Is para-aortic lymph node metastasis a contraindication for radical resection in biliary carcinoma? World J Surg. 2011;35:1085-1093. [PMID: 21400012 DOI: 10.1007/s00268-011-1036-4]

Prognostic Impact of Para-Aortic Lymph Node Metastasis in Resected Non-Pancreatic Periampullary Cancers

BACKGROUND

Surgery remains debatable in para-aortic lymph node (PALN, station 16b1) metastasis in non-pancreatic periampullary cancer (NPPAC). This study examined the impact of PALN metastasis on outcomes following pancreaticoduodenectomy (PD) in NPPAC.

METHODS

A retrospective analysis of patients with NPPAC who were explored for PD with PALN dissection was performed. Based on the extent of nodal involvement on final histopathology, they were stratified as node-negative (N0), regional node involved (N+) and metastatic PALN (N16+) and their outcomes were compared.

RESULTS

Between 2011 and 2022, 153/887 PD patients underwent a PALN dissection, revealing N16+ in 42 patients (27.4%), of whom 32 patients underwent resection. The 3-years overall survival (OS) for patients with N16+ was 28% (95% confidence interval [CI] 13-60%), notably lower than the 67% (95% CI 53-83.5%; p = 0.007) for those without PALN metastasis. Stratified by nodal involvement, the median OS for N+ and N16+ patients was similar (28.4 months and 26.2 months, respectively). The N0 subgroup had a significantly longer 3-years OS of 87.5% (95% CI 79-96.7%; p = 0.0051). Interestingly, 10 patients not offered resection following N16+ identified on frozen section had a median survival of only 9 months. The perioperative morbidity and mortality in patients undergoing PD with PALN dissection were similar to standard resections.

CONCLUSION

In a select group of patients with NPPAC, PD in isolated PALN metastasis was associated with improved OS. The survival in this group of patients was comparable with regional node-positive patients and significantly better than palliative treatment alone.

Practice guidelines for managing extrahepatic biliary tract cancers

Backgrounds/Aims

Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021.

Methods

Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop.

Results

In November 2021, the finalized draft was presented for public scrutiny during a formal hearing.

Conclusions

The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.

Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma

Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how 'resectable' disease is defined - molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.

Interaortocaval Lymph Node Metastasis in Gall Bladder Cancer: Is It Regional Node or Metastatic Disease?

BACKGROUND AND OBJECTIVES

Interaortocaval or para-aortic lymph node (IACLN) metastasis in gall bladder cancer (GBC) is usually a contraindication to curative resection with a prognosis similar to liver or peritoneal metastases. However, few authors have reported survival similar to regional lymph node (RLN) positive disease after curative resection in these patients. This study aims to analyse the role of curative surgery in such cases.

METHODS

Data of all patients operated for GBC from 2012 to 2019 was retrieved. Survival of the IACLN- and RLN-positive patients was compared and factors associated with recurrence and survival were analysed.

RESULTS

Patients were divided in RLN-positive (n = 47) and IACLN-positive (n = 17) group. At a median follow-up of 19.7 months, median disease-free survival (18 vs 13 months) and median overall survival (27 vs 20 months) were inferior (p = 0.06) in IACLN group. But it was higher than the patients who received only palliative therapy (median OS, 14 months). Lack of adjuvant therapy was a significant factor for disease recurrence.

CONCLUSION

Selected cases of GBC with IACLN metastases can achieve meaningful survival after curative resection and adjuvant therapy. Survival was inferior to RLN-positive cases but it was higher than the patients who received only palliative chemotherapy. This concept needs further evaluation in a prospective study with larger number of patients.

Recommendations of the clinical target volume for the para-aortic region based on the patterns of lymph node metastasis in patients with biliary tract cancer

BACKGROUND

Even though the clinical target volume (CTV) in biliary tract cancer (BTC) patients has been proposed by several previous studies, the para aortic CTV for BTC is still not well-defined. The objective of this study was to determine the precise delineation of the para aortic CTV for BTC according to the distribution pattern and failure pattern of lymph nodes.

METHODS

Computed tomography (CT)-, magnetic resonance imaging (MRI)- or positron emission tomography-computed tomography (PET-CT)-generated images of patients with BTC from 2015 to 2020 were analyzed retrospectively. The distribution patterns of lymph nodes in different regions were summarized. The diagnosed para aortic lymph nodes (PALNs) were manually mapped to standard axial CT images. The asymmetric CTV expansions from the para aortic were defined according to the distance from the volumetric centre of lymph node to the most proximal border of aorta.

