Prognostic value of lymphadenectomy for long-term outcomes in node-negative intrahepatic cholangiocarcinoma: A multicenter study

Impact of Lymph Node Dissection for Patients With Clinically Node-Negative Intrahepatic Cholangiocarcinoma: A Multicenter Cohort Study

Background

Lymph node status is a prominent prognostic factor for intrahepatic cholangiocarcinoma (ICC). However, the prognostic value of performing lymph node dissection (LND) in patients with clinical node-negative ICC remains controversial. The aim of this study was to evaluate the clinical value of LND on long-term outcomes in this subgroup of patients.

Methods

We retrospectively analyzed patients who underwent radical liver resection for clinically node-negative ICC from three tertiary hepatobiliary centers. The propensity score matching analysis at 1:1 ratio based on clinicopathological data was conducted between patients with and without LND. Recurrence-free survival (RFS) and overall survival (OS) were compared in the matched cohort.

Results

Among 303 patients who underwent radical liver resection for ICC, 48 patients with clinically positive nodes were excluded, and a total of 159 clinically node-negative ICC patients were finally eligible for the study, with 102 in the LND group and 57 in the non-LND group. After propensity score matching, two well-balanced groups of 51 patients each were analyzed. No significant difference of median RFS (12.0 vs. 10.0 months, P = 0.37) and median OS (22.0 vs. 26.0 months, P = 0.47) was observed between the LND and non-LND group. Also, LND was not identified as one of the independent risks for survival. Among 51 patients who received LND, 11 patients were with positive lymph nodes (lymph node metastasis (LNM) (+)) and presented significantly worse outcomes than those with LND (-). On the other hand, postoperative adjuvant therapy was the independent risk factor for both RFS (hazard ratio (HR): 0.623, 95% confidence interval (CI): 0.393 - 0.987, P = 0.044) and OS (HR: 0.585, 95% CI: 0.359 - 0.952, P = 0.031). Furthermore, postoperative adjuvant therapy was associated with prolonged survivals of non-LND patients (P = 0.02 for RFS and P = 0.03 for OS).

Conclusions

Based on the data, we found that LND did not significantly improve the prognosis of patients with clinically node-negative ICC. Postoperative adjuvant therapy was associated with prolonged survival of ICC patients, especially in non-LND individuals.

Management of intrahepatic and perihilar cholangiocarcinomas: Guidelines of the French Association for the Study of the Liver (AFEF)

Intrahepatic cholangiocarcinoma (iCCA) is the second most common malignant primary liver cancer. iCCA may develop on an underlying chronic liver disease and its incidence is growing in relation with the epidemics of obesity and metabolic diseases. In contrast, perihilar cholangiocarcinoma (pCCA) may follow a history of chronic inflammatory diseases of the biliary tract. The initial management of CCAs is often complex and requires multidisciplinary expertise. The French Association for the Study of the Liver wished to organize guidelines in order to summarize the best evidence available about several key points in iCCA and pCCA. These guidelines have been elaborated based on the level of evidence available in the literature and each recommendation has been analysed, discussed and voted by the panel of experts. They describe the epidemiology of CCA as well as how patients with iCCA or pCCA should be managed from diagnosis to treatment. The most recent developments of personalized medicine and use of targeted therapies are also highlighted.

Is routine lymph node dissection recommended for liver resection of intrahepatic cholangiocarcinoma? A systematic review and meta-analysis

BACKGROUND/PURPOSE

This meta-analysis aimed to elucidate the therapeutic effects of routine lymph node dissection (LND) with liver resection on intrahepatic cholangiocarcinoma (ICC).

METHODS

Databases, including MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials, were searched to identify studies comparing LND and non-LND for ICC liver resection. The primary outcome was overall survival (OS), and secondary outcomes were disease-free survival (DFS), in-hospital morbidity, blood loss, and R0 rate.

RESULTS

Seventeen studies involving 4407 patients were included. The OS did not differ between the LND (n = 2158) and non-LND (n = 2249) groups (HR, 1.05; 95% CI, 0.83-1.32). The secondary outcomes did not differ significantly between the groups. Subgroup analyses stratified by the risk of bias showed a significant difference in OS between the high- and low-risk groups (P = 0.0008). In the low-risk group, LND (vs. non-LND) was associated with superior OS (HR, 0.76; 95% CI, 0.59-0.98). Most studies in low-risk groups involved patients who were clinically node-negative.

CONCLUSIONS

The therapeutic effects of routine LND for ICC have not been demonstrated. However, LND had a positive impact on OS in studies with a low risk of bias, thus suggesting that there may be a subset of ICC patients who would benefit from LND.

A snapshot on current approaches to lymphadenectomy in liver resection for intrahepatic cholangiocarcinoma: results from an international survey

The use of lymphadenectomy (LND) during resection of intrahepatic cholangiocarcinoma (ICC) is still debated, leading to differing practices in different centers and countries. The aim of this study was to assess such differences. A survey on LND for ICC was distributed to the members of the International Hepato-PancreatoBiliary Association (IHPBA) and the Italian Chapter of IHPBA (AICEP). Two-hundred thirty-four surgeons completed the survey (88% males; median age 46 years). Preoperative nodal staging was deemed mandatory/very important by 65%. Adequate LND was defined as hepatoduodenal ligament LND by 33%, LND at specific nodal stations by 28% and retrieval of > 5 nodes by 28%. The decision to perform LND was influenced by comorbidities (48%), chronic liver disease (38%) and satellitosis (32%). Most participants modify perioperative management in case of clinically positive nodes, 50% stating they would give neoadjuvant therapy. The role of LND in clinically node negative disease was adequate staging for 88%, survival benefit for 50.5% and clinical trials eligibility for 18.5%. Our survey confirms heterogeneity in the evaluation of role and extent of LND for ICC, how this relates to subjective perception of importance of LND, and need of a systematic approach in this area.

Short-term postoperative outcomes of lymphadenectomy for cholangiocarcinoma, hepatocellular carcinoma and colorectal liver metastases in the modern era of liver surgery: Insights from the StuDoQ|Liver registry

INTRODUCTION

The clinical role of lymphadenectomy (LAD) as part of hepatic resection for malignancies of the liver remains unclear. In this study, we aimed to report on the use cases and postoperative outcomes of liver resection and simultaneous LAD for hepatic malignancies (HM).

MATERIALS AND METHODS

Clinicopathological data from patients who underwent surgery at 13 German centers from 2017 to 2022 (n = 3456) was extracted from the StuDoQ|Liver registry of the German Society of General and Visceral Surgery. Propensity-score matching (PSM) was performed to account for the extent of liver resection and patient demographics.

RESULTS

LAD was performed in 545 (16%) cases. The most common indication for LAD was cholangiocarcinoma (CCA), followed by colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC). N+ status was found in 7 (8%), 59 (35%), and 56 cases (35%) for HCC, CCA, and CRLM, respectively (p < 0.001). The LAD rate was highest for robotic-assisted resections (28%) followed by open (26%) and laparoscopic resections (13%), whereas the number of resected lymph nodes was equivalent between the techniques (p = 0.303). LAD was associated with an increased risk of liver-specific postoperative complications, especially for patients with HCC.

CONCLUSION

In this multicenter registry study, LAD was found to be associated with an increased risk of liver-specific complications. The highest rate of LAD was observed among robotic liver resections.

Value of lymph node dissection in intrahepatic cholangiocarcinoma: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to perform a systematic review and meta-analysis to investigate the impact of lymph node dissection (LND) on outcomes following resection of intrahepatic cholangiocarcinoma (ICC).

