Extended pancreatic resections and lymphadenectomy: An appraisal of the current evidence

Table 1 Multi-visceral resections for pancreatic cancer (where studies have included vascular resections in the analysis this has been specified)

Author (Ref)	Year	Number of patients	Neoadjuvant therapy	Organs resected	Morbidity/Mortality	Survival	Conclusions
Klempnauer et al[54]	1996	45	Not specified	Colon, stomach, liver, kidney, adrenal	31%/17.7%	5-YSR = 11.9% Median survival = 7.3 mo (n = 34)	Increased mortality and impaired long-term prognosis
Sasson et al[20]	2002	37	76% (5-FU or Gemcitabine)	Colon & mesocolic vessels, celiac axis, portal vein, liver, adrenal, stomach	35%/2.7%	5-YSR = 16% (P < 0.08 in favour of en bloc resections)	Safe; beneficial in selected patients who receive neoadjuvant therapy
Hartwig et al[51]	2009	101	20.8%	Colon, stomach, adrenal gland, liver, hepatic or celiac artery, kidney, or small intestine	37.6%/3%	3-YSR = 37.2%	Increased morbidity; Comparable mortality and long-term outcomes
1Nikfarjam et al[52]	2009	7 (19)	Not specified	Colon, kidney, liver	68%/0%	Not specifically addressed	Comparable morbidity to routine PD
Shoup et al[55]	2003	22	Not specified	Colon, stomach, adrenal, portal vein	Not specified	5-YSR = 22% 10-YSR = 18%	Markedly improved survival as compared to those not resected

¹Includes resections for tumours that infiltrated the pancreas from the retroperitoneum, also includes PDs performed for GISTs; Abbreviations: 5-FU: 5-Fluorouracil; YSR: Year survival rate; PD: Pancreatoduodenectomy.

Table 2 Definitions of lymphadenectomy for pancreatic cancer according to the consensus definitions published in 1999[60]

Lymph node group	Lymph node stations
Pancreatic head cancers
Standard Lymphadenectomy
Lymph nodes of the right side of the hepatoduodenal ligament	12b1, 12b1, 12c
Posterior pancreaticoduodenal nodes	13a, 13b
Nodes to the right side of the superior mesenteric artery from the origin of the superior mesenteric artery at the aorta to the inferior pancreatico-duodenal artery	14a, 14b
Anterior pancreaticoduodenal nodes	17a, 17b
Extended Lymphadenectomy
Skeletonization of the common and proper hepatic artery lymph nodes	All 8
Celiac axis nodes	9
Lymph nodes of the left and right side of the hepatoduodenal ligament	All 12
Circumferential skeletonization of the superior mesenteric artery between the aorta and the inferior pancreaticoduodenal artery	All 14
All lymph nodes of the anterolateral aspect of the aorta and of the inferior vena cava, in continuity with Gerota’s fascia, between the celiac axis and the inferior mesenteric artery	16a2, 16b1
Pancreatic body and tail cancers
Standard Lymphadenectomy
Celiac axis nodes	9
Nodes of the hilum of the spleen	10
Splenic artery lymph nodes	11
Nodes along the inferior border of the body and tail of the pancreas	18
Extended Lymphadenectomy
Anterior-superior region of the common hepatic artery	8a
Circumferential skeletonization of the superior mesenteric artery between the aorta and the inferior pancreaticoduodenal artery	All 14
Lymph nodes of the anterolateral aspect of the aorta and of the inferior vena cava, in continuity with Gerota’s fascia, between the celiac axis and the inferior mesenteric artery	16a2, 16b1

Table 3 Randomised controlled trials analysing the benefits of SL versus EL for pancreatic cancer

Author (Ref) & year	Number of patients randomised	Mean lymph nodes harvested±SD	Adjuvant CT	Morbidity/Mortality	Survival	Conclusions
Pedrazolli et al[61] 1998	PD: 40 PD/EL: 41	PD: 13.3 ± 8.3 PD/EL: 19.8 ± 15.1 (P < 0.03)	-	PD: 45%/5% PD/EL: 34%/4.8%	4-YSR = (actuarial) PD: 12% PD/EL: 6%	No difference in morbidity and mortality Trend toward longer survival in node positive patients treated with EL
Yeo et al[62] 2002	PD: 146 PD/EL: 148	PD: 17.0 ± 0.6 PD /EL: 28.5 ± 0.6 (P < 0.001)	Both groups	PD: 29%/4% PD/EL: 43%/2%	5-YSR = (actuarial) PD: 10% PD/EL: 25%	Similar mortality but increased morbidity with no survival benefit
1Nimura et al[63] 2004	PD: 51 PD/EL: 50	PD: 13 PD/EL: 40 (P < 0.03)	-	PD: 12%/0% PD/EL: 20%/2%	3-YSR = (actuarial) PD: 28.5% PD/EL: 16.6%	No improvement in survival with EL
Farnell et al[64] 2005	PD: 40 PD/EL: 39	PD: 15 (3-31) 2PD/EL: 36 (6-74) (P < 0.0001)	Both Groups (+ RT)	PD: 35%/0% PD/EL: 45%/2.6%	5-YSR = (actuarial) PD: 16.4% PD/EL: 16.5%	No improvement in survival along with a decreased QOL with EL

¹Published only in abstract form;

²Expressed as median (range); Abbreviations: CT: Chemotherapy; QOL: Quality of life; RT: Radiotherapy; SL: standard lymphadenectomy; EL: Extended lymphadenectomy.