Abstract
Background
Two distinct lymph nodes reproducibly assessed by computed tomography for the evaluation of periampullary tumors are the common bile duct (CBD) node and the gastroduodenal artery (GDA) node. We examined whether radiographical enlargement of either lymph node predicts tumor resectability, nodal metastasis, or patient survival.
Methods
Ninety-four consecutive patients underwent attempted curative resection of periampullary tumors between September 2001 and June 2003. A single radiologist recorded in a retrospective, blinded fashion the short- and long-axis measurements of the CBD and GDA nodes.
Results
Sixty-one percent (n = 57) of tumors were resectable by pancreaticoduodenectomy. Overall, actual 6-, 12-, and 18-month survival was 87%, 68%, and 63%, respectively. Enlarged radiographical nodal size by either axis was not associated with the presence of metastasis to these lymph nodes or with reduced overall patient survival. Only a CBD node short-axis size >10 mm predicted unresectability (odds ratio, 3.2; P = .036). Liver metastasis and/or carcinomatosis were present in 43% of unresectable patients, and this was associated with decreased survival at both 1 year (25% vs. 77%; P < .001) and 18 months (19% vs. 72%; P <.001). A pathologic diagnosis of metastasis to the GDA node, but not the CBD node, was associated with a similarly decreased survival (1 year: 33% vs. 78%, P = .028; 18 months: 22% vs. 70%, P = .023).
Conclusions
For presumed periampullary malignancy, a CBD node short-axis size >10 mm predicts tumor unresectability. Metastatic disease to the GDA node, particularly for pancreatic adenocarcinoma, portends a poor prognosis equivalent to that of hepatic or peritoneal spread. Given these findings, radiographical CBD lymph node measurements may guide selection for performing laparoscopic staging with or without ultrasonography in conjunction with GDA nodal biopsy in patients with periampullary malignancy.
Similar content being viewed by others
References
Sarmiento JM, Nagomey DM, Sarr MG, et al. Periampullary cancers: are there differences? Surg Clin North Am 2001; 81:543–55
Bouvet M, Gamagami RA, Gilpin EA, et al. Factors influencing survival after resection for periampullary neoplasms. Am J Surg 2000; 180:13–7
Cleary SP, Gryfe R, Guindi M, et al. Prognostic factors in resected pancreatic adenocarcinoma: analysis of actual 5-year survivors. J Am Coll Surg 2004; 198:722–31
Chen CH, Tseng LJ, Yanc CC, et al. Preoperative evaluation of periampullary tumors by endoscopic sonography, transabdominal sonography, and computed tomography. J Clin Ultrasound 2001; 29:313–21
Tomazic A, Pegan V. Preoperative staging of periampullary cancer with US, CT, EUS, and CA 19-9. Hepatogastroenterology 2000; 47:1135–7
Catalano C, Laghi A, Fraioli F, et al. Pancreatic carcinoma: the role of high-resolution multislice spiral CT in the diagnosis and assessment of resectability. Eur Radiol 2003; 13:149–56
Phoa SS, Reeders JW, Rauws EA, et al. Spiral computed tomography for preoperative staging of potentially resectable carcinoma of the pancreatic head. Br J Surg 1999; 86:789–94
Jin Z, Li X, Cai L. Assessing the resectability of pancreatic ductal adenocarcinoma: a comparison of dual-phase helical CT arterial portography with conventional angiography. Chin Med Sci J 2001; 16:40–5
Diehl SJ, Lehmann KJ, Sadick M, et al. Pancreatic cancer: value of dual-phase helical CT in assessing resectability. Radiology 1998; 206:373–8
Callery MP, Strasberg SM, Doherty GM, et al. Staging laparoscopy with laparoscopic ultrasonography: optimizing resectability in hepatobiliary and pancreatic malignancy. J Am Coll Surg 1997; 185:33–9
Potter MW, Shah SA, McEnaney P, et al. A critical appraisal of laparoscopic staging in hepatobiliary and pancreatic malignancy. Surg Oncol 2000; 9:103–10
Reddy KR, Levi J, Livingstone A, et al. Experience with staging laparoscopy in pancreatic malignancy. Gastrointest Endosc 1999; 49(4 Pt 1):498–503
