Prognostic relevance of the lymph node ratio in surgical patients with extrahepatic cholangiocarcinoma

British Society of Gastroenterology guidelines for the diagnosis and management of cholangiocarcinoma

These guidelines for the diagnosis and management of cholangiocarcinoma (CCA) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included a multidisciplinary team of experts from various specialties involved in the management of CCA, as well as patient/public representatives from AMMF (the Cholangiocarcinoma Charity) and PSC Support. Quality of evidence is presented using the Appraisal of Guidelines for Research and Evaluation (AGREE II) format. The recommendations arising are to be used as guidance rather than as a strict protocol-based reference, as the management of patients with CCA is often complex and always requires individual patient-centred considerations.

Neoadjuvant Therapy for Extrahepatic Biliary Tract Cancer: A Propensity Score-Matched Survival Analysis

Background: Although surgery is the mainstay of curative-intent treatment for extrahepatic biliary tract cancer (EBTC), recurrence following surgery can be high and prognosis poor. The impact of neoadjuvant therapy (NAT) relative to upfront surgery (US) among patients with EBTC remains unclear. Methods: The Surveillance, Epidemiology, and End Results (SEER) databases was utilized to identify patients who underwent surgery from 2006 to 2017 for EBTC, including gallbladder cancer (GBC) and extrahepatic cholangiocarcinoma (ECC). Trends in NAT utilization were investigated, and the impact of NAT on prognosis was compared with US using a propensity score-matched (PSM) analysis. Results: Among 6582 EBTC patients (GBC, n = 4467, ECC, n = 2215), 1.6% received NAT; the utilization of NAT for EBTC increased over time (Ptrend = 0.03). Among patients with lymph node metastasis, the lymph node ratio was lower among patients with NAT (0.18 vs. 0.40, p < 0.01). After PSM, there was no difference in overall survival (OS) and cancer-specific survival (CSS) among patients treated with NAT versus US (5-year OS: 24.0% vs. 24.6%, p = 0.14, 5-year CSS: 38.0% vs. 36.1%, p = 0.21). A subgroup analysis revealed that NAT was associated with improved OS and CSS among patients with stages III-IVA of the disease (OS: HR 0.65, 95%CI 0.46-0.92, p = 0.02, CSS: HR 0.62, 95%CI 0.41-0.92, p = 0.01). Conclusions: While NAT did not provide an overall benefit to patients undergoing surgery for EBTC, individuals with advanced-stage disease had improved OS and CSS with NAT. An individualized approach to NAT use among patients with EBTC may provide a survival benefit.

The short- and long-term outcomes of pancreaticoduodenectomy for distal cholangiocarcinoma

BACKGROUND

The aim of the study was to calculate the short-term and long-term outcomes of curative-intent surgery in distal cholangiocarcinoma (DCC) patients to identify potential prognostic factors.

PATIENTS AND METHODS

A retrospective cohort study of 32 consecutive DCC patients treated with pancreaticoduodenectomy between 2009-2017. The clinicopathological and histopathological data were evaluated for prognostic factors using the univariable Cox regression analysis. The Overall Survival (OS) was estimated using the Kaplan-Meier analysis.

RESULTS

The study comprised a total of 32 patients, with a mean age of 65.8 (± 9.0) years at the time of surgery. R0 resection was achieved in 25 (86.2%) patients, 19 (65.5%) patients received adjuvant oncological therapy. The OS rates at 1, 3 and 5 years were 62.5%, 37.5% and 21.9%, respectively. The 90-day mortality was 3/32 (9.4%) accounting for one-fourth of the first-year mortality rate. The median OS was 28.5 months. The only statistically significant prognostic factor was vascular resection, which was associated with worse OS in the univariable analysis (HR: 3.644; 95%-CI: 1.179-11.216, P=0.025). An age less than 65 years, ASA grade I/II, hospital stay of fewer than 15 days, R0 resection, lymph node ratio less than 0.2 and adjuvant oncological therapy tended to be associated with better OS but without statistically significant relevance.

CONCLUSION

The main factor directly influencing the survival of DCC patients is surgical complications. Surgical mortality comprises a significant group of patients, who die in the first year following pancreaticoduodenectomy. Vascular resection is the most important negative prognostic factor for long-term survival.

Lymph Node Ratio Nomogram-Based Prognostic Model for Resected Distal Cholangiocarcinoma

BACKGROUND

Several variables have been described as prognostic factors for resected distal cholangiocarcinoma (dCC), including lymph node metastases (N status) and lymph node ratio (LNR). The present study aimed to evaluate the prognostic value of LNR on survival and to establish a novel prognostic nomogram to predict the cancer-specific recurrence-free survival (RFS) of dCC.

STUDY DESIGN

Between December 2006 and September 2020, 415 consecutive patients who underwent pancreaticoduodenectomy (PD) for dCC in 10 centers were identified. Multivariate Cox analysis was used to identify all independent risk factors among several prognostic factors. A nomogram was then developed and assessed by integrating the independent prognostic factors into the model, and the concordance index (C-index) was used to evaluate its performance.

RESULTS

According to Cox regression multivariate analysis, a nomogram based on independent prognostic factor for RFS was performed including LNR 15 (hazard ratio [HR] 2.442, 95% CI 1.348-4.425, p = 0.003), perineural invasion (HR 3.100, 95% CI 1.183-8.122, p = 0.025), differentiation grade (HR 2.100, 95% CI 1.172-4.143, p = 0.021), and radicality of PD (HR 2.276, 95% CI 1.223-4.234, p = 0.009). The C-index of the nomogram, tailored based on the previous significant factors, was 0.8.

CONCLUSIONS

LNR15 yields a high prognostic efficiency for RFS. The nomogram based on LNR can provide an accurate prognosis assessment for patients with resected dCC.

