Removing Additional Lymph Nodes Appears Not to Improve Survival

Surgery for Pancreatic Cancer: Removing Additional Lymph Nodes Appears Not to Improve Survival.

Persons with cancer of the head of the pancreas often undergo surgery to remove part or all of the pancreas, upper section of the small intestine, and nearby lymph nodes. Researchers have debated about whether a more extensive surgery, to remove more lymph nodes, might produce a better outcome. A new study by researchers in Germany indicates not.

The pancreas is an organ that is surrounded by the stomach, small intestine, bile ducts (tubes that connect the liver to the small intestine), gallbladder, liver, and spleen. The pancreas is wider on its right side (called the head) and is narrowest on its left side (called the tail).

The pancreas helps the body to break down food and produces hormones, such as insulin, to regulate the bodys storage and use of food. Depending on the stage of disease (extent of cancer at the time of diagnosis), pancreatic cancer may be treated with surgery, radiation therapy, chemotherapy, and/or biologic therapy to fight the cancer, relieve some of the symptoms of cancer, and/or prolong survival time.

When cancer of the head of the pancreas is confined to the abdomen and the area behind the abdomen, called the retroperitoneum, there is a chance that the cancer can be removed surgically. In these cases, a procedure is performed to remove part or all of the pancreas, the upper section of the small intestine (duodenum), and nearby lymph nodes.

This procedure is called a pancreaticoduodenectomy. However, even when all visible cancer is removed, small amounts of cancer may be remaining and may grow and cause a recurrence of the disease (return of disease, or relapse). For this reason, some researchers in the United States and Japan have advocated for a more extensive initial surgery, removing surrounding veins and more lymph nodes.

Researchers in Germany performed a (partial) pancreaticoduodenectomy, with removal of nearby lymph nodes only, in 26 persons with cancer of the pancreas. They performed a pancreaticoduodenectomy, with more extensive removal of lymph nodes in the abdomen and retroperitoneum, in 46 persons with the same disease. Of these 72 patients, 58 had all visible cancer removed. There was no difference in survival time between the 2 surgery groups. Although no differences were found based on the type of surgery performed, there were differences in survival times in association with other disease factors. Sixty-three percent of patients with early-stage cancers (stage I and II) survived 5 years, compared with 15% of patients with advanced cancers (stage III and IV). Examination of the cancer under a microscope led to the determination that persons with cancer cells that looked well differentiated (well defined) had higher 1-year survival rates (55%) than those with cancer cells that were poorly differentiated (0%). Those without cancer cells in the lymph nodes had higher 5-year survival rates (47%) than those with cancer cells in the lymph nodes (15%). Persons who did not have cancer affecting the portal vein had a 1-year survival rate of 63%, compared with 0% in those with portal vein involvement.

These findings suggest that more extensive removal of lymph nodes with a pancreaticoduodenectomy provides no survival benefit over the less extensive surgery in persons with cancer of the head of the pancreas. Researchers are currently studying this matter further. Individuals who have cancer of the head of the pancreas may wish to talk with their doctor about the risks and benefits of undergoing less versus more extensive surgery and of participating in a clinical trial in which promising new treatment approaches are being studied.

(World Journal of Surgery, Vol 24, No 5, pp 595-601, 2000)

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