Annals of … Extrahepatic Lymph-Node Metastases In addition to loco-regional nodal basins, CRC may metastasize to peri-hepatic, hilar, or para-aortic lymph nodes. Nodal metastasis outside

the regional CRC basin may represent “metastasis from metastasis” as a subset of patients who do not have regional lymph node metastasis can subsequently #Alvocidib nmr keyword# be found to have peri-hepatic or hilar lymph node metastasis (57-59). While the overall incidence of lymph node metastasis in the setting of CLM is hard to define, most studies have reported a range of 1-10% (21,60-63). Traditionally, metastatic disease in the hilar or para-aortic lymph nodes has been considered a strong relative contraindication to Inhibitors,research,lifescience,medical surgery due to poor long-term survival among this group of patients. With more effective chemotherapy, as well as the recent publication on improved outcomes for patients with non-regional lymph node metastasis, the role of resection of CLM in the setting of lymph node metastasis has been reconsidered (8,11,22,64,65).

Several studies have examined the impact of lymph node metastasis through the use of empiric routine lymphadenectomy at the time of liver surgery (21,59,63,66). In a study by Elias et al., lymph node dissection of the hepatic pedicle was undertaken in 100 consecutive patients undergoing curative Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical hepatectomy for CLM in whom lymph node involvement of the hepatic pedicle was not macroscopically detectable (63). Microscopic lymph node involvement was found in 14 patients. In a separate study by the Strasbourg

group, among 160 patients who had routine lymphadenectomy, the authors reported an 11% incidence of microscopic Inhibitors,research,lifescience,medical disease in the lymph nodes (59). Laurent et al. reported an incidence of 15% for microscopic disease in the peri-hepatic/hilar lymph nodes (21). Early reports from these centers noted a poor survival among patients with microscopic lymph node metastasis, with 5-year survival in the range of 5-18%. More recently other groups reported more out favorable long-term survival, noting that the specific site of the metastatic lymph node disease is important in stratifying patients with regards to prognosis (11,22,67). Among patients with CLM, the location of the lymph node metastasis may dictate the relative survival benefit of surgical intervention. Specifically, Jaeck et al. note that liver resection did not offer a survival benefit among patients with lymph node metastasis along the common hepatic artery and celiac axis (area 2), but was beneficial for those patients with lymph node disease restricted to the hepatoduodenal ligament and retro-pancreatic location (area 1) (59). Adam et al. similarly noted a difference in outcome when comparing survival of patients with lymph node metastasis in area 1 versus area 2 (22).