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Porta Hepatis Nodes
Surgery in patients with porta hepatis nodal disease
Commentator: JOHN PRIMROSE, MD
Comment (from Case 39):
It can be argued that a patient with obvious lymph node disease in the porta hepatis is a poor candidate for curative surgery. I think this is an area of uncertainty. Conventional thinking is that patients with extrahepatic disease — particularly disease in the lymph nodes around the porta hepatis — are not suitable for curative treatment. However, some European data suggest that if the lymph nodes are in the region near the liver, rather than centrally at the celiac axis, removing them confers a survival benefit in combination with liver resection, so some patients with extrahepatic disease benefit from resection. We have no data for patients who present with obvious, bulky nodal disease on CT. I think most liver surgeons would regard this to be a highly unfavorable situation that is probably not amenable to cure.
Treatment of patients with porta hepatis nodal disease
Commentator: ALAN VENOOK, MD
Although there are different opinions, I believe that with the involvement of porta hepatis nodes, the horse is out of the barn. That’s based largely on a breadth of literature that precedes the era of FOLFOX/FOLFIRI and the newer agents, so the temptation is to expand on the criteria and be a little more aggressive. I’m not certain that is the right idea.
I think different folks have different opinions. This is another example where the patients have great interest. Patients may say, “Well, just remove the lymph nodes.” Especially when the nodes are negative on resection, we think, “Well, maybe we got away with one.” However, some of us believe it’s a virtual contraindication, and some of us are not sure. I believe if the lymph node is marginal and didn’t change much in size, performing a resection for these patients is reasonable because you don’t know if the lymph node is malignant or not.
A real dilemma is that there are no absolutes. When discussing the durability of the disease, if it’s black and white, if it’s100 percent and zero percent, the decisions are made for you. When it’s 95 percent and five percent, or in those instances when there’s an unpredicted or unprecedented exception, the decisions are not so clear-cut — it’s tough. When making societal decisions, you can be dogmatic, but even if you have the patient in front of you, you don’t know if that patient’s going to be the exception.
Impact of positive portal nodes on curability
Commentator: AXEL GROTHEY, MD
The identification of positive portal nodes during a hepatic metastatectomy doesn’t change my treatment approach. Even if I knew about the metastatic involvement of the portal nodes in advance, I would still generally send the patient to surgery. In a recent paper from René Adam’s group, they showed cure was still possible despite positive portal lymph nodes. While their presence might influence prognosis, we believe they might be linked to the hepatic disease, unlike positive retroperitoneal nodes that indicate two different metastatic sites.
Prognostic factors: Periportal lymph node-positive disease
Commentator: MICHAEL CHOTI, MD
If both the liver and periportal lymph nodes are positive, the prognosis is worse. One study from Europe suggests that prognosis depends on whether the positive nodes are so-called hilar lymph nodes — not near the portal, but near what’s called the celiac artery. The hilar lymph node location suggests that patients probably don’t fare well at all. If the nodes are right near the portal vein, then there is occasionally a cure.
As recently as five to 10 years ago, we used to define periportal node disease as incurable and thought that surgery should not even be performed. At this time, if you remove those positive lymph nodes, the prognosis is still worse than if those lymph nodes were negative, but occasionally those patients will be cured long term. We think that surgery prolongs survival in those patients. Positive periportal lymph nodes are definitely a poor prognostic factor, but they are not an absolute contraindication to surgery, although the pros and cons of surgical risks need to be weighed carefully. If a patient developed a slow-growing tumor years after their colon cancer, and disease in the liver was stable with one slow-growing periportal positive node, we would certainly operate on that patient. It’s not all or none.