Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: A consensus statement by the International Study Group on Pancreatic Surgery (ISGPS)

doi:10.1016/j.surg.2014.06.016

Surgery

Volume 156, Issue 3, September 2014, Pages 591-600

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https://doi.org/10.1016/j.surg.2014.06.016 Get rights and content

Background

The lymph node (Ln) status of patients with resectable pancreatic ductal adenocarcinoma is an important predictor of survival. The survival benefit of extended lymphadenectomy during pancreatectomy is, however, disputed, and there is no true definition of the optimal extent of the lymphadenectomy. The aim of this study was to formulate a definition for standard lymphadenectomy during pancreatectomy.

Methods

During a consensus meeting of the International Study Group on Pancreatic Surgery, pancreatic surgeons formulated a consensus statement based on available literature and their experience.

Results

The nomenclature of the Japanese Pancreas Society was accepted by all participants. Extended lymphadenectomy during pancreatoduodenectomy with resection of Ln's along the left side of the superior mesenteric artery (SMA) and around the celiac trunk, splenic artery, or left gastric artery showed no survival benefit compared with a standard lymphadenectomy. No level I evidence was available on prognostic impact of positive para-aortic Ln's. Consensus was reached on selectively removing suspected Ln's outside the resection area for frozen section. No consensus was reached on continuing or terminating resection in cases where these nodes were positive.

Conclusion

Extended lymphadenectomy cannot be recommended. Standard lymphadenectomy for pancreatoduodenectomy should strive to resect Ln stations no. 5, 6, 8a, 12b1, 12b2, 12c, 13a, 13b, 14a, 14b, 17a, and 17b. For cancers of the body and tail of the pancreas, removal of stations 10, 11, and 18 is standard. Furthermore, lymphadenectomy is important for adequate nodal staging. Both pancreatic resection in relatively fit patients or nonresectional palliative treatment were accepted as acceptable treatment in cases of positive Ln's outside the resection plane. This consensus statement could serve as a guide for surgeons and researchers in future directives and new clinical studies.

Section snippets

Methods

A computerized search of the PubMed and Embase database was made using the following terms: “pancreatic cancer,” “pancreatic adenocarcinoma,” “surgery,” “radical lymphadenectomy,” “extended lymphadenectomy,” “complications,” “para-aortic,” “lymph nodes,” and “nodal staging.” Publications of rated in descending order of level of evidence: Systematic reviews and meta-analyses, prospective (randomized) studies, major publications from high-volume centers, and existing consensus reports; case

Nomenclature for nodal stations in pancreatic surgery

Both the Union International Contre le Cancer criteria and the Japanese Pancreas Society rules have been described in all level I RCTs.1, 2, 3, 4, 5, 6 During the European consensus meeting in 1999, the nomenclature of the Japanese Pancreas Society was selected and specification of the lymphadenectomy during pancreatoduodenectomy was described thereafter.⁹ There now seems to be general acceptance to use the “classification of pancreatic carcinoma” proposed by the Japanese Society (Fig 1).

Consensus statement

Based

Definition of standard lymphadenectomy during left-sided pancreatectomy in patients with pancreatic ductal adenocarcinoma in the body or tail area

Studies on lymphadenectomy during left-sided pancreatectomy for body and tail tumors are scarce. A study from 1997 described Ln involvement in 30 specimens. The greatest incidence of Ln involvement was around the splenic artery (Ln station 11), aorta (Ln station 16), SMA (Ln station 14), and celiac trunk (Ln station 9).²⁵ Another study reported similar findings with the greatest incidence of involvement seen in nodes around the splenic artery, along the inferior border of the body and tail of

General discussion

The standard lymphadenectomy formulated by the ISGPS members based on the literature and expert opinions is a guide for surgeons when operating on patients with resectable pancreatic ductal adenocarcinoma. The diversity of extent and site of lymphadenectomy described in the literature makes it difficult to compare results across studies, institutions, and countries, and to determine the optimal procedure. There are many potential advantages in adopting this consensus statement, including new

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: Conflicts of interest: The authors disclose no conflicts.

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ConsensusDefinition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: A consensus statement by the International Study Group on Pancreatic Surgery (ISGPS)

Background

Methods

Results

Conclusion

Section snippets

Methods

Nomenclature for nodal stations in pancreatic surgery

Consensus statement

Definition of standard lymphadenectomy during left-sided pancreatectomy in patients with pancreatic ductal adenocarcinoma in the body or tail area

General discussion

Surgery

J Clin Epidemiol

Eur J Surg Oncol

Surgery

Surgery

J Am Coll Surg

J Gastrointest Surg

J Gastrointest Surg

J Gastrointest Surg

Surgery

J Gastrointest Surg

Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas

Ann Surg

Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome

Ann Surg

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

Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma–part 3: update on 5-year survival

J Gastrointest Surg

Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial

J Hepatobiliary Pancreat Sci

A surgical and pathological based classification of resective treatment of pancreatic cancer. Summary of an international workshop on surgical procedures in pancreatic cancer

Dig Surg

Standard Kausch-Whipple pancreatoduodenectomy

Dig Surg

Classification of pancreatic carcinoma

Practical usefulness of lymphatic and connective tissue clearance for the carcinoma of the pancreatic head

Ann Surg

Modified standard pancreaticoduodenectomy for the treatment of pancreatic head cancer

Cancer

Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer

Br J Surg

Japan Pancreatic Cancer Registry; 30th year anniversary

Pancreas

Consensus
Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: A consensus statement by the International Study Group on Pancreatic Surgery (ISGPS)