Common Hepatic Artery Lymph Nodes Research Articles

Common hepatic artery lymph node metastasis in pancreatic ductal adenocarcinoma: an analysis of actual survival

BackgroundThe common hepatic artery lymph node represents a second-echelon node for tumors in the head of the pancreas. Although early studies suggested survival was comparable between the common hepatic artery lymph node and remote metastasis in pancreatic ductal adenocarcinoma, 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. MethodsWe studied 215 patients with pancreatic head pancreatic ductal adenocarcinoma, who underwent pancreaticoduodenectomies at a single institution from 2010 to 2017 wherein the common hepatic artery lymph nodes were excised. We performed actual and actuarial overall survival and disease-free survival analyses, with subsequent univariate and multivariate analyses in node-positive patients. ResultsOf this cohort, 7.3% of patients had involvement of the common hepatic artery lymph node, 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 disease-free survival analyses yielded similar results. ConclusionsWe found no difference in actual survival in node-positive patients regardless of the common hepatic artery lymph node involvement and recommend against its assessment in prognosticating survival or guiding surgical treatment.

Prognostic significance of common hepatic artery lymph node metastasis in gastric cancer.

The number of lymph nodes is used to determine the prognosis in patients with gastric cancer undergoing D2 lymph node dissection. However, a group of extraperigastric lymph nodes, including lymph node 8a, are also considered to be effective in prognosis. In our clinical experience, in most patients during D2 lymph node dissection, the lymph nodes are removed en-bloc with the specimen and are not marked separately. The aim was to analyze the importance and prognostic impact of 8a lymph node metastasis in patients with gastric cancer. Patients who underwent gastrectomy and D2 lymph node dissection for gastric cancer between 2015 and 2022 were included in the study. Patients were divided into two groups based on metastasis to the 8a lymph node: metastatic and nonmetastatic. The effect of clinicopathologic features and the prevalence of lymph node metastasis on the prognosis of the two groups were analyzed. The present study included 78 patients. The mean number of dissected lymph nodes was 27 (IQR, 15-62). There were 22 (28.2%) patients in the 8a lymph node metastatic group. Patients with 8a lymph node metastatic disease had shorter overall survival and shorter disease-free survival. Those with metastatic 8a lymph nodes among pathologic N2/3 patients had shorter overall and disease-free survival rates (p < 0.05). In conclusion, we believe that anterior common hepatic artery (8a) LN metastasis is a key factor that negatively affects both disease-free and overall survival in patients with locally advanced gastric cancer.

Appropriate Lymph Node Dissection Sites for Cancer in the Body and Tail of the Pancreas: A Multicenter Retrospective Study.

Simple SummaryDistal pancreatectomy has become the standard surgery for patients with pancreatic body–tail cancers. The optimal area for dissection remains controversial, and there is an emphasis on preserving as much tissue as possible while eradicating the cancer. This multicenter, retrospective study evaluated the frequency and patterns of lymph node metastasis based on tumor site among 235 patients with pancreatic body–tail cancers to determine the optimal lymph node dissection area for distal pancreatectomy. Patients with pancreatic body cancer tumors showed no metastasis to the splenic hilum lymph node. Spleen-preserving pancreatectomy might be feasible for Pb cancer.Distal pancreatectomy (DP) with lymphadenectomy is the standard surgery for pancreatic body–tail cancer. However, the optimal lymph node (LN) dissection area for DP remains controversial. Thus, we evaluated the frequency and patterns of LN metastasis based on the tumor site. In this multicenter retrospective study, we examined 235 patients who underwent DP for pancreatic cancer. Tumor sites were classified as confined to the pancreatic body (Pb) or pancreatic tail (Pt). The efficacy index (EI) was calculated by multiplying the frequency of metastasis to each LN station by the five-year survival rate of patients with metastasis to that station. LN metastasis occurred in 132/235 (56.2%) of the patients. Patients with Pb tumors showed no metastasis to the splenic hilum LN. Distal splenic artery LNs and anterosuperior/posterior common hepatic artery LNs did not benefit from dissection for Pb and Pt tumors, respectively. In multivariate analysis, splenic artery LN metastasis was identified as an independent predictor of poor overall survival in patients with pancreatic body–tail cancer. In conclusion, differences in metastatic LN sites were evident in pancreatic body–tail cancers confined to the Pb or Pt. Spleen-preserving pancreatectomy might be feasible for Pb cancer.

