Extended Lymphadenectomy Group Research Articles

Extended lymphadenectomy benefits patients with borderline resectable pancreatic head cancer-a single-center retrospective study.

Whether standard lymphadenectomy or extended lymphadenectomy should be performed is still under debate during pancreaticoduodenectomy (PD). We aimed to compare their morbidity and mortality rates among patients with pancreatic head cancer (PHC). In this retrospective study, a total of 322 patients were enrolled. According to the scope of intraoperative lymph node dissection, patients were divided into extended lymphadenectomy group (n=120) and standard lymphadenectomy group (n=202). Based on the resectability of the tumor, there were 198 cases of resectable PHC and 124 cases of borderline resectable PHC, respectively, in which further stratified analysis was carried out according to the extent of lymph node dissection. All patients completed the operation successfully, with a perioperative morbidity rate of 27.9% and mortality rate of 0.9%. As for the overall patients, patients in the extended lymphadenectomy group had higher neutrophil-to-lymphocyte ratio (NLR), longer operation time, more intraoperative blood loss, lymph node dissection and patients with borderline resectable pancreatic head cancer (BRPHC) (P<0.05). The 1-, 2- and 3-year overall survival rates of patients with extended lymphadenectomy and standard lymphadenectomy were 71.9%, 50.6%, 30.0% and 70.0%, 32.9%, 21.5%, respectively (P=0.068). With regards to patients with BRPHC, the number of lymph node dissection in the extended lymphadenectomy group was more (P<0.05), and the 1-, 2- and 3-year overall survival rates of patients with extended lymphadenectomy and standard lymphadenectomy were 60.7%, 43.3%, 27.4% and 43.2%, 17.7%, 17.7%, respectively (P=0.007). Patients with BRPHC tended to have vast lymph node metastasis. Extended lymphadenectomy can improve their long-term survival.

Optimal extent of lymphadenectomy for radical surgery of pancreatic head adenocarcinoma: 2-year survival rate results of single-center, prospective, randomized controlled study.

Background:Radical pancreaticoduodenectomy is the only possible cure for pancreatic head adenocarcinoma, and although several RCT studies have suggested the extent of lymph node dissection, this issue remains controversial. This article wanted to evaluate the survival benefit of different lymph node dissection extent for radical surgical treatment of pancreatic head adenocarcinoma.Methods:A total of 240 patients were assessed for eligibility in the study, 212 of whom were randomly divided into standard lymphadenectomy group (SG) or extended lymphadenectomy group (EG), there were 97 patients in SG and 95 patients in EG receiving the radical pancreaticoduodenectomy.Result:The demography, histopathology and clinical characteristics were similar between the 2 groups. The 2-year overall survival rate in the SG was higher than the EG (39.5% vs 25.3%; P = .034). The 2-year overall survival rate in the SG who received postoperative adjuvant chemotherapy was higher than the EG (60.7% vs 37.1%; P = .021). There was no significant difference in the overall incidence of complications between the 2 groups (P = .502). The overall recurrence rate in the SG and EG (70.7% vs 77.5%; P = .349), and the patterns of recurrence between 2 groups were no significant differences.Conclusion:In multimodality therapy system, the efficacy of chemotherapy should be based on the appropriate lymphadenectomy extent, and the standard extent of lymphadenectomy is optimal for resectable pancreatic head adenocarcinoma. The postoperative slowing of peripheral blood lymphocyte recovery might be 1 of the reasons why extended lymphadenectomy did not result in survival benefits.Clinical trial registration:This trial was registered at ClinicalTrials.gov (NCT02928081) in October 7, 2016. https://clinicaltrials.gov/

Esophageal squamous cell carcinoma patients with positive lymph nodes benefit from extended radical lymphadenectomy