Surgical Treatment of Distal Cholangiocarcinoma

Distal cholangiocarcinoma (dCCA) is a rare malignancy arising from the epithelial cells of the distal biliary tract and has a poor prognosis. dCCA is often clinically silent and patients commonly present with locally advanced and/or distant disease. For patients identified with early stage, resectable disease, surgical resection with negative margins remains the only curative treatment strategy available. However, despite appropriate treatment and diligent surveillance, risk of recurrence remains high with nearly 50% of patients experiencing recurrence at 5 years subsequent to surgical resection; therefore, it is prudent to continue to optimize neoadjuvant and adjuvant therapies in order to reduce the risk of recurrence and improve overall survival. In this review, we discuss the clinical presentation, workup and surgical treatment of dCCA.

Comparison of Four Lymph Node Stage Methods for Predicting the Prognosis of Distal Cholangiocarcinoma Patients After Surgery

Background

The metastatic status of regional lymph nodes is an effective risk factor for the prognosis of distal cholangiocarcinoma (dCCA). But existing lymph node staging is not accurate enough and is susceptible to interference. This study aims to explore the predictive ability of the log odds of positive lymph nodes (LODDS) staging system of dCCA compared with existing lymph node staging systems.

Methods

A total of 928 dCCA patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database as the training cohort, and 207 dCCA patients from West China Hospital who underwent surgery were reviewed as the validation cohort. The least absolute shrinkage and selection operator (LASSO) and multivariate Cox regression were conducted to identify the most meaningful factors relevant to prognosis. The performance of four lymph node stage systems was compared by a model-based approach.

Result

Age at diagnosis, pathological grade, American Joint Committee on Cancer (AJCC) tumor 7th T stage, tumor size, radiotherapy, chemotherapy, and lymph node stage system were independent prognostic factors. The model with the LODDS system had a better model fit with the highest C-index (0.679) and 1-/3-/5- area under the receiver operating characteristic curve (AUC) (0.739/0.671/0.658) as well as the lowest Akaike information criterion (AIC) (5,020.52). External validation results from 207 dCCA patients showed a C-index of 0.647 and 1-/3-/5-AUC of 0.740/0.683/0.589. Compared with the lymph node ratio (LNR), AJCC 8th N system, and 7th N system, the 5-year net reclassification improvement (NRI) of the LODDS system was 0.030 (95% CI: -0.079 to 0.147), 0.042 (95% CI: -0.062 to 0.139), and 0.040 (95% CI: -0.057 to 0.146), respectively. The integrated discrimination improvement (IDI) of LODDS improved compared with the LNR model (0.016; 95% CI: -0.001 to 0.036), AJCC 8th N system (0.020; 95% CI: 0.003-0.037), and AJCC 7th N system (0.019; 95% CI: 0.002-0.036). Decision curve analysis (DCA) also shows a greater net benefit of LODDS. In lymph node-negative patients, LODDS reveals a positive linear relationship with the hazard ratio (HR). The stage capacity of LODDS in a subgroup analysis stratified by examined lymph node number (ELNN) was consistent.

Conclusions

The LODDS lymph node stage system has superior predictive performance as compared with the LNR, AJCC 7th, and 8th lymph node stage systems. Meanwhile, LODDS has a more detailed staging ability and good stability.

A Nomogram Based on the Log Odds of Positive Lymph Nodes Predicts the Prognosis of Patients With Distal Cholangiocarcinoma After Surgery

Background: Lymph node (LN) metastasis is considered one of the most important risk factors affecting the prognosis of distal cholangiocarcinoma (DCC). This study aimed to demonstrate the superiority of log odds of positive lymph nodes (LODDS) compared with other LN stages, and to establish a novel prognostic nomogram to predict the cancer-specific survival (CSS) of DCC.

Methods: From the Surveillance, Epidemiology and End Results (SEER) database, the data of 676 patients after DCC radical operation were screened, and patients were randomly divided into training (n = 474) and validation sets (n = 474). The prognostic evaluation performance of the LODDS and American Joint Commission on Cancer (AJCC) N stage and lymph node ratio (LNR) were compared using the Akaike information criteria, receiver operating characteristic area under the curve (AUC), and C-index. Multivariate Cox analysis was used to screen independent risk factors, and a LODDS-based nomogram prognostic staging model was established. The nomogram's precision was verified by C-index, calibration curves, and AUC, and the results were compared with those of the AJCC TNM staging system.

Results:Compared with the other two stages of LN metastasis, LODDS was most effective in predicting CSS in patients with DCC. Multivariate analysis proved that LODDS, histologic grade, SEER historic stage, and tumor size were independent risk factors for DCC. The C-index of the nomogram, based on the above factors, in the validation set was 0.663. The 1-, 3-, and 5-y AUCs were 0.735, 0.679, and 0.745, respectively. Its good performance was also verified by calibration curves. In addition, the C-index and Kaplan-Meier analysis showed that the nomogram performed better than the AJCC TNM staging system.

Conclusion:For postoperative patients with DCC, the LODDS stage yielded better prognostic efficiency than the AJCC N and LNR stages. Compared with the AJCC TNM staging system, the nomogram, based on the LODDS, demonstrated superior performance.

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.

