# The Prognostic Role of Para-Aortic Lymph Node Metastasis in Patients with Resected Pancreatic Adenocarcinoma

## TL;DR

This study finds that removing para-aortic lymph nodes during pancreatic cancer surgery does not improve survival but helps identify patients with worse outcomes.

## Contribution

The study demonstrates that para-aortic lymph node metastasis is an independent prognostic factor in pancreatic cancer patients.

## Key findings

- Para-aortic lymph node dissection does not improve overall or disease-free survival in pancreatic cancer patients.
- Patients with para-aortic lymph node metastases have significantly worse survival outcomes and pathological features.
- Para-aortic lymph node status is an independent prognostic factor for survival in pancreatic ductal adenocarcinoma.

## Abstract

Pancreatic cancer remains one of the deadliest cancers, and even after surgery, many patients experience early recurrence and poor survival. During surgery for pancreatic cancer, removal and examination of para-aortic lymph nodes can help determine how far the cancer has spread. However, it is unclear whether removing these lymph nodes improves survival. This study examined patients who underwent pancreatic surgery with or without para-aortic lymph node dissection to assess its value. The results showed that removing these lymph nodes does not directly improve survival but helps identify patients whose cancer has spread further and who therefore have a worse prognosis. Recognizing these high-risk patients may help clinicians tailor follow-up treatments, such as intensified chemotherapy, and improve decision-making in patient care in the future.

Background: This study aimed to evaluate the prognostic significance of para-aortic lymph node dissection (PALND) during pancreatic head resection and the impact of para-aortic lymph node metastasis (PALN+) on survival outcomes in patients with resected pancreatic ductal adenocarcinoma (PDAC). Methods: A retrospective analysis was conducted on 198 patients who underwent primary pancreatic head resection for PDAC at the University Hospital Erlangen between 2003 and 2022. Patients were stratified based on the presence or absence of PALND and PALN metastases, and their clinicopathological characteristics and survival outcomes were compared. Results: Of the 198 patients, 113 (57%) underwent additional PALND. PALND itself had no significant impact on overall survival (OS) or disease-free survival (DFS) compared to those without PALND. Among patients who underwent PALND, 17 (15%) had PALN metastases (PALN+). PALN+ patients exhibited significantly worse pathological features, including a higher rate of regional lymph node metastases (pN+), lymphovascular invasion (L1) and vascular invasion (V1). Survival analysis showed that PALN+ was associated with significantly poorer OS (8.7 vs. 29.3 months, p < 0.001) and DFS (3.8 vs. 17.0 months, p < 0.001). In multivariate analysis, PALN+ was confirmed as an independent prognostic factor for both OS (HR 1.9 [1.0–3.6], p = 0.035) and DFS (HR 2.2 [1.2–4.0], p = 0.006). Conclusions: While PALND does not impact survival outcomes in PDAC, it plays a crucial role in identifying PALN+ patients, who have significantly worse prognoses. PALN status should be integrated into clinical decision-making, particularly when considering intensified adjuvant therapy.