Para-aortic lymph node involvement should not be a contraindication to resection of pancreatic ductal adenocarcinoma

Abstract

BACKGROUND Para-aortic lymph nodes (PALN) are found in the aortocaval groove and they are staged as metastatic disease if involved by pancreatic ductal adenocarcinoma (PDAC). The data in the literature is conflicting with some studies having associated PALN involvement with poor prognosis, while others not sharing the same results. PALN resection is not included in the standard lymphadenectomy during pancreatic resections as per the International Study Group for Pancreatic Surgery and there is no consensus on the management of these cases. AIM To investigate the prognostic significance of PALN metastases on the oncological outcomes after resection for PDAC. METHODS This is a retrospective cohort study of data retrieved from a prospectively maintained database on consecutive patients undergoing pancreatectomies for PDAC where PALN was sampled between 2011 and 2020. Statistical comparison of the data between PALN+ and PALN- subgroups, survival analysis with the Kaplan-Meier method and risk analysis with univariable and multivariable time to event Cox regression analysis were performed, specifically assessing oncological outcomes such as median overall survival (OS) and disease-free survival (DFS). RESULTS 81 cases had PALN sampling and 17 (21%) were positive. Pathological N stage was significantly different between PALN+ and PALN- patients ( P = 0.005), while no difference was observed in any of the other characteristics. Preoperative imaging diagnosed PALN positivity in one case. OS and DFS were comparable between PALN+ and PALN- patients with lymph node positive disease (OS: 13.2 mo vs 18.8 mo, P = 0.161; DFS: 13 mo vs 16.4 mo, P = 0.179). No difference in OS or DFS was identified between PALN positive and negative patients when they received chemotherapy either in the neoadjuvant or in the adjuvant setting (OS: 23.4 mo vs 20.6 mo, P = 0.192; DFS: 23.9 mo vs 20.5 mo, P = 0.718). On the contrary, when patients did not receive chemotherapy, PALN disease had substantially shorter OS (5.5 mo vs 14.2 mo; P = 0.015) and DFS (4.4 mo vs 9.8 mo; P < 0.001). PALN involvement was not identified as an independent predictor for OS after multivariable analysis, while it was for DFS doubling the risk of recurrence. CONCLUSION PALN involvement does not affect OS when patients complete the indicated treatment pathway for PDAC, surgery and chemotherapy, and should not be considered as a contraindication to resection.

Impact of para aortic lymph node removal on survival following resection for pancreatic adenocarcinoma

“…As PALN + status is captured in the N-status, with 79% of PALN + patients having N2 disease, the value of the N-classification may thus be superior to PALN + status when assessing overall survival. These findings are in line with other studies [ 16 ].…”

From Left to Right. Para-Aortic Lymph Nodes Sampling During Pancreatoduodenectomy for Pancreatic Cancer

“…In this context, considering metastatic PALN as a contraindication to pancreaticoduodenectomy (PDD) in up-front resectable pancreatic cancer is a source of fiery debate [9][10][11] . Some studies have shown that patients with metastatic PALN could still benefit from radical PDD compared to the double bypass procedure 7 and benefit from modern chemotherapy regimens 3,6 .…”

“…However, there is no consensus on the dissection of a 16b1 group 16 . Recent studies showed that PALN involvement might not affect survival in patients who complete the full curative strategy (adequate systemic treatment and radical surgery) 6 , 8 , 15 . Thus, we systematically perform PALN dissection with frozen-section analysis in order to guide a personalized surgical approach, as follows:…”

Exploring prognostic survival factors in patients with advanced pancreatic cancer receiving PD-1 inhibitors

“…In the present study, the mOS of patients with advanced PC with a history of surgery was much greater than that of patients without a history of surgery (44.2 months vs. 10 months), a result that is consistent with widespread public perception. The study of surgery and survival of PC patients in a broad sense dates back to the 1970s and 1980s [26,27] ; then interest in factors affecting postoperative survival began and numerous studies were done, when lymph node metastasis was considered the most important postoperative prognostic factor [28,29] ; with progressive research, the prognosis of surgical treatment of PC is more carefully studied today, for example para-aortic lymph nodes are not a contraindication to PC surgery [30] ,…”