahan
- Department of Cancer Informatics, University Hospitals Cleveland Medical Center/Seidman Cancer Center, Cleveland, OH
| | - Tashinga Musonza
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jordan M Winter
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mohamed ElHag
- Department of Pathology, Cleveland Clinic Foundation, Cleveland, OH
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
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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
| | - 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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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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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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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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Amr B, Miles G, Shahtahmassebi G, Roobottom C, Stell DA. Systematic evaluation of radiological findings in the assessment of resectability of peri-ampullary cancer by CT using different contrast phase protocols. Clin Radiol 2017; 72:691.e11-691.e17. [PMID: 28292513 DOI: 10.1016/j.crad.2017.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 02/01/2017] [Accepted: 02/09/2017] [Indexed: 01/25/2023]
Abstract
AIMS To determine the relative significance of radiological signs in determining the resectability of peri-ampullary cancer (PC) and to assess the value of multi-phase imaging in detecting these findings. MATERIALS AND METHODS Blinded, double re-reporting of preoperative imaging from five hospitals was undertaken of 411 patients undergoing surgery for PC over an 8-year period, of whom 119 patients were found to be inoperable at the time of surgery. RESULTS The median tumour size was 26.7 mm and the proportion of patients reported to have regional lymphadenopathy (RL), venous (VI) and arterial involvement (AI) was 24.7%, 11.5%, and 3.9%, respectively and was similar regardless of the number of contrast phases undertaken. Significant associations were, however, noted between individual risk factors: VI was closely associated with tumour size (p=0.002) and AI (p<0.0001). In multivariate analysis AI, VI, and RL were independently associated with resectability (relative risk of resection=0.05, 0.31, and 0.51, respectively). Tumour size, however, was not associated with resectability when VI was included in the multivariate model. CONCLUSIONS The use of multiple vascular contrast phases has no measureable impact on the rate of determination of tumour resectability of PC. In preoperative staging, AI is the most significant adverse finding for resectability. Large tumour diameter is not an adverse finding in isolation from other risk factors.
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Affiliation(s)
- B Amr
- Peninsula HPB Unit, Derriford Hospital, Plymouth PL6 8DH, UK; Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth PL6 8BU, UK
| | - G Miles
- Peninsula Radiology Academy, Plymouth International Business Park, Plymouth PL6 5WR, UK
| | - G Shahtahmassebi
- School of Science and Technology, Nottingham Trent University, Nottingham NG1 4BU, UK
| | - C Roobottom
- Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth PL6 8BU, UK; Peninsula Radiology Academy, Plymouth International Business Park, Plymouth PL6 5WR, UK.
| | - D A Stell
- Peninsula HPB Unit, Derriford Hospital, Plymouth PL6 8DH, UK; Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth PL6 8BU, UK
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Nguyen HV, Gore J, Zhong X, Savant SS, Deitz-McElyea S, Schmidt CM, House MG, Korc M. MicroRNA Expression in a Readily Accessible Common Hepatic Artery Lymph Node Predicts Time to Pancreatic Cancer Recurrence Postresection. J Gastrointest Surg 2016; 20:1699-706. [PMID: 27456015 PMCID: PMC5035215 DOI: 10.1007/s11605-016-3208-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 07/10/2016] [Indexed: 01/31/2023]
Abstract
Lymph node involvement in pancreatic adenocarcinoma (PAC) predicts postresection survival, but early lymph node metastasis detection is not easily accomplished. We assessed a panel of microRNAs (miRNAs) in a common hepatic artery lymph node (station 8) that is readily accessible during pancreatoduodenectomy (PD) to determine if increased miRNA levels correlate with postresection recurrence. Station 8 lymph nodes overlying the common hepatic artery collected during PD were assayed for miRNA-10b, miRNA-30c, miRNA-21, and miRNA-155 and cytokeratin-19 (CK19), an epithelial cell marker, using quantitative PCR. Expression was correlated with disease recurrence, recurrence-free survival (RFS), and overall survival (OS). Station 8 lymph nodes from 37 patients (30 periampullary carcinomas (PCs), 2 chronic pancreatitis, 5 other cancers) exhibited increased miRNA-10b levels in 14/30 PCs, and in 10 of these 14 patients, cancer recurred during the study period (2012-2015). High miRNA-10b was also associated with shorter RFS (42.5 vs. 92.4 weeks, p < 0.05) but not OS, whereas miRNA-30c, miRNA-21, and miRNA-155 levels and CK19 mRNA levels in station 8 nodes were variable and did not correlate with RFS or OS. We conclude that elevated miRNA-10b levels in station 8 lymph nodes could be utilized to assess risk for early disease progression in patients with periampullary tumors.