Re-appraising the role of lymph node status in predicting survival in resected distal cholangiocarcinoma - A meta-analysis and systematic review

This systematic review and meta-analysis aimed to confirm the prognostic value of lymph node ratio (LNR), and determine an optimal LNR cut-off for overall survival (OS) in patients with distal cholangiocarcinoma (DCC) undergoing curative surgery. We additionally aimed to provide a consolidated review of current evidence regarding prognostic significance of positive lymph node count (PLNC) and total lymph node count (TLNC). A systematic search of PubMed, EMBASE and Cochrane Library was conducted from inception to October 2020. Studies were included into meta-analysis if there was histological diagnosis, curative surgery, restriction to DCC and relevant LNR results. Quality assessment was performed using the Newcastle Ottawa Scale. Findings for 1228 patients were pooled across 6 studies. Meta-analysis delineated a dose-effect gradient in which higher LNR cut-offs correlated with larger pooled hazard ratios: 0<LNR<0.2 (HR 1.54; 95% CI 1.08-2.20; p = 0.02), LNR>0.2 (HR 3.26; 95% CI 2.07-5.13; p < 0.00001) and LNR>0.4 (HR 3.59; 95% CI 2.31-5.58; p < 0.00001) when compared against a control group of LNR = 0. LNR of 0.2 (HR 2.12; 95% CI: 1.57-2.86; p < 0.0001) was found to be a significant and ideal cut-off for prognostication of poorer OS. A review of current literature reveals an ongoing debate regarding the comparative prognostic value of differing PLNC cut-offs (0/1/3 versus 0/1/4). TLNC of 10-13 is widely reported to be the minimum necessary to ensure improved long term outcomes. PLNC and LNR are strong prognostic factors for OS in DCC. An ideal LNR cut-off of 0.2 is most significantly associated with poorer OS.

Prognostic impact of lymph node parameters in distal cholangiocarcinoma after pancreaticoduodenectomy

Background

Pancreaticoduodenectomy is the only definitively curative therapy for the long-term survival of distal cholangiocarcinoma patients. Lymph node metastasis is widely accepted as an important prognostic factor for distal cholangiocarcinoma. The latest American Joint Committee on Cancer (AJCC) TNM classification system for distal cholangiocarcinoma has divided the lymph node metastasis patients into N1 and N2 by lymph node metastasis number. However, some studies suggested that the lymph node metastasis ratio may be better than the lymph node metastasis number. Therefore, we develop a program to analyze the correlation between lymph node parameters (lymph node dissection number, lymph node metastasis number, and lymph node metastasis rate) and long-term prognosis.

Methods

We retrospectively reviewed 123 distal cholangiocarcinoma patients after pancreatoduodenectomy from January 2011 to December 2019. The patients were grouped according to lymph node metastases and tumor-free and overall survival rates which were investigated with the Kaplan-Meier analysis. The logistic regression models were used for multivariate analysis to determine the risk factors for lymph node metastases. And the X-tile program was used to calculate the cutoff values for the lymph node parameters that discriminated survival.

Results

The 1-year, 3-year, and 5-year overall survival rates of patients with distal cholangiocarcinoma after pancreatoduodenectomy were 75.2%, 37.1%, and 31.5%, respectively. And the 1-year, 3-year, and 5-year overall survival rates of patients without and with lymph node metastasis were 83.0%, 50.7%, and 42.5% and 63.5%, 19.0%, and 19.0% (p = 0.000), respectively. Logistic regression showed CA19-9 and portal vein system invasion as independent risk factors for lymph node metastases. The receiver operating characteristic curve showed the optimal cutoff value of CA19-9 to predict the lymph node metastases was 75.5 U/mL. Determined by the X-tile software, the optimal cutoff values of the lymph node dissection number were 24 (p = 0.021), the lymph node metastasis number were 1 and 7 (p = 0.504), and the lymph node metastasis rate were 0.13 (p = 0.002).

Conclusion

Lymph node metastasis is an important factor affecting the long-term survival of distal cholangiocarcinoma patients.CA19-9 and portal vein system invasion are independent risk factors for lymph node metastasis. Besides, the lymph node dissection number and lymph node metastasis rate can predict the long-term survival better than lymph node metastasis number.

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.

Proposal of the optimal numbers of examined and positive lymph nodes to the 8th edition of American Joint Committee on Cancer (AJCC) staging for 758 patients with distal cholangiocarcinoma

Introduction

The American Joint Committee on Cancer (AJCC) recommended retrieval of at least 12 lymph nodes and firstly classified N category by the number of positive lymph nodes (PLNs) for Distal Cholangiocarcinoma (DCC).

Objective

The end of this cohort study was to explore the optimal cut-off values of the number of examined lymph nodes (ELNs) and PLNs to better stratify patients by utilizing a population-based database.

Methods

A number of 758 patients with DCC from the Surveillance, Epidemiology, and End Results (SEER) database were enrolled in the study and comparing by the survival analysis.

Results

Survival analysis found that patients with ELNs < 5 had a lower 3-year disease-specific survival rate than ELNs ≥ 5 in N0M0 cohort (35.3% vs. 53.0%, P = 0.001) and in M0 cohort (42.7% vs. 32.8%, P = 0.006); survival curves between patients with ELNs < 12 and ELNs ≥ 12 were overlapped in N0M0 cohort (P = 0.256) and in M0 cohort (P = 0.233). Among patients with ELNs ≥ 5, using the optimal cut-off value of the number of PLNs (0, 2) could accurately stratify patients, but the recommendation of the number of PLNs (0, 3) by the AJCC could not.

Conclusions

This study recommended examining at least 5 lymph nodes and defining PLNs = 1–2 as the N1 category and PLNs ≥ 3 as the N2 category, which may better stratify distal cholangiocarcinoma patients and improve the accuracy of the eighth edition AJCC staging.

Proposed Modification of Staging for Distal Cholangiocarcinoma Based on the Lymph Node Ratio Using Korean Multicenter Database

The 8th American Joint Committee on Cancer (AJCC) staging system for distal cholangiocarcinoma (DCC) included a positive lymph node count (PLNC), but a comparison of the prognostic predictive power of PLNC and lymph node ratio (LNR) is still under debate. This study aimed to compare various staging models made by combining the abovementioned factors, identify the model with the best predictive power, and propose a modified staging system. We retrospectively reviewed 251 patients who underwent surgery for DCC at four centers. To determine the superiority of various staging models for predicting overall OSR, Akaike information criterion (AIC), Bayesian information criterion (BIC), AIC correction (AICc), and Harrell’s C-statistic were calculated. In multivariate analysis, age (p = 0.003), total lymph node count (p = 0.033), and revised T(LNR)M staging (p < 0.001) were identified as independent factors for overall survival rate. The predictive performance of revised T (LNR) M staging (AIC: 1288.925, BIC: 1303.377, AICc: 1291.52, and Harrell’s C statics: 0.667) was superior to other staging system. A modified staging system consisting of revised T category and LNR predicted better overall survival of DCC than AJCC 7th and AJCC 8th editions. In the future, external validation of the proposed new system using a larger cohort will be required.

