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Impact of Regional Lymph Node Evaluation in Staging Patients With Periampullary Tumors

¹ Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Stoneman 9, 330 Brookline Avenue, Boston, Massachusetts 02215, USA
² Department of Surgery, University of Toronto, Toronto, Ontario, Canada
³ Department of Medical Imaging, University Health Network and Mount Sinai Hospitals, University of Toronto, Toronto, Ontario, Canada
⁴ Department of Pathology, University of Toronto, Toronto, Ontario, Canada
⁵ Department of Surgery, University of Calgary, Calgary, Alberta, Canada

Correspondence: Address correspondence and reprint requests to: Charles M. Vollmer Jr., MD; E-mail: cvollmer{at}bidmc.harvard.edu

Background: Two distinct lymph nodes reproducibly assessed by computed tomography for the evaluation of periampullary tumors are the common bile duct (CBD) node and the gastroduodenal artery (GDA) node. We examined whether radiographical enlargement of either lymph node predicts tumor resectability, nodal metastasis, or patient survival.

Methods: Ninety-four consecutive patients underwent attempted curative resection of periampullary tumors between September 2001 and June 2003. A single radiologist recorded in a retrospective, blinded fashion the short- and long-axis measurements of the CBD and GDA nodes.

Results: Sixty-one percent (n = 57) of tumors were resectable by pancreaticoduodenectomy. Overall, actual 6-, 12-, and 18-month survival was 87%, 68%, and 63%, respectively. Enlarged radiographical nodal size by either axis was not associated with the presence of metastasis to these lymph nodes or with reduced overall patient survival. Only a CBD node short-axis size >10 mm predicted unresectability (odds ratio, 3.2; P = .036). Liver metastasis and/or carcinomatosis were present in 43% of unresectable patients, and this was associated with decreased survival at both 1 year (25% vs. 77%; P < .001) and 18 months (19% vs. 72%; P <.001). A pathologic diagnosis of metastasis to the GDA node, but not the CBD node, was associated with a similarly decreased survival (1 year: 33% vs. 78%, P = .028; 18 months: 22% vs. 70%, P = .023).

Conclusions: For presumed periampullary malignancy, a CBD node short-axis size >10 mm predicts tumor unresectability. Metastatic disease to the GDA node, particularly for pancreatic adenocarcinoma, portends a poor prognosis equivalent to that of hepatic or peritoneal spread. Given these findings, radiographical CBD lymph node measurements may guide selection for performing laparoscopic staging with or without ultrasonography in conjunction with GDA nodal biopsy in patients with periampullary malignancy.

Key Words: Periampullary tumors • Staging laparoscopy • Lymph nodes • Resectability

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