Differences in the clinicopathological features of pancreatic head carcinoma in dorsal and ventral pancreas: A single institution retrospective review.

The embryonic development of the pancreas originates from dorsal and ventral anlagen, and the pancreatic cancer arising from dorsal or ventral pancreas may have different clinical pathology features. This study aims to explore whether there are differences in clinicopathological features and prognosis of pancreatic head carcinoma arising from dorsal or ventral pancreas.Between January 2014 and February 2018, 101 patients with resectable pancreatic head cancer who underwent pancreaticoduodenectomy in our institution were retrospectively reviewed. The patients were assigned into 2 groups according to tumor location on preoperative imaging materials (computed tomography/magnetic resonance imaging [CT/MRI]), and the clinicopathological features and prognosis were retrospectively analyzed in view of the embryonic development of the pancreas.Among these patients with pancreatic head cancer, 42 patients had tumors arising from dorsal pancreas (D group) and 59 patients had tumors arising from ventral pancreas (V group). The frequency of lymph node (LN) metastasis around the common hepatic artery (CHA) and hepatoduodenal ligament lymph nodes in the D group was higher than that in the V group (45.2% vs 10.2%, P = .001). And the rate of LN metastasis in the superior mesenteric artery (SMA) region in the V group is higher than that in the D group (32.2% vs 4.8%, P = .002). The D group was more likely to invade the common bile duct (78.6% vs 59.3%, P = .042) and duodenum (71.4% vs 44.1%, P = .006) than the V group. In addition, the survival outcome of V group was better than D group (median overall survival [OS], 15.37 months vs 10.53 months, P = .048, median DFS 9.73 months vs 5.93 months, P = .046).The clinicopathological features of pancreatic head carcinoma arising from dorsal or ventral pancreas are different, and the pancreatic head carcinoma arising from ventral pancreas has a better survival outcome.

Resection of caudate lobe hepatocellular carcinoma with enbloc IVC resection and replacement

Presenter: Iswanto Sucandy MD | AdventHealth Tampa Background: This video describes how we undertook the resection of the caudate lobe for hepatocellular carcinoma with enbloc IVC resection and replacement. Methods: The patient is a 74-year-old man who present with a 6 cm caudate lobe mass. Patient has a history of Hepatitis C with liver cirrhosis (Child A). Workup included an MRI which showed the caudate lobe mass circumferentially invading the IVC. A percutaneous biopsy confirmed hepatocellular carcinoma. Results: The operation began with a complete mobilization of the left hemiliver. The falciform ligament was taken down to the hepatocaval confluence. The gastrohepatic ligament was then opened in a stellate fashion along the Arantius ligament, which was dissected all the way up to the origin of the left hepatic vein. Dissection along the caudal border of the tumor was undertaken by following the common hepatic artery, which was displaced by the tumor mass. The common hepatic artery lymph nodes were removed. The pancreas was then exposed and retracted caudally. The left gastric artery was involved by the tumor; therefore, it was isolated and transected with a laparoscopic vascular load stapler. The minor curvature of the stomach was dissected all the way up to the crus. The pars flaccida was open to show the anatomical landmarks of this operation. The gallbladder was then removed. Next, the Arantius ligament was ligated and divided. The hepatic artery and portal vein branches to the caudate lobe were isolated and divided. The duodenum was widely kocherized to access the retroduodenal IVC just above the left renal vein. The right gonadal vein was preserved. The entire retrohepatic IVC was removed after applying cross-clamping on the IVC (proximal vascular clamp was placed immediately caudal to the root of the hepatic veins and the distal vascular clamp was placed through the retroduodenal space behind the head of the pancreas). A 16mm woven Dacron vascular conduit was used for the IVC replacement. Once the graft-IVC anastomosis was completed, the IVC was unclamped. A vascular Doppler was utilized to check the flow within the vena cava conduit. Conclusion: Patient tolerated the procedure well and had an uneventful recovery. Pathology confirmed a 10 cm enbloc mass containing caudate lobe hepatocellular carcinoma and retrohepatic IVC. There was an absence of lymphatic invasion. Patient was discharged on post-operative day 4 after ambulating and tolerating oral diet.

