Role of Nodal Involvement and the Periductal Soft-Tissue Margin in Middle and Distal Bile Duct Cancer

Abstract

ObjectiveTo determine the pattern of middle (Bim) and distal (Bi) bile duct cancers in an attempt to optimize surgical treatment. Summary Background DataLymph node involvement and neural plexus invasion are the prognostic factors most amenable to surgery in Bm and Bi disease. However, a detailed analysis of these factors has not been conducted. MethodsFifty patients with Bm and Bi disease (Bm 14 patients, Bi 36 patients) were examined histopathologically. A precise determination was made of lymph node involvement and neural plexus invasion. Important prognostic factors were examined by clinicopathologic study to apply these findings to surgical management. ResultsFrequencies of nodal involvement for Bm and Bi disease were 57% and 71 %, respectively. The inferior periductal and superior pancreaticoduodenal lymph nodes were most commonly involved. Neural plexus invasion occurred in 20% of patients, particularly involving the plexus in the hepatoduodenal ligament and pancreatic head. Tumor was present at the surgical margin in 50% and 14% of patients with Bm and Bi disease, respectively. Five-year survival rates were 65% in the absence of nodal metastasis and 21 % with nodal metastasis. A significant correlation existed between absence of tumor at the surgical margin and survival. A Cox proportional hazard model projected absence of tumor at the surgical margin, followed by nodal involvement, as the strongest prognostic variables. ConclusionsAbsence of tumor at the surgical margin and nodal involvement are important independent prognostic factors in Bm and Bi disease. Skeletonization of the hepatoduodenal ligament, including portal vein resection, is necessary for patients with Bm disease, and a wide nodal dissection is essential in all patients.The survival rate for periampullary carcinoma is low among the malignant gastrointestinal diseases. The prognosis of bile duct cancer is better than that of carcinoma of the head of the pancreas.' Pancreatobiliary carcinoma is characterized by tumor spread by neural invasion and lymph node metastasis.24 Nodal involvement and nerve plexus invasion are important prognostic factors that may be surgically resectable. We already have reported that a radical resection is necessary for pancreatobiliary cancer.26 However, even after curative surgery, some patients still have recurrence.The goal of the current study was to determine the pattern of tumor spread, including nodal involvement and nerve plexus invasion, and other factors that may affect long-term survival. We also discuss the implications for the surgical treatment of carcinoma of the middle or distal bile duct.Address reprint requests to Masato Kayahara, MD, PhD, The Second

Carcinoma of the middle bile duct: Is bile duct segmentalresection appropriate?

“…There have been occasional reports of BDSR for treating extrahepatic cholangiocarcinoma in selected patients [7,8,[19][20][21][22] . In the series from the Memorial Sloan Kettering Cancer Center [7] , only 13% of patients (6 of 45) were amenable to bile duct excision alone, while this figure was 8% (3 of 34) in the Veterans Hospital study [22] .…”

“…PD or bile duct segmental resection (BDSR) is performed at the surgeon's discretion. Clinicopathological studies on hilar and distal cholangiocarcinomas have been done by many authors [2][3][4][5][6][7][8][9][10][11] , and the results of BDSR for MBD have been reported, but most of these studies involved a very limited number of cases, and the number of cases is not enough to justify BDSR as a standard treatment.…”

Depth of invasion determines the postresectional prognosis for patients with T1 extrahepatic cholangiocarcinoma

“…Regarding EHC, mucosal tumors are characterized by the absence of lymphovascular invasion. 8,11,28 In contrast, it has been reported that lymphovascular invasion is not rare for tumors that have invaded the fibromuscular layer. 11,[14][15][16][17]28 These previous findings are confirmed in the current study, which also reveals a tendency toward higher histologic grades for fibromuscular layer-invasive tumors (Table 2).…”

“…8,11,28 In contrast, it has been reported that lymphovascular invasion is not rare for tumors that have invaded the fibromuscular layer. 11,[14][15][16][17]28 These previous findings are confirmed in the current study, which also reveals a tendency toward higher histologic grades for fibromuscular layer-invasive tumors (Table 2). These observations indicate that adverse histologic factors, such as lymphovascular invasion and higher histologic grades, emerge once the tumor has invaded the fibromuscular layer.…”

Superficial vs deep pancreatic parenchymal invasion in the extrahepatic bile duct carcinomas: a significant prognostic factor

“…6,16,[19][20][21] The dependency between the depth of invasion and the status of lymph node metastasis was not statistically significant (P ¼ 0.07). When lymph node metastasis was absent, group 2 demonstrated significantly worse survival than group 1 (Po0.001), while when lymph node metastasis was present, the difference was not statistically significant (P ¼ 0.17).…”