RESULTS

A total of 251 positive lymph nodes were found in the study cohort (n = 61 patients, 92 PALN). All PALNs were projected onto axial CT image of the standard patient. PALNs were concentrated in the 16a2 and 16b1 regions, and the involvement rates were 17% and 13% respectively. Therefore, the upper boundary of 16a2 and the lower boundary of 16b1 were defined as the cranial and caudal border of para aortic CTV, respectively. For the study cohort, the mean distance from the volume center of all lymph nodes in 16a2 and 16b1 to the proximal border of the aorta was 9 mm (range 4-24) in the front, 7 mm (range 3-14) on the left, and 12 mm (range 5-29) on the right. For the validation cohort (n=19 patients, 56 PALN), the mean distance from the center of the lymph node to the border of the aorta were both 10 mm on the left (range 5-20) and right (range 6-23). The mean distance in front of the aorta was 9 mm (range 5-23). Finally, a CTV expansion from the aorta of 18 mm in the front, 12 mm on the left, and 24 mm on the right resulted in 96% (73/76) coverage of PALNs in the study cohort. At the time of the validation, the described CTV could include 96% (47/49) of recurrent PALNs in the validation cohort.

CONCLUSIONS

The involvement rates of PALNs in 16a2 and 16b1 were the highest. Based on the distribution of PALNs, a new para-aortic CTV was defined to construct a more accurate target volume for adjuvant radiotherapy in BTC.

Variation in clinical target volume delineation in postoperative radiotherapy for biliary tract cancer

We aimed to evaluate the inter-clinician variability in the clinical target volume (CTV) for postoperative radiotherapy (PORT) for biliary tract cancer (BTC) including extrahepatic bile duct cancer (EBDC) and gallbladder cancer (GBC). Nine experienced radiation oncologists delineated PORT CTVs for distal EBDC (pT2N1), proximal EBDC (pT2bN1) and GBC (pT2bN1) patients. The expectation maximization algorithm for Simultaneous Truth and Performance Level Estimation (STAPLE) was used to quantify expert agreements. We generated volumes with a confidence level of 80% to compare the maximum distance to each CTV in six directions. The degree of agreement was moderate; overall kappa values were 0.573 for distal EBDC, 0.513 for proximal EBDC, and 0.511 for GBC. In the distal EBDC, a larger variation was noted in the right, post, and inferior direction. In the proximal EBDC, all borders except the right and left direction showed a larger variation. In the GBC, a larger variation was found in the anterior, posterior, and inferior direction. The posterior and inferior borders were the common area having discrepancies, associated with the insufficient coverage of the paraaortic node. A consensus guideline is needed to reduce inter-clinician variability in the CTVs and adequate coverage of regional lymph node area.

Retroperitoneal Lymph Node Metastasis in Gallbladder Cancer: As Bad as Distant Metastasis

Ashish SinghBackground  Regarding gallbladder cancer (GBC) there is conflicting evidence in the literature whether retroperitoneal lymph nodal metastases (RLNM) should be considered as regional nodal metastasis or as distant metastasis (DM) and the jury is out on radical curative surgery in presence of RLNM. This is an analysis of GBC patients, to see the effect of RLNM on survival and to compare with that of patients with DMs. Methods  A retrospective analysis of a prospective database of patients of GBC with RLNM (interaortocaval and paraaortic) or DM on frozen section biopsy at surgery, between January 2013 and December 2018. Data was analyzed using the Statistical Package for the Social Sciences software (version 22.0). Survival in these two groups (RLNM and DM) was compared with log-rank test. A p -value of < 0.05 was considered significant. Results  A total of 235 patients with ostensibly resectable GBC underwent surgical exploration. The planned curative resection was abandoned in 91 (39%) patients because of RLNM ( n  = 20, 9%) or DM ( n  = 71, 30%) on frozen section biopsy. Demographic profile and blood parameters were similar. The median survival for RLNM and DM groups were 5 (range 2-26) and 6 (range 2-24) months, respectively, with no significant difference on log-rank test ( p  = 0.64). There was no 3-year or longer survivor in either group. Conclusion  Due to similar poor survival in presence of RLNM or DM, RLNM should be considered as the equivalent of DM. This study strengthens evidence to avoid curative surgery in patients with RLNM. These lymph nodes should be sampled preoperatively, if suspicious on imaging, for fine-needle aspiration cytology and at surgery, as a routine for frozen section histological examination before initiating curative resection to avert a futile exercise.