Regional lymphadenectomy vs. extended lymphadenectomy for hilar cholangiocarcinoma (Relay-HC trial): study protocol for a prospective, multicenter, randomized controlled trial

Background

The prognostic benefits and safety of extended lymphadenectomy for hilar cholangiocarcinoma remain uncertain. The available evidence is still insufficient concerning its retrospective aspect. The aim of this study is to explore the clinical effect and safety of extended lymphadenectomy compared to regional lymphadenectomy in patients with hilar cholangiocarcinoma.

Methods

The Relay-HC trial is a prospective, multicenter, and randomized controlled trial. Seven hundred and thirty-four eligible patients with resectable perihilar cholangiocarcinoma across 15 tertiary hospitals in China will be randomly assigned (1:1) to receive either regional lymphadenectomy or extended lymphadenectomy. The primary objective is to determine the overall survival after the two approaches. Secondary objectives of the study include the evaluation of perioperative mortality, postoperative complication, and disease-free survival. This study has been approved by the ethics committee of each participating hospital.

Discussion

The Relay-HC trial is designed to investigate the prognostic benefits and safety of expanded lymphadenectomy for hilar cholangiocarcinoma. Currently, it has never been investigated in a prospective randomized controlled clinical trial.

Trial registration

Chinese Clinical Trial Registry (ChiCTR), ChiCTR1800015688. Registered on 15 April 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3605-z) contains supplementary material, which is available to authorized users.

Prognostic Significance of the Lymph Node Ratio in Surgical Patients With Distal Cholangiocarcinoma

BACKGROUND

The aim of this study was to compare the prognostic impact of the lymph node ratio (LNR) versus positive lymph node count (PLNC) in patients who had undergone resection for distal cholangiocarcinoma.

METHODS

We identified 448 patients with resected distal cholangiocarcinoma from the Surveillance, Epidemiology, and End Results database. The X-Tile program was used to calculate the cutoff values for the LNR and PLNC that discriminate survival. The overall survival and cancer-specific survival rates were calculated. Relationships between clinicopathological factors and patient survival were assessed using univariate and multivariate analyses.

RESULTS

The optimal cutoff values for the LNR and PLNC were 0.45 and 3, respectively. Univariate analysis revealed that tumor size, the American Joint Committee on Cancer stage, T stage, the LNR and PLNC were significantly associated with prognosis (P < 0.05). Multivariate analysis demonstrated that the LNR, T stage, and tumor size were independent prognostic factors for cancer-specific and overall survival, whereas PLNC was not. In the subgroup of patients with positive lymph nodes, patients with an LNR of greater than 0.45 had significantly worse cancer-specific survival (hazard ratio, 2.418; 95% confidence interval, 1.588 to 3.682; P < 0.001) and overall survival (hazard ratio, 2.149; 95% CI, 1.421 to 3.249; P < 0.001) than those with an LNR of 0.45 or less.

CONCLUSIONS

The LNR was a better predictor of long-term prognosis than PLNC in patients with distal cholangiocarcinoma.

Prognostic value of lymph nodes count on survival of patients with distal cholangiocarcinomas

AIM

To evaluate the prognostic value of the number of retrieved lymph nodes (LNs) and other prognostic factors for patients with distal cholangiocarcinomas, and to determine the optimal retrieved LNs cut-off number.

METHODS

The Surveillance, Epidemiology and End Results database was used to screen for patients with distal cholangiocarcinoma. Patients with different numbers of retrieved LNs were divided into three groups by the X-tile program. X-tile from Yale University is a useful tool for outcome-based cut-point optimization. The Kaplan-Meier method and Cox regression analysis were utilized for survival analysis.

RESULTS

A total of 449 patients with distal cholangiocarcinoma met the inclusion criteria. The Kaplan-Meier survival analysis for all patients and for N1 patients revealed no significant differences among patients with different retrieved LN counts in terms of overall and cancer-specific survival. In patients with node-negative distal cholangiocarcinoma, patients with four to nine retrieved LNs had a significantly better overall (P = 0.026) and cancer-specific survival (P = 0.039) than others. In the subsequent multivariate analysis, the number of retrieved LNs was evaluated to be independently associated with survival. Additionally, patients with four to nine retrieved LNs had a significantly lower overall mortality risk [hazard ratio (HR) = 0.39; 95% confidence interval (CI): 0.20-0.74] and cancer cause-specific mortality risk (HR = 0.32; 95%CI: 0.15-0.66) than other patients. Additionally, stratified survival analyses showed persistently better overall and cancer-specific survival when retrieving four to nine LNs in patients with any T stage of tumor, a tumor between 20 and 50 mm in diameter, or a poorly differentiated or undifferentiated tumor, and in patients who were ≤ 70-years-old.

CONCLUSION

The number of retrieved LNs was an important independent prognostic factor for patients with node-negative distal cholangiocarcinoma. Additionally, patients with four to nine retrieved LNs had better overall and cancer-specific survival rates than others, but the reason and mechanism were unclear. This conclusion should be validated in future studies.

Outcome and evaluation of prognostic factors after pancreaticoduodenectomy for distal cholangiocarcinoma

Background

The aim of the present study was to examine the outcomes and prognostic factors after surgery with curative intent for distal cholangiocarcinoma during a modern timespan, in a Swedish tertiary referral center.

Methods

All patients who underwent pancreaticoduodenectomy for distal cholangiocarcinoma between April 2008 and December 2015 were identified. Survival was estimated using the Kaplan-Meier analysis. Demographic, clinical, laboratory and histopathological data were evaluated for prognostic factors relating to mortality, using univariable and multivariable statistical analysis.

