Long-term survival after resection of pancreatic ductal adenocarcinoma with para-aortic lymph node metastasis: case report

Abstract

Pancreatic cancer patients with para-aortic lymph node metastasis have a poor prognosis and patients living longer than 3 years are rare. We had a patient with pancreatic cancer who survived for more than 10 years after removal of the para-aortic lymph node metastasis. A 57-year-old woman was diagnosed with pancreatic head cancer and underwent a pancreaticoduodenectomy with subtotal gastric resection following Whipple reconstruction in 2000. Para-aortic lymph node metastasis was detected during the operation by intraoperative pathological diagnosis and an extended lymphadenectomy was performed with vascular skeletonization of the celiac and superior mesenteric arteries. In 2004, a low-density area was detected around the superior mesenteric artery (SMA) 5 cm from its root and she was treated with gemcitabine, and the area was undetectable after 3 years of treatment. In 2010, computed tomography showed a low-density area around the same lesion with an increased carcinoembryonic antigen level. After 4 months of gemcitabine treatment, we resected the tumor en bloc with the associated superior mesenteric vein and perineural tissue. Histopathological examination of the resected specimen revealed a well-differentiated tubular adenocarcinoma that closely resembled the original primary pancreatic cancer, indicating perineural recurrence 10 years after the initial resection. She had no recurrence around the SMA for more than one year. Although a meta-analysis has not proved the efficacy of preventive radical dissection, this case indicates that a patient with well-differentiated, chemotherapy-responsive pancreatic cancer with para-aortic lymph node metastasis could have a long survival time through extended dissection of the lymph nodes.

Does sentinel node biopsy play a role in pancreatic adenocarcinoma?

“…This fact is mainly correlated with the high capacity of the pancreatic adenocarcinoma to spread via lymphatic route; therefore, it has been demonstrated that lymph node metastases develop early in the course of disease in pancreatic adenocarcinomas and represent one of the most important prognostic factors for the long-term survival. However, the extent of the lymph node dissection has been permanently debated, different opinions being reported so far; while the European countries sustain the idea that an extended lymph node dissection in pancreatic adenocarcinoma does not improve the survival and, moreover, increases the postoperative morbidity rates, the Eastern countries consider that such a lymph node dissection is perfectly justified in order to increase the chances for an improved survival [13][14][15][16][17] .…”

The lymphatic system and pancreatic cancer

“…Evidence suggests that metastasis to lymph nodes is an early event in pancreatic cancer progression, and presence of tumor cells in lymph nodes represents one of the most negative prognostic factors with respect to patient outcomes [8,27,29,37,60–63]. Conservative surgical views support the standard PD with loco-regional lymphadenectomy [27,31,34,36,38,42,56,59,64–74], while others, most notably numerous Japanese groups, advocate that a more radical PD with extensive removal of retroperitoneal soft tissue and extended lymphadenectomy [27,34,39,42,75–84] results in better patient outcomes. Collected studies in Table 1 [8,27,31,34,36,37,39,40,42,59,64–75,77–99] demonstrate the broad range of study designs and conclusions that have fueled this debate.…”

“…Conservative surgical views support the standard PD with loco-regional lymphadenectomy [27,31,34,36,38,42,56,59,64–74], while others, most notably numerous Japanese groups, advocate that a more radical PD with extensive removal of retroperitoneal soft tissue and extended lymphadenectomy [27,34,39,42,75–84] results in better patient outcomes. Collected studies in Table 1 [8,27,31,34,36,37,39,40,42,59,64–75,77–99] demonstrate the broad range of study designs and conclusions that have fueled this debate. A recent set of randomized, controlled clinical trials from several centers around the world and a mathematical model of outcomes prediction have concluded that extended lymphadenectomy does not improve survival over traditional, more conservative resection and that quality-of-life may be decreased with more radical surgery [67–70,72,74,81,83,87,88,95].…”

“…The occasional case report continues to demonstrate the biological diversity of pancreatic malignancy and challenge these recommendations. In 2013 a Japanese group reported that extended lymphadenectomy in a welldifferentiated, chemotherapy-responsive PDAC with para-aortic lymph node metastases resulted in patient survival of over ten years [75]. Peparini, et al 2015 [93], addressed para-aortic lymph node involvement (stations 16a2 and 16b1), stating that involvement of these lymph nodes may be due to direct invasion of the primary pancreatic tumor as opposed to dissemination and seeding of migratory cancer cells in the traditional definition of metastasis and that their removal may favorably impact R margin status.…”

“…The peripancreatic region is densely innervated, housing large nerve plexuses with sensory, sympathetic, and parasympathetic nerves extending into the pancreas [82,282,283]. Incidence of perineural invasion in PDAC approaches 100% [44,82] and has been implicated in local and distant recurrence [75,82,284,285] after resection and neuropathic pain [286,287]. In an effort to decrease these effects, it has been suggested that nerve tissue be removed as part of radical pancreatic resection procedures [71,75,82,84,285,288].…”