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PROGNOSTIC SIGNIFICANCE OF LYMPH NODE METASTASIS ALONG THE LEFT SIDE OF SUPERIOR MESENTERIC ARTERY IN PANCREATIC HEAD CANCER.
Kenjiro Okada^*, Yoshiaki Murakami, Kenichiro Uemura, Naru Kondo, Naoya Nakagawa, Taijiro Sueda
Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan., Hiroshima, Japan

Background and Objectives. Lymph nodes (LNs) along the right side of the superior mesenteric artery (SMA) should be resected as a standard lymphadenectomy during pancreatoduodenectomy (PD) for pancreatic head cancer, whereas dissection of the left side of SMA-LNs (SMA-LN-lt) was not commonly performed. Although metastasis in SMA-LNs-lt are sometimes found, the survival benefit of SMA-LN-lt dissection during PD for pancreatic head cancer is still disputed. The purpose of this study is to evaluate the prognostic significance of SMA-LN-lt metastasis and micrometastasis in patients with pancreatic head cancer. Methods. Medical records of patients who underwent PD for pancreatic head cancer in Hiroshima University Hospital between 2002 and 2017 were reviewed retrospectively. All patients in the current study underwent PD with dissection of LNs along not only the right side but also the left side of SMA. Micrometastasis in SMA-LNs-lt was examined by immunohistochemical staining of CAM 5.2 monoclonal antibody when metastasis was not detected by standard hematoxylin and eosin (HE) staining. Patient characteristics and clinicopathological factors were compared among the SMA-LN-lt status groups, and the relationship between SMA-LN-lt status and overall survival (OS) was analyzed by univariate and multivariate analyses. Results. A total of 166 patients with pancreatic head cancer were eligible for this study. Of the enrolled 166 patients, 20 patients (12%) had SMA-LN-lt metastasis detected by HE staining (SMA-LN-lt HE-positive). Of the remaining 146 patients with SMA-LN-lt HE-negative, 8 patients (5%) had SMA-LN-lt micrometastasis identified by CAM 5.2 immunohistochemistry. No significant difference in OS analysis was found between SMA-LN-lt HE-positive group and micrometastasis group. Patients with SMA-LN-lt HE-positive or micrometastasis (SMA-LN-lt metastasis patients) experienced significantly shorter OS than those without SMA-LN-lt metastasis (p=.015). In multivariate analysis, SMA-LN-lt metastasis (p=.034), portal vein resection (p=.002), histologic grade (Grade 1 vs. 2/3) (p=.046), regional lymph node metastasis (p=.002), and lack of adjuvant chemotherapy (p<.001) were independent risk factors for poor OS. Within a subset of 28 patients with SMA-LN-lt metastasis, median survival time of 16 patients treated with adjuvant chemotherapy was 27.6 months. Multivariate analysis revealed that lack of adjuvant chemotherapy was an independent prognostic factor for poor OS (p=.003). Conclusions. In the current study, SMA-LN-lt metastasis including micrometastasis was found in 17% of eligible patients. SMA-LN-lt metastasis was the independent poor prognostic factor in patients who received PD for pancreatic head cancer. Adjuvant chemotherapy may contribute to improvement of prognosis in pancreatic head cancer patients with SMA-LN-lt metastasis.

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