Results

Fifty-four patients were included. The mean age was 68±8 years and 21 (39%) of the patients were female. Jaundice was present at diagnosis in 73% of the patients. There was no 90-day mortality. Complications graded as Clavien-Dindo ≥3 occurred in 10 (19%) of the patients. Twenty-eight (52%) received adjuvant therapy. Overall survival rates at 1, 3, and 5 years were 80%, 21%, and 9.2%, respectively. Median survival was 22.2 months. The presence of lymph node metastases was found to be the only independent predictor of survival (hazard ratio 2.88, 95% confidence interval 1.22-6.84; P=0.016). The total number of lymph node metastases, lymph node ratio or total number of resected nodes did not improve the prediction.

Conclusions

We found that the recurrence rate was higher and the survival poorer after surgery for distal cholangiocarcinoma than has previously been reported. Lymph node status at the time of resection was the most important prognostic factor for survival in the current material.

The Prognostic Importance of the Number of Metastatic Lymph Nodes for Patients Undergoing Curative Resection Followed by Adjuvant Chemoradiotherapy for Extrahepatic Bile Duct Cancer

BACKGROUND

Current nodal staging system for extrahepatic bile duct (EHBD) cancer is controversial. The number of metastatic lymph nodes (mLN) and lymph node ratio (LNR) has been studied for the assessment of the nodal status in many other gastrointestinal cancers, but there are few studies on assessing the prognostic impact of these parameters in EHBD cancer.

METHODS

We retrospectively reviewed 239 consecutive patients who underwent curative resection followed by adjuvant chemoradiotherapy for adenocarcinoma of EHBD from 1995 to 2009 in our institution. The prognostic value of the number of mLN and LNR was evaluated by adjusting for other known factors. Optimal cutoff points were determined using maximally selected chi-square test.

RESULTS

Lymph node metastasis was found in 77 (32 %) patients. Univariate analysis for overall survival (OS) revealed both the number of mLN (0 vs. 1-3 vs. ≥4; p < 0.001) and LNR (<0.2 vs. ≥0.2; p < 0.001) as significant prognosticators. Multivariate analysis demonstrated that the number of mLN was an independent prognostic factor, whereas LNR was not. The estimated 5-year OS was 48.7 % for patients with negative nodes, 33.4 % for patients with 1-3 mLN, and 9.1 % for patients with 4 or more mLN (p < 0.001).

CONCLUSIONS

The number of mLN is a powerful parameter to predict survival in the EHBD cancer, which is more reliable than LNR. As for many other gastrointestinal cancers, further classification of node positive patients based on the number of mLN seems to be useful and may provide precise information.

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.

Adjuvant Chemotherapy and Radiation Therapy is Associated with Improved Survival for Patients with Extrahepatic Cholangiocarcinoma

BACKGROUND

This study aimed to analyze adjuvant therapy among patients with extrahepatic cholangiocarcinoma (EHC) at a national level.

METHODS

The American College of Surgeons National Cancer Data Base was used to identify patients with resected EHC (pathologic stages 1-3) between 1998 and 2006 (n = 8741). Three groups were compared: surgery only (S, n = 5766), surgery plus adjuvant chemotherapy (AC, n = 450), and surgery plus adjuvant chemotherapy and radiation therapy (ACR, n = 1918). The study investigated how patient demographics, provider characteristics, and tumor-specific variables were associated with receipt of adjuvant therapy and overall survival.

RESULTS

Patients who received adjuvant treatment were more likely to be younger (median age S, 70 years; AC, 65 years; ACR, 63 years), in the highest income quartile (>$46,000: S, 38.3 %; AC, 43.4 %; ACR, 44.7 %), and treated at a community cancer center (S, 43.0 %; AC, 50.7 %; ACR, 52.9 %) (all p < 0.001). These patients also were more likely to have positive lymph nodes (S, 34.7 %; AC, 69.6 %; ACR, 63.3 %), positive surgical margins (S, 5.9 %; AC, 7.1 %; ACR, 10.7 %), and stage 3 disease (S, 21.4 %; AC, 37.8 %; ACR, 37.9 %) (all p < 0.001). Multivariate analysis of the entire cohort showed improved survival with ACR (hazard ratio [HR] 0.82; 95 % confidence interval [CI] 0.75-0.91). The survival benefit was independent of margin status (R0: HR 0.88; 95 % CI 0.79-0.97; R1: HR 0.49; 95 % CI 0.38-0.62).

CONCLUSIONS

This national analysis suggests that ACR are associated with improved survival for high-risk EHC patients, such as those with positive lymph nodes. Until randomized clinical trials are conducted, these may be the best available data to guide adjuvant therapy for resected EHC.

Prognostic impact of lymph node metastasis in distal cholangiocarcinoma

BACKGROUND

The aim of the study was to investigate the prognostic impact of lymph node metastasis in cholangiocarcinoma using three different classifications.

METHODS

Patients who underwent pancreaticoduodenectomy for distal cholangiocarcinoma in 24 hospitals in Japan between 2001 and 2010 were included. Survival was calculated by means of the Kaplan-Meier method and differences between subgroups were assessed with the log rank test. The Cox proportional hazards model was used to identify independent predictors of survival. χ(2) scores were calculated to determine the cut-off value of the number of involved nodes, lymph node ratio (LNR) and total lymph node count (TLNC) for discriminating survival.

RESULTS

Some 370 patients were included. The median (range) TLNC was 19 (3-59). Nodal metastasis occurred in 157 patients (42·4 per cent); the median (range) number of involved nodes and LNR were 2 (1-19) and 0·11 (0·02-0·80) respectively. Four or more involved nodes was associated with a significantly shorter median survival (1·3 versus 2·2 years; P = 0·001), as was a LNR of at least 0·17 (1·4 versus 2·3 years; P = 0·002). Involvement of nodes along the common hepatic artery, present in 21 patients (13·4 per cent), was also associated with a shorter survival (median 1·3 versus 2·1 years; P = 0·046). Multivariable analysis among 157 node-positive patients identified the number of involved nodes as an independent prognostic factor (risk ratio 1·87; P = 0·002).