Extended Field Postoperative Radiotherapy (EFRT) Yields better Outcomes as Compared to Localised Field RT (LFRT) in Radically Resected Gallbladder Cancer (GBC)

Background: Postoperative adjuvant RT is recommended in node positive and positive resection margins patients after radical surgery (RS) in GBC. However there are no guidelines to suggest the regions to be irradiated. Our aim is to compare whether EFRT or LFRT improves outcomes. Methods and Materials: Records of GBC patients who underwent adjuvant chemo-radiotherapy after RS, between January 2007 and December 2014 were reviewed. Demographic data, histopathological data, target delineation, RT treatment planning details, concurrent chemotherapy, side-effects of treatment, and survival data were collated. Patients were treated with either of two techniques: Localised field RT [LFRT] [from 2007-2010] or Extended field RT [EFRT] [from 2011-2014] along with concurrent 5-FU/capecitabine. LFRT involved RT to GB bed, peri-portal, common hepatic artery (CHA) and coeliac lymph nodes and EFRT involved RT to GB bed, peri-portal, CHA, coeliac, gastro-duodenal, superior mesenteric and para aortic lymph nodes. The RT dose was 50.4 Gy/28fractions/5.5 weeks. Loco-regional recurrence rate (LRR), Overall (OS) and Disease free Survival (DFS) was computed with Kaplan Meier method.Results: Out of 60 patients reviewed, 30 were treated with EFRT and 30 with LFRT. There was no significant difference in the acute and late side-effects between the two techniques. At a median follow-up of 44 months (range 36-120 months), 37.5 % patients developed LRR (13.3 % vs 40% in EFRT and LFRT, p = NS).The median OS was not reached (NR) vs 42 months and the median DFS was NR vs 30 months in EFRT vs LFRT respectively (p=0.01 and 0.016). The 5 year OS was 80% vs 42% and 5 year DFS was 80% vs 40% for EFRT and LFRT respectively (p=0.01 and 0.016). Conclusions: Based on our findings, we conclude that EFRT reduces LRR and improves survival in patients with absence of lymphovascular space invasion (LVI) and perineural invasion (PNI). This observation is hypothesis generating and merits validation in a randomised study.

Extended Lymphadenectomy Versus Regional Lymphadenectomy in Resectable Hilar Cholangiocarcinoma

AimThe aim of this study is to compare the effects of extended lymphadenectomy (E-LD) and regional lymphadenectomy (R-LD) on outcome after radical resection of hilar cholangiocarcinoma (HCCA). MethodsData of 290 patients who underwent radical resection of HCCA were retrospectively analyzed. Demographic characteristics, surgical variables, and tumor and LN characteristics were evaluated for association with survival. ResultsA total of 63 patients underwent E-LD. Patients who underwent E-LD were more likely to have portal vein embolization (14.3% vs. 5.7%), radical hepatectomy (36.2% vs. 26.0%), higher proportion of M1 patients (22.2% vs. 5.3%), more lymph nodes (LNs) retrieved (17 vs. 7), and positive common hepatic artery lymph nodes (21.4% vs. 12.6%) when compared with R-LD (all P < 0.05). The Kaplan–Meier curve of overall survival for patients who underwent E-LD indicated improvement over patients who underwent R-LD in M0 (33.39 vs. 21.31 months; P = 0.032) and R0 resection (32.97 vs. 21.02 months; P = 0.044) disease, but not observed in M1 disease (P > 0.05). After propensity score matching, E-LD was not associated with a significant improvement in overall survival (OS) even in all subgroup analysis (all P > 0.05). On multivariable analysis, E-LD was associated with improved overall survival, but not after propensity score matching. ConclusionE-LD is more likely to be performed in higher stage tumors. E-LD significantly increases LN retrieval, thereby preventing under-staging and improving survival prediction. E-LD should not be adopted for HCCA patients with intraoperatively confirmed distant LN metastases. Future studies are required to further assess whether E-LD should be performed in negative celiac, superior mesenteric, and para-aortic lymph node in HCCA patients.