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Affiliation(s)
- Hai V Nguyen
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Jesse Gore
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- The Pancreatic Cancer Signature Center, Indiana University Simon Cancer Center, Indianapolis, IN, 46202, USA
| | - Xin Zhong
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Sudha S Savant
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Samantha Deitz-McElyea
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- The Pancreatic Cancer Signature Center, Indiana University Simon Cancer Center, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- The Pancreatic Cancer Signature Center, Indiana University Simon Cancer Center, Indianapolis, IN, 46202, USA
| | - Murray Korc
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
- The Pancreatic Cancer Signature Center, Indiana University Simon Cancer Center, Indianapolis, IN, 46202, USA.
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
- IU Simon Cancer Center, Indiana University School of Medicine, 980 West Walnut Street, Rm 528, Indianapolis, IN, 46202, USA.
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Balci S, Basturk O, Saka B, Bagci P, Postlewait LM, Tajiri T, Jang KT, Ohike N, Kim GE, Krasinskas A, Choi H, Sarmiento JM, Kooby DA, El-Rayes BF, Knight JH, Goodman M, Akkas G, Reid MD, Maithel SK, Adsay V. Substaging Nodal Status in Ampullary Carcinomas has Significant Prognostic Value: Proposed Revised Staging Based on an Analysis of 313 Well-Characterized Cases. Ann Surg Oncol 2015; 22:4392-401. [PMID: 25783680 PMCID: PMC4575255 DOI: 10.1245/s10434-015-4499-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current nodal staging (N-staging) of ampullary carcinoma in the TNM staging system distinguishes between node-negative (N0) and node-positive (N1) disease but does not consider the metastatic lymph node (LN) number. METHODS Overall, 313 patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma were categorized as N0, N1 (1-2 metastatic LNs), or N2 (≥3 metastatic LNs), as proposed by Kang et al. Clinicopathological features and overall survival (OS) of the three groups were compared. RESULTS The median number of LNs examined was 11, and LN metastasis was present in 142 cases (45 %). When LN-positive cases were re-classified according to the proposed staging system, 82 were N1 (26 %) and 60 were N2 (19 %). There was a significant correlation between proposed N-stage and lymphovascular invasion, perineural invasion, increased tumor size (each p < 0.001), and surgical margin positivity (p = 0.001). The median OS in LN-negative cases was significantly longer than that in LN-positive cases (107.5 vs. 32 months; p < 0.001). Patients with N1 and N2 disease had median survivals of 40 and 24.5 months, respectively (p < 0.0001). In addition, 1-, 3-, and 5-year survivals were 88, 76, 62 %, respectively, for N0; 90, 55, 31.5 %, respectively, for N1; and 68, 34, 30 %, respectively for N2 (p < 0.001). Even with multivariate modeling, the association between higher proposed N stage and shorter survival persisted (hazard ratio 1.6 for N1 and 1.9 for N2; p = 0.018). CONCLUSIONS Classification of nodal status in ampullary carcinomas based on the number of metastatic LNs has a significant prognostic value. A revised N-staging classification system should be incorporated into the TNM staging of ampullary cancers.