Friess H, Kleeff J, Silva JC, et al. The role of diagnostic laparoscopy in pancreatic and periampullary malignancies. J Am Coll Surg 1998; 186:675–82
Vollmer CM, Drebin JA, Middleton WD, et al. Utility of staging laparoscopy in subsets of peripancreatic and biliary malignancies. Ann Surg 2002; 235:1–7
Roche CJ, Hughes ML, Garvey CJ, et al. CT and pathologic assessment of prospective nodal staging in patients with ductal adenocarcinoma of the head of the pancreas. AJR Am J Roentgenol 2003; 180:475–80
Lemenshow S, Hosmer D. A review of goodness of fit statistics for use in the development of logistic regression models. Am J Epidemiol 1982; 115:92–106
Soriano A, Castells A, Ayuso C, et al. Preoperative staging and tumor resectability assessment of pancreatic cancer: prospective study comparing endoscopic ultrasonography, helical computed tomography, magnetic resonance imaging, and angiography. Am J Gastroenterol 2004; 99:492–501
Legmann P, Vignaux O, Dousset B, et al. Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography. AJR Am J Roentgenol 1998; 170:1315–22
Howard TJ, Chin AC, Streib EW, et al. Value of helical computed tomography, angiography, and endoscopic ultrasound in determining resectability of periampullary carcinoma. Am J Surg 1997; 174:237–41
Valls C, Andia E, Sanchez A, et al. Dual-phase helical CT of pancreatic adenocarcinoma: assessment of resectability before surgery. AJR Am J Roentgenol 2002; 178:821–6
Zeman RK, Cooper C, Zeiberg AS, et al. TNM staging of pancreatic carcinoma using helical CT. AJR Am J Roentgenol 1997; 169:459–64
Schwarz M, Pauls S, Sokiranski R, et al. Is a preoperative multidiagnostic approach to predict surgical resectability of periampullary tumors still effective? Am J Surg 2001; 182:243–9
Menack MJ, Spitz JD, Arregui ME. Staging of pancreatic and ampullary cancers for resectability using laparoscopy with laparoscopic ultrasound. Surg Endosc 2001; 15:1129–34
Barreiro CJ, Lillemoe KD, Koniaris LG, et al. Diagnostic laparoscopy for periampullary and pancreatic cancer: what is the true benefit? J Gastrointest Surg 2002; 6:75–81
Brooks AD, Mallis MJ, Brennan MF, et al. The value of laparoscopy in the management of ampullary, duodenal, and distal bile duct tumors. J Gastrointest Surg 2002; 6:139–46
Shyr YM, Su CH, Lo SS, et al. Is pancreatoduodenectomy justified for periampullary cancers with regional lymph node involvement? Am Surg 1995; 61:288–93
Yeo CJ, Sohn TA, Cameron JL, et al. Periampullary adenocarcinoma: analysis of 5-year survivors. Ann Surg 1998; 227:821–31
van Geenen RC, van Gulik TM, Offerhaus GJ, et al. Survival after pancreaticoduodenectomy for periampullary adenocarcinoma: an update. Eur J Surg Oncol 2001; 27:549–57
Kayahara M, Nagakawa T, Ohta T, et al. Analysis of paraaortic lymph node involvement in pancreatic carcinoma: a significant indication for surgery. Cancer 1999; 85:583–90
Yoshida T, Matsumoto T, Sasaki A, et al. Outcome of paraaortic node-positive pancreatic head and bile duct adenocarcinoma. Am J Surg 2004; 187:736–40
Yeo CJ, Cameron JL, Lillemoe KD, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality. Ann Surg 2002; 236:355–66
Bogoevski D, Yekebas EF, Schurr P, et al. Mode of spread in the early phase of lymphatic metastasis in pancreatic ductal adenocarcinoma: prognostic significance of nodal microinvolvement. Ann Surg 2004; 240:993–1001
Author information
Authors and Affiliations
Additional information
Presented in part at the annual meetings of the American Hepato-Pancreatico-Biliary Association on April 15, 2005 and The Pancreas Club on May 15, 2005.
Rights and permissions
About this article
Cite this article
Maithel, S.K., Khalili, K., Dixon, E. et al. Impact of Regional Lymph Node Evaluation in Staging Patients With Periampullary Tumors. Ann Surg Oncol 14, 202–210 (2007). https://doi.org/10.1245/s10434-006-9041-9
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-006-9041-9