BackgroundThe usefulness of lymphadenectomy for advanced esophageal cancer is unclear. A post-hoc subgroup analysis involving a randomized controlled trial was performed to compare the long-term survival of patients with esophageal cancer and lymph nodes metastasis (LNM) after extended lymphadenectomy via the right thoracic approach with that of those undergoing limited lymphadenectomy via the left thoracic approach. MethodsBetween May 2010 and July 2012, 300 patients with thoracic esophageal cancer were randomized to undergo esophagectomy through either the right or left thoracic approach. Of these patients, 129 with esophageal squamous cell carcinoma and LNM by postoperative pathology were included in this analysis. Disease-free survival and overall survival (OS) were compared between the extended (n = 64) and limited (n = 65) lymphadenectomy groups after 5 years’ follow-up. Cox regression analysis was used to identify the factors associated with OS. ResultsThe 5-year disease-free survival rates were 40% and 26% in the extended and limited lymphadenectomy groups, respectively (hazard ratio [HR], 1.542; 95% confidence interval [CI], 1.018-2.335; P = .037), and the 5-year OS rates were 51% and 31%, respectively (HR, 1.719; 95% CI, 1.111-2.660; P = .013). The extended lymphadenectomy group had less locoregional recurrence (HR, 0.583; 95% CI, 0.375-0.908; P = .015) and delayed distant metastasis (HR, 1.407; 95% CI, 0.914-2.167; P = .115). Reduced OS was associated with limited lymphadenectomy, R1/2 resection margins, TNM stage IV, and lack of postoperative adjuvant therapy, as per the Cox regression analysis. ConclusionsImproved long-term survival was observed in patients with esophageal squamous cell carcinoma and LNM after extended lymphadenectomy via the right thoracic approach.

Systematic review and Meta-analysis of intraoperative lymphadenectomy in pancreatic cancer

Objective To compare the incidence of postoperative complications and long-term survival rates in head cancer with and lymphadenectomy, and conclude an appropriate cleaning range. Methods Published randomized controlled trials about with (ELPD) vs (SLPD)in cancer patients on Pubmed, Embase and the Cochrane library were retrieved from database building to October 1st 2017 with the keywords including pancreatoduonectomy pancreatic adenocarcinoma whipple lymphadenectomy extended and standard . Obtained literatures were screened independently by two researchers(the PRISMA statement). After included literatures reviewed and data extracted, a meta-analysis was carried out using Revman 5.3 software. Results A total of 7 RCTs were included in the analysis, and the total number of cases was 850, of which 426 cases were lymph node dissection and 424 were standard. The results showed that the ELPD group had longer operation time (373.1 min and 318.4 min, respectively, P=0.003), increased intraoperative bleeding and blood transfusion (681.5 ml and 556.2 ml, respectively, P= 0.03). The incidence rate of postoperative complications (40.8% and 28.9%, respectively, P=0.0006) and the delayed gastric emptying (16.2% and 10.0%, P= 0.02), postoperative hospitalization time (19.7 d and 15.0 d, P<0.05) also increased in ELPD group. At the same time, the 1-、3-、5-year survival rate (66.0% and 70.8%, P=0.17; 24.7% and 27.5%, P=0.41; 16.6% and 14.3%, respectively, P=0.45) was not improved in cancer patients. Conclusion ELPD increase the postoperative complications and prolong the hospital stay of cancer patients and did not improve postoperative survival rate at the same time, SLPD should be preferred during the operation. By summarizing the latest research progress. Key words: Pancreatic neoplasms; Pancreaticoduodenectomy; Lymph node excision; Meta-analysis

Diagnostic yield and complications of extended lymphadenectomy versus limited lymphadenectomy combined with radical prostatectomy

BackgroundLymphadenectomy for prostate cancer (PC) is the most reliable procedure for detecting lymphatic metastases. The optimal extension of this procedure is still a topic of debate. ObjectiveTo analyze the diagnostic performance and complications of extended lymphadenectomy (ELD) and limited lymphadenectomy (LLD) in a series of patients with high-risk PC who underwent radical prostatectomy (RP). Material and methodsA retrospective study was conducted on patients with high d’Amico risk who underwent RP with lymphadenectomy between 1999 and 2014.A comparative analysis was performed of the diagnostic capacity of lymphatic metastases of ELD and LLD and of postoperative complications at 90 days. ResultsNinety-three patients were analyzed, 20 (21.5%) and 73 (78.5%) of whom underwent ELD and LLD, respectively. The mean age of the series was 65.26 years (SD, 5.51). The median follow-up was 1.51 (0.61–2.29) years in the ELD group and 5.94 (3.61–9.10) in the LLD group.The median number of nodes obtained was 13 (9–23) in the ELD group compared with 5 (2–8) in the LLD group (p<.001). The percentages of patients with positive nodes in the ELD and LLD groups were 35% and 5.47%, respectively (p<.001).The overall complication rate at 90 days was 35.5% (33 patients). In the ELD group, 12 patients (60%) had complications, compared with 21 patients (28.8%) in the LLD group (p=.016), with no significant differences in severity according to the Clavien scale (p=.73). ConclusionsIn our series, the detection of metastatic nodes was significantly greater with ELD. ELD increases the number of complications, with no differences compared with LLD in severity according to the modified Clavien scale.

