The Future of Surgical Lymph Node Management

On this episode of the SO Files, Brad and Linda discuss the current state and future of surgical lymph node management. The SO Files welcome special guest, Dr. William Hawkins, Neidorff Family and Robert C. Packman Professor of Surgery and Chief, Section of Hepatobiliary-Pancreatic and Gastrointestinal Surgery at the Washington University School of Medicine/ Siteman Cancer Center. We hope you enjoy this interesting discussion!

Background Reading

Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome.

Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, Hruban RH, Pitt HA, Lillemoe KD.

Randomized single center trial out of Johns Hopkins, with 114 patients accrued from 1996-97. Bottom line: radical pancreaticoduodenectomy (+distal gastrectomy/ RP lymphandenectomy) can be done with similar morbidity/mortality to traditional Whipple. 

Extended pancreatic resections and lymphadenectomy: An appraisal of the current evidence.

Shailesh V Shrikhande and Savio G Barreto.

Review article outlining recent data on extended pancreatic resections for pancreatic cancer. The overall conclusion from multiple trials shows that extended resection can be done safely and is technically feasible, but there is a lack of data supporting improved overall survival in patients undergoing more radical resection.

Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial.

Songun I, Putter H, Kranenbarg EM, Sasako M, van de Velde CJ.

15 year follow-up data from the Dutch D1D2 trial for gastric cancer. D2 lymphadenectomy resulted in a 29% overall survival for the D2 group vs. 21% for the D1 group (p=0.34). Gastric cancer related death was higher in the D1 group than the D2 group (48% vs. 37%, respectively, p=0.01).  

Papers we Discuss/ Mention

Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial.

Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, Whitworth PW, Blumencranz PW, Leitch AM, Saha S, McCall LM, Morrow M.

A practice changing article that established that for patients with clinical T1-2 N0 breast cancer with <3 SLN metastases found on SLN biopsy, there is no benefit of completion axillary lymph node dissection over no further surgical treatment of the axilla. This is high yield for the ABSITE, and a good thing to know for any medical student scrubbing in on a breast cancer operation during their surgical rotation.

Final Trial Report of Sentinel-Node Biopsy versus Nodal Observation in Melanoma.

Donald L. Morton, M.D., John F. Thompson, M.D., Alistair J. Cochran, M.D., Nicola Mozzillo, M.D., Omgo E. Nieweg, M.D., Ph.D., Daniel F. Roses, M.D., Harold J. Hoekstra, M.D., Ph.D., Constantine P. Karakousis, M.D., Ph.D., Christopher A. Puleo, P.A.-C., Brendon J. Coventry, B.M., B.S., Ph.D., Mohammed Kashani-Sabet, M.D., B. Mark Smithers, M.B., B.S., Eberhard Paul, M.D., William G. Kraybill, M.D., J. Gregory McKinnon, M.D., He-Jing Wang, M.D., Robert Elashoff, Ph.D., and Mark B. Faries, M.D., for the MSLT Group

Phase III MSLT1 trial which definitively established the utility of SLN biopsy for intermediate thickness melanomas. Improved recurrence free and melanoma specific survival for patients with SLN metastases identified.

Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma.

Faries MB, Thompson JF, Cochran AJ, Andtbacka RH, Mozzillo N, Zager JS, Jahkola T, Bowles TL, Testori A, Beitsch PD, Hoekstra HJ, Moncrieff M, Ingvar C, Wouters MWJM, Sabel MS, Levine EA, Agnese D, Henderson M, Dummer R, Rossi CR, Neves RI, Trocha SD, Wright F, Byrd DR, Matter M, Hsueh E, MacKenzie-Ross A, Johnson DB, Terheyden P, Berger AC, Huston TL, Wayne JD, Smithers BM, Neuman HB, Schneebaum S, Gershenwald JE, Ariyan CE, Desai DC, Jacobs L, McMasters KM, Gesierich A, Hersey P, Bines SD, Kane JM, Barth RJ, McKinnon G, Farma JM, Schultz E, Vidal-Sicart S, Hoefer RA, Lewis JM, Scheri R, Kelley MC, Nieweg OE, Noyes RD, Hoon DSB, Wang HJ1, Elashoff DA, Elashoff RM.

MSLTII Trial: Among patients with intermediate thickness melanoma (1.2-3.5mm) and a positive SLN biopsy there is equivalent melanoma specific survival at 3 years in the immediate completion lymphadenectomy group and the observation group (DSS 86% in both groups at 3 yrs). 

Origins of lymphatic and distant metastases in human colorectal cancer.

Naxerova K, Reiter JG, Brachtel E, Lennerz JK, van de Wetering M, Rowan A, Cai T, Clevers H, Swanton C, Nowak MA, Elledge SJ, Jain RK.

For a highly selected group of colorectal cancer patients, the primary tumor, lymph node met(s), and distant met(s) were characterized via hypermutable DNA regions to create phylogenetic trees. In ~2/3rds of cases distant mets came from a different sub-clone than the sub-clone found in the lymph node met–suggesting they arose separately from the primary colorectal tumor.