Preoperative prediction of metastatic body-tail peripancreatic lymph nodes as a guide for surgical decision-making in pancreatic neck ductal adenocarcinoma

The oncologically appropriate surgery for neck pancreatic ductal adenocarcinoma (PDAC) remains challenging due to the absence of standardized criteria. This study aims to preoperatively identify patients with neck PDAC at high risk of metastatic body-tail peripancreatic lymph nodes (BT-PLNs). This retrospective cohort study included adult patients undergoing resection for neck PDAC at San Raffaele Hospital (Milan, Italy). Patients with metastatic BT-PLNs were identified from histopathological records. Age, preoperative tumor size, preoperative Ca19.9, radiological response to neoadjuvant chemotherapy (NAT), resectability at diagnosis, and tumor site (distance in millimeters from the superior mesenteric vein and the point where the Wirsung duct starts dilating [W-SMV] on preoperative CT scan) were evaluated as potential predictors of metastatic BT-PLNs. Predictors were selected using multiple logistic regression with stepwise backward selection and then included in a predictive model to identify patients at high risk of metastatic BT-PLNs (online calculator: www.pancreaticneck.altervista.org). A total of 143 patients were included (67 years [IQR 59–73], 60% female). Among patients undergoing total pancreatectomy (TP) or distal pancreatectomy (DP) (n = 81/143), W-SMV (p < 0.001), radiological response to NAT (p < 0.001) and age (p = 0.021) acted as predictors of metastatic BT-PLNs. Additionally, the protective effect of NAT on the risk of lymph node metastasis decreased with each year increase in age (p < 0.001). Neck PDAC at high risk of metastatic BT-PLNs could benefit from at least a DP. Preoperative prediction of metastatic BT-PLNs could minimize the risk of suboptimal treatment for neck PDAC.