Perihilar Cholangiocarcinoma: Number of Nodes Examined and Optimal Lymph Node Prognostic Scheme

Abstract

BACKGROUND The role of routine lymphadenectomy for perihilar cholangiocarcinoma is still controversial and no study has defined the minimum number of lymph nodes examined (TNLE). We sought to assess the prognostic performance of American Joint Committee on Cancer/Union Internationale Contre le Cancer (7th edition) N stage, lymph node ratio, and log odds (LODDS; logarithm of the ratio between metastatic and nonmetastatic nodes) in patients with perihilar cholangiocarcinoma and identify the optimal TNLE to accurately stage patients. METHODS A multi-institutional database was queried to identify 437 patients who underwent hepatectomy for perihilar cholangiocarcinoma between 1995 and 2014. The prognostic abilities of the lymph node staging systems were assessed using the Harrell’s c-index. A Bayesian model was developed to identify the minimum TNLE. RESULTS One hundred and fifty-eight (36.2%) patients had lymph node metastasis. Median TNLE was 3 (interquartile range, 1 to 7). The LODDS had a slightly better prognostic performance than lymph node ratio and American Joint Committee on Cancer, in particular among patients with <4 TNLE (c-index = 0.568). For 2 TNLE, the Bayesian model showed a poor discriminatory ability to distinguish patients with favorable and poor prognosis. When TNLE was >2, the hazard ratio for N1 patients was statistically significant and the hazard ratio for N1 patients increased from 1.51 with 4 TNLE to 2.10 with 10 TNLE. Although the 5-year overall survival of N1 patients was only slightly affected by TNLE, the 5-year overall survival of N0 patients increased significantly with TNLE. CONCLUSIONS Perihilar cholangiocarcinoma patients undergoing radical resection should ideally have at least 4 lymph nodes harvested to be accurately staged. In addition, although LODDS performed better at determining prognosis among patients with <4 TNLE, both lymph node ratio and LODDS outperformed compared with American Joint Committee on Cancer N stage among patients with ≥4 TNLE.

Nodal CTV selection according to primary tumour location and pT stage for biliary tract cancer

“…The pooled weighted rate of involvement of each LNS was calculated separately for pEHC (four studies, 519 patients), mEHC (five studies, 132 patients) and dEHC (10 studies, 642 patients). Data on the rate of involvement of each LNS according to the pT stage were available only for dEHC (pT1‐2: three studies, 30 patients; pT3‐4: three studies, 61 patients) (Table , Figs –S8).…”

Prognostic value of retrieved lymph node counts in patients with node‐negative perihilar cholangiocarcinomas

“…Bagante et al . revealed that the overall survival of N0 patients improved as the number of retrieved LNs increased, whereas the influence of retrieved LNs on survival of N+ patients was slight . Therefore, the impact of retrieved LNs counts on survival was better embodied in N0 patients.…”

“…There have been plenty of studies to reveal the pivotal prognostic factors of perihilar cholangiocarcinoma patients with LN metastasis. The prognostic value of LN ratio, number of retrieved LNs and number of positive LNs were validated and compared several times in recent studies . No matter the studies on LN ratio, the number of retrieved LNs or the number of positive LNs, the focus of attention was always on patients with LN metastasis, and studies on patients without LN metastasis are still rare.…”

Laparoscopic resection for Bismuth type III and IV hilar cholangiocarcinoma: How to improve the radicality without direct palpation

“…16) metastases . Bagante et al reported that tumor metastases in lymph node Nos. 9, 14, and 16 are found in 21.7% (5 of 23) of patients with HCCA and indicated that extended lymphadenectomy including para‐aortic and superior mesenteric nodes may yield an accurate tumor stage and improve the HCCA patient's survival with acceptable postoperative morbidity.…”

“…Abbreviations: AJCC, American Joint Committee on Cancer; MA, mucinous adenocarcinoma the tumor-infiltrated lymph nodes, and consequently, extended lymphadenectomy should be implemented to remove all potentially involved lymph nodes (including No. 8,9,12,13,14, and 16 nodes) and thereby attempt to prolong these patients' survival. Through these techniques, the radicality of laparoscopic resection for Bismuth type III and IV HCCA can be greatly improved, realizing the desire of minimal invasive surgery in patients with HCCA.…”