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Pancreatic Cancer Patients With Lymph Node Involvement by Direct Tumor Extension Have Similar Survival to Those With Node-Negative Disease
Jennifer L. Williams*1, Andrew H. Nguyen2, Matthew Rochefort2, James S. Tomlinson2, Oscar J. Hines2, Howard a. Reber2, Timothy Donahue2
1Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; 2Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
Introduction: Lymph node (LN) involvement is a well-known poor prognostic factor in patients with pancreatic ductal carcinoma (PDAC). However, PDAC often invades into peri-pancreatic tissues, and there have been conflicting results on the prognostic significance of the mechanism of LN involvement: "direct" tumor invasion versus "metastatic" disease.
Methods: Clinicopathologic and survival records from all patients who underwent resection for PDAC from 1990 to 2014 at a single-institution were reviewed from a prospectively maintained database.
Results: Of the 381 total patients, most (n= 335, 87.9%) underwent pancreaticoduodenectomy. One-hundred and ninety-one patients (50.1%) were female, and median age was 66 years. There was tumor growth outside of the pancreas (AJCC T stage 3 or 4) in 290 (76.2%) patients, and margins were microscopically positive in 79 (20.7%). Overall, 237 (62.2%) had node-positive disease: (i) 218 (92.0%) by "metastatic" involvement, (ii) 14 (5.9%) by "direct" tumor extension, and (iii) 5 (2.1%) by a mix of "metastatic" and "direct". The median number of LNs pathologically examined was significantly lower in the "direct" versus "metastatic" group (11 vs. 18, P=0.015); however, there was no difference in the median number of involved LNs (1 vs. 2, P=0.64). "Direct" involvement ranged from 1 - 7 (mean: 2.0) LNs per patient. Similar to LN involvement, there were no significant differences in other clinicopathologic factors associated with PDAC survival between "metastatic" and "direct" LN patients, including tumor size, tumor grade, margin status, lymphovascular invasion, perineural invasion, and neoadjuvant or adjuvant therapy. The median and 5-year overall survivals for the whole cohort were 30.1 months and 27.3%. As compared to overall survival in patients with LN negative disease (median: 40.4 months, 5-year 37.1%), those with: (i) any number or mechanism of LNs involved was significantly shorter (median: 26.1 months, 5-year: 19.3%; P < 0.001), yet (ii) "direct" LN extension was similar (median 48.1 months, 5-year survival 29.2%; P=0.719). Furthermore, there was no survival benefit to having only 1 "metastatic" LN involved (median: 22.8 months, 5-year: 18.3%) as compared to 2 or more (median: 26.7 months, 5-year: 18.3%) (P =0.821).
Conclusions: These results indicate that the mechanism of LN involvement matters in PDAC. Patients with LNs involved by direct extension have a similar survival to those with node negative disease.
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