An Insight into Cholangiocarcinoma and Recent Advances in its Treatment

BACKGROUND

Cholangiocarcinoma (CCA) is a malignant disease of the epithelial cells of the intrahepatic and extrahepatic bile ducts. This review focuses on various aspects of cholangiocarcinoma such as its associated causes, treatment criteria, and more.

METHODS

Although it remains a rare malignancy and is the second most common primary malignancy of the liver, the incidence is increasing, especially the incidence of intrahepatic CCA. Several studies suggested that surgery is not only solution; recently, reported targeted drugs may have the potential to become an alternative option.

RESULTS

This review provides an overview of the current scenario of targeted therapies for CCA, which were tabulated with their current status and it also included its associated causes and its treatment criteria.

CONCLUSION

Because of its rarity and complexity, surgery remains the preferred treatment in resectable patients. Howerver, the studies suggested that the recently reported drugs may have the potential to be an alternative option for the treatment of CCA and related complications. In addition, this review will certainly benefit the community and researcher for further investigation.

The value of lymphadenectomy in surgical resection of perihilar cholangiocarcinoma: a systematic review and meta-analysis

Surgical resection is the only potentially curative treatment for patients with resectable perihilar cholangiocarcinoma (PHC). There is still no consensus on the value of lymphadenectomy despite evidence indicating lymph node (LN) status is an important prognostic indicator for postoperative long-term survival. We sought to perform a meta-analysis to summarize the current evidence on the value of lymphadenectomy among patients undergoing surgery for PHC. The PubMed (OvidSP), Embase and Cochrane Library were systematically searched for studies published before July 2020 that reported on lymphadenectomy at the time of surgery for PHC after curative surgery. 7748 patients from 28 studies were included in the meta-analysis. No survival benefit was identified with increased number of LN resected (all P > 0.05). Meanwhile, overall LN status was an important prognostic factor. Patients with lymph node metastasis had a pooled estimate hazard ratio of death that was over two-fold higher than patients without lymph node metastasis (HR 2.07, 95% CI 1.65-2.59, P < 0.001). The examination of 5 LNs on histology was associated with better staging of lymph node status and stratification of patients into positive or negative LN groups. While the extent of LN dissection was not associated with a survival benefit, examination of more than 5 LNs better staged patients into positive or negative LN groups with a lower risk of nodal understaging.

Prognostic Impact of Paraaortic Lymph Node Metastasis in Extrahepatic Cholangiocarcinoma

BACKGROUND

Surgical resection in patients with extrahepatic cholangiocarcinoma (EHCC) with paraaortic lymph node metastasis (PALNM) remains controversial. The objective of this study was to investigate the prognostic impact of PALNM in resected EHCC.

METHODS

The present retrospective study included 410 patients, including 16 patients with PALNM, who underwent surgical resection of EHCC between September 2002 and December 2018. These were compared to 9 patients in whom EHCC was not resected due to PALNM. The clinicopathological features and survival outcomes were investigated to identify the prognostic factors in resected EHCC.

RESULTS

The overall survival in the resected patients with PALNM was significantly better than that in unresected patients (median survival time [MST] 33.7 vs. 16.7 months, p=0.009) and was not significantly worse than that of patients with regional lymph node metastasis (LNM) (MST 33.7 vs 36.0 months, p=0.278). The multivariate analysis identified age > 70 years, male sex, tumor location (perihilar), residual tumor status, histological grade, microscopic venous invasion, and regional LNM as independent prognostic factors.

CONCLUSIONS

There was no significant difference in survival between the resected patients with PALNM and patients with regional LNM, and PALNM was not a significant prognostic factor in the multivariate analysis. Surgical resection may be considered an acceptable approach for EHCC with PALNM in selected patients.

BRAZILIAN CONSENSUS ON INCIDENTAL GALLBLADDER CARCINOMA

Background:

Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis.

Aim:

To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil.

Methods:

Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment.

Results:

Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely.

