Lymph node spread of gallbladder cancer from the perspective of embryologically-based anatomy and significance of the lymphatic basin along the embryonic right hepatic artery

Abstract

Abstract. Lymph node metastasis from gallbladder cancer is often found in the pericholedochal area; however, these regional lymph nodes are not typically accompanied by arteries. We hypothesized that the artery accompanying pericholedochal lymph nodes was either the regressed embryonic right hepatic artery (eRHA) or an aberrant right hepatic artery (aRHA) remaining without regression. This study aimed to determine the artery supplying pericholedochal lymph nodes. We obtained serial tissue sections of resected specimens from 10 patients who underwent pancreaticoduodenectomy with combined resection of the superior mesenteric artery and vein and investigated the association between the distribution of enlarged lymph nodes and the course of blood vessels in each section. In 2 cases with aRHA, enlarged lymph nodes were distributed in the posterosuperior area, pancreaticoduodenal region and retroportal area along this artery. By contrast, no blood vessels accompanied enlarged lymph nodes in 8 patients exhibiting a normal hepatic artery branching pattern, although these nodes exhibited a distribution pattern similar to that of patients with the aRHA. Thus, the artery supplying pericholedochal lymph nodes appears to be either the regressed eRHA or an aRHA persisting without regression. IntroductionThe prognosis of gallbladder cancer (GBC) with lymph node metastases is poor. The 5-year survival rate following surgical resection has been reported to be 65% for patients with no lymph node metastases and <30% for those with regional lymph node metastases (pN1) (1). In the pN1 group, lymph node metastases characteristically arise in the pericholedochal area or the posterosuperior pancreaticoduodenal region, rather than around the hepatic artery (2,3). However, no feeding arteries are present around the pericholedochal lymph nodes and posterosuperior pancreaticoduodenal lymph nodes (PPLNs), although lymph nodes and lymphatic vessels generally exist along a feeding artery (4-7).We previously performed pancreaticoduodenectomy (PD) for pancreatic cancer in patients with an aberrant right hepatic artery (aRHA). In such cases, PPLNs were distributed along the aRHA. This artery is considered to represent an embryonic right hepatic artery (eRHA) that has not regressed. We hypothesized that the artery responsible for PPLNs would be the eRHA. If this hypothesis is accurate, lymphadenectomy for GBC should be performed based on the course of the eRHA (8). The aim of this study was to determine the artery supplying the PPLNs. Materials and methodsPatients. Between 1997 and 2005, a total of 58 patients underwent PD for invasive pancreatic ductal cancer in the Department of Gastroenterologic Surgery at Kanazawa University. Among these cases, radical PD with major vessel resection [superior mesenteric artery (SMA) and superior mesenteric vein (SMV) resection] was performed in 18 patients for complete clearance of the soft tissues around these arteries (9). This study was approved by the Ethics Committee at our institution and was conducted ...

Surgical Anatomy of the Mesopancreas in Obese Patients: A Retrospective Study

“…Looking at the challenge imposed by the presence of aRHA during TMpE, namely that aRHA may be encountered during initial dissection of the SMA at the level of LRV, our study showed that the mean distance from the origin of SMA to the origin of aRHA (denoted by the green arrow in Figure 2A ) was 19.52 ± 3.87 mm, suggesting that dissecting the root of SMA at the level of LRV (denoted by the green line in Figure 2B ) is safe as this plane is posterior to the root and the course of aRHA. Furthermore, our study observed that the aRHA was related posteriorly to lymph nodes (Figure 3 ), this finding being compatible with the findings of Nakagawara and colleague’s manuscript [ 6 ]. These lymph nodes separate the aRHA from the dissection plane; however, they should be excised later as part of the standard lymphadenectomy during pancreatoduodenectomy.…”

Lymph Nodal Metastatic Pattern in Carcinoma Gallbladder with Multidetector Computed Tomography: An Institutional Experience

“…They gave the reasoning that in en bloc resection procedure, it is difficult to determine the location of lymph node. 16,17 The meta-analysis by de Savornin Lohman et al evaluated the diagnostic accuracy of five studies and revealed uncertainty regarding the optimal imaging strategy for the preoperative detection of lymph nodal metastasis in carcinoma gallbladder. Routine imaging by CT is followed for preoperative staging.…”

“…They suggested that in cases with normal hepatic arterial branching, the lymphadenopathy observed was compatible with lymph nodes along a regressed embryonic right hepatic artery, and emphasized the importance of dissection along its course. 17 Lymphatic spread of gallbladder carcinoma occurs to lymph nodes around the cystic duct, common bile duct, and pancreaticoduodenal region. Carcinoma gallbladder spreads directly into the adjacent liver segments (IV and V), duodenum, colon, anterior abdominal wall, and common hepatic duct.…”