METHODS

PubMed, EMBASE, and Cochrane were searched from inception to 30th January 2023 for studies that compared LND with no LND (NLND) among patients with ICC. To limit the effect of unbalanced covariates, only studies that utilized propensity score-based methods were included. Subgroup analysis of patients with clinically node-negative (cN0) ICC was analyzed.

RESULTS

Among 3776 patients with ICC, individuals in the LND versus NLND cohorts had comparable overall survival (OS) (Hazard ratio [HR] 0.78, 95 % confidence interval [CI] 0.57-1.06, P = 0.11), disease-free survival (DFS) (HR 0.84, 95 % CI 0.70-1.01, P = 0.07) and risk of major complications (odds ratio [OR] 1.07, 95 % CI 0.70-1.62, P = 0.75). Subgroup analysis of cN0 patients, OS was significantly higher in patients who underwent LND (HR 0.61, 95 % CI 0.50-0.74, P < 0.01), with a non-significant trend towards improved DFS (HR 0.81, 95 % CI 0.65-1.01, P = 0.06).

CONCLUSION

This study found no differences in long-term survival or morbidity following LND for ICC. Subgroup analysis of cN0 patients, who underwent LND detected improved OS with a trend towards better DFS, compared to patients with NLND.

Role of routine lymph node dissection alongside resection of intrahepatic cholangiocarcinoma: Systematic review and meta-analysis

BACKGROUND

The global incidence of intrahepatic cholangiocarcinoma (ICCA) is soaring. Due to often delayed presentation, only a narrow spectrum of the disease is usually surgically resectable. To more accurately stage the disease, reduce recurrence, and improve overall survival, surgical teams are increasingly performing intraoperative lymph node dissection (LND) as well. This procedure has its associated morbidity, while there is no consensus or formal guidelines on its role in this setting. Hence, there is a need to better delineate the evidence for performing LND alongside surgical resection of the ICCA.

AIM

To perform a systematic review and meta-analysis on the role of LND in improving prognostication and survival post-resection of ICCA.

METHODS

We performed a systematic literature search using Pubmed, Medline, Embase, and the Cochrane Library, for all studies involving LND, ICCA, and surgical resection using several keywords, Medical Subject Headings (MeSH) tags, and appropriate synonyms. All clinical studies comparing curative intent resection of ICCA with LND vs resection without LND were included, while single-arm case series, studies with insufficient data, and duplicates were excluded. We included all English-language studies from the different academic databases up till early December 2022. The primary outcome measures were set for overall survival (OS) and disease-free survival (DFS).

RESULTS

This systematic review and meta-analysis included 15 studies that fulfilled the selection criteria comprising 11413 patients with surgically-resectable ICCA, of whom 6424 (56.3%) underwent hepatectomy with LND while the remainder underwent hepatectomy only. In patients who underwent LND, on average, 27.7% of the resected lymph nodes were positive for metastatic disease. Overall, the results showed that performing LND did not significantly improve OS or DFS. However, the effect of LND on OS showed a degree of variability by geographical region, in Eastern and Western countries. As LND is increasingly being performed, further time-based analysis was undertaken to identify time-dependent changes in the role of LND. An increasing adoption of LND was not associated with improved OS. Furthermore, no roles were identified for neoadjuvant/adjuvant chemotherapy or increasing lymph node retrieval in improving OS either.

CONCLUSION

LND might aid in staging, prognosticating, and deciding further management of resected ICCA, but does not improve OS and DFS and is unsuitable for high-risk patients unlikely to benefit from further treatments.

Robotic Approach for Lymphadenectomy in Biliary Tumors: The Missing Ring Between the Benefits of Laparoscopic and Reproducibility of Open Approach?

OBJECTIVE

This study aimed to evaluate the oncological adequacy of lymphadenectomy (LND) for biliary tumors and surgical outcomes of resections performed using robotic, laparoscopic, and open approaches and to compare the techniques within a weighted propensity score analysis.

BACKGROUND

The need to perform formal LND is considered a limit for the applicability of minimally invasive liver surgery.

METHODS

Overall, 25 robotic resections with LND (2021-2022) from a single-center constituted the study group (Rob group), matched by inverse probability treatment weighting with 97 laparoscopic (Lap group) and 113 open (Open group) procedures to address the primary endpoint. A "per-period" analysis was performed comparing the characteristics and outcomes of the Rob group with the first 25 consecutive laparoscopic liver resections with associated LND (LapInit group).

RESULTS

Minimally invasive techniques performed equally well regarding the number of harvested nodes, blood transfusions, functional recovery, length of stay, and major morbidity and provided a short-term benefit to patients when compared with the open technique. A better performance of the robotic approach over laparoscopic approach (and both approaches over the open technique) was recorded for patients achieving LND with retrieval of >6 nodes. The open approach reduced both the operative time and time for LND, and robotic surgery performed better than laparoscopic surgery.

CONCLUSIONS

Minimally invasive techniques are excellent tools for the management of LND in patients with biliary tumors, showing feasibility, and oncological adequacy. Robotics could contribute to the large-scale diffusion of these procedures with a high profile of complexity.

The optimal number of examined lymph nodes for accurate staging of intrahepatic cholangiocarcinoma: A multi-institutional analysis using the nodal staging score model

BACKGROUND

This study aims to develop a nodal staging score (NSS) to determine the optimal number of lymph nodes (LNs) examined in intrahepatic cholangiocarcinoma (iCCA) patients.

METHODS

Clinicopathologic data were collected from the SEER database (development cohort, n = 2782) and seven Chinese tertiary hospitals (validation cohort, n = 363). NSS was constructed based on a binomial distribution to indicate the probability of nodal disease absence. In addition, its prognostic value was examined by survival analysis and multivariable modeling on pN0 patients.

RESULTS

A model fit was performed in node-positive patients and a subgroup analysis was performed according to clinical characteristics. Statistically significant differences were only found in the subgroups when divided by the tumor size of 3 cm. As the number of examined lymph nodes (ELNs) increased, the likelihood of missing a metastatic LN decreased. NSS escalated as ELNs increased in groups with different tumor sizes, with plateaus at 7 and 11 LNs ensuring an NSS of 90.0% for ≤3 cm and >3 cm tumors, respectively. For pN0 patients, multivariate analysis revealed that NSS was an independent prognostic factor for overall survival (OS) and recurrence-free survival (RFS).

CONCLUSIONS

For accurate staging of iCCA, the optimal number of ELNs was related to tumor size. We recommend that at least 7 and 11 LNs should be examined for tumor size ≤3 cm and >3 cm, respectively. Therefore, the NSS model could be helpful to make clinical decisions for pN0 iCCA.

Association of Laparoscopic Surgery with Improved Perioperative and Survival Outcomes in Patients with Resectable Intrahepatic Cholangiocarcinoma: A Systematic Review and Meta-Analysis from Propensity-Score Matched Studies

BACKGROUND

Recent studies have associated laparoscopic surgery with better overall survival (OS) in patients with hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM). The potential benefits of laparoscopic liver resection (LLR) over open liver resection (OLR) have not been demonstrated in patients with intrahepatic cholangiocarcinoma (iCC).

METHODS

A systematic review of the PubMed, EMBASE, and Web of Science databases was performed to search studies comparing OS and perioperative outcome for patients with resectable iCC. Propensity-score matched (PSM) studies published from database inception to May 1, 2022 were eligible. A frequentist, patient-level, one-stage meta-analysis was performed to analyze the differences in OS between LLR and OLR. Second, intraoperative, postoperative, and oncological outcomes were compared between the two approaches by using a random-effects DerSimonian-Laird model.