Conclusions:

It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

Extended Lymphadenectomy Versus Regional Lymphadenectomy in Resectable Hilar Cholangiocarcinoma

AIM

The aim of this study is to compare the effects of extended lymphadenectomy (E-LD) and regional lymphadenectomy (R-LD) on outcome after radical resection of hilar cholangiocarcinoma (HCCA).

METHODS

Data of 290 patients who underwent radical resection of HCCA were retrospectively analyzed. Demographic characteristics, surgical variables, and tumor and LN characteristics were evaluated for association with survival.

RESULTS

A total of 63 patients underwent E-LD. Patients who underwent E-LD were more likely to have portal vein embolization (14.3% vs. 5.7%), radical hepatectomy (36.2% vs. 26.0%), higher proportion of M1 patients (22.2% vs. 5.3%), more lymph nodes (LNs) retrieved (17 vs. 7), and positive common hepatic artery lymph nodes (21.4% vs. 12.6%) when compared with R-LD (all P < 0.05). The Kaplan-Meier curve of overall survival for patients who underwent E-LD indicated improvement over patients who underwent R-LD in M0 (33.39 vs. 21.31 months; P = 0.032) and R0 resection (32.97 vs. 21.02 months; P = 0.044) disease, but not observed in M1 disease (P > 0.05). After propensity score matching, E-LD was not associated with a significant improvement in overall survival (OS) even in all subgroup analysis (all P > 0.05). On multivariable analysis, E-LD was associated with improved overall survival, but not after propensity score matching.

CONCLUSION

E-LD is more likely to be performed in higher stage tumors. E-LD significantly increases LN retrieval, thereby preventing under-staging and improving survival prediction. E-LD should not be adopted for HCCA patients with intraoperatively confirmed distant LN metastases. Future studies are required to further assess whether E-LD should be performed in negative celiac, superior mesenteric, and para-aortic lymph node in HCCA patients.

Extended lymphadenectomy in hilar cholangiocarcinoma: What it will bring?

Lymph node dissection is always a hot issue in radical resection of hilar cholangiocarcinoma (HCCA). There are still controversies regarding whether some lymph nodes should be dissected, of which the para-aortic lymph nodes are the most controversial. This review synthesized findings in the literature using the PubMed database of articles in the English language published between 1990 and 2019 on the effectiveness of extended lymphadenectomy including para-aortic lymph nodes dissection in radical resection of HCCA. Hepatobiliary surgeons have basically achieved a consensus that enough lymph nodes should be obtained to accurately stage HCCA. Only a very small number of studies have focused on the effectiveness of extended lymphadenectomy including para-aortic nodes dissection on HCCA. They reported that extended lymphadenectomy can bring some survival benefits for patients with potential para-aortic lymph node metastasis and more lymph nodes can be obtained to make the patient's tumor staging more accurate without increasing the related complications. Extended lymphadenectomy should not be adopted for HCCA patients with intraoperatively confirmed distant lymph node metastases. For these patients, radical resection combined with postoperative adjuvant chemotherapy seems to be a better choice. A prospective, multicenter, randomized, controlled clinical study of regional lymphotomy and extended lymphadenectomy in HCCA should be conducted to guide clinical practice. A standardized extended lymphadenectomy may help to more accurately stage HCCA. Future studies are required to further assess whether extended lymphadenectomy can improve long-term survival in negative celiac, superior mesenteric, and para-aortic lymph node diseases.

Prognostic impact of para-aortic lymph node metastases in non-pancreatic periampullary cancer

Background

Resection of the para-aortic lymph node (PALN) group Ln16b1 during pancreatoduodenectomy remains controversial because PALN metastases are associated with a worse prognosis in pancreatic cancer patients. The present study aimed to analyze the impact of PALN metastases on outcome after non-pancreatic periampullary cancer resection.

Methods

One hundred sixty-four patients with non-pancreatic periampullary cancer who underwent curative pancreatoduodenectomy or total pancreatectomy between 2005 and 2016 were retrospectively investigated. The data were supplemented with a systematic literature review on this topic.