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Affiliation(s)
- Serdar Balci
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Olca Basturk
- Department of Pathology, New York University, New York, NY, USA
| | - Burcu Saka
- Department of Pathology, İstanbul Medipol University, İstanbul, Turkey
| | - Pelin Bagci
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Takuma Tajiri
- Department of Pathology, Tokai University Hachiouji Hospital, Tokyo, Japan
| | - Kee-Taek Jang
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nobuyuki Ohike
- Department of Pathology, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Alyssa Krasinskas
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Hyejeong Choi
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Juan M Sarmiento
- Division of General and Gastrointstinal Surgery, Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | | | | | - Michael Goodman
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Gizem Akkas
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Michelle D Reid
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Volkan Adsay
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA.
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Chen SC, Shyr YM, Chou SC, Wang SE. The role of lymph nodes in predicting the prognosis of ampullary carcinoma after curative resection. World J Surg Oncol 2015. [PMID: 26205252 PMCID: PMC4513626 DOI: 10.1186/s12957-015-0643-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Lymph node involvement is one of the well-demonstrated prognostic factors in ampullary carcinoma. The aim of this study is to clarify the role of lymph nodes in predicting the survival outcome of ampullary carcinoma. METHODS A cohort of consecutive curative pancreaticoduodenectomies for ampullary carcinoma from 1999 to 2014 was retrospectively analyzed. The effect of node-associated variables, including lymph node status, positive lymph node number, total harvested lymph node (THLN) number, and lymph node ratio (LNR) was examined using univariate and multivariate analyses for survival outcome prediction. RESULTS In 194 evaluable patients, univariate analysis demonstrated that stage, cell differentiation, perineural invasion, and nodal status were significant conventional prognostic factors. Concerning the node-associated variables, positive nodal status, positive lymph node number≥2, THLN number<14, and LNR≥0.15 were significantly associated with poorer survival outcomes, with a 5-year survival rate of 20.3, 38.9, 25.4, and 18%, respectively. By multivariate analysis, nodal status and THLN number were two independent predictors of survival. The most favorable 5-year survival rate was 84.4% in patients with negative nodal involvement and THLN number≥14, compared with the poorest 5-year survival rate of 16.1% in those with positive nodal status and THLN number<14. CONCLUSIONS Tumor biology reflected by lymph node status is the most important independent prognostic factor; nevertheless, surgical radicality based on THLN number also plays a significant role in the survival outcome for patients with ampullary carcinoma after curative pancreaticoduodenectomy.
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Affiliation(s)
- Shih-Chin Chen
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, 10 F 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, 10 F 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
| | - Shu-Cheng Chou
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, 10 F 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, 10 F 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
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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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13
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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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14
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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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15
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LaFemina J, Chou JF, Gönen M, Rocha FG, Correa-Gallego C, Kingham TP, Fong Y, D'Angelica MI, Jarnagin WR, DeMatteo RP, Allen PJ. Hepatic arterial nodal metastases in pancreatic cancer: is this the node of importance? J Gastrointest Surg 2013; 17:1092-7. [PMID: 23588624 DOI: 10.1007/s11605-012-2071-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 10/26/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND The hepatic artery lymph node (HALN) is frequently sampled during pancreaticoduodenectomy (PD). Data suggest that survival in the setting of HALN metastases is similar to that of stage IV pancreatic ductal adenocarcinoma (PDAC). The objectives of this study were to describe the prognostic significance of HALN metastases and to assess the predictive performance of HALN compared to peripancreatic lymph node status. METHODS Patients undergoing PD for PDAC from January 2000-October 2010 were identified from a prospectively maintained database. Patients were included if during PD the HALN was submitted for pathologic evaluation. Patients were excluded if margins were macroscopically positive, if pathology was found to be consistent with a diagnosis other than PDAC. Overall (OS) and disease-free survival (DFS) were estimated by Kaplan-Meier methods. RESULTS Of the 671 patients who underwent PD for PDAC, HALN status was analyzed for 147 patients. HALN was positive in 23 patients (16 %), 38 were peripancreatic lymph node (PPLN) and HALN negative, and 86 were PPLN+/HALN-. Median follow-up for survivors was 10 months. In a multivariable model, lymph node status and tumor differentiation predicted OS and DFS. Hazard of death and relapse/death were highest among the HALN+ patients (hazard ratio [HR] 2.94; p = 0.017 and HR 2.66; p = 0.011, respectively). Kaplan-Meier analysis revealed significant differences in OS (p = 0.017) and DFS (p = 0.013) based on lymph node status. CONCLUSIONS OS and DFS are significantly reduced in patients with a positive HALN. Differentiation and lymph node status were predictors of OS and DFS. In the multivariate models, differentiation and lymph node status remain independent predictors of OS and DFS.