RESULTS

Six PSM studies involving data from 1.042 patients (530 OLR vs. 512 LLR) were included. LLR in patients with resectable iCC was found to significantly decrease the hazard of death (stratified hazard ratio [HR]: 0.795 [95% confidence interval [CI]: 0.638-0.992]) compared with OLR. Moreover, LLR appears to be significantly associated with a decrease in intraoperative bleeding (- 161.47 ml [95% CI - 237.26 to - 85.69 ml]) and transfusion (OR = 0.41 [95% CI 0.26-0.69]), as well as with a shorter hospital stay (- 3.16 days [95% CI - 4.98 to - 1.34]) and a lower rate of major (Clavien-Dindo ≥III) complications (OR = 0.60 [95% CI 0.39-0.93]).

CONCLUSIONS

This large meta-analysis of PSM studies shows that LLR in patients with resectable iCC is associated with improved perioperative outcomes and, being conservative, yields similar OS outcomes compared with OLR.

Modified staging system of positive lymph nodes based nomogram in intrahepatic cholangiocarcinoma

BACKGROUND

Intrahepatic cholangiocarcinoma (iCCA) presents the similar trend and prevalence of lymph node metastasis to other biliary tract cancer. There is still a necessity and possibility for the current classification of lymph node in the 8th TNM of iCCA, which is the same as the criteria of hepatoma carcinoma (HCC), to further improve the prognostic capacity. We aim to explore the optimal positive lymph nodes cutoff value that could predict the survival outcomes of patients with iCCA and further establish a prognostic nomogram.

METHOD

Clinical characteristics were retrospectively collected in 292 patients with iCCA from Sun Yat-sen University Cancer Center (SYSUCC) for preliminary analysis. A retrospective analysis of 107 patients with iCCA in the First Hospital of Dalian Medical University (FHDMU) was performed for verification. R software was used to determine the optimal cutoff value of positive lymph nodes (PLN) and further establish the nomogram with the Cox regression model in the primary cohort.

RESULTS

In those patients who were graded into the N1 stage in 8th TNM staging system, the patients with PLN between 1 and 3 showed significantly better overall survival than those patients with more than 4 PLN (P < 0.0001). Moreover, there was a significant correlation between the new PLN classification and adverse clinical characteristic including Micro Invasion (P = 0.001), Lymph Vessel Invasion (P = 0.040), Satellite Sites (P < 0.001), and Tumor Size (P = 0.005). The PLN and ELN were both independent prognostic factors for survival outcomes in the multivariate analysis, and further showed large contribution to the nomogram. The nomogram achieved a satisfied C-index of 0.813 for overall survival (OS), 0.869 for progression-free survival (PFS) in the primary cohort, and 0.787 for OS, 0.762 for PFS in the validation cohort.

CONCLUSION

The modified classification of PLN in iCCA could accurately stratify the N1 stage patients in 8th TNM staging system into two groups with significantly different overall survival. The development of this nomogram can offer new evidence to precisely post-operative management of iCCA patients.

Predictors, Patterns, and Impact of Adequate Lymphadenectomy in Intrahepatic Cholangiocarcinoma

INTRODUCTION

Despite lymph node metastases (LNMs) being associated with worse survival, adequate lymph node evaluation (LNE) has not been universally adopted for intrahepatic cholangiocarcinoma (ICC). We sought to evaluate trends in LNE, predictors of LNE and LNM, as well as the role of adequate lymphadenectomy in stratifying patients relative to survival.

METHODS

Patients who underwent curative-intent liver resection for ICC (2010-2019) were identified from the National Cancer Database and stratified according to LNE: 0, 1-5 (inadequate lymphadenectomy) and ≥6 (adequate lymphadenectomy). Multivariate logistic regression was utilized to assess predictors of LNE and LNM. Overall survival and receipt of adequate lymphadenectomy were assessed relative to LNM and log-odds of lymph nodes (LODDS).

RESULTS

Among 6507 patients, adequate lymphadenectomy was performed in only 1118 (17.2%) patients, although compliance with adequate lymphadenectomy increased over time (2010-2012: 14.2% vs. 2016-2019: 18.9%; p < 0.001). After controlling for relevant factors, region (reference: Northeast; Midwest: odds ratio [OR] 1.90, 95% confidence interval [CI] 1.48-2.44; South: OR 1.64, 95% CI 1.28-2.10; West: OR 1.83, 95% CI 1.37-2.44) and preoperative nodal status (reference: cN0; cNx: OR 2.18, 95% CI 1.68-2.95; cN1: OR 3.88, 95% CI 3.02-4.98) strongly predicted adequate lymphadenectomy. Furthermore, adequate lymphadenectomy resulted in higher odds of detecting ≥1 LNMs (OR 2.63, 95% CI 2.25-3.08), regardless of preoperative nodal status. Adequate lymphadenectomy demonstrated an improved ability to stratify patients relative to 5-year survival based on LNM (N0: 51.3% vs. N1: 30.6% vs. N2: 13.7%; p < 0.001) and LODDS (LODDS1: 50.7% vs. LODDS2: 27.4% vs. LODDS3: 15.7%; p < 0.001).

CONCLUSIONS

Compliance with adequate lymphadenectomy at the time of surgery for ICC remains suboptimal with marked regional variations. Adequate lymphadenectomy was associated with higher odds of detecting LNM and improved survival stratification relative to both LNM and LODDS. Greater emphasis on nodal evaluation is required to ensure optimal management of ICC.

The impact of tumor location on the value of lymphadenectomy for intrahepatic cholangiocarcinoma

BACKGROUND

The therapeutic role of lymphadenectomy (LND) for intrahepatic cholangiocarcinoma (ICC) patients remains ill-defined. We sought to analyze the therapeutic value of LND relative to tumor location and preoperative lymph node metastasis (LNM) risk.

METHODS

Patients who underwent curative-intent hepatic resection of ICC between 1990 and 2020 were included from a multi-institutional database. Therapeutic LND (tLND) was defined as LND that harvested ≥3 lymph nodes.

RESULTS

Among 662 patients, 178 (26.9%) individuals received tLND. Patients were categorized into central type ICC (n = 156, 23.6%) and peripheral type ICC (n = 506, 76.4%). Central type harbored multiple adverse clinicopathologic factors and worse overall survival (OS) compared with peripheral type (5-year OS, central: 27.0% vs. peripheral: 47.2%, p < 0.001). After consideration of preoperative LNM risk, patients with central type and high-risk LNM who underwent tLND survived longer than individuals who did not (5-year OS, tLND: 27.9% vs. non-tLND: 9.0%, p = 0.001), whereas tLND was not associated with better survival among patients with peripheral type ICC or low-risk LNM. The therapeutic index of hepatoduodenal ligament (HDL) and other regions was higher in central type than in peripheral type, which was more pronounced among high-risk LNM patients.

CONCLUSIONS

Central type ICC with high-risk LNM should undergo LND involving regions beyond the HDL.

Adequate lymph node dissection is essential for accurate nodal staging in intrahepatic cholangiocarcinoma: A population-based study

PURPOSE

To comprehensively investigate the implications of lymph node dissection (LND) and the prognostic impact of the number of lymph node (LN) metastases on survival in intrahepatic cholangiocarcinoma (ICC) using a large-scale study.