Results

In 67 cases, the PALNs were clearly assigned and could be histopathologically analyzed. In 10.4% of cases (7/67), tumor-infiltrated PALNs (PALN+) were found. Metastatic PALN+ stage was associated with increased tumor size (P = 0.03) and a positive nodal stage (P < 0.001). The median overall survival (OS) of patients with metastatic PALN and non-metastatic PALN (PALN–) was 24.8 and 29.5 months, respectively. There was no significant difference in the OS of PALN+ and pN1 PALN patients (P = 0.834). Patients who underwent palliative surgical treatment (n = 20) had a lower median OS of 13.6 (95% confidence interval 2.7–24.5) months. Including the systematic literature review, only 23 cases with PALN+ status and associated OS could be identified; the average survival was 19.8 months.

Conclusion

PALN metastasis reflects advanced tumor growth and lymph node spread; however, it did not limit overall survival in single-center series. The available evidence of the prognostic impact of PALN metastasis is scarce and a recommendation against resection in these cases cannot be given.

Laparoscopic Radical Cholecystectomy for Primary or Incidental Early Gallbladder Cancer: The New Rules Governing the Treatment of Gallbladder Cancer

AIM

To evaluate the technical feasibility and oncologic safety of laparoscopic radical cholecystectomy (LRC) for primary or incidental early gallbladder cancer (GBC) treatment.

METHODS

Articles reporting LRC for GBC were reviewed from the first case reported in 2010 to 2015 (129 patients). 116 patients had a preoperative diagnosis of gallbladder cancer (primary GBC). 13 patients were incidental cases (IGBC) discovered during or after a laparoscopic cholecystectomy.

RESULTS

The majority of patients who underwent LRC were pT2 (62.7% GBC and 63.6% IGBC). Parenchyma-sparing operation with wedge resection of the gallbladder bed or resection of segments IVb-V were performed principally. Laparoscopic lymphadenectomy was carried out according to the reported depth of neoplasm invasion. Lymph node retrieved ranged from 3 to 21. Some authors performed routine sampling biopsy of the inter-aorto-caval lymph nodes (16b1 station) before the radical treatment. No postoperative mortality was documented. Discharge mean day was POD 5th. 16 patients had post operative morbidities. Bile leakage was the most frequent post-operative complication. 5 y-survival rate ranged from 68.75 to 90.7 months.

CONCLUSION

Laparoscopy can not be considered as a dogmatic contraindication to GBC but a primary approach for early case (pT1b and pT2) treatment.

Clinical prognostic significance of regional and extended lymphadenectomy for biliary cancer with para-aortic lymph node metastasis: A systematic review and meta-analysis

BACKGROUND

The aim of our study was to evaluate clinical prognostic significance of regional and extended lymphadenectomy for biliary cancer with para-aortic lymph node metastasis.

METHODS

A thorough literature search was performed in PubMed/Medline, Cochrane Central Register, Embase, ISI Web of Science and Google Scholar between January 1965 and May 2014 with restricted articles for the English language. Data were processed for a meta-analysis by RevMan 5 software.

RESULTS

Altogether 10 retrospective studies were finally enrolled in our study. For positive para-aortic lymph node group irrespective of regional lymph node metastasis, the overall 1-, 3-, 5-yr pooled RR estimates of survival rates were 2.30, 1.70, and 1.42. There were significant differences between positive para-aortic lymph node group and negative group. For positive para-aortic lymph node group in the setting of regional lymph node metastasis, the overall 1-, 3-, 5-yr pooled RR estimates of survival rates were 1.57, 1.29, and 1.11, respectively. The long-term outcomes referred to 5-yr survival rate were similar between para-aortic lymph node metastasis and regional lymph node metastasis only.

DISCUSSION

Radical resection with extended lymphadenectomy should be caution in terms of the results of an intraoperative sampling biopsy of para-aortic lymph node, which requires a well-designed, prospective controlled study in the future.

Incidence and prognostic impact of para-aortic lymph nodes metastases during pancreaticoduodenectomy for peri-ampullary cancer

BACKGROUND

Standard lymphadenectomy during pancreaticoduodenectomy (PD) for peri-ampullary cancer does not include the routine removal of para-aortic lymph nodes (PALN) (station 16, according to the JPS staging system). The aim of this study was to report the incidence and the prognostic value of PALN metastases in patients undergoing PD for peri-ampullary cancer.

MATERIALS AND METHODS

One hundred thirty-five consecutive patients who underwent PD and PALN dissection for peri-ampullary cancer were prospectively evaluated. The relationship between clinicopathological factors, including PALN metastases and survival was evaluated at univariate and multivariate analysis.

