Surgical Strategy based on Review of Prospective, Randomized Controlled Trial of Standard versus Extended Lymphadenectomy for Cancer of the Pancreatic Head

Takehisa Hiraoka and Katsuhiko Inoue

Department of Surgery, Kumamoto Rousai Hospital

Controversy exists about the survival advantage between standard and extended lymphadenectomy in the pancreatic head cancer. Four prospective, randomized controlled trials (RCT)-one in Italy, two in the USA, and one in Japan-have been to define a surgical approach to this disease. Extended lymphadenectomy involved pancreatoduodenectomy with extended para-aortic lymph node dissection, including clearance of retroperitoneal connective and neural tissue to get a surgical margin free of cancer cells. Extended lymphadenectomy had a curative resection similar to standard lymphadenectomy, and did not show a survival advantage over standard lymphadenectomy. These results should be taken into due consideration of the differences in study design concerning adjuvant therapy in each RCT, despite similar demographics. Pancreatic cancer, however, may be best thought of as a systemic disease for most if not all patients, even for a diagnosis of apparently resectable disease. Retroperitoneal lymph node dissection around abdominal aorta for this systemic process may thus yield only negligible benefit. It is calculated theoretically that the difference in survival benefit of extended lymphadenectomy is biostatistically negligible. Definitive evaluation of the potential survival benefit of extended lymphadenectomy would require a prohibitively large sample size, making adequate RCTs unfeasible. Curative resection without extended lymphadenectomy is therefore recommended as the resection of choice for subjects with pancreatic head cancer, and adjuvant therapy is therefore essential for improving long-term survival in this disease.

Key words
pancreatic cancer, extended lymphadenectomy, randomized controlled trial

Reprint requests
Takehisa Hiraoka Department of Surgery, Kumamoto Rousai Hospital
1670 Takeharamachi, Yatsusiro, 866-8533 JAPAN

Accepted
November 18, 2009

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