title: Nodal involvement as an indicator of postoperative liver metastasis in carcinoma of the papilla of Vater.
abstract: OBJECTIVE
  Although lymph node metastatic involvement is one of the most important prognostic factors for carcinoma of the papilla of Vater, a detailed analysis of this factor in relation to prognosis has not been conducted.
  
  
  METHODS
  From 1985 to 2003, 29 patients with carcinoma of the papilla of Vater underwent pancreaticoduodenectomy and dissection of regional lymph nodes at Yamagata University Hospital. We analyzed clinicopathologic variables in relation to prognosis and precisely evaluated nodal involvement in each patient to determine lymphatic flow. Furthermore, the relationship between recurrent site and nodal involvement was investigated.
  
  
  RESULTS
  The overall survival rate was 55% at 5 years. The significant prognostic factors were morphological ulcer formation (P = 0.04), histological type (P = 0.03), nodal involvement (P = 0.002), and lymphatic invasion (P = 0.03). Multivariate analysis indicated no independent factor, but nodal involvement may be the strongest prognostic factor. The overall rate of nodal involvement was 41.4% (12 of 29 patients). The metastatic rates in the superior posterior pancreaticoduodenal lymph nodes, the inferior posterior pancreaticoduodenal lymph nodes, the superior mesenteric lymph nodes, and paraaortic lymph nodes were high (31.0%, 20.7%, 17.2%, and 13.8%, respectively). Patients with nodal involvement had a significantly higher rate of liver metastasis after surgery than those without it (P = 0.02). Ulcer formation and histological type were significantly correlated with nodal involvement (P = 0.05 and P = 0.002, respectively).
  
  
  CONCLUSIONS
  Nodal involvement is the most important prognostic factor in patients with carcinoma of the papilla of Vater. Patients with nodal involvement are at high risk of liver metastasis; therefore, adjuvant therapy may be necessary for the control of liver metastasis. Preoperative ulcer formation and histological type in the biopsy specimen are good indicators for extended lymph node dissection and adjuvant therapy, because these variables are correlated with nodal involvement. However, our data revealed only the sites of the positive nodes, without addressing the effect of extended lymph node dissection and adjuvant chemotherapy. To date, there has been reporting of extended lymph node dissection and adjuvant chemotherapy in patients with carcinoma of the papilla of Vater. Further studies will be necessary to resolve these problems.
authors.affiliation: Gastroenterology and General Surgery, Yamagata University School of Medicine, Yamagata, Japan.
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Moriya
authors.forename: Wataru
authors.initials: W
authors.lastname: Kimura
authors.forename: Ichiro
authors.initials: I
authors.lastname: Hirai
authors.forename: Masaomi
authors.initials: M
authors.lastname: Mizutani
authors.forename: Jingfeng
authors.initials: J
authors.lastname: Ma
authors.forename: Masahiro
authors.initials: M
authors.lastname: Kamiga
authors.forename: Akira
authors.initials: A
authors.lastname: Fuse
mesh_terms: D000328:Adult; D000368:Aged; D014670:Ampulla of Vater; D003138:Common Bile Duct Neoplasms / Q000473:pathology* / Q000601:surgery; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000556:secondary / Q000601:surgery*; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D016577:Pancreaticoduodenectomy; D011184:Postoperative Period; D011379:Prognosis; D016019:Survival Analysis