CONCLUSION

The number of involved nodes was a strong predictor of survival in patients with distal cholangiocarcinoma.

The Association between Survival and the Pathologic Features of Periampullary Tumors Varies over Time

Introduction. Several histopathologic features of periampullary tumors have been shown to be correlated with prognosis. We evaluated their association with mortality at multiple time points. Methods. A retrospective chart review identified 207 patients with periampullary adenocarcinomas who underwent pancreaticoduodenectomy between January 1, 2001 and December 31, 2009. Clinicopathologic features were assessed, and the data were analyzed using univariate and multivariate methods. Results. In univariate analysis, perineural invasion had a strong association with 1-year mortality (OR 3.03, CI 1.42–6.47), and one lymph node (LN) increase in the LN ratio (LNR) equated with a 5-fold increase in mortality. In contrast, LN status (OR 6.42, CI 3.32–12.41) and perineural invasion (OR 5.44, CI 2.81–10.52) had the strongest associations with mortality at 3 years. Using Cox proportional hazards, perineural invasion (HR 2.61, CI 1.77–3.85) and LN status (HR 2.69, CI 1.84–3.95) had robust associations with overall mortality. Recursive partitioning analysis identified LNR as the most important risk factor for mortality at 1 and 3 years. Conclusions. Overall mortality was closely related to the LNR within the first year, while longer follow-up periods demonstrated a stronger association with perineural invasion and overall LN status. Therefore, the current staging for periampullary tumors may need to be updated to include the LNR.

Assessment of nodal status for perihilar cholangiocarcinoma location, number, or ratio of involved nodes

Surgical treatment of perihilar cholangiocarcinoma (PCC) is the treatment of choice that can achieve long term results. Unfortunately the presence of lymph node metastases is frequent and it is one of the major negative prognostic factors in patients submitted to surgery. In literature there are few data about the prognostic significance of location, number and ratio of involved nodes. Moreover guidelines about the extent of lymph node dissection are not available. In this commentary the data of literature about prognostic significance of lymph node involvement are described and analysed.

Prognostic factors for survival after curative resection of distal cholangiocarcinoma: perineural invasion and lymphovascular invasion

PURPOSE

The purpose of this study was to elucidate the prognostic factors for distal cholangiocarcinoma after curative resection, and to assess the significance of perineural invasion (PNI) and lymphovascular invasion (LVI) as prognostic factors.

METHODS

A retrospective analysis of 91 patients who underwent radical surgery for distal cholangiocarcinoma between March 2004 and October 2011 was performed. We analyzed the survival rate and prognostic factors affecting the survival.

RESULTS

The overall 1-, 3- and 5-year survival rates were 84.1, 49.7 and 38.9 %, respectively. In the univariate analysis, the prognostic factors influencing the survival were the histological differentiation, lymph node (LN) involvement and TNM stage. In the multivariate analysis, LN metastasis was the only independent prognostic factor. Although patients with PNI tended to show poorer survival, it was not a statistically significant factor (3- and 5-year OS; 62.0 and 54.6 % vs. 42.8 and 30.9 %, P = 0.166). In the patients with a total lymph node count (TLNC) of 11 or less, PNI was a significant prognostic factor; however, it was not a significant factor in the patients with a TLNC over 11. Overall, the LVI had no influence on the patient survival.

CONCLUSIONS

LN metastasis was the only significant prognostic factor after the curative resection of distal cholangiocarcinoma. In cases where adequate dissection was performed, it appeared that the PNI and LVI had no influence on the survival.

Impact of intrapancreatic or extrapancreatic bile duct involvement on survival following pancreatoduodenectomy for common bile duct cancer

BACKGROUND

The clinicopathological factors that influence survival following pancreatoduodenectomy (PD) for common bile duct (CBD) cancer are not well known. This study aimed to investigate the effect of tumour involvement of the intrapancreatic versus extrapancreatic CBD on margin status, overall (OS) and disease-free (DFS) survival.

METHODS

This was a retrospective study of patients who underwent PD for CBD cancer between 2001 and 2009. Pathological examination was performed according to a previously described standardized protocol based on axial slicing. Clinicopathological data and outcome in terms of margin status, DFS and OS were compared between cancers involving exclusively the intrapancreatic CBD (CBDin) and those involving the extrapancreatic CBD, in isolation or combined with invasion of the intrapancreatic part of the duct (CBDex).

RESULTS

A total of 66 patients were enrolled. Most CBD cancers were locally advanced (97 per cent pathological (p) T3, 76 per cent pN1). Microscopic margin involvement (R1) was more frequent in CBDex than in CBDin cancers (34 of 39 versus 13 of 27; P = 0.001), more often multifocal (P < 0.001) and more frequently affected the periductal margin (P = 0.005). Venous resection was more often required for CBDex cancers (P = 0.009). CBDex cancers were associated with worse OS (median 21 versus 28 months; P = 0.020) and DFS (14 versus 31 months; P = 0.015), but the rate and site of recurrence did not differ. Metastasis to more than two lymph nodes was an independent predictor of OS and DFS.

CONCLUSION

CBDex cancer is associated with a higher rate of R1 resection and venous resection after PD, and has a worse outcome than CBDin cancer.

Patterns and prognostic significance of lymph node dissection for surgical treatment of perihilar and intrahepatic cholangiocarcinoma

INTRODUCTION

The prognostic significance of lymph node dissection (LND), the number and status of harvested lymph nodes (LNs), and the lymph node ratio (LNR) are still under debate in intrahepatic (ICC) and perihilar (PCC) cholangiocarcinoma. The aims of this study were to evaluate the prognostic value of the extent of LN dissection, the number of positive LNs, the distribution of positive LNs along different LN stations, and the LNR in a cohort of patients with ICC and PCC who underwent surgical resection and to compare the different prognostic values of lymph node involvement.