Spectrum of lymphnodal involvement following extended cholecystectomy and its correlation with pT stage in carcinoma gall bladder patients

Introduction: The spectrum of lymph nodal involvement following extended cholecystectomy and its correlation with pT Stage in carcinoma gall bladder patients is an area with less reported inspite of its pivotal role in staging and prognosis. Method: A prospective observational study including 57 patients with Carcinoma gall bladder who had undergone extended cholecystectomy with systematic lymphadenectomy between January 2014 to December 2015 in PGIMER, Chandigarh. All the resectable patients underwent standard extended Cholecystectomy with n aim to achieve R0 resections and lymphnodal dissection of cystic, pericholedochal, peripancreactic, periportal, coeliac artery, Common Hepatic Artery, LHA, RHA, Hepato-duodenal lymph nodes were sent separately with main specimen for evaluation. Result: Out of 57 patients, 8 were excluded (5 were xanthogranulomatous cholecystitis, 2 were chronic cholecystitis, 1 was IgG4 related disease). A total of 555 lymph nodes were examined in 49 patients with range of 0 to 26 and median of 11.79.Lymph nodal involvement found in 19 patients(38.7% ) out of 49. Lymph nodal involvement in order of frequency was peripancreatic (n=9/49;18.4%),common hepatic artery(n=7/49;14.3%), periportal(n=7/49;14.3%), hepato-duodenal(n=5/49;10.2%), pericholedochal (n=4/49;8.2%), cystic (n=3/49;6.1%) ,coeliac (n=2/49;4.1%), LHA nodes(1/49;2%) and RHA lymph nodes (1/49;2%). Lymph nodal involvement in our study with respect to tumor staging was, pT1 stage (n=5/49;10.2%) - periportal lymph nodes involved(n=1/5;20%), pT2 stage (n=12/49;24.5%) - pericholedochal (n=3/12;25%), cystic (n=2/12;16.6%) ,peripancreatic (n=2/12;16.6%) ,Common Hepatic Artery nodes (n=1/12;8.3%),periportal(n=1/12;8.3)hepato-duodenal nodes(n=1/12;8.3), pT3 stage tumors(n=32/49;65.3%) - peri-pancreatic(n=7/32;21.9%),Common Hepatic Artery (n=6/32;18.7%), periportal (n=5/32;15.6%),hepato-duodenal(n=4/32;12.5%) ,celiac (n= 2/32 ;6.25%) ,pericholdecochal (n=1/32;3.1%), LHA nodes (n=1/32;3.1%),RHA nodes(n=1/32;3.1%),cystic lymph nodes (n=1/32;3.1%) with p>0.05. Conclusion: Peripancreatic lymph nodes were the most commonly involved irrespective of ‘pT’stage. Our study mandates the role of systemic lymphadenctomy for better tumor clearance and staging even in early carcinoma Gallbladder however its translation in to better survival is yet to be studied.

AB009. 93. Minimally invasive oesophagectomy

: Ivor-Lewis oesophagectomy is the standard treatment for resectable oesophageal carcinoma, although it is associated with significant postoperative morbidity and mortality. Minimally invasive oesophagectomy (MIO) is increasingly adopted as the preferred surgical approach in order to decrease perioperative morbidity and facilitate earlier functional recovery. (I) stage I: with the surgeon on the right and the assistant on the left a 5-port technique is used to perform a laparoscopic gastric mobilisation with an en bloc lymphadenectomy of the common hepatic, left gastric and splenic artery lymph node stations. The stomach is fully mobilized with preservation of the right gastroepiploic arcade. After full mobilisation of the stomach a 3.5–4 cm gastric conduit is fashioned by sequential firing of an EndoGIA 4.8-mm stapler. The gastric conduit is then sutured to the transected stomach for retrieval later in the chest. A Heineke-Mikulicz pyloroplasty is fashioned in selected cases. Using a seldinger technique a 9-Fr feeding jejunostomy is inserted into the jejunum and secured to the anterior abdominal wall with a purse-string suture. (II) Stage II: a 5-post thoracoscopy is performed in the left lateral decubitus position. The oesophagus is fully mobilized to the thoracic inlet and an en bloc lymphadenectomy is performed of the paraesophageal, subcarinal, right and left bronchial and lower paratracheal lymph node stations. The 9th intercostal port site is converted to a 3–4 cm mini-thoracotomy. A 28 mm circular anvil is placed in the proximal oesophagus and secured with a purse-string suture. A gastrotomy is made in the tip of the gastric conduit through which an EEA circular stapler is inserted. An esophagogastric end-to-side anastomosis is fashioned and the redundant fundal tissue excised with a linear stapler. A 16 French chest tube is placed prior to closure of the wounds. MIO has been successfully implemented in the Mercy University Hospital with a median length of stay of 8 days and an in-hospital mortality of 3.5%.

Gall Bladder Cancer - Is the Stage Set? Yet!

