Prognostic value of examined lymph node count in patients with lymph node negative pancreatic head carcinoma: A single-center experience
Keywords:Lymph node ratio, Regional lymphadenectomy, Whipple
Background/Aim: One of the important prognostic factors for pancreatic cancer is the count of examined lymph nodes (ELN). The ratio of metastatic to ELNs reflects survival and is required for accurate staging. The survival effect of the count of ELNs in patients with an absence of metastatic lymph nodes is unclear. However, the single-center survival outcomes related to higher ELN count based on only lymph node negative-patients are limited to a few studies with controversial results. We aimed to present the single-center experience in survival outcomes based on ELN count in patients with lymph node-negative pancreatic head cancer after pancreaticoduodenectomy. Methods: The data of 129 patients who underwent pancreaticoduodenectomy for pancreatic cancer from October 2011-December 2021 were analyzed. Among them, those who had metastatic lymph nodes, those who died from non-PC causes, died in the first 90 days postoperatively, or had missing follow-up data were excluded. Finally, 37 patients with negative lymph nodes who satisfied our criteria were included. The cut-off value for the examined lymph node count was 15, according to the minimum LN count recommended by the International Study Group of Pancreatic Surgery and the European Society for Medical Oncology for accurate staging. Thus, node-negative patients were divided into ELN <15 and ≥15 groups. The effect of <15 and ≥15 ELN count, tumor T stage, tumor grade, presence or absence of lymphovascular invasion and perineural invasion, and the resection margin status on cancer-specific survival were evaluated by univariate and multivariate survival analyses. Results: The median age was 63 years (interquartile range (IQR) 55.50-75.0), and 17 (45.9%) were female. The median count of examined lymph nodes was 15. The median follow-up time was 36.5 months (IQR 21.4-56.2). The 1- 3- 5- years of cancer-specific survivals were 86.2%, 61.5%, 49.6%, respectively. Seventeen patients died due to pancreatic carcinoma during the follow-up period, and 12 out of 17 patients were in the <15 group. In multivariate analyses, the examined lymph node count <15 was a negative independent risk factor for cancer-specific survival (HR: 0.293; 95% CI, 0.096-0.897; P=0.032). The other negative independent risk factor was a positive resection margin (HR: 5.777; 95% CI, 1.436-23.245; P=0.014). Conclusion: Patients with node-negative pancreatic head cancer with <15 ELN count, and positive resection margin have shorter survival, suggesting missed metastatic lymph nodes due to assessment of too few lymph nodes. At least a 15 ELN count is required to stratify the survival more accurately in these cohorts.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394-424. doi: 10.3322/caac.21492.
Strobel O, Neoptolemos J, Jäger D, Büchler MW. Optimizing the outcomes of pancreatic cancer surgery. Nat Rev Clin Oncol. 2019;16(1):11-26. doi: 10.1038/s41571-018-0112-1.
Han SS, Jang JY, Kim SW, Kim WH, Lee KU, Park YH. Analysis of long term survivors after surgical resection for pancreatic cancer. Pancreas. 2006;32(3):271-5. doi: 10.1097/01.mpa.0000202953.87740.93.
Huebner M, Kendrick M, Reid-Lombardo KM, Que F, Therneau T, Qin R, et al. Number of lymph nodes evaluated: prognostic value in pancreatic adenocarcinoma. J Gastrointest Surg. 2012;16(5):920-6. doi: 10.1007/s11605-012-1853-2.
Ashfaq A, Pockaj BA, Gray RJ, Halfdanarson TR, Wasif N. Nodal counts and lymph node ratio impact survival after distal pancreatectomy for pancreatic adenocarcinoma. J Gastrointest Surg. 2014;18(11):1929-35. doi: 10.1007/s11605-014-2566-5.
6 Li YF, Xiang YC, Zhang QQ, Wang WL. Impact of examined lymph node count on prognosis in patients with lymph node-negative pancreatic body/tail ductal adenocarcinoma. J Gastrointest Oncol. 2020;11(4):644-53. doi: 10.21037/jgo-20-158.
Slidell MB, Chang DC, Cameron JL, Wolfgang C, Herman JM, Schulick RD, et al. Impact of total lymph node count and lymph node ratio on staging and survival after pancreatectomy for pancreatic adenocarcinoma: a large, population-based analysis. Ann Surg Oncol. 2008;15(1):165-74. doi: 10.1245/s10434-007-9587-1.
