Prognostic factors in the operative treatment of ductal pancreatic carcinoma

Background and aims: The average 5-year survival rate following resection o f a ductal adenocarcinoma of the pancreas is 10% worldwide. Despite increas ing resection rates, only about 20% can be operated on with curative intent . A differential histopathological analysis of the resected tumors may help to justify expanding the surgical procedure by extended lymph-node dissect ion. Patients/methods: Between January 1986 and December 1995, a total of 1 13 patients underwent resection with curative intent for a ductal pancreati c carcinoma with regional lymph-node dissection. All histological findings were reviewed and reclassified in Int with the 1997 Union Internationale Co ntra la Cancrum (UICC) classification. Survival data for all of these patie nts were obtained from family doctors and registration offices. Independent prognostic factors were statistically analyzed. Results: Of the 113 patien ts, 93 received an RO resection. The postoperative mortality rate was 2.2% (2 of 93). More than one-half of the tumors had a diameter of between 2.1 c m and 4 cm. Among the 22 tumors measuring up to 2 cm in diameter, 41% alrea dy had lymph-node metastasis and 86% invasion of the lymphatic vessels. Car cinomas measuring between 4.1 cm and 6 cm were all associated with lymph-ve ssel invasion. Perineural invasion was present in 504b of the tumors. A not eworthy finding was the fact that 64% of the 25 tumors with negative lymph nodes had lymph-vessel invasion, and 48% perineural invasion. The cumulativ e 5-year survival rate of the RO-resected patients was 10.5%. Patients with lymph-node-negative stages survived significantly longer (26.5%) than pati ents with lymph-node-positive stages (5%). Furthermore, a significant diffe rence was seen between pN1a and pN1b (16.7% vs 2.2%). Multivariate analysis identified tumor grading, tumor size and lymph vessel invasion as independ ent prognostic factors. Conclusions: Apart from the factors tumor size and tumor grading, lymph-vessel invasion appears to be of special significance for the longterm prognosis. Already in the pN0 stage, the latter was presen t in 64% of the cases and must be considered a precursor of lymphogenic met astasization. Since lymph-vessel invasion was demonstrated in 86% of tumors measuring less than 2 cm, the therapeutic consequence for all ductal pancr eatic tumors is an extended lymphatic and soft tissue dissection that goes beyond the regional lymph-node stations.