The current TNM staging of gall bladder cancer (GBC) has some shortcomings. We propose some changes in the current TNM staging of GBC. We propose that involvement of muscularis propria should be classified as T2 (instead of current T1b) and stage grouped as II (instead of current I). T4 in GBC should be subdivided into T4a (perforation of serosa, involvement of omentum, CBD, stomach/duodenum and colon) and T4b (involvement of pancreas, hepatic artery and portal vein). Hepato-duodenal ligament lymph nodes alone should be classified as N1; periduodenal, peripancreatic and common hepatic artery lymph nodes should be classified as N2 and stage grouped as IVA; non-regional (distant) lymph nodes should be classified as M1a and distant (non-nodal) metastases should be classified as M1b. We also propose changes in the TNM stage grouping of GBC – stage I (T1 N0 M0), II (T2 N0 M0), III (T3 N0 M0, T1-3 N1 M0) and IV (T4 Any N M0, Any T N2 M0, Any T Any N M1). Tumors at GB neck are difficult to resect and have poorer prognosis even after resection. Surgical obstructive jaundice (SOJ) in GBC makes resection difficult and is associated with poorer prognosis even after resection. We also propose inclusion of non TNM factors viz. site of tumor (fundus/body or neck) and SOJ in staging of GBC.

Synchronous multiple primary gallbladder and gastric malignancies: Report of two cases and review of the literature

Multiple primary malignancies (MPM) are rare. In particular, synchronous gallbladder and gastric malignancies are extremely rare, are associated with a concealed onset and atypical symptoms, and are highly likely to be overlooked or misdiagnosed. The clinical data of two patients with synchronous gallbladder and gastric malignancies are herein reported and integrated with the relevant literature to retrospectively analyze and summarize the pathogenesis and clinical characteristics of MPM. Case 1 was a male 46-year-old patient who underwent laparoscopic cholecystectomy, and succumbed to extensive tumor metastasis 2 months after the operation. Case 2 was an 80-year-old female patient who was treated with distal gastrectomy for gastric cancer, cholecystectomy, gastrojejunostomy and dissection of 5 suprapyloric, 6 subpyloric, 7 left gastric and 8 common hepatic artery lymph nodes, and succumbed to multiple organ failure induced by extensive tumor invasion within 1 week after the operation. Clinical physicians must pay closer attention to early symptoms of MPM in order to make an accurate diagnosis, perform timely radical surgical treatment and achieve favorable therapeutic outcomes, in terms of significantly increasing long-term patient survival rates.

Extended Lymphadenectomy Is Required for Incidental Gallbladder Cancer Independent of Cystic Duct Lymph Node Status

BackgroundWe examined whether the incidental cystic duct nodal status predicts the status of the hepatoduodenal ligament (D1) or common hepatic artery, the pancreaticoduodenal and paraaortic lymph nodes (D2), and the overall prognosis and thus indicates whether an oncologic extended resection (OER) is required. MethodsThe study included patients who underwent OER for incidental gallbladder cancer (IGBC) during 1999–2015. Associations between a positive cystic duct node and D2 nodal status and disease-specific survival (DSS) were analyzed. ResultsOne-hundred-eight-seven patients were included. Seventy-three patients (39%) had the incidental cystic duct node retrieved. Cystic duct node positivity was associated with positive D1 (odds ratio 5.2, p = 0.012) but not with D2. Among all patients, a positive cystic duct node was associated with worse DSS (hazard ratio [HR] 2.09). Patients without residual cancer at OER and positive incidental cystic duct node had similar DSS to patients with negative nodes 70 vs 60% (p = 0.337). Positive D1 (HR 6.07) or positive D2 (HR 13.8) was predictive of worse DSS. ConclusionsPatients with no residual cancer at OER and regional disease limited to their incidental cystic duct node have similar DSS to pN0 patients. The status of the cystic duct node only predicts the status of hepatic pedicle nodes.

Lymph node metastasis in gastric cancer: Location of positive station to predict survival after preoperative therapy.