Warschkow R, Widmann B, Beutner U, Marti L, Steffen T, Schiesser M, et al. The More the Better-Lower Rate of Stage Migration and Better Survival in Patients With Retrieval of 20 or More Regional Lymph Nodes in Pancreatic Cancer: A Population-Based Propensity Score Matched and Trend SEER Analysis. Pancreas. 2017;46(5):648-657. doi: 10.1097/MPA.0000000000000784.
Tomlinson JS, Jain S, Bentrem DJ, Sekeris EG, Maggard MA, Hines OJ, et al. Accuracy of staging node-negative pancreas cancer: a potential quality measure. Arch Surg. 2007;142(8):767-74. doi: 10.1001/archsurg.142.8.767.
Tol JA, Gouma DJ, Bassi C, Dervenis C, Montorsi M, Adham M, et al.; International Study Group on Pancreatic Surgery. Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS). Surgery. 2014;156(3):591-600. doi: 10.1016/j.surg.2014.06.016.
Chun YS, Pawlik TM, Vauthey JN. 8th Edition of the AJCC Cancer Staging Manual: Pancreas and Hepatobiliary Cancers. Ann Surg Oncol. 2018;25(4):845-7. doi: 10.1245/s10434-017-6025-x.
Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, et al; ESMO Guidelines Committee. Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up. Ann Oncol. 2015;26Suppl5:v56-68. doi: 10.1093/annonc/mdv295.
Riediger H, Keck T, Wellner U, Zur Hausen A, Adam U, Hopt UT, et al. The lymph node ratio is the strongest prognostic factor after resection of pancreatic cancer. J Gastrointest Surg. 2009;13(7):1337-44. doi: 10.1007/s11605-009-0919-2.
Pawlik TM, Gleisner AL, Cameron JL, Winter JM, Assumpcao L, Lillemoe KD, et al. Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer. Surgery. 2007;141(5):610-8. doi: 10.1016/j.surg.2006.12.013.
Smith DD, Schwarz RR, Schwarz RE. Impact of total lymph node counts on staging and survival after gastrectomy for gastric cancer: data from a large US-population database. J Clin Oncol. 2005;23(28):7114-24. doi: 10.1200/JCO.2005.14.621.
Swanson RS, Compton CC, Stewart AK, Bland KI. The prognosis of T3N0 colon cancer is dependent on the number of lymph nodes examined. Ann Surg Oncol. 2003;10(1):65-71. doi: 10.1245/aso.2003.03.058.
Malleo G, Maggino L, Ferrone CR, Marchegiani G, Mino-Kenudson M, Capelli P, et al. Number of Examined Lymph Nodes and Nodal Status Assessment in Distal Pancreatectomy for Body/Tail Ductal Adenocarcinoma. Ann Surg. 2019;270(6):1138-46. doi: 10.1097/SLA.0000000000002781.
Lidsky ME, Sun Z, Nussbaum DP, Adam MA, Speicher PJ, Blazer DG 3rd. Going the Extra Mile: Improved Survival for Pancreatic Cancer Patients Traveling to High-volume Centers. Ann Surg. 2017;266(2):333-8. doi: 10.1097/SLA.0000000000001924.
Sun J, Yang Y, Wang X, Yu Z, Zhang T, Song J, et al. Meta-analysis of the efficacies of extended and standard pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas. World J Surg. 2014;38(10):2708-15. doi: 10.1007/s00268-014-2633-9.
Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, Hruban RH, et al. Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome. Ann Surg. 1999;229(5):613-24. doi: 10.1097/00000658-199905000-00003.
Verbeke CS, Leitch D, Menon KV, McMahon MJ, Guillou PJ, Anthoney A. Redefining the R1 resection in pancreatic cancer. Br J Surg. 2006;93(10):1232-7. doi: 10.1002/bjs.5397.
Ravikumar R, Sabin C, Abu Hilal M, Bramhall S, White S, Wigmore S, et al.; UK Vascular Resection in Pancreatic Cancer Study Group. Portal vein resection in borderline resectable pancreatic cancer: a United Kingdom multicenter study. J Am Coll Surg. 2014;218(3):401-11. doi: 10.1016/j.jamcollsurg.2013.11.017.
Tseng JF, Raut CP, Lee JE, Pisters PW, Vauthey JN, Abdalla EK, et al. Pancreaticoduodenectomy with vascular resection: margin status and survival duration. J Gastrointest Surg. 2004;8(8):935-50. doi: 10.1016/j.gassur.2004.09.046.
How to Cite
Copyright (c) 2022 Oğuzhan Özşay, Mehmet Can Aydın
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.