SURGICAL STRATEGY FOR CARCINOMA OF THE PANCREAS HEAD AREA BASED ON CLINICOPATHOLOGICAL ANALYSIS OF NODAL INVOLVEMENT AND PLEXUS INVASION

Background. The pattern of tumor spread vis-a-vis nodal involvement an d invasion of the extrapancreatic plexus (Plx), has not been thoroughl y described for carcinoma of the pancreatic head area. Methods. From 1 973 to 1991, 110 patients (49 with carcinoma of the pancreatic head [P h], 29 with distal bile duct cancer [Bi], and 32 with carcinoma of the papilla of Vater [Pv]) underwent pancreatectomy at Kanazawa Universit y Hospital. Nodal involvement and Plx invasion were precisely evaluate d by histopathologic examination. Results. Thirty-seven (76%) of the 4 9 patients with Ph, 20 (69%) of the 29 with Bi, and 14 (44%) of the 32 with Pv had nodal involve,ent. The lymph nodes most commonly involved for Ph were the posterior pancreaticoduodenal lymph nodes (numbers 13 a [superior] and 13b [inferior]), the superior mesenteric lymph nodes (number 14), the paraaortic lymph nodes (number 16), and the anterior pancreaticoduodenal lymph nodes (number 17) (13a, 51% 13b, 47%; 14, 36 .7%; 16, 18.4%; 17a, 33%; 17b, 22%). In patients with Bi, lymph nodes around the hepatoduodenal ligament (number 12) and lymph nodes numbers 13a and 14 were most commonly involved (12, 27.6%; 13a, 51.7%; 14, 34 .5%). In patients with Pv, lymph node numbers 13b and 74 were most fre quently involved (13b, 34.4%; 14, 15.6%). No significant correlation w as noted between the tumor size and nodal involvement in these three l esions. Nodal involvement was an important prognostic factor for carci noma of the pancreatic head area. Pix invasion in these three carcinom as was observed in 61% of patients with Ph, 29% of patients with Bi, a nd 3% of patients with Pv. Conclusions. Nodal involvement and Plx inva sion differed significantly among carcinomas of the pancreatic head ar ea. We believe that nodal dissection of at least group number 14 is ne eded for Ph, Bi, and Pv cancers. In addition, dissection of lymph node s of number 16 and the Pix around the superior mesenteric artery and c eliac axis are needed in Ph cancer. Pix dissection of the first portio n of plexus plexus pancreaticus capitalis is needed in Bi cancer.