166 Background: We sought to determine the association between the identification of positive lymph nodes on D2 lymph node dissection (LND) with stage and outcomes, in the era of preoperative treatment for gastric cancer. Methods: We reviewed data from a prospectively maintained database of gastric cancer patients who underwent resection of gastric or gastroesophageal cancer at our institution from 2005-2016. Central lymph nodes (CnLN) were defined as common hepatic, celiac, and proximal splenic artery lymph nodes (stations #8, 9, and 11p). Risk factors for CnLN metastases, and overall survival (OS) were examined. Results: We identified 356 patients, median age was 64 years (IQR 54-71) and 59% were male. Preoperative therapy was given in 66% of patients. D2 LND was performed in 80% of patients, and the median number of LN examined was 25 (IQR 18-34). Most patients (N = 244, 68%) had separately-examined CnLN in pathology and the median number of examined LNs was higher in this group (27 vs 19; p &lt; 0.001). The CnLN positivity rate was 9.1% (22/244; #8: 4.8%, #9: 6.1%, and #11p: 4.8%), which was higher in advanced pT stage patients (pT0 - 3%, pT1 - 0%, pT2 - 6%, pT3 - 18%, pT4 - 13%; p = 0.001). If we assume that D2 LND was not performed on these patients, a total of 7 (3%, 7/244) patients would have had pN stage down-migration (6 with N1 to N0, 1 with N2 to N1). Of the 22 CnLN-positive patients, 10 (45%) had pN1, 2 (9%) had pN2, and 10 (45%) had pN3 stages. On multivariate analysis, EUS N stage (positive) was associated with positive CnLNs (OR 2.86 [95%CI 1.08-7.58]). Among 342 patients who had R0 resection, the median follow-up was 3.6 years, and the median OS was 11.6 years. Among patients who received preoperative therapy, pT3/4 stage (HR 2.44 [1.27-4.69]; p = 0.01) and positive CnLN (HR 5.44 [2.36-12.52]; p &lt; 0.001) were negatively associated with OS by multivariate analysis. Conclusions: CnLN metastases are uncommon in gastric cancer, and are associated with an adverse impact on OS. However, long-term survival is still possible in patients with positive CnLN whom underwent a D2 lymph node dissection. Larger multi-institutional studies are needed to determine if CnLN positivity requires a separate staging category.

MicroRNA Expression in a Readily Accessible Common Hepatic Artery Lymph Node Predicts Time to Pancreatic Cancer Recurrence Postresection

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.

Long-term survival of a recurrent gallbladder carcinoma patient with lymph node and peritoneal metastases after multidisciplinary treatments: a case report.

BackgroundGallbladder carcinoma with peritoneal metastasis has a poor prognosis, with a median survival time of 4.8 months. We report the survival of a patient with gallbladder carcinoma with peritoneal metastasis for 7.6 months owing to treatment with tumor resection after chemoradiotherapy.Case presentationA 69-year-old man was referred to our hospital for gallbladder carcinoma with hepatic invasion. Cholecystectomy was performed along with S4a and S5 hepatectomy and extrahepatic bile duct resection with lymph node dissection. The postoperative pathological diagnosis was moderately differentiated adenocarcinoma, T3, N0, M0, stage IIIA by the International Union Against Cancer TNM classification. Despite treatment with gemcitabine, the common hepatic artery and para-aortic lymph nodes showed metastases after 3 months from surgery. Although a combination of cisplatin, gemcitabine, and radiotherapy reduced the size of the lymph node metastasis, the peritoneal metastasis persisted. The peritoneal metastasis responded to chemoradiotherapy using tegafur-uracil and leucovorin, but it recurred. The metastasis was resected after 3 years and 9 months from the first surgery, and chemotherapy was discontinued. Seven years and 6 months after the initial surgery, the patient exhibited no signs of tumor recurrence or metastasis.ConclusionsMultidisciplinary treatment including resection without residual tumors could achieve complete remission of gallbladder carcinoma with lymph node and peritoneal metastases in the selected patient.

MicroRNA expression in common hepatic artery lymph nodes as a prognostic marker in pancreatic ductal adenocarcinoma

MicroRNA expression in common hepatic artery lymph nodes as a prognostic marker in pancreatic ductal adenocarcinoma

Extent of lymph node dissection: common hepatic artery lymph node dissection can be omitted for esophageal squamous cell carcinoma.