METHODS

Patients who underwent surgical resection for ICC between 2004 and 2018 were identified from the Surveillance, Epidemiology, and End Results (SEER) registries. The Kaplan-Meier and log-rank tests were used to compare cancer-specific survival (CSS) and overall survival (OS) between different groups. Propensity score matching (PSM) and subgroup analyses were performed to balance potential confounding factors. A multivariate Cox proportional hazards regression model was used to identify prognostic factors of survival outcomes. Restricted cubic splines fitted in the Cox proportional hazard regression models were also conducted to examine associations between continuous variables and outcomes.

RESULTS

In all, 1028 patients were enrolled. There were 652 (63.4%) patients undergoing LND, with lymph node metastasis (LNM) confirmed in 212 (32.5%) cases. Patients receiving LND did not show better survival outcomes than those receiving non-LND (NLND). We divided the LND group into two subgroups: patients with LNM (+) and those without LNM (-). Among these three groups, patients with LNM experienced the worst CSS and OS, while NLND patients had similar survival times to LNM (-) patients. Restricted cubic spline analysis indicated that an increased number of LNM was associated with a decreased chance of survival (p < 0.001). Patients who received LND were further categorized as having no nodal metastasis (N0), 1-2 LNM (N1), or ≥3 LNM (N2) according to the number of LNM. The Kaplan-Meier curves showed that the mortality risk of patients with N0, N1, and N2 disease (median CSS, N0 50.0 vs. N1 22.0 vs. N2 14.0 months; median OS, N0 46.0 vs. N1 21.0 vs. N2 14.0 months, all p < 0.01) increased significantly, except for patients who had <6 LNs harvested. On multivariable survival analysis, a higher nodal stage (N1 vs. N0: CSS, hazard ratio [HR] 2.135, 95% CI 1.636-2.788, p < 0.001; OS, HR 2.100, 95% CI 1.624-2.717, p < 0.001; N2 vs. N0: CSS, HR 4.027, 95% CI 2.791-5.811, p < 0.001; OS, HR 3.678, 95% CI 2.561-5.282, p < 0.001) was an independent prognostic risk factor for survival.

CONCLUSIONS

Despite the lack of a clear survival benefit of LND in patients with ICC, a significant positive association between the number of LNM and poor outcomes was observed. We still suggest adequate LND by examining at least six LNs to ensure precise staging. On this basis, the recently proposed nodal classification of N0, N1, and N2 stages may also allow better prognostic stratification of ICC patients.

Optimization of a laparoscopic procedure for advanced intrahepatic cholangiocarcinoma based on the concept of "waiting time": a preliminary report

INTRODUCTION

Clinicians increasingly perform laparoscopic surgery for intrahepatic cholangiocarcinoma (ICC). However, this surgery can be difficult in patients with advanced-stage ICC because of the complicated procedures and difficulty in achieving high-quality results. We compared the effects of a three-step optimized procedure with a traditional procedure for patients with advanced-stage ICC.

METHODS

Forty-two patients with advanced-stage ICC who received optimized laparoscopic hemihepatectomy with lymph node dissection (LND, optimized group) and 84 propensity score-matched patients who received traditional laparoscopic hemihepatectomy plus LND (traditional group) were analyzed. Surgical quality, disease-free survival (DFS), and overall survival (OS) were compared.

RESULTS

The optimized group had a lower surgical bleeding score (P = 0.038) and a higher surgeon satisfaction score (P = 0.001). Blood loss during hepatectomy was less in the optimized group (190 vs. 295 mL, P < 0.001). The optimized group had more harvested LNs (12.0 vs. 8.0, P < 0.001) and more positive LNs (8.0 vs. 5.0, P < 0.001), and a similar rate of adequate LND (88.1% vs. 77.4%, P = 0.149). The optimized group had longer median DFS (9.0 vs. 7.0 months, P = 0.018) and median OS (15.0 vs. 13.0 months, P = 0.046). In addition, the optimized group also had a shorter total operation time (P = 0.001), shorter liver resection time (P = 0.001), shorter LND time (P < 0.001), shorter hospital stay (P < 0.001), and lower incidence of total morbidities (14.3% vs. 36.9%, P = 0.009).

CONCLUSIONS

Our optimization of a three-step laparoscopic procedure for advanced ICC was feasible, improved the quality of liver resection and LND, prolonged survival, and led to better intraoperative and postoperative outcomes.

Preoperative Serum Markers and Risk Classification in Intrahepatic Cholangiocarcinoma: A Multicenter Retrospective Study

Accurate risk stratification selects patients who are expected to benefit most from surgery. This retrospective study enrolled 225 Japanese patients with intrahepatic cholangiocellular carcinoma (ICC) who underwent hepatectomy between January 2009 and December 2020 and identified preoperative blood test biomarkers to formulate a classification system that predicted prognosis. The optimal cut-off values of blood test parameters were determined by ROC curve analysis, with Cox univariate and multivariate analyses identifying prognostic factors. Risk classifications were established using classification and regression tree (CART) analysis. CART analysis revealed decision trees for recurrence-free survival (RFS) and overall survival (OS) and created three risk classifications based on machine learning of preoperative serum markers. Five-year rates differed significantly (p < 0.001) between groups: 60.4% (low-risk), 22.8% (moderate-risk), and 4.1% (high-risk) for RFS and 69.2% (low-risk), 32.3% (moderate-risk), and 9.2% (high-risk) for OS. No difference in OS was observed between patients in the low-risk group with or without postoperative adjuvant chemotherapy, although OS improved in the moderate group and was prolonged significantly in the high-risk group receiving chemotherapy. Stratification of patients with ICC who underwent hepatectomy into three risk groups for RFS and OS identified preoperative prognostic factors that predicted prognosis and were easy to understand and apply clinically.

Prognostic value of lymphadenectomy in node-negative intrahepatic cholangiocarcinoma: A multicenter, retrospectively study

BACKGROUND

This study aimed to evaluate the prognostic value of lymph node dissection (LND) in node-negative intrahepatic cholangiocarcinoma (ICC) and identify the appropriately total number of lymph nodes examined (TNLE).

METHODS

Data from node-negative ICC patients who underwent curative intent resection in ten Chinese hepatobiliary centers from January 2010 to December 2018 were collected. Overall survival (OS), relapse-free survival (RFS) and postoperative complications were analyzed. Propensity score matching (PSM) was performed to reduce the bias due to confounding variables in LND group and non-lymph node dissection (NLND) group. The optimal TNLE was determined by survival analysis performed by the X-tile program using the enumeration method.

RESULTS

A total of 637 clinically node-negative ICC patients were included in this study, 74 cases were found lymph node (LN) positive after operation. Among the remaining 563 node-negative ICC patients, LND was associated with longer OS but not RFS before PSM (OS: 35.4 vs 26.0 months, p = 0.047; RFS: 15.0 vs 15.4 months, p = 0.992). After PSM, patients in LND group had better prognosis on both OS and RFS (OS: 38.0 vs 23.0 months, p < 0.001; RFS: 15.0 vs 13.0 months, p = 0.029). There were no statistically differences in postoperative complications. When TNLE was greater than 8, OS (48.5 vs 31.1 months, p = 0.025) and RFS (21.0 vs 13.0 months, p = 0.043) were longer in the group with more dissected LNs.

CONCLUSION

Routinely LND for node-negative ICC patients is recommended for it helps accurate tumor staging and associates with better prognosis. The optimal TNLE is more than 8.

Effect of lymph node resection on prognosis of resectable intrahepatic cholangiocarcinoma: A systematic review and meta-analysis

Background

The purpose of this meta-analysis was to evaluate the efficacy of lymph node dissection in patients with intrahepatic cholangiocarcinoma (ICC).