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Affiliation(s)
- J LaFemina
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Kobayashi S, Nagano H, Hoshino H, Wada H, Marubashi S, Eguchi H, Takeda Y, Tanemura M, Kim T, Shimosegawa E, Hatazawa J, Doki Y, Mori M. Diagnostic value of FDG-PET for lymph node metastasis and outcome of surgery for biliary cancer. J Surg Oncol 2010; 103:223-9. [DOI: 10.1002/jso.21811] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 10/25/2010] [Indexed: 12/21/2022]
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Abstract
Pancreatic carcinoma is the fourth cause of death from cancer in the United States, with a survival rate at 5 years of less than 5%. About 60% of tumors originate at the head of the pancreas, 15% in the body, 5% in the tail; 20% are diffuse within the pancreas. This article discusses the imaging and staging of pancreatic cancer.
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Affiliation(s)
- G Morana
- Radiological Department, General Hospital Cá Foncello, Treviso, Italy.
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Shimada K, Sano T, Nara S, Esaki M, Sakamoto Y, Kosuge T, Ojima H. Therapeutic value of lymph node dissection during hepatectomy in patients with intrahepatic cholangiocellular carcinoma with negative lymph node involvement. Surgery 2009; 145:411-6. [PMID: 19303990 DOI: 10.1016/j.surg.2008.11.010] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 11/17/2008] [Indexed: 12/29/2022]
Abstract
BACKGROUND Routine and radical lymph node dissection is a clinical concern for improving the surgical outcome in patients with intrahepatic cholangiocarcinoma (ICC). The therapeutic value of the procedure during hepatectomy has, however, not been evaluated. METHODS Between January 1990 and December 2004, 104 patients with ICC undergoing macroscopic curative resections were investigated retrospectively with special reference to lymph node status. The role of lymph node dissection was evaluated according to macroscopic type: mass-forming (MF) type (n = 68) and MF plus periductal infiltration (PI) type (n = 36) of ICC. RESULTS Lymph node involvement and intrahepatic metastases were an independent, unfavorable prognostic factor in the MF type of ICC. Negative lymph node involvement provided a favorable survival rate in the 41 patients without intrahepatic metastases (P < .0001). Among the 29 patients without lymph node involvement and intrahepatic metastases, there was no difference according to the use of lymph node dissection (P = .8071). Also, no difference was seen with lymph node involvement in the 24 patients with the MF plus PI type of ICC who had no intrahepatic metastases (P = .6620). CONCLUSION For purpose of diagnostic staging and exclusion of positive regional lymph nodes, lymph node dissections might be useful in patients with the MF type and the MF plus PI type of ICC; however, routine use of lymph node dissection in patients with the MF type of ICC is not recommended, because no difference in survival was observed in the patients with negative lymph node metastases, irrespective of the use of lymph node dissection.
