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The Role of Lymphadenectomy for Liver Tumors: Further Considerations on the Appropriateness of Treatment Strategy

Ercolani, Giorgio MD*; Grazi, Gian Luca MD*; Ravaioli, Matteo MD*; Grigioni, Walter Franco MD†; Cescon, Matteo MD*; Gardini, Andrea MD*; Del Gaudio, Massimo MD*; Cavallari, Antonino MD*

Original Articles

Objective: To evaluate the role of regional lymphadenectomy in patients with liver tumors.

Background: Lymph node status is 1 of the most important prognostic factors in oncologic surgery; however, the role of lymph node dissection remains unclear for hepatic tumors.

Methods: A total of 120 consecutive patients undergoing liver resections for primary and secondary hepatic tumors were prospectively enrolled in the study. “Regional” lymphadenectomy was carried out routinely after specimen removal. Incidence, site, and influence on survival of node metastases were analyzed.

Results: Only 1 postoperative complication (intra-abdominal bleeding) was related to lymph node excision. Median number of dissected nodes was 6.8 ± 3.6. Periportal, pericholedochal, and common hepatic artery stations were always removed. Lymph node metastases were found in 17 (16.5%) patients. The percentage rises to 20.3% when considering only noncirrhotic patients. The incidence of lymph node metastases was 7.5% for hepatocellular carcinoma, 14% for colorectal metastases, 40% for noncolorectal metastases, and 40% for intrahepatic cholangiocarcinoma (P < 0.002). Median survival time was 486 ± 93.2 days among all patients with node metastases and 725 ± 29.7 among patients without node metastases. The 2-year survival was 37.1% and 86.7%, in the 2 groups (P < 0.05). The 2-year recurrence rate was 77.6% and 45.3%, respectively (P < 0.05).

Conclusions: Regional lymphadenectomy is a safe procedure after liver resection, and it should be routinely applied in patients with primary and secondary hepatic tumors, particularly in those without chronic disease. A careful evaluation of node status is nevertheless advisable also in patients with hepatocellular carcinoma on cirrhosis.

Lymph node status is a definite prognostic factor in oncologic surgery and significantly affects long-term survival, as reported by the tumor staging system of the International Union Against Cancer (IUCC), which is the most widespread classification of malignant tumors worldwide.1 The impact on survival of lymph node metastases has already been reported for lung cancer,2 esophageal cancer,3 and renal cancer.4 The prognostic value and the extent of lymph node dissection are strongly defined for breast carcinoma5 and other gastrointestinal neoplasms.6–8 Some authors have claimed that a minimum number of lymph nodes should be dissected in gastric and colorectal carcinoma to obtain a reliable staging of the tumor.9,10

Regional lymphadenectomy is already the standard procedure that completes hepatic resection in the case of carcinoma arising from the extrahepatic bile duct.11,12 However, the indication, extent, and role of lymph node excision are still a matter of discussion, and no clear guidelines exist in patients with other types of primary or secondary hepatic tumors. An increased operative risk of liver resection has been reported when lymph node dissection is performed in patients with liver tumors.13,14 Therefore, concerns still remain with regard to its routine application.

It is of great interest to clarify which patients with hepatic cancers should benefit from lymph node excision, in which cases this procedure should be mandatory and whether the operative risk is really increased by it.

We have prospectively evaluated the feasibility and safety of a routine regional lymphadenectomy and the incidence, site, and impact on survival of lymph node metastases in patients with primary and secondary liver tumors amenable to curative liver resection. Our results therefore refer to the most recent therapeutic strategies in the field of liver tumors.

Regional lymphadenectomy was carried out prospectively in 120 patients undergoing liver resection for different primary and secondary hepatic tumors. Incidence of lymph node metastases was 20.3% in noncirrhotic patients. The 2-year survival and recurrence rates were significantly affected by the presence of lymph node metastases.

From the *Departments of Surgery and Transplantation and †Pathology, Sant'Orsola Hospital, University of Bologna, Bologna, Italy.

Reprints: Gian Luca Grazi, MD, Department of Surgery and Transplantation, University of Bologna, Sant'Orsola-Malpighi Hospital, Via Massarenti, 9, 40138 Bologna, Italy.

© 2004 Lippincott Williams & Wilkins, Inc.