Methods

The literature from January 2009 to December 2021 was searched to determine the comparative study of lymph node dissection and non-lymph node dissection in patients with ICC.

Results

Seventeen studies were included in the analysis. There were no significant differences in 1-, 3-, and 5-year overall survival (OR = 0.80, p = 0.10; OR = 0.93, p = 0.71; OR = 0.80, p = 0.21) and 1-, 3-, and 5-year disease-free survival (OR = 0.89, p = 0.73; OR = 0.92, p = 0.81; OR = 0.85, p = 0.62).

Conclusions

Lymph node dissection does not seem to have a positive effect on the overall survival and disease-free survival.

Tumor location influences perioperative and oncologic outcomes in solitary intrahepatic cholangiocarcinoma following curative resection: a multi-center analysis

BACKGROUND

To compare perioperative and oncologic outcomes of patients with different locations of intrahepatic cholangiocarcinoma (ICC).

METHODS

A total of 352 ICC patients underwent curative intent hepatectomy were included. Clinical outcomes were compared between ICC patients with tumors located at subcapsular and non-subcapsular, perihepatic vein (pHV) and non-pHV, or periportal vein (pPV) and non-pPV. Kaplan-Meier curves were used to evaluate the influence of tumor location on survival outcomes.

RESULTS

Surgical procedures for pPV ICC were associated with longer operative time and elevated intraoperative blood loss compared to non-pPV. Patients with pPV ICC significantly correlated to increased frequency of log odds of positive lymph nodes (LODDS) classification 3-4. In addition, the ICC located at pPV was correlated with both worse overall survival (OS) and disease-free survival (DFS) compared to non-pPV, whereas no significant difference was observed between subcapsular and non-subcapsular or between pHV and non-pHV.

CONCLUSIONS

A pPV location contributed to poor perioperative outcomes and quick tumor recurrence for patients with solitary ICC undergoing curative resection. A pPV location also contributed to regional lymph node metastases and was a risk factor for intrahepatic recurrence. Subcapsular and pHV locations did not influence clinical outcomes of ICC patients.

Preoperative prediction of intrahepatic cholangiocarcinoma lymph node metastasis by means of machine learning: a multicenter study in China

Background

Hepatectomy is currently the most effective modality for the treatment of intrahepatic cholangiocarcinoma (ICC). The status of the lymph nodes directly affects the choice of surgical method and the formulation of postoperative treatment plans. Therefore, a preoperative judgment of lymph node status is of great significance for patients diagnosed with this condition. Previous prediction models mostly adopted logistic regression modeling, and few relevant studies applied random forests in the prediction of ICC lymph node metastasis (LNM).

Methods

A total of 149 ICC patients who met clinical conditions were enrolled in the training group. Taking into account preoperative clinical data and imaging features, 21 indicators were included for analysis and modeling. Logistic regression was used to filter variables through multivariate analysis, and random forest regression was used to rank the importance of these variables through the use of algorithms. The model’s prediction accuracy was assessed by the concordance index (C-index) and calibration curve and validated with external data.

Result

Multivariate analysis shows that Carcinoembryonic antigen (CEA), Carbohydrate antigen19-9 (CA19-9), and lymphadenopathy on imaging are independent risk factors for lymph node metastasis. The random forest algorithm identifies the top four risk factors as CEA, CA19-9, and lymphadenopathy on imaging and Aspartate Transaminase (AST). The predictive power of random forest is significantly better than the nomogram established by logistic regression in both the validation group and the training group (Area Under Curve reached 0.758 in the validation group).

Conclusions

We constructed a random forest model for predicting lymph node metastasis that, compared with the traditional nomogram, has higher prediction accuracy and simultaneously plays an auxiliary role in imaging examinations.

Tumor budding may be a promising prognostic indicator in intrahepatic cholangiocarcinoma: A multicenter retrospective study

Purpose

This retrospective study evaluated our hypothesis that high tumor budding (≥10 buds) may help determine the appropriate T category for more accurate staging of intrahepatic cholangiocarcinoma (ICC).

Methods

We analyzed the clinical and histopathologic data of 235 consecutive patients with histologically confirmed ICC following hepatectomy at five university hospitals in the Kansai region of Japan between January 2009 and December 2020. ICC staging was based on the Liver Cancer Study Group of Japan (LCSGJ) staging system, 6th edition.

Results

Patients with ICC with high budding showed significantly shorter disease-specific survival (DSS) and disease-free survival (DFS) than patients with low/intermediate budding. Cox proportional hazards regression analysis showed a hazard ratio of 2.2-2.3 (P < 0.05) for high budding. Based on these results, we modified the T category of ICC in the LCSGJ staging system by adding severity of tumor budding as a fourth determinant. This proposed staging system for ICC has significantly improved the prognostic accuracy for both DSS and DFS (both: P < 0.05).

Conclusions

High tumor budding is a new candidate for an additional determinant of the T category in staging ICC. An LCSGJ staging system containing an additional evaluation of tumor budding may lead to improved staging accuracy.

Radiomics-Based Preoperative Prediction of Lymph Node Metastasis in Intrahepatic Cholangiocarcinoma Using Contrast-Enhanced Computed Tomography

BACKGROUND

Lymph node (LN) metastasis is significantly associated with worse prognosis for patients with intrahepatic cholangiocarcinoma (ICC). Improvement in preoperative assessment on LN metastasis helps in treatment decision-making. We aimed to investigate the role of radiomics-based method in predicting LN metastasis for patients with ICC.

METHODS

A total of 296 patients with ICC who underwent curative-intent hepatectomy and lymphadenectomy at two centers in China were analyzed. Radiomic features, including histogram- and wavelet-based features, shape and size features, and texture features were extracted from four-phase computerized tomography (CT) images. The clinical and conventional radiological variables which were independently associated with LN metastasis were also identified. A combined nomogram predicting LN metastasis was developed, and its performance was determined by discrimination, calibration, and stratification of long-term prognosis. The results were validated by the internal and external validation cohorts.

RESULTS

Twenty-four radiomic features were selected into the nomogram. The established nomogram demonstrated good discrimination and calibration, with areas under the curve (AUCs) of 0.98 [95% confidence interval (CI) 0.96-0.99], 0.93 (0.88-0.98), and 0.89 (0.81-0.96) in the training and two validation cohorts, respectively. The 5-year overall survival (OS) and recurrence-free survival (RFS) rates of patients with high risk of LN metastasis as grouped by nomogram were poorer than those of patients with low risk in the training cohort (OS 28.8% versus 53.9%, p < 0.001; RFS 26.3% versus 44.2%, p = 0.001). Similar results were observed in the two validation cohorts.

CONCLUSIONS

Radiomics-based method provided accurate prediction of LN metastasis and prognostic assessment for ICC patients, and might aid the preoperative surgical decision.

Prognostic impact of the metastatic lymph node number in intrahepatic cholangiocarcinoma

BACKGROUND

Lymph node metastasis in intrahepatic cholangiocarcinoma is a poor prognostic factor after radical surgery. However, unlike other biliary tract malignancies, the nodal stage of intrahepatic cholangiocarcinoma only reflects the presence of metastatic lymph nodes, not the number of metastatic lymph nodes. This study aimed to identify the prognostic impact of the metastatic lymph node number in intrahepatic cholangiocarcinoma.