MATERIAL AND METHODS

A retrospective analysis was done evaluating extent of LND, number, status, and location of harvested LNs in a cohort of 145 patients with cholangiocarcinoma submitted to surgical resection with curative intent from 1990 to 2012.

RESULTS

Seventy patients had ICC and 75 had PCC. The median survival times of patients with N0 and N+ tumors were 42 and 19 months in ICC patients (p = 0.05) and 42 and 22 months in PCC patients (p = 0.01). In patients without LN metastases, the median survival times of patients with up to three LNs retrieved and with more than three LNs retrieved were 38 and 69 months in ICC patients (p = 0.05) and 18 and 43 months in PCC patients (p = 0.04), respectively. In N+ patients, the location of positive LNs (hepatoduodenal ligament or other regional stations) did not influence overall survival in ICC or PCC patients (p = 0.6). The median survival times of patients with LNRs of 0 and >0.25 were 43 and 19 months in ICC patients (p = 0.01); the 0-0.25 group did not reach the value. In PCC patients, median survival of 0, 0-0.25, and >0.25 groups of patients were 42, 23, and 11 months (p = 0.01), respectively.

CONCLUSIONS

LN metastasis is a major prognostic factor after surgical resection of cholangiocarcinoma. The number of harvested LNs and the LNR showed a high prognostic value in ICC and PCC.

Adjuvant surgery for advanced extrahepatic cholangiocarcinoma

Patients with Stage IV cholangiocarcinoma are currently not considered to be surgical candidates and are typically offered systemic chemotherapy. Recently, several novel systemic chemotherapy regimens have allowed an initially unresectable cholangiocarcinoma to be resectable. The aim of this article is to present the usefulness of adjuvant surgery in a case of advanced cholangiocarcinoma that was successfully treated with gemcitabine. A 72-year-old man was diagnosed with distal cholangiocarcinoma with liver metastases (cT2N0M1, Stage IV). He underwent metal stent placement in the duodenum to alleviate jaundice. After 18 courses of chemotherapy using gemcitabine without severe drug toxicities, a computed tomography scan showed that the liver metastases in S6 and S7 had disappeared. The patient underwent subtotal stomach-preserving pancreaticoduodenectomy and lymph node dissection. The pathological stage was pT2N0M0, Stage IB. The patient underwent 6 cycles of adjuvant chemotherapy using gemcitabine. The patient is alive and well 6 years and 9 mo after the diagnosis.

Perineural invasion in extrahepatic cholangiocarcinoma: prognostic impact and treatment strategies

BACKGROUND

The significance of perineural invasion in extrahepatic cholangiocarcinoma has not been fully elucidated. This study aims to determine the prognostic impact of and optimal treatment strategy for perineural invasion in patients with extrahepatic cholangiocarcinoma.

METHODS

Medical records of 133 patients with extrahepatic cholangiocarcinoma who underwent curative resection were reviewed retrospectively. Ninety-eight patients had perineural invasion and 35 patients did not. Univariate and multivariate survival analyses were performed to clarify the prognostic impact of and optimal treatment strategy for perineural invasion.

RESULTS

Only tumor differentiation (P=0.024) was independently associated with perineural invasion in the multivariate logistic regression model. Multivariate survival analysis revealed that perineural invasion (P=0.002), resection margin status(P=0.016), and International Union Against Cancer (UICC) pT factor (P=0.015) were independent prognostic factors of overall survival. Overall 5-year survival rates for patients with and without perineural invasion were 28 and 74 %, respectively. Among 98 patients with perineural invasion, the use of adjuvant chemotherapy (P=0.003), lymph node status (P=0.015), resection margin status (P=0.008), and UICC pT factor (P=0.016) were independently associated with overall survival by multivariate analysis. Overall 5-year survival rates for patients with perineural invasion who did and did not receive adjuvant chemotherapy were 33 and 21 %, respectively (P=0.023).

CONCLUSIONS

Perineural invasion is a potent prognostic factor in extrahepatic cholangiocarcinoma. Adjuvant chemotherapy may improve the overall survival of patients with perineural invasion.

Quantitative analysis of VEGF-C mRNA of extrahepatic cholangiocarcinoma with real-time PCR using samples obtained during endoscopic retrograde cholangiopancreatography

OBJECTIVE

Vascular endothelial growth factor (VEGF)-C overexpression in extrahepatic cholangiocarcinoma (ECC) has been shown to be correlated with lymph node metastasis. The intensity of immunohistochemical staining of VEGF-C protein in surgical samples has been used as index of VEGF-C overexpression in previous studies. The aim of the study was to examine if VEGF-C overexpression in ECC could be preoperatively detected by using samples obtained during ERCP.

METHODS

Consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for biliary stricture during the study period were prospectively analyzed. VEGF-C mRNA was quantified by real-time PCR methods using endoscopic samples obtained during ERCP. The high intensity of immunohistochemical staining of VEGF-C protein in surgical samples was used for the reference standard of VEGF-C overexpression. The level of S100P mRNA which was a novel diagnostic marker of ECC was also quantified to evaluate whether the endoscopic samples contained ECC cells.

RESULTS

Twenty-five patients were enrolled in this study. Eighteen patients were diagnosed as ECC and seven patients were diagnosed as benign biliary structure. Nine of eighteen patients with ECC, who showed positive S100P mRNA in endoscopic samples and received surgical resection, were finally analyzed. Receiver operating characteristics analysis yielded VEGF-C mRNA cut-off value of 3.85 for detection of VEGF-C overexpression, and the diagnostic performance of VEGF-C mRNA measurement in the endoscopic sample for VEGF-C overexpression reached sensitivity of 75.0%, specificity of 100%, and accuracy of 88.9%.