Rentabilidad diagnóstica y complicaciones de la linfadenectomía ampliada frente a la limitada asociada a prostatectomía radical

BackgroundLymphadenectomy for prostate cancer (PC) is the most reliable procedure for detecting lymphatic metastases. The optimal extension of this procedure is still a topic of debate. ObjectiveTo analyse the diagnostic performance and complications of extended lymphadenectomy (ELD) and limited lymphadenectomy (LLD) in a series of patients with high-risk PC who underwent radical prostatectomy (RP). Material and methodsA retrospective study was conducted on patients with high d’Amico risk who underwent RP with lymphadenectomy between 1999 and 2014.A comparative analysis was performed of the diagnostic capacity of lymphatic metastases of ELD and LLD and of postoperative complications at 90 days. ResultsNinety-three patients were analysed, 20 (21.5%) and 73 (78.5%) of whom underwent ELD and LLD, respectively. The mean age of the series was 65.26 years (SD, 5.51). The median follow-up was 1.51 (0.61–2.29) years in the ELD group and 5.94 (3.61–9.10) in the LLD group.The median number of nodes obtained was 13 (9–23) in the ELD group compared with 5 (2–8) in the LLD group (p <.001). The percentages of patients with positive nodes in the ELD and LLD groups were 35% and 5.47%, respectively (p <.001).The overall complication rate at 90 days was 35.5% (33 patients). In the ELD group, 12 patients (60%) had complications, compared with 21 patients (28.8%) in the LLD group (p=.016), with no significant differences in severity according to the Clavien scale (p=.73). ConclusionsIn our series, the detection of metastatic nodes was significantly greater with ELD. ELD increases the number of complications, with no differences compared with LLD in severity according to the modified Clavien scale.

Comparaison de la morbidité entre curage étendu et curage limité au cours de la prostatectomie radicale laparoscopique

To compare the morbidity of limited pelvic lymphadenectomy to extended lymphadenectomy in patients undergoing LRP (Laparoscopic Radical Prostatectomy) for clinically localized prostate cancer.We performed a prospective monocentric study focused on 303 consecutive patients having a pelvic lymphadenectomy during LRP from June 2000 to April 2010. One hundred and seventy six patients had a limited pelvic lymphadenectomy (June 2000-June 2006, group 1). One hundred and twenty seven patients had an extended pelvis lymphadenectomy (June 2006-April 2010, group 2) including two sub-groups according to the lateral limit of the procedure i.e. with (group 2a, 60 patients) or without dissection of the lateral side of the iliac artery (group 2b, 67 patients).Preoperative data (age, BMI, cTNM, Gleason score and PSA) were comparable between the groups. The number of lymph nodes and the incidence of metastatic lymph nodes were lower in group 1 (6,7 lymph nodes and 5,7%) compared to group 2 (a+b) (15.6 lymph nodes and 18.9%) (P=0.001 and P=0.0004). However, there was no difference between groups 2a and 2b (15.4 and 16.7% vs 15,8 and 20.8% P=0.65 respectively). There were more complications in the extended lymphadenectomy group compared to the limited procedure (35.4% vs 14.2%, P=0.0001), in particular more lymphatic complications (27.5% vs 10.2% P=0.0001) and lymphoedema (LO) (15.7% vs 0.6% P=0.00001). However the lymphorhea (LR) and lymphocele (LC) rate was not different (P=0.11 and P=0.17). All complications were mainly of low Clavien's classification grade (1+2) whatever the group of lymphadenectomy. The hospital stay was not increased in group 2a or 2b in regard to group 1. The rate of LR and LC was higher in group 2a than in group 1 (P=0.02 and P=0.05) but not between group 2b and 1 (P=0.81 and P=0.47).Our study showed a higher rate of complications after extended pelvic lymphadenectomy but of low grade in most cases. Moreover the lateral dissection sparing the lateral side of the iliac artery reduced the risk of lymphatic complications without decreasing the number of lymph nodes removed and the rate of metastasis.

Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas

The value of pancreatoduodenectomy (PD) with extended lymphadenectomy for pancreatic cancer has been evaluated by many retrospective studies and 3 randomized controlled trials (RCT). However, the protocols used and the results found in the 3 RCTs were diverse. Therefore, a multicenter RCT was proposed in 1998 to evaluate the primary end point of long-term survival and the secondary end points of morbidity, mortality and quality of life of patients undergoing standard versus extended lymphadenectomy in radical PD for pancreatic cancer. From March 2000 to May 2003, 112 patients with potentially curable pancreatic head cancer were enrolled and intraoperatively randomized to a standard or extended lymphadenectomy group. No resected patients received any adjuvant treatments. A hundred and one eligible patients were analyzed. Demographic and histopathological characteristics of the two groups were similar. The mean operating time, intraoperative blood loss and number of retrieved lymph nodes were greater in the extended group, but the other operative results were comparable. Although this multicenter RCT was conducted in a strict setting, extended lymphadenectomy in radical PD did not benefit long-term survival in patients with resectable pancreatic head cancer and led to levels of morbidity, mortality and quality of life comparable to those found after standard lymphadenectomy.

Does the Extent of Lymphadenectomy in Radical Cystectomy for Bladder Cancer Influence Disease-Free Survival? A Prospective Single-Center Study

BackgroundControversy exists regarding the optimal extent of lymphadenectomy and the number of lymph nodes to be retrieved at radical cystectomy (RC). ObjectiveTo compare the disease-free survival of patients with standard lymphadenectomy (endopelvic region composed of the internal, external iliac, and obturator groups of lymph nodes) versus extended lymphadenectomy (up to the level of origin of the inferior mesenteric artery) at RC in a prospective cohort of patients at a single, high-volume center. Design, setting, and participantsProspective data were collected from 400 consecutive patients treated with RC for bladder cancer by two high-volume surgeons at Mansoura Urology and Nephrology Center. Of the 400 patients, 200 (50%) received extended lymphadenectomy and the other 200 (50%) underwent standard lymphadenectomy at RC. The patients did not receive any neoadjuvant or adjuvant therapy. MeasurementsPatient characteristics and outcomes are evaluated. Results and limitationsMedian patient age for the entire group was 53.0 yr. Ninety-six patients (24.0%) had lymph node metastases. Median follow-up was 50.2 mo. Estimates of 5-yr disease-free survival in the extended lymphadenectomy group were 66.6% compared with 54.7% for patients with standard lymphadenectomy (p=0.043). Extended lymphadenectomy was associated with better disease-free survival after adjusting for the effects of standard pathologic features (p=0.02). When restricting the analyses to lymph node–positive patients, patients with extended lymphadenectomy had much better 5-yr disease-free survival compared with patients with standard lymphadenectomy (48.0% vs 28.2%; p=0.029). The study was nonrandomized. ConclusionsExtended lymphadenectomy is associated with better disease-free survival for bladder cancer patients with endopelvic lymph node involvement and should be considered in these patients.

Lateral pelvic lymph-node dissection: still an option for cure

114 www.thelancet.com/oncology Vol 11 February 2010 We read with great interest the article “Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis” by Georgiou and colleagues in The Lancet Oncology. However, we have to disagree with the methodology and conclusions. The title of the paper suggests that the authors did a meta-analysis and concluded that extended lymphadenectomy does not confer a signifi cant oncological advantage, and is associated with increased genito-urinary dysfunction, compared with conventional surgery. However, there are some fundamental problems with the methods used which result in some misleading conclusions. The main issue revolves around the validity of doing a meta-analysis on disparate groups. With the exception of the single small randomised study, the extended lymphadenectomy group undoubtedly had more advanced tumours—ie, larger (higher T stage), nodepositive, and more aggressive pathology—compared with the non-extended lymphadenectomy group. Therefore, one cannot “meta-analyse” these entirely diff erent groups. In fact we would interpret the results as the exact opposite to the authors’ conclusion: the extended lymphadenectomy group benefi ted substantially, as the survival and local recurrence were the same despite the more advanced nature of the disease. Furthermore, the time period of this review is very long (1984–2007). Over the past two decades, as Moriya argued in his article in the same issue of The Lancet Oncology, there have been substantial changes in the Japanese approach to treating rectal cancer in terms of indication criteria and the techniques used. Extended lymphadenectomy for upper rectal cancer has practically been abandoned, and Japanese surgeons are far more selective in the indications for extended lymphadenectomy using meticulous analysis of their experiences, and outcomes, and using modern imaging techniques. Additionally, nerve-sparing techniques have recently been developed and refi ned with markedly improved function. Based on a large recent multicentre study and other reports, we strongly believe that recent refi nements and optimal extended lymphadenectomy might be benefi cial to selected patients, particularly with low rectal cancer, and perhaps equivalent or better than pre-operative chemoradiotherapy and standard total mesorectal excision. The misinterpretation of the data in Lateral pelvic lymph-node dissection: still an option for cure

Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis

Lateral pelvic lymph-node metastases occur in 10-25% of patients with rectal cancer, and are associated with higher local recurrence and reduced survival rates. A meta-analysis was undertaken to assess the value of extended lateral pelvic lymphadenectomy in the operative management of rectal cancer. We searched Medline, Embase, Ovid, Cochrane Library, and Google Scholar for studies published between 1965 and 2009 that compared extended lymphadenectomy (EL) with standard rectal resection. 20 studies, which included 5502 patients from one randomised, three prospective non-randomised, and 14 retrospective case-control studies published between 1984 and 2009, met our search criteria and were assessed. 2577 patients underwent EL and 2925 underwent non-EL for rectal cancer. Random and fixed-effects meta-analytical models were used where indicated, and between-study heterogeneity was assessed. End-points evaluated included peri-operative outcomes, 5-year survival and recurrence rates. Operating time was significantly longer in the EL group by 76.7 min (95% CI 18.77-134.68; p=0.0096). Intra-operative blood loss was greater in the EL group by 536.5 mL (95% CI 353.7-719.2; p<0.0001). Peri-operative mortality (OR 0.81, 95% CI 0.34-1.93; p=0.63) and morbidity (OR 1.45, 95% CI 0.89-2.35; p=0.13) were similar between the two groups. Data from individual studies showed that male sexual dysfunction and urinary dysfunction (three studies: OR 3.70, 95% CI 1.66-8.23; p=0.0012) were more prevalent in the EL group. There were no significant differences in 5-year survival (hazard ratio [HR] 1.09, 95% CI 0.78-1.50; p=0.62), 5-year disease-free survival (HR 1.23, 95% CI 0.75-2.03, p=0.41), and local (OR 0.83, 95% CI 0.61-1.13; p=0.23) or distant recurrence (OR 0.93, 95% CI 0.72-1.21; p=0.60). Extended lymphadenectomy does not seem to confer a significant overall cancer-specific advantage, but does seem to be associated with increased urinary and sexual dysfunction.

Lymphadenectomy in carcinoma stomach: Experience from a regional cancer centre

14121 Background: Carcinoma stomach is the most common cancer in males in chennai city. Lot of controversy exists regarding the need for extended lymphadenectomy because of the morbidity and mortality associated. Methods: A retrospective analysis was done to assess the benefit of extended lymphadenectomy. The records of all the patients operated at Cancer Institute from 1991 to 2004 were analysed. Out of 5050 cases of carcinoma stomach seen, only 570 cases were taken up for some form of treatment. 400 cases underwent resection, of which 366 patients records were retreived from the tumor registry for analysis. Followup ranged from 1 year to 10 years. Results: Male to female ratio was 3:1, most patients were in 40 - 60 year age group (60%). 60% patients had antral tumors and the rest were evenly distributed. 79 patients (21%) underwent conventional gastrectomy (D1), 243 patients (66%) underwent extended lymphadenectomy and 44 patients (12%)underwent palliative gastrectomy. 280 patients underwent subtotal gastrectomy, 54 patients total gastrectomy, 28 esophago gastrectomy and 5 had transhiatal esophagectomies. Stage wise distribution was IA 4.9%, IB 9.8%, II 21%, IIIA 29.4%, IIIB 12.8%, IV 22.1%. The total number of nodes dissected in the Extended nodal dissection group was less than or equal to 15 in 12% patients, 15 to 30 nodes in 48% patients and &gt;30 nodes in 40% patients. 72% patients had node positive disease. Overall Survival at 5years was 38.9% for all the cases. 5year ovarall survival for conventional gastrectomy group was 37% and was 48% for the extended lymphadenectomy group which was statistically significant(p =0.06) .On substratification for T status and stage, the difference in survival between conventional and extended lymphadenectomy arms was not found to be significant.However,there was a trend towards improved survival in the lymphadenectomy arm.There were 7 post operative deaths in the lymphadenectomy arm,5 of which were in the first year of starting extended lymphadenectomies, which points to the learning curve for these procedures. Conclusions: Larger trials may be required to prove the advantage of extended lymphadenectomies in Gastric cancer. In addition neoadjuvant chemotherapy and Intraoperative radiotherapy may need to be studied to improve survival in gastric cancer. No significant financial relationships to disclose.