METHODS

The data from 87 patients with intrahepatic cholangiocarcinoma who had undergone hepatectomy with 5 or more harvested lymph nodes and covering stations 12 and 8 based on the previous criteria from January 2006 to December 2019 were retrospectively reviewed. The hazard ratio according to the increasing metastatic lymph node number was calculated with other known prognostic factors for intrahepatic cholangiocarcinoma. The patients were then divided into 3 groups according to the metastatic lymph node number (N0 [n = 45]: no metastatic lymph nodes; N⁺ <4 [n = 32]: 1 to 3 metastatic lymph nodes; N⁺ ≥4 [n = 10]: ≥4 metastatic lymph nodes). Disease-free survival and overall survival were also analyzed.

RESULTS

The metastatic lymph node number was a prognostic factor of oncologic survival (disease-free survival: hazard ratio = 1.18 [1.05-1.32], P = .005; overall survival: hazard ratio = 1.21 [1.06-1.37], P = .004). Survival analysis revealed significantly poorer outcomes with an increasing metastatic lymph node number (disease-free survival: N0 vs N⁺ <4 vs N⁺ ≥4: 36.0 [0.0-76.0] vs 8.0 [0.0-16.9] vs 2.0 [0.0-5.1] months, P < .001; overall survival: N0 vs N⁺ <4 vs N⁺ ≥4: 69.0 [24.5-113.5] vs 28.0 [18.9-37.1] vs 11.0 [6.4-15.6] months, P < .001). In post hoc analysis, a significant difference was found between adjacent groups (disease-free survival and overall survival: N⁺ <4 vs N⁺ ≥4, P = .001).

CONCLUSION

With proper lymph node dissection, the number of metastatic lymph nodes is a prognostic factor of intrahepatic cholangiocarcinoma.

Incidence Trend and Competing Risk Analysis of Patients With Intrahepatic Cholangiocarcinoma: A Population-Based Study

Background

Intrahepatic cholangiocarcinoma (ICCA) is a primary liver cancer characterized by rapid progression and poor prognosis. There are few effective tools for evaluating the prognosis of ICCA patients, and the use of liver transplantation (LT) of the treatment for ICCA is still controversial.

Methods

We analyzed ICCA incidence data and clinicopathological data from the Surveillance, Epidemiology, and End Results database. Prognostic predictors were identified by univariate and multivariate Cox regression analyses and then used to establish a nomogram. The prediction performance of the nomogram was evaluated with receiver operating characteristic (ROC) curves, calibration plots and decision curve analysis (DCA) plots. Propensity score matching (PSM) was used to balance the baseline data of patients undergoing LT and other operations, and then, univariate Cox regression analysis was used to evaluate the therapeutic value of LT for ICCA.

Results

The incidence of ICCA increased significantly, from 0.6 per 100,000 in 2,000 to 1.3 per 100,000 in 2018. The median overall survival (OS) of the patients was 13 months, and the 1-, 3-, and 5-year OS rates were 51.40, 22.14, and 13.79%, respectively. Cox regression analysis showed that age under 60 years old, female, tumor size ≤ 50 mm, better differentiation, smaller range of tumor invasion, lack of distant metastasis, regional lymph node surgery and treatment were associated with a better prognosis. The ROC curves, calibration plots, and DCA plots showed that the nomogram had good discrimination and calibration power, as well as clinical utility. After PSM, the univariate Cox regression analysis showed no significant difference in OS between patients treated with LT and patients treated with other operations.

Conclusion

The incidence of ICCA increased significantly. A nomogram with good predictive performance was developed to predict the OS of ICCA patients. LT might be considered as a potential option for some ICCA patients.

A2M is a potential core gene in intrahepatic cholangiocarcinoma

Background

Intrahepatic cholangiocarcinoma (ICC) is a type of malignant tumor ranking the second in the incidence of primary liver cancer following hepatocellular carcinoma. Both the morbidity and mortality have been increasing in recent years. Small duct type of ICC has potential therapeutic targets. But overall, the prognosis of patients with ICC is usually very poor.

Methods

To search latent therapeutic targets for ICC, we programmatically selected the five most suitable microarray datasets. Then, we made an analysis of these microarray datasets (GSE26566, GSE31370, GSE32958, GSE45001 and GSE76311) collected from the Gene Expression Omnibus (GEO) database. The GEO2R tool was effective to find out differentially expressed genes (DEGs) between ICC and normal tissue. Gene Ontology (GO) function and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis were executed using the Database for Annotation, Visualization and Integrated Discovery (DAVID) v 6.8. The Search Tool for the Retrieval of Interacting Genes (STRING) database was used to analyze protein–protein interaction of these DEGs and protein–protein interaction of these DEGs was modified by Cytoscape3.8.2. Survival analysis was performed using Gene Expression Profiling Interactive Analysis (GEPIA) online analysis tool.

Results

A total of 28 upregulated DEGs and 118 downregulated DEGs were screened out. Then twenty hub genes were selected according to the connectivity degree. The survival analysis results showed that A2M was closely related to the pathogenesis and prognosis of ICC and was a potential therapeutic target for ICC.

Conclusions

According to our study, low A2M expression in ICC compared to normal bile duct tissue was an adverse prognostic factor in ICC patients. The value of A2M in the treatment of ICC needs to be further studied.

Extent of Lymph Node Dissection for Accurate Staging in Intrahepatic Cholangiocarcinoma

BACKGROUND

Although lymph node metastasis is a known factor predictive of a poor prognosis after radical surgery for intrahepatic cholangiocarcinoma (ICC), few studies have investigated lymph node dissection (LND) areas for accurate staging. The aim of this study was to identify the optimal LND level for ICC considering lymphatic flow.

METHODS

Clinical characteristics and pathologic nodal status (presence of metastasis) for 163 patients were reviewed according to tumor location. In the node-positive (N1) group, the distribution of metastatic nodes was described. The coverage of metastatic nodes according to dissection level was assessed, and the minimum dissection level for accurate ICC staging was estimated accordingly. For validation, the node-negative (N0) group was divided into two subgroups according to the estimated dissection level, and survival outcomes were compared.

RESULTS

In the N1 group, expanding dissection to stations no. 12 and 8 covered 82.0% (n = 50) of metastatic cases regardless of tumor location. In survival analysis of N0 group, patients who underwent LND covering stations no. 8+12 showed better disease-free survival (DFS) and overall survival (OS), although the differences were not statistically significant (DFS: covering no. 12+8 vs. not covering no. 12+8, 109.0 months [24.2-193.8] vs. 33.0 months [10.3-55.7], p = 0.078; OS: covering no. 12+8 vs. not covering no. 12+8, 180.0 months [21.6-338.4] vs. 73.0 months [42.8-103.2], p = 0.080).

CONCLUSION

LND including at least stations no. 12 (hepatoduodenal ligament) and 8 (common hepatic artery), regardless of tumor location, is recommended for accurate staging in ICC patients.

Clinical application of indocyanine green fluorescence imaging in laparoscopic lymph node dissection for intrahepatic cholangiocarcinoma: A pilot study (with video)

BACKGROUND

Intrahepatic cholangiocarcinoma is a highly lethal malignancy characterized by lymph node metastasis. This study aimed to evaluate the efficacy of indocyanine green fluorescence for visualization of lymphatic drainage and to assess its clinical application during laparoscopic lymph node dissection for intrahepatic cholangiocarcinoma.

METHODS

All patients with intrahepatic cholangiocarcinoma who underwent laparoscopic left hepatectomy and lymph node dissection between October 2018 and January 2021 were reviewed. The patients were assigned to the indocyanine green group or non-intrahepatic cholangiocarcinoma group based on the staining technique used.

