Abstract
BackgroundMost pancreatoduodenectomy resections do not meet the minimum of 12 lymph nodes recommended by the American Joint Committee on Cancer for accurate staging of periampullary malignancies. The purpose of this study was to investigate factors affecting the likelihood of adequate nodal yield in pancreatoduodenectomy specimens subject to routine pathological assessment.MethodsSix hundred sixty-two patients subject to pancreatoduodenectomy between 1990 and 2013 for pancreatic, ampullary, and common bile duct cancers were reviewed. Predictors of yielding at least 12 lymph nodes were evaluated with a logistic regression model, and a survival analysis was carried out to verify the prognostic implications of nodal counts.ResultsThe median number of evaluated nodes was 17 (interquartile range 11 to 25), and less than 12 lymph nodes were reported in surgical specimens of 179 (27 %) patients. Tumor diameter ≥20 mm (odds ratio [OR] 2.547, 95 % confidence interval [CI] 1.225 to 5.329, P = 0.013), lymph node metastases (OR 2.642, 95 % CI 1.378 to 5.061, P = 0.004), and radical lymphadenectomy (OR 5.566, 95 % CI 2.041 to 15.148, P = 0.01) were significant predictors of retrieving 12 or more lymph nodes. Lymph node counts did not influence the overall prognosis of the patients. However, a subgroup analysis carried out for individual cancer sites demonstrated that removing at least 12 lymph nodes is associated with better prognosis for pancreatic cancer.ConclusionsFew variables affect adequate nodal yield in pancreatoduodenectomy specimens subject to routine pathological assessment. Considering the ambiguities related to the only modifiable factor identified, appropriate pathology training should be considered to increase nodal yield rather than more aggressive lymphatic dissection.
Highlights
Most pancreatoduodenectomy resections do not meet the minimum of 12 lymph nodes recommended by the American Joint Committee on Cancer for accurate staging of periampullary malignancies
ASA American Society of Anesthesiologists, Interquartile range (IQR) interquartile range, PD pancreatoduodenectomy range 2 to 92), and less than 12 lymph nodes were reported in surgical specimens of 179 (27 %) patients
This study has demonstrated that the adequate lymph node yield with standard pathologic processing of pancreatoduodenectomy specimens in patients with suspected periampullary malignancy is influenced by only three factors, i.e., tumor diameter, metastases to lymph nodes and extent of lymphadenectomy
Summary
Most pancreatoduodenectomy resections do not meet the minimum of 12 lymph nodes recommended by the American Joint Committee on Cancer for accurate staging of periampullary malignancies. The accuracy of staging lymph node status is directly proportional to the number of lymph nodes retrieved and the optimum cutoff value minimizing the stage migration phenomenon reported previously for pancreatic cancer varies from 10 to 15 [1, 2]. Others suggested that pathologic assessment of more than 12 lymph nodes may provide more accurate survival estimates for patients with nodenegative disease [5, 6]. Based on these observations, at least 12 lymph nodes are required for adequate staging for pancreatoduodenectomy specimens of pancreatic, distal bile
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