Controversy persists regarding the adequate extent of lymph node (LN) dissection in thoracic esophageal cancer (EC) surgery. Oncologic efficacy should be balanced with the increased risk of postoperative complications after aggressive radical LN dissection. Here, we evaluate the effectiveness of common hepatic artery LN dissection in surgery for thoracic esophageal squamous cell carcinoma. Among a total of 1,563 EC patients who underwent surgery from May 2005 to December 2012 at the Fudan University Shanghai Cancer Center, 1,248 thoracic esophageal squamous cell carcinoma were selected for this study, including 682 patients who underwent esophagectomy with common hepatic artery LN dissection and 566 patients who underwent esophagectomy without common hepatic artery LN dissection. The clinical data of patients were retrospectively analyzed. In addition, the locoregional LN metastasis, relationship between metastatic rates of common hepatic artery LN and clinicopathological factors were analyzed. A propensity score match analysis were performed to control for potential differences in the characteristics of patients with EC cell carcinoma, and postoperative complications were analyzed after propensity score-matching. The metastatic rate of common hepatic LN was 3.5%. Logistic regression analysis revealed tumor diameter, N classification and pTNM stage were risk factors for common hepatic LN metastasis. Matching based on propensity scores produced 361 patients in each group. The overall incidence of postoperative complications was 32.70% and 35.45%, respectively, no significant difference was found (P=0.432). The metastatic rate of common hepatic artery LN is low. For patients who undergo resection for Stage I thoracic esophageal squamous cell carcinoma, the dissection of common hepatic artery LN may be safely omitted.

Discussion on the strategies of common hepatic artery lymph node dissection for thoracic esophageal squamous cell carcinoma

Objective To analyze the metastatic rule of common hepatic artery lymph node of thoracic esophageal squamous cell carcinoma,and to investigate the strategies of common hepatic artery lymph node dissection.Methods The clinical data of 682 patients with esophageal squamous cell carcinoma who were admitted to the Cancer Hospital of Fudan University from May 2005 to December 2010 were retrospectively analyzed.The locoregional lymph node metastasis of thoracic esophageal squamous cell carcinoma,relationship between metastatic rates of common hepatic artery lymph node and clinicopathological factors and the postoperative complications were analyzed.The enumeration data were analyzed using the chi-square test.Results A total of 18 277 lymph nodes were dissected (27 lymph nodes per patient).The lymph node metastatic rate was 55.87％ (381/682),and the metastatic lymph node ratio was 7.87％ (1438/18 277).Lymph nodes adjacent to the cardia of stomach,laryngeal nerve,lesser curvature of stomach,cervical esophagus,left gastric artery had a higher metastatic rate,while common hepatic artery lymph node had a lower metastatic rate.All the common hepatic artery lymph node metastasis was accompanied with locoregional metastasis.A total of 1480 common hepatic artery lymph nodes were dissected (2 common hepatic artery lymph nodes per patient).Twenty-four patients had common hepatic artery lymph node metastasis,with the metastatic rate of 3.52％ (24/682) and the lymph node ratio of 2.16％ (32/1480).The common hepatic artery lymph node metastatic rates of upper,middle and lower esophageal squamous cell carcinoma were 2.33％ (1/43),3.76％ (16/425) and 3.27％ (7/217),with no significant difference (x2 =0.295,P ＞ 0.05).The common hepatic artery lymph node metastatic rates of patients in T1,T2 and T3 stages were 2.35％ (2/85),5.46％ (10/183) and 2.90％ (12/414),with no significant difference (x2 =2.850,P ＞ 0.05).The common hepatic artery lymph node metastatic rates of patients with high,moderate and poor differentiated esophageal squamous cell carcinoma were 0(0/63),3.50％ (16/457) and 4.94％ (8/162),with no significant difference (x2=3.259,P ＞ 0.05).The common hepatic artery lymph node metastatic rates of patients with diameter of tumor under 3 cm,3-5 cm and above 5 cm were 2.59％ (6/232),3.02％ (11/364) and 8.14％ (7/86),with significant difference (x2 =6.267,P ＜ 0.05).The common hepatic artery lymph node metastatic rates of patients in N0,N1,N2,N3 stages were 0(0/301),2.53％ (5/198),5.65％ (7/124) and 20.34％ (12/56),with significant difference (x2 =62.368,P ＜ 0.05).The common hepatic artery lymph node metastatic rates of patients in stage Ⅰ,Ⅱ,Ⅲ and Ⅳ were 0(0/62),1.78％ (6/337),5.06％ (13/257) and 19.23％ (5/26),with significant difference (x2=25.959,P ＜0.05).Two hundred and twenty-eight patients had postoperative complications with the complication rate of 33.43％ (228/682).The incidence of anastomotic fistula was the highest,which was 11.58％(79/682).Conclusions The metastatic rates of common hepatic artery lymph node in thoracic esophageal squamous cell carcinoma is the lowest.For patients suffered from esophageal cancer in stage I or the tumor diameter under 5 cm,the dissection of common hepatic lymph node can be ommitted in surgery. Key words: Esophageal neoplasms; Common hepatic artery lymph node; Lymph node dissection

Can common hepatic artery lymph node dissection be safely omitted in surgery for clinical T1N0 thoracic esophageal squamous cell carcinoma?

