Para-aortic lymph node metastases in pancreatic cancer should not be considered a watershed for curative resection

Sebastian Hempel,Marius Distler,Jürgen Weitz,Franz Mierke,Thilo Welsch,Daniela E Aust,Verena Plodeck,Hans-Detlev Saeger

doi:10.1038/s41598-017-08165-w

Sebastian Hempel, Marius Distler + Show 6 more

Open Access

https://doi.org/10.1038/s41598-017-08165-w

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Abstract

No international consensus regarding the resection of the para-aortic lymph node (PALN) station Ln16b1 during pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) has been reached. The present retrospectively investigated 264 patients with PDAC who underwent curative pancreatoduodenectomy or total pancreatectomy between 2005–2015. In 95 cases, the PALN were separately labelled and histopathologically analysed. Metastatic PALN (PALN+) were found in 14.7% (14/95). PALN+ stage was associated with increased regional lymph node metastasis. The median overall survival (OS) of patients with metastatic PALN and with non-metastatic PALN (PALN−) was 14.1 and 20.2 months, respectively. Five of the PALN+ patients (36%) survived >19 months. The OS of PALN+ and those staged pN1 PALN− was not significantly different (P = 0.743). Patients who underwent surgical exploration or palliative surgery (n = 194) had a lower median survival of 8.8 (95% confidence interval: 7.3–10.1) months. PALN status could not be reliably predicted by preoperative computed tomography. We concluded that the survival data of PALN+ cases is comparable with advanced pN+ stages; one-third of the patients may expect longer survival after radical resection. Therefore, routine refusal of curative resection in the case of PALN metastasis is not indicated.

Highlights

One of the unsolved difficulties in treating patients with pancreatic ductal adenocarcinoma (PDAC) is early lymph node spread, which probably leads to tumour recurrence even after complete surgical resection
An International Study Group for Pancreatic Surgery (ISGPS) consensus statement defined the international standard lymphadenectomy based on a current literature review3
The present study provides additional evidence and aims to assess the prognosis of para-aortic lymph node (PALN) metastases and their resection in a European population, with a special focus on regional lymph node status

Summary

Introduction

One of the unsolved difficulties in treating patients with pancreatic ductal adenocarcinoma (PDAC) is early lymph node spread, which probably leads to tumour recurrence even after complete surgical resection. No consensus was reached for recommending routine resection of the para-aortic lymph node (PALN) station Ln16b1 dorsal to the pancreas. Metastasis to this lymph node station is classified as pM1 stage, because these lymph nodes do not belong to the regional lymph node stations. Single studies advocated against performing tumour resection if PALN metastasis is histologically verified, making PALN metastasis a watershed for curative resection. Single studies advocated against performing tumour resection if PALN metastasis is histologically verified, making PALN metastasis a watershed for curative resection5 These contradictive management recommendations warrant further data acquisition and analysis. The present study provides additional evidence and aims to assess the prognosis of PALN metastases and their resection in a European population, with a special focus on regional lymph node status

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