RESULTS

PALN metastases (N16+) were found in 11.1% of cases. At univariate analysis, R1 resection, metastatic nodes different from para aortic (N1) and N16+ significantly affected patients' prognosis. Compared with N16+, the median overall survival (OS) of N0 patients was significantly longer (32 versus 69 months, respectively; P < 0.05), whereas no difference was found between N16+ and N1 patients (32 versus 34 months, respectively) (P > 0.05). At multivariate analysis, only R1 resection reached statistical significance and was confirmed an independent prognostic factor.

CONCLUSIONS

Neoplastic involvement of PALN in peri-ampullary cancer is frequent and, so, their removal during PD could be justified. Moreover, PALN metastases should be not considered an absolute contraindication to radical surgery.

Lymph node dissection in resectable perihilar cholangiocarcinoma: a systematic review

BACKGROUND

Perihilar cholangiocarcinoma is usually unresectable at the time of diagnosis. Only few patients are candidates for a potential curative treatment. For those patients, prognosis is strongly related to negative resection margin and lymph node status. Thus, a certain benchmark of lymph node count is necessary to secure relevant lymph node recovery and to avoid understaging. However, the required minimum number of retrieved lymph nodes remains unclear for perihilar cholangiocarcinoma. The 7th American Joint Committee on Cancer tumor, nodes, metastases edition increased the requirement for the histologic examination of lymph nodes in perihilar cholangiocarcinoma patients from 3 to 15. The applicability of such recommendation appears difficult and questionable. Therefore, the purpose of this systematic review is to evaluate the number of retrieved lymph nodes for staging of patients undergoing surgery for perihilar cholangiocarcinoma.

METHODS

The MEDLINE, EMBASE, and The Cochrane Library databases were systematically screened up to December 2014. All studies reporting the number of lymph node count in perihilar cholangiocarcinoma were included and assessed for eligibility.

RESULTS

A total of 725 abstracts were screened and 20 studies were included for analysis, comprising almost 4,000 patients. The cumulative median lymph node count was 7 (2 to 24). A median lymph node count greater than or equal to 15 was reported in 9% of perihilar cholangiocarcinoma patients and could only be achieved in extended lymphadenectomy. Subgroup analysis revealed a median lymph node count of 7 (range 7 to 9), which was associated with the detection of most lymph node positive patients and showed the lowest risk for understaging patients. Lymph node count greater than or equal to 15 did not increase detection rate of lymph node positive patients.

CONCLUSIONS

This systematic analysis suggests that lymph node count greater than or equal to 7 is adequate for prognostic staging, while lymph node count greater than or equal to 15 does not improve detection of patients with positive lymph nodes.

Survival analysis following resection of AJCC stage III gallbladder carcinoma based on different combinations of T and N stages

Backgrounds/Aims

According to 7th AJCC TNM staging system, gallbladder carcinoma (GBC) with lymph node (LN) metastasis is classified as N1 or N2; thus making the stage IIIB (N1) or IVB (N2). Stage IIIB consists of N1 status with wide coverage of T1-3, but T3N1 group often showed poorer outcomes than T1-2N1 groups. This study intended to assess post-resection prognosis of T3N1 versus other stage III subgroups.

Methods

We selected 103 patients from our institutional database of GBC who underwent R0 resection between July 1996 and June 2009 and whose GBC was confined to stage T3N0, T1-3N1 or T1-3N2. These patients were stratified into five groups, namely, T3N0 (n=26), T1N1 (n=13), T2N1 (n=35), T3N1 (n=20) and T1-3N2 (n=9), and were followed for ≥5 years or until death.

Results

Surgical procedures were minor liver resection (n=53), minor liver resection with bile duct resection (n=23), major liver resection (n=12), major liver resection with bile duct resection (n=5), and hepatopancreatoduodenectomy (n=12). Mean follow-up period was 57.2±68.5 months. Overall 5-year survival rate based on all-cause death and cancer-associated death, respectively, was 57.7% and 60.6% in T3N0, 15.4% and 15.4% in T1N1 (n=13), 28.6% and 28.6% in T2N1 (n=35), 5.0% and 5.7% in T3N1 (n=20), and 22.2% and 22.2% in T1-3N2. The survival outcome of T3N1 group was the poorest among the four stage III groups and was comparable to that of stage IVB (p=0.53).