Common hepatic artery lymph node dissection is regarded as a standard procedure in esophageal cancer surgery because of aggressive lymphatic dissemination of esophageal cancer. However, lymph node dissection can prolong operation time and may be associated with complications such as chylous ascites. Here, we aimed to evaluate the effectiveness of common hepatic artery lymph node dissection in clinical T1N0 thoracic esophageal squamous cell carcinoma. Between 1996 and 2009, 1390 patients underwent surgery for esophageal cancer in our institution, and 209 were found to have clinical T1N0 disease. Exclusion criteria were nonsquamous carcinoma, double primary cancer, definite distant metastasis, administration of neoadjuvant treatment, and incomplete abdominal lymph node dissection. We retrospectively analyzed medical records, operative and pathologic data, and follow-up information. Forty-two patients were excluded from the study. Among the 167 enrolled patients, preoperative endoscopic ultrasound evaluation was performed in 160 patients. Fifty-two patients had distal esophageal or esophagogastric junction tumor. Surgery included 2 cases of tri-incisional esophagectomy, 17 cases of transhiatal esophagectomy, and 148 cases of two-field esophagectomy (Ivor Lewis operation). Common hepatic artery lymph node dissection was performed in all cases, and none of the patients had metastasis. Mean follow-up period was 35.4 ± 28.7 months. In-hospital mortality was one, and 5-year survival rate was 80.6%. Among the 15 patients with recurrence, there were two distant metastases and five distant and local recurrences but no intra-abdominal recurrence with common hepatic artery lymph node. Common hepatic artery lymph node dissection may be safely omitted in surgery for clinical T1N0 esophageal squamous cell carcinoma when preoperative evaluations including chest computed tomography, positron emission tomography and computed tomography, and esophagogastroduodenoscopy or endoscopic ultrasound are performed.

Study on the clinicopathological characteristics and pattern of lymph node metastasis in patients with gastric remnant cancer

To investigate clinicopathological characteristics and the pattern of lymph node metastasis of patients with gastric remnant cancer. The data of the clinicopathological characteristics and the pattern of lymph node metastasis in 56 patients with gastric remnant cancer treated from March 1994 to December 2008 was investigated and compared with those in 1171 patients with primary gastric cancer treated over the same period. Fifty-six patients (4.6%) with gastric remnant cancer were enrolled in this study during the period. Compared with patients with primary gastric cancer, the age of cancer onset was older [(64.3+/-9.0) vs. (58.3+/-12.6) yrs], lymph node metastasis rate was higher (31.8% vs. 25.5%), Borrmann's classification was later and neighbor organ resection rate was higher (57.1% vs. 26.4%) in patients with gastric remnant cancer; the differences were all significant (chi2=18.800, 11.679, 9.177, 25.190; P<0.05). Patients with gastric remnant cancer who underwent lymph node dissection tended to have a higher incidence of No.10 (splenic hilar lymph node) and No.11 (splenic artery lymph node) group lymph node metastasis than those in primary gastric cancer (chi2=5.558, 6.099; P<0.05). In contrast, patients with primary gastric cancer had a higher incidence of No. 2 (left cardiac lymph node), No.3 (lesser curvature lymph node) and No.8 (common hepatic artery lymph node) group lymph node metastasis than those in gastric remnant cancer (chi2=15.508, 6.003, 4.084; P<0.05). The jejunal mesentery lymph node metastasis was 24.0% (6/25) in patients with gastric remnant cancer and the peripheral connective tissue infiltration rate was 14.3% (8/56). It suggested that patients with gastric remnant cancer has different clinicopathologic characteristics and the pattern of lymph node metastasis from those with primary gastric cancer. D2 lymph node dissection of proximate gastric cancer and jejunal mesentery lymph node dissection should be the standard operation for these patients; but combined neighboring organ resection should be taken into consideration.