RESULTS

Of 38 patients with left hemiliver intrahepatic cholangiocarcinoma, 20 underwent intrahepatic cholangiocarcinoma tracer-guided laparoscopic radical left hepatectomy; 12 procedures were successful (indocyanine green group). During the same period, 18 patients were treated with traditional laparoscopic resection (control group). Their intraoperative factors were comparable and there were no differences in the incidence or severity of their postoperative complications 30 days after surgery (P > .05). In the indocyanine green group, more lymph nodes were harvested (mean [range]: 7.0 [6.0-8.0] vs 3.5 [3.0-5.0], P < .001) and the proportion of confirmed pathologic lymph nodes was higher (75.0%, 66.7%-87.5% vs 40%, 33.3%-50.0%, P < .001). ICG staining was observed in all (12/12, 100%) patients in the intrahepatic cholangiocarcinoma group at stations 8 and 12, and 9 (9/12, 75%) and 10 (11/12, 91.7%) patients at Stations 13 and 7, respectively.

CONCLUSION

The indocyanine green fluorescence imaging system is feasible, safe, and effective for tracing lymph nodes. It can be used to identify regional lymphatic drainage patterns and help define the scope of lymph node dissection in patients with intrahepatic cholangiocarcinoma.

The role of lymph node dissection in intrahepatic cholangiocarcinoma: a multicenter retrospective study

BACKGROUND

Lymph node dissection (LND) is of great significance in intrahepatic cholangiocarcinoma (ICC). Although the National Comprehensive Cancer Network (NCCN) guidelines recommend routine LND in ICC, the effects of LND remains controversial. This study aimed to explore the role of LND and some related issues and of in ICC.

METHODS

Patients were identified in two Chinese academic centers. Inverse probability of treatment weighting (IPTW) was used to reduce bias. Kaplan-Meier curves and Cox proportional hazards models were used to compare overall survival (OS) and disease-free survival (DFS).

RESULTS

Of 232 patients, 177 (76.3%) underwent LND, and 71 (40.1%) had metastatic lymph nodes. A minimum of 6 lymph nodes were dissected in 66 patients (37.3%). LND did not improve the prognosis of ICC. LNM > 3 may have worse OS and DFS than LNM 1-3, especially in the LND >  = 6 group. For patients who did not underwent LND, the adjuvant treatment group had better OS and DFS.

CONCLUSIONS

The proportions of patients who underwent LND and removed >  = 6 lymph nodes were not high enough. LND has no definite predictive effect on prognosis. Patients with 4 or more LNMs may have a worse prognosis than patients with 1-3 LNMs. Adjuvant therapy may benefit patients of nLND.

Clinical Staging of Mass-Forming Intrahepatic Cholangiocarcinoma: Computed Tomography Versus Magnetic Resonance Imaging

We compared the performance of computed tomography (CT) and magnetic resonance imaging (MRI) for preoperative clinical staging of mass‐forming intrahepatic cholangiocarcinoma (iCCA), using the eighth American Joint Committee on Cancer (AJCC) system. This retrospective, multicenter, cohort study consecutively identified patients who underwent partial hepatectomy for mass‐forming iCCA and had preoperative CT and MRI performed from January 2009 to December 2015. CT and MRI characteristics were used to determine clinical stage based on the eighth AJCC system. Performances of CT and MRI for clinical T and N staging were compared using generalized estimating equations. In 334 patients (median age, 63 years; 221 men), MRI sensitivities were significantly higher than CT sensitivities for detecting T1b or higher stages (91.0% vs. 80.5%, respectively, P < 0.001), T2 or higher stages (89.1% vs. 73.8%, respectively, P < 0.001), and T3 or T4 stage (77.8% vs. 58.0%, respectively, P < 0.001). MRI was also more sensitive at identifying multiple tumors than CT (66.7% vs. 50.0%, respectively, P = 0.026), without a significant difference in specificity (78.1% vs. 80.1%, respectively, P = 0.342). Sensitivities were comparable between CT and MRI for determination of size >5 cm (i.e., T1b for single tumor) and extrahepatic organ invasion (i.e., T4). Sensitivities of CT and MRI were not different for N stage (65.0% vs. 64.0%, respectively, P = 0.808), but the specificity of CT was significantly higher than that of MRI (80.7% vs. 72.9%, respectively, P = 0.001) when using a composite reference standard. Conclusion: MRI showed superior sensitivity to CT for diagnosing T2 and T3 stages, particularly multiple tumors. CT and MRI had comparable sensitivity for N staging, but CT provided higher specificity than MRI.

Laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma: Report of an international multicenter cohort study with propensity score matching

BACKGROUND

Intrahepatic cholangiocarcinoma is a rare disease with a poor prognosis. In patients where surgical resection is possible, outcome is influenced by perioperative morbidity and lymph node status. Laparoscopic liver resection is associated with improved clinical and oncological outcomes in primary and metastatic liver cancer compared with open liver resection, but evidence on intrahepatic cholangiocarcinoma is still insufficient. The primary aim of this study was to compare overall survival for a large series of patients treated for intrahepatic cholangiocarcinoma by open or laparoscopic approach. Secondary objectives were to compare disease-free survival, predictors of death, and recurrence.

METHODS

Patients treated with laparoscopic or open liver resection for intrahepatic cholangiocarcinoma from 2000 to 2018 from 3 large international databases were analyzed retrospectively. Each patient in the laparoscopic resection group (case) was matched with 1 open resection control (1:1 ratio), through a propensity score calculated on clinically relevant preoperative covariates. Overall and disease-free survival were compared between the matched groups. Predictors of mortality and recurrence were analyzed with Cox regression, and the Textbook Outcomes were described.

RESULTS

During the study period, 855 patients met the inclusion criteria (open liver resection = 709, 82.9%; laparoscopic liver resection = 146, 17.1%). Two groups of 89 patients each were analyzed after propensity score matching, with no significant difference regarding pre- and postoperative variables. Overall survival at 1, 3, and 5 years was 92%, 75%, and 63% in the laparoscopic liver resection group versus 92%, 58%, and 49% in the open liver resection group (P = .0043). Adjusted Cox regression revealed severe postoperative complications (hazard ratio: 10.5, 95% confidence interval [1.01-109] P = .049) and steatosis (hazard ratio: 13.8, 95% confidence interval [1.23-154] P = .033) as predictors of death, and transfusion (hazard ratio: 19.2, 95% confidence interval [4.04-91.4] P < .001) and severe postoperative complications (hazard ratio: 4.07, 95% confidence interval [1.15-14.4] P = .030) as predictors of recurrence.

CONCLUSION

The survival advantage of laparoscopic liver resection over open liver resection for intrahepatic cholangiocarcinoma is equivocal, given historical bias and missing data.

The role of lymphadenectomy in the surgical treatment of intrahepatic cholangiocarcinoma: A review

Cholangiocarcinoma is the second most common primary tumor of the liver. The incidence and mortality of its intrahepatic form has been increasing over the past 2 decades. Currently, the only available curative treatment for intrahepatic cholangiocarcinoma is surgical resection. There is still no prospective evidence to support neoadjuvant systemic treatments in resectable disease, while adjuvant chemotherapy with Capecitabine is currently the only recommended systemic treatment after liver resection based on the results of randomised trial. Despite the implementation of perioperative treatments and improvements in resective surgery, intrahepatic cholangiocarcinoma remains a disease characterized by high incidence of recurrence and poor long-term survival. Lymph node metastases can be found in 45-65% of patients and are one of the most impacting prognostic factors after surgical resection. Preoperative imaging is not always sufficient in assessing lymph node status, thus hepatic pedicle lymphadenectomy can be important to ensure precise staging in surgical patients. An increasing trend in performing lymph node dissection during liver resection for intrahepatic cholangiocarcinoma has been observed in the last 20 years, although its actual efficacy compared to the potential complications remains debated. The current evidence on the prognostic role of the lymph node status, its preoperative predictability, the basis for a correct hepatic pedicle lymphadenectomy and its prognostic role in the surgical treatment of intrahepatic cholangiocarcinoma are presented.