CONCLUSION

The quantification of VEGF-C mRNA of ECC with real-time PCR using endoscopic samples was useful for preoperative detection of VEGF-C overexpression.

Assessment of nodal status for perihilar cholangiocarcinoma: location, number, or ratio of involved nodes

OBJECTIVE

To analyze lymph node status in resected perihilar cholangiocarcinoma, to clarify which index (ie, location, number, or ratio of involved nodes) is better for staging, and to determine the minimum requirements for node examination.

BACKGROUND

In the TNM classification for perihilar cholangiocarcinoma, the number or ratio of involved nodes is not considered for nodal staging. The minimum requirement for histologic examination of lymph nodes is arbitrary.

METHODS

This study involved 320 patients with perihilar cholangiocarcinoma who underwent resection from January 2000 to December 2009 at Nagoya University Hospital. The relationship between lymph node status and patient survival was retrospectively analyzed.

RESULTS

Total lymph node counts (TLNCs), ie, the number of lymph nodes examined histologically, averaged 12.9 ± 8.3 (range: 1-59). Lymph node metastasis was found in 146 (45.6%) patients and was an independent, powerful prognostic factor. The survival rates were not significantly different between patients with regional node metastasis alone and those with distant node metastasis (19.2% vs 11.5% at 5 years, P = 0.058). The survival for patients with multiple node metastases was significantly worse than that for patients with single metastasis (12.1% vs 27.6% at 5 years, P = 0.002), regardless of the presence or absence of distant lymph node metastasis. The survival for patients with lymph node ratios (LNRs) of 0.2 or less was significantly better than that for patients with LNRs greater than 0.2 (21.4% vs 13.5% at 5 years, P = 0.032). Upon multivariate analysis of the 146 patients with lymph node metastasis, the number of involved nodes (single vs multiple) was identified as an independent prognostic factor (RR of 1.61, P = 0.045), whereas the locations (regional alone vs distant) and ratios (LNR ≤ 0.2 vs LNR > 0.2) of involved nodes were not. When the 148 pN0-R0 patients were divided into 3 groups (ie, those with TLNC ≥ 8, with TLNC = 5, 6, or 7, and with TLNC ≤ 4), survivals were identical between the first and second groups, whereas they were largely different between the former two and the third.

CONCLUSIONS

Lymph node metastasis is a powerful, independent prognostic factor in perihilar cholangiocarcinoma and is better classified based not on location but on the number of involved nodes. To adequately assess nodal status, histologic examination of 5 or more nodes is recommended.

Prognostic relevance of number and ratio of metastatic lymph nodes in resected pancreatic, ampullary, and distal bile duct carcinomas

BACKGROUND

Lymph node ratio (LNR) may be more useful than nodal (N) status in prognostic subclassification of adenocarcinomas after pancreatoduodenectomy. Ampullary (AC), biliary (DBC), and pancreatic (PC) adenocarcinomas are biologically distinct, and nodal involvement may have different prognostic importance among these separate cancers.

METHODS

We included 179 consecutive pancreatoduodenectomies for PC, AC, or DBC, and performed standardized histopathologic evaluation, including prospective registration and retrospective reevaluation of the cancer origin. Associations between histopathologic variables and LNR, N status, and number of metastatic nodes were evaluated. Unadjusted and adjusted survival analysis was performed.

RESULTS

Overall 5 year survival was 6% for PC (n=72), 26% for DBC (n=46), and 46% for AC (n=61). Lymph node involvement was more frequent in PC (75%) than in AC (48%) and DBC (57%). In PC, N status did not discriminate between prognostic groups (N1 vs. N0; p=0.31). However, increasing LNR was associated with poorer survival in unadjusted analysis, as well as when adjusting for margin involvement, degree of differentiation, and tumor diameter (p=0.032; hazard ratio 1.87, 95% confidence interval 1.06-3.31). In AC and DBC, N status clearly discriminated between subgroups of patients with different long-term survival in unadjusted and adjusted survival analysis (N1 vs. N0; p<0.001), whereas number of metastatic nodes and LNR did not predict survival among node-positive resections.

CONCLUSIONS

The predictive value of nodal involvement depends on the type of cancer within the pancreatic head. In AC and DBC, N status adequately discriminates between good and poor prognosis. In PC, LNR may be more powerful in prognostic subclassification.

The prognostic importance of lymphovascular invasion in cholangiocarcinoma above the cystic duct: a new selection criterion for adjuvant therapy?

OBJECTIVE

Criteria for selecting patients to receive adjuvant chemotherapy in cases of resected intrahepatic or hilar cholangiocarcinoma (CC) are lacking. Some clinicians advocate the provision of adjuvant therapy in patients with lymph node (LN)-positive disease; however, nodal assessment is often inadequate. The aim of this study was to identify a surrogate criterion based on primary tumour characteristics.

METHODS

All patients who underwent resection for hilar or intrahepatic CC at a single institution between January 2000 and September 2009 were identified from a prospectively maintained database. Pathological factors were recorded. The primary outcome assessed was overall survival (OS).

RESULTS

In total, 69 patients underwent resection for hilar (n=34) or intrahepatic (n=35) CC. Their median age was 66 years and 27 patients (39%) were male. Median follow-up was 22 months and median OS was 17 months. Median tumour size was 5 cm. Overall, 23% of patients had a positive resection margin, 44% had perineural invasion, 32% had lymphovascular invasion (LVI) and 25% had positive LNs. The median number of LNs removed was two and the median number of positive LNs was zero. The presence of LVI was associated with reduced OS (11.9 months vs. 23.1 months; P=0.023). After accounting for all other adverse tumour factors, the presence of LVI persisted as the only negative prognostic factor for OS on multivariate Cox regression.

CONCLUSIONS

In patients who had undergone resection of hilar or intrahepatic CC, the presence of LVI was strongly associated with reduced OS. Thus the finding of LVI may potentially be used as a criterion in the selection of patients for adjuvant chemotherapy.