Background and Objective: Several surgical series have clearly demonstrated the prognostic signficance of curative (R0) resection. The aim of this study is to evaluate the role of R0 resection and of the extent of lymphnodes (LN) involvement.Patients and
Methods: Fifty four patients were submitted to modified extended pancreaticoduodenectomy (MEPD) for pancreatic cancer from 1994 to 2005. After MEPD 20 pts received adjuvant chemotherapy:15 with intra-arterial chemotherapy employng FLEC regimen (in 7 pts followed by systemic gemcitabine) and 5 with other adjuvant regimens.
Results: Median follow up time for surviving pts was 46 months (range 26-157). In 44 pts (82 %) MEPD had negative margin resection; all pts with R1 resection showed positive retroperitoneal margin. All the patinets had more than 10 LN dissected, 11 patients had 10 to 20 LN examinated, 27 had 20 to 40 LN examinated and 16 patients had more than 40 LN examinated. Negative LN were found in 10 pts, positive N1 in 33 pts, positive N1+N2 in 9 pts and positive N2 in 2 pts. 12 patients had 1-2 positive LN, 28 patients had 3-9 positive LN and 4 patients had more than 10 positive LN. The overall median survival was 18 months with actuarial 3 and 5-year survival rates of 29 % and 19 %. At univariate analysis we identified that factors related with survival were: histological grading (p=0.01), LN status (p=0.04), radical resection (p=0.01), UICC TNM stage (p=0.005). We did not identify statistical differences between survival in pts with positive N1 and N2 LN, however all 11 pts with N2 LN metastases died within 46 months. A statistical significant relationship between the number of positive LN and survival was observed with a median survival time of 16, 17 and 7 months for patients with 1-2 positive LN, 3-9 positive LN and more than 10 positve LN, respectively (p=0.03). These data were confirmed also with linear regression model.Multivariate analysis in pts with R0 resection showed that factors related with survival were adjuvant chemotherapy (HR 0.39, p=0.04), histological grading (HR=2.5, p=0.02) and LN status (HR=1.95, p=0.04).
Conclusions: Our study confirm the prognostic significance of R0 resection that can be achieved with a accurate clearance of lymphatic, neural and connective tissue at the right side of superior mesenteric artery and of retroperitoneum. Our results emphasize the prognostic significance of the number of positve LN; in our opinion an accurate lymph node dissection (more than 10 LN) can improve the evaluation of LN status. Adjuvant chemotherapy improved significantly long term survival after R0 resection while in R1 it did not show benefit.