Reappraisal of the T Category for Solitary Intrahepatic Cholangiocarcinoma by Tumor Size in 611 Early-Stage (T1-2N0M0) Patients After Hepatectomy: a Surveillance, Epidemiology, and End Results (SEER) Analysis

BACKGROUND

The association between tumor size and survival in patients with intrahepatic cholangiocarcinoma (ICC) after hepatectomy is controversial, and the T category in the American Joint Committee on Cancer (AJCC) stage for ICC is a topic of debate.

METHODS

Data from 611 T1-2N0M0 ICC patients classified by the AJCC 8th edition who underwent hepatectomy were extracted from the Surveillance, Epidemiology, and End Results (SEER) database during 1988-2015. Cancer-specific survival was evaluated using Kaplan-Meier analysis. The optimal cutoff value of solitary tumor size was used an adjusted p value approach to discriminating patient survival.

RESULTS

In the AJCC 8th staging system, using a 5-cm cut-off value of tumor size for solitary ICC without vascular invasion (S/VI-) was not associated with survival in T1 category (p = 0.201), and multifocal ICC with vascular invasion had a worse survival than solitary ICC with vascular invasion (S/VI+) in T2 category (p = 0.014). Tumor size was a prognostic factor for both S/VI- and S/VI+, the optimal cutoff value of tumor size was obtained 8 cm for S/VI- and 3 cm for S/VI+. S/VI- ≤ 8 cm had a similar survival to S/VI+ ≤ 3 cm (p = 0.126), S/VI- > 8 cm had a similar survival to S/VI+ > 3 cm (p = 0.655), and multifocal ICC had a similar survival with S/VI- > 8 cm (p = 0.159) and S/VI+ > 3 cm (p = 0.196). When the cohort was divided into two groups-new T1 (S/VI- ≤ 8 cm and S/VI+ ≤ 3 cm) and new T2 (S/VI- > 8 cm, S/VI+ > 3 cm and multifocal ICC)-significant survival difference was observed (p < 0.0001).

CONCLUSIONS

The discriminatory power of the AJCC 8th edition for solitary ICC could be further enhanced by subdividing tumors according to size and vascular invasion (8 cm for S/VI- and 3 cm for S/VI+).

The clinical value of regional lymphadenectomy for intrahepatic cholangiocarcinoma

OBJECTIVE

The aim of this study was to explore the clinical value of lymph node dissection (LND) for intrahepatic cholangiocarcinoma (ICC).

METHODS

Clinical and pathological data were collected from 147 ICC patients who attended two tertiary centers over the past 5 years. The patients were classified into two groups: the LND group (group A) and the no-performance LND (NLND) group (group B). Clinical and pathological parameters were compared between the two groups to analyze the impact of LND on the long-term survival time of ICC patients.

RESULTS

Of the 147 patients, 54.4% (80) received LND and 42.5% (34/80) of these were found to have lymph node metastasis (LNM). LND did not increase postoperative complications (27.5%, P = 0.354), but postoperative hospital stays were longer (12.2 ± 6.3 d, P = 0.005) in group A compared with group B (20.9%, 9.5 ± 3.5 d). The 5-year survival rates of groups A and B are almost similar (21% vs 29%, P = 0.905). The overall survival rate of cN0 (diagnosis obtained by imaging) is better than pN1 (diagnosis obtained by histopathology), but lower than pN0 (all P < 0.05). Compared with NLND, the median survival time of LND patients with T1 has not significantly improved (29.3 vs 35.1 months, P = 0.762), but the patients with T2-4 has been significantly increased (29.0 vs 17.1 months, P = 0.040). Elevated CA19-9 level (HR = 1.764, 95% CI: 1.113-2.795, P = 0.016), vascular invasion (HR = 2.697, 95% CI: 1.103-6.599, P = 0.030), and T category (HR = 1.848, 95% CI: 1.059-3.224, P = 0.031) were independent risk factors for poor long-term survival time of the ICC patients (all P values < 0.05).

CONCLUSION

ICC patients with cN0 may have LNM, and the long-term survival time of LNM patients is usually poor. We suggest that patients with ICC may require routine LND, especially those with T2-4 category.

Current Surgical Management of Peri-Hilar and Intra-Hepatic Cholangiocarcinoma

Cholangiocarcinoma accounts for approximately 10% of all hepatobiliary tumors and represents 3% of all new-diagnosed malignancies worldwide. Intrahepatic cholangiocarcinoma (i-CCA) accounts for 10% of all cases, perihilar (h-CCA) cholangiocarcinoma represents two-thirds of the cases, while distal cholangiocarcinoma accounts for the remaining quarter. Originally described by Klatskin in 1965, h-CCA represents one of the most challenging tumors for hepatobiliary surgeons, mainly because of the anatomical vascular relationships of the biliary confluence at the hepatic hilum. Surgery is the only curative option, with the goal of a radical, margin-negative (R0) tumor resection. Continuous efforts have been made by hepatobiliary surgeons in order to achieve R0 resections, leading to the progressive development of aggressive approaches that include extended hepatectomies, associating liver partition, and portal vein ligation for staged hepatectomy, pre-operative portal vein embolization, and vascular resections. i-CCA is an aggressive biliary cancer that arises from the biliary epithelium proximal to the second-degree bile ducts. The incidence of i-CCA is dramatically increasing worldwide, and surgical resection is the only potentially curative therapy. An aggressive surgical approach, including extended liver resection and vascular reconstruction, and a greater application of systemic therapy and locoregional treatments could lead to an increase in the resection rate and the overall survival in selected i-CCA patients. Improvements achieved over the last two decades and the encouraging results recently reported have led to liver transplantation now being considered an appropriate indication for CCA patients.

The role of lymph node dissection and a new N-staging system for intrahepatic cholangiocarcinoma: a study from the SEER database

BACKGROUND

Although the National Comprehensive Cancer Network guidelines recommend routine lymph node dissection (LND) in intrahepatic cholangiocarcinoma (ICC), the role of LND remains controversial, and the node (N) stage is oversimplified.

METHODS

Patients were identified from the Surveillance, Epidemiology, and End Results research data 18 (SEER 18). Propensity score matching (PSM) was used to reduce bias, and Kaplan-Meier curves and Cox proportional hazards models were used to compare overall survival (OS). The best cutoff values were found using X-tile software.

RESULTS

Of 2037 patients included in SEER 18, 1147 underwent LND (56.3%); 389 (34.3%) had pathologically confirmed lymph node metastasis (LNM), and 316 (27.6%) had at least 6 LNDs. The median OS was worse for LND patients (34 months vs. 40 months, respectively), and this result remained after PSM. Male sex, age ≥60 years, tumor size > 5 cm, and LNM were independent prognostic risk factors for ICC. LNM ≥3 was associated with worse OS.

CONCLUSIONS

Only a few LNDs met the requirements per the guidelines. LND does not improve OS in ICC, and the best approach to LND and a better N staging method should be explored further.

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.

The Role of Surgical Resection and Liver Transplantation for the Treatment of Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) is a rare and complex malignancy of the biliary epithelium. Due to its silent presentation, patients are frequently diagnosed late in their disease course, resulting in poor overall survival. Advances in molecular profiling and targeted therapies have improved medical management