Conclusions

The prognosis of T3N1 GBC is unusually poor even after R0 resection, thus we suggest extensive LN dissection may be necessary in patients with T3 tumors for accurate prognostic evaluation and radical removal of potential nodal micrometastasis. Further validation of this result is necessary in large patient populations from multiple centers.

Radical lymph node dissection and assessment: Impact on gallbladder cancer prognosis

AIM: To investigate the lymph node metastasis patterns of gallbladder cancer (GBC) and evaluate the optimal categorization of nodal status as a critical prognostic factor.

METHODS: From May 1995 to December 2010, a total of 78 consecutive patients with GBC underwent a radical resection at Liaocheng People’s Hospital. A radical resection was defined as removing both the primary tumor and the regional lymph nodes of the gallbladder. Demographic, operative and pathologic data were recorded. The lymph nodes retrieved were examined histologically for metastases routinely from each node. The positive lymph node count (PLNC) as well as the total lymph node count (TLNC) was recorded for each patient. Then the metastatic to examined lymph nodes ratio (LNR) was calculated. Disease-specific survival (DSS) and predictors of outcome were analyzed.

RESULTS: With a median follow-up time of 26.50 mo (range, 2-132 mo), median DSS was 29.00 ± 3.92 mo (5-year survival rate, 20.51%). Nodal disease was found in 37 patients (47.44%). DSS of node-negative patients was significantly better than that of node-positive patients (median DSS, 40 mo vs 17 mo, χ² = 14.814, P < 0.001), while there was no significant difference between N1 patients and N2 patients (median DSS, 18 mo vs 13 mo, χ² = 0.741, P = 0.389). Optimal TLNC was determined to be four. When node-negative patients were divided according to TLNC, there was no difference in DSS between TLNC < 4 subgroup and TLNC ≥ 4 subgroup (median DSS, 37 mo vs 54 mo, χ² = 0.715, P = 0.398). For node-positive patients, DSS of TLNC < 4 subgroup was worse than that of TLNC ≥ 4 subgroup (median DSS, 13 mo vs 21 mo, χ² = 11.035, P < 0.001). Moreover, for node-positive patients, a new cut-off value of six nodes was identified for the number of TLNC that clearly stratified them into 2 separate survival groups (< 6 or ≥ 6, respectively; median DSS, 15 mo vs 33 mo, χ² = 11.820, P < 0.001). DSS progressively worsened with increasing PLNC and LNR, but no definite cut-off value could be identified. Multivariate analysis revealed histological grade, tumor node metastasis staging, TNLC and LNR to be independent predictors of DSS. Neither location of positive lymph nodes nor PNLC were identified as an independent variable by multivariate analysis.

CONCLUSION: Both TLNC and LNR are strong predictors of outcome after curative resection for GBC. The retrieval and examination of at least 6 nodes can influence staging quality and DSS, especially in node-positive patients.

Adjuvant chemotherapy with gemcitabine and S-1 after surgical resection for advanced biliary carcinoma: outcomes and prognostic factors

BACKGROUND/PURPOSE

The aims of this study were to evaluate long-term outcomes and to determine prognostic factors for survival in patients with resected biliary carcinoma who received adjuvant gemcitabine plus S-1 chemotherapy.

METHODS

Seventy patients with International Union Against Cancer (UICC) stage II, III, or IV biliary carcinoma received postoperative adjuvant chemotherapy consisting of intravenous gemcitabine 700 mg/m(2) on day 1 and oral S-1 60-100 mg/body for seven consecutive days, followed by a 1-week pause of chemotherapy. Patients received up to ten 2-week cycles. Long-term outcomes and predictors of survival with this adjuvant chemotherapy regimen were analyzed.

RESULTS

The median duration of follow-up was 47 months. Fifty-six percent of patients had node-positive disease, and 80% of patients underwent R0 resection. Overall and disease-free survival rates were 91 and 81% at 1 year, 56 and 55% at 3 years, and 40 and 46% at 5 years, respectively. Lymph node status (p = 0.025) and surgical margin status (p = 0.033) were independently associated with long-term survival by multivariate analysis.

CONCLUSIONS

Adjuvant gemcitabine plus S-1 chemotherapy may be a promising strategy for patients with resected biliary carcinoma, and nodal status and surgical margin status may be predictors of survival with this treatment strategy.