Significance of lymph node metastases in the surgical management of pancreatic head carcinoma.
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A prognostic evaluation on esophageal carcinoma with lymph node metastasis —An analysis of 212 cases
The authors studied retrospectively lymph node metastatic status impacting on survival of 212 patients with thoracic esophageal squamous cell carcinoma 663 (19.4%) of the total 3, 419 lymph nodes examined (an average of 16.1 per patient) were proved to be positive. The overall 5-year survival rate was 19.3% (41/212). The results showed that no difference in survival was observed in relation to the site of the involved lymph node. Difference in survival based on the number of metastatic lymph nodes (1 or ≥2) and the frequence of positive nodes ≤10% or >10%) is statistically significant. The results indicated that the clinical staging of esophageal carcinoma should be made according to the absolute number and the relative frequency of lymph nodes involved. The effectiveness and limitation of extended lymph node dissection in relation to prognosis was discussed.
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A 64-year-old patient underwent pancreaticoduodenectomy for adenocarcinoma of the third and fourth portions of the duodenum. The local, but not the aortic, lymph nodes were involved. He has remained well for the subsequent four years. The tumor was not seen on one earlier upper gastrointestinal tract x-ray film and on surgical exploration at another hospital. A careful review of the literature reveals among numerous reports no previous pancreaticoduodenectomy for this lesion, but limited procedures and inadequate documentation of the extent of local and lymph node involvement.
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Recent reports have demonstrated an improvement in 5-year actuarial survival of patients with resected ductal adenocarcinoma. The purpose of this study was to determine the factors favoring long-term survival after pancreaticoduodenectomy. Between 1974 and 1995, 75 patients with pancreatic head carcinoma underwent pancreaticoduodenectomy in our department. The overall postoperative mortality rate was 5.3% and morbidity was 24%. Median survival following resection was 17 months. The estimated 1-, 2- and 5-year survival rates were 68%, 46.7% and 18.7%, respectively. Five-year survival was significantly greater for node-negative versus node-positive patients (41.7% vs 7.8%, P < 0.001), for smaller (< 3 cm) versus larger tumours (33.3% vs 8.8%, P < 0.006), and for negative versus positive resection margins (23.3% vs 0, P < 0.001). Other factors, including gender, age, and blood transfusion had no significant effect on survival. The multivariate analysis was done using the Cox proportional hazards model to determine independent prognostic determinants of survival. The presence of positive resection margins was the strongest independent predictor of decreased survival. Lymph node metastasis, tumour size > 3 cm, and poor histologic differentiation were also independent predictors of poor survival. The most favorable subset consisted in 17 patients who had negative resection margins, negative lymph nodes, and tumor size < 3 cm. Their 5-year survival rate was 52.9%.
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Abstract BackgroundRadical 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.MethodsA total of 240 patients were enrolled 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.ResultThe demography, histopathology and clinical characteristics were similar between the two groups. The 2-year overall survival rate in the SG was higher than the EG (39.5% vs 25.3%; p=0.034). 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=0.021). There was no significant difference in the overall incidence of complications between the two groups (p=0.502). The number of peripheral blood lymphocytes of the EG was significantly lower than that in the SG at 1 week (mean [SD], 0.957[0.429] vs 1.278[0.521], p=0.001) and 1 month (mean [SD], 1.538[0.618] vs 1.917[0.796], p=.009) after operation.ConclusionIn 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 one of the reasons why extended lymphadenectomy did not result in survival benefits.Clinical trial registrationThis trial was registered at ClinicalTrials.gov (NCT02928081) in October 7, 2016. https://clinicaltrials.gov/
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