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Falconi M, Crippa S, Domínguez I, Barugola G, Capelli P, Marcucci S, Beghelli S, Scarpa A, Bassi C, Pederzoli P. Prognostic relevance of lymph node ratio and number of resected nodes after curative resection of ampulla of Vater carcinoma. Ann Surg Oncol 2008; 15:3178-86. [PMID: 18712568 DOI: 10.1245/s10434-008-0099-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Revised: 07/18/2008] [Accepted: 07/19/2008] [Indexed: 12/21/2022]
Abstract
BACKGROUND Nodal metastasis is considered a major prognostic factor in patients with ampulla of Vater carcinoma (AVC). No study has investigated the significance of the ratio between metastatic and resected/examined lymph nodes (LNR) in patients with AVC. METHODS Demographic, operative, and pathology data, including number of resected/evaluated nodes and LNR, were collected from patients who underwent pancreaticoduodenectomy with radical intent for invasive AVC from 1990 to 2005. Survival rates and recurrence patterns were evaluated and predictors were identified. RESULTS In 90 evaluable patients (51 males, 39 females, median age 62.5 years), 5-year disease-specific survival (DSS) was 61%. The median number of resected/evaluated nodes was 16 (range: 5-47); 50% of the patients had nodal metastases. The 5-year DSS according to LNR was 75%, 49%, 38%, and 0% for LNR = 0, LNR >0 and < or =0.2, LNR >0.2, and < or =0.4, and LNR >0.4 (P = 0.002), respectively. The 5-year DSS was 81% in patients with >16 resected/evaluated nodes compared with 45% in those with < or =16 resected/evaluated nodes (P = 0.001). On multivariate analysis LNR and a number of resected/evaluated nodes >16 were significant predictors of survival; a number of resected/evaluated nodes >16 was also the only independent predictor of recurrence. CONCLUSIONS After curative resection for AVC, LNR and a cutoff of 16 resected/evaluated nodes are powerful prognostic factors. LNR might represent a major parameter for patient stratification in adjuvant treatment trials.
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Affiliation(s)
- Massimo Falconi
- Chirurgia Generale B (Pancreas Unit), Department of Surgery, University of Verona, Policlinico GB Rossi, Piazzale LA Scuro, 37134 Verona, Italy.
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20
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Brennan DDD, Zamboni GA, Raptopoulos VD, Kruskal JB. Comprehensive Preoperative Assessment of Pancreatic Adenocarcinoma with 64-Section Volumetric CT. Radiographics 2007; 27:1653-66. [DOI: 10.1148/rg.276075034] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Zamboni GA, Kruskal JB, Vollmer CM, Baptista J, Callery MP, Raptopoulos VD. Pancreatic adenocarcinoma: value of multidetector CT angiography in preoperative evaluation. Radiology 2007; 245:770-8. [PMID: 17951353 DOI: 10.1148/radiol.2453061795] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To retrospectively assess the sensitivity and specificity of multidetector computed tomographic (CT) angiography in the preoperative evaluation of pancreatic adenocarcinoma by using surgical findings as the reference standard. MATERIALS AND METHODS The institutional review board approved this HIPAA-compliant study; informed consent was waived. We reviewed CT reports, surgical notes, and pathology reports from 114 patients with pancreatic or distal cholangiocarcinoma who underwent multidetector CT angiography and surgery at our institution between March 2003 and March 2006. When CT findings and surgical reports were discordant, radiologists experienced in pancreatic imaging retrospectively reviewed images for lesion resectability; four-, eight-, 16-, and 64-row CT scanners were used in 54, 19, 25, and 16 patients, respectively. Collimation of 1.25 mm was used for four- and eight-row CT and 0.5 or 0.625 mm for 16- and 64-row CT. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for resectability were calculated for initial clinical interpretation and blinded retrospective review. RESULTS Eighty-eight patients had resectable lesions according to CT angiographic criteria (group A: 46 women, 42 men; mean age, 67 years; age range, 39-85 years): resection was aborted in 10 patients (11%). Twenty-six patients underwent surgery despite lesion unresectability assessed according to CT angiographic criteria (group B: 16 women, 10 men; mean age, 62 years; age range, 33-83 years); all lesions were confirmed as unresectable. The initial clinical interpretation of CT angiographic scans in all 114 patients had 100% sensitivity in the detection of resectability, 72% specificity, 89% PPV, and 100% NPV. These parameters did not appear to vary among different types of scanner. With the blinded retrospective evaluation by experienced readers, specificity increased to 94% and PPV to 98%, with no difference in sensitivity and NPV. CONCLUSION Multidetector CT angiography is an effective preoperative tool that reduces the number of aborted pancreatic resections; there is no evidence from this retrospective study suggesting varying results from the various generations of multidetector CT scanners used.
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Affiliation(s)
- Giulia A Zamboni
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA
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Cordera F, Arciero CA, Li T, Watson JC, Hoffman JP. Significance of Common Hepatic Artery Lymph Node Metastases During Pancreaticoduodenectomy for Pancreatic Head Adenocarcinoma. Ann Surg Oncol 2007; 14:2330-6. [PMID: 17492334 DOI: 10.1245/s10434-006-9339-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Accepted: 12/07/2006] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Fernando Cordera
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania, 19111, USA.
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23
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Brennan DD, Zamboni G, Sosna J, Callery MP, Vollmer CMV, Raptopoulos VD, Kruskal JB. Virtual Whipple: Preoperative Surgical Planning with Volume-Rendered MDCT Images to Identify Arterial Variants Relevant to the Whipple Procedure. AJR Am J Roentgenol 2007; 188:W451-5. [PMID: 17449742 DOI: 10.2214/ajr.06.0925] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The purposes of this study were to combine a thorough understanding of the technical aspects of the Whipple procedure with advanced rendering techniques by introducing a virtual Whipple procedure and to evaluate the utility of this new rendering technique in prediction of the arterial variants that cross the anticipated surgical resection plane. CONCLUSION The virtual Whipple is a novel technique that follows the complex surgical steps in a Whipple procedure. Three-dimensional reconstructed angiographic images are used to identify arterial variants for the surgeon as part of the preoperative radiologic assessment of pancreatic and ampullary tumors.
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Affiliation(s)
- Darren D Brennan
- Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd., Boston, MA 02215, USA
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Rassadi R, Tarnasky PR, Linder JD, Joe Saad A, Rohan Jeyarajah D. Nodal sampling in pancreaticoduodenectomy: does it change our management? HPB (Oxford) 2007; 9:461-5. [PMID: 18345295 PMCID: PMC2215361 DOI: 10.1080/13651820701713733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lymph node involvement in periampullary malignancy is the single most important factor in predicting survival in pancreaticoduodenectomy (PD). The role of nodal sampling in PD has not been well evaluated. This study evaluates the utility of nodal sampling of nodal stations 8 and 12, which are easily dissected early in PD, in overall final nodal status. PATIENTS AND METHODS Fifty patients underwent PD at a single institution by a one surgeon over a 15 month period. Nodal stations 8 and 12 were sent separately for pathologic evaluation. Twenty-eight patients had a final diagnosis of periampullary malignancy. Demographic and pathologic data were collected retrospectively from patient charts. Positive and negative predictive values of nodes 8 and 12 were evaluated. RESULTS Eighteen of 28 patients with a diagnosis of periampullary malignancy had pathologically negative nodes 8 and 12, and a final nodal status (all peripancreatic lymph nodes) negative for nodal involvement. Nine of 28 patients had a negative nodal sampling result, but a positive final nodal status for metastatic tumor. The remaining four patients had both positive nodal sampling and final nodal status for metastatic tumor. The negative predictive value of negative nodes 8 and 12 was 0.625. CONCLUSION The negative predictive of a negative node 8 and 12 of 0.625 suggests that the decision to proceed with or abort PD should not be based on intraoperative evaluation of these nodes. Performance of PD should be undertaken if technically feasible, and not based on intraoperative nodal assessment.
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Affiliation(s)
- Roozbeh Rassadi
- Departments of Surgery, Methodist Dallas Medical CenterDallas TXUSA
| | | | | | - A. Joe Saad
- Pathology, Methodist Dallas Medical CenterDallas TXUSA
| | - D. Rohan Jeyarajah
- Departments of Surgery, Methodist Dallas Medical CenterDallas TXUSA,Pathology, Methodist Dallas Medical CenterDallas TXUSA
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