Department of Surgery, Kantonsspital St. Gallen, Gallen, Switzerland.
Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland.
Langenbecks Arch Surg. 2020 Feb;405(1):43-54. doi: 10.1007/s00423-020-01859-2. Epub 2020 Feb 10.
While the importance of lymphadenectomy is well-established for patients with resectable pancreatic cancer, its direct impact on survival in relation to other predictive factors is still ill-defined.
The National Cancer Data Base 2006-2015 was queried for patients with resected pancreatic adenocarcinoma (stage IA-IIB). Patients were dichotomized into the following two groups, those with 1-14 resected lymph nodes and those with ≥ 15. Optimal number of resected lymph nodes and the effect of lymphadenectomy on survival were assessed using various statistical modeling techniques. Mediation analysis was performed to differentiate the direct and indirect effect of lymph node resection on survival.
A total of 21,912 patients were included; median age was 66 years (IQR 59-73), 48.9% were female. Median number of resected lymph nodes was 15 (IQR 10-22), 10,163 (46.4%) had 1-14 and 11,749 (53.6%) had ≥ 15 lymph nodes retrieved. Lymph node positivity increased by 4.1% per lymph node up to eight examined lymph nodes, and by 0.6% per lymph node above eight. Five-year overall survival was 17.9%. Overall survival was better in the ≥ 15 lymph node group (adjusted HR 0.91, CI 0.88-0.95, p < 0.001). On a continuous scale, survival improved with increasing LNs collected. Patients who underwent adjuvant chemotherapy and were treated at high-volume centers had improved overall survival compared with their counterparts (adjusted HR 0.59, CI 0.57-0.62, p < 0.001; adjusted HR 0.86, CI 0.83-0.89, p < 0.001, respectively). Mediation analysis revealed that lymphadenectomy had only 18% direct effect on improved overall survival, while 82% of its effect were mediated by other factors like treatment at high-volume hospitals and adjuvant chemotherapy.
While higher number of resected lymph nodes increases lymph node positivity and is associated with better overall survival, most of the observed survival benefit is mediated by chemotherapy and treatment at high-volume centers.
虽然淋巴结清扫术对可切除胰腺癌患者的重要性已得到充分证实，但它对生存的直接影响与其他预测因素的关系仍不明确。
从 2006 年至 2015 年的国家癌症数据库中查询接受可切除胰腺腺癌（IA-IIB 期）治疗的患者。将患者分为两组：淋巴结清扫 1-14 枚的患者和淋巴结清扫≥15 枚的患者。使用各种统计建模技术评估最佳的淋巴结清扫数量和淋巴结清扫对生存的影响。进行中介分析以区分淋巴结切除术对生存的直接和间接影响。
共纳入 21912 例患者；中位年龄为 66 岁（IQR 59-73），48.9%为女性。中位数淋巴结清扫数量为 15（IQR 10-22），10163 例（46.4%）有 1-14 枚淋巴结转移，11749 例（53.6%）有≥15 枚淋巴结转移。淋巴结阳性率每增加一个淋巴结增加 4.1%，达到 8 个检查淋巴结后，每增加一个淋巴结增加 0.6%。5 年总生存率为 17.9%。淋巴结清扫≥15 枚的患者总生存率更好（调整 HR 0.91，CI 0.88-0.95，p<0.001）。在连续尺度上，随着收集的淋巴结数量增加，生存率也有所提高。与对照组相比，接受辅助化疗和在高容量中心治疗的患者总生存率提高（调整 HR 0.59，CI 0.57-0.62，p<0.001；调整 HR 0.86，CI 0.83-0.89，p<0.001）。中介分析显示，淋巴结清扫术对提高总生存率的直接影响仅为 18%，而 82%的影响是通过化疗和在高容量医院治疗等其他因素介导的。
虽然更多数量的淋巴结清扫会增加淋巴结阳性率，并与更好的总生存率相关，但观察到的生存获益大部分是由化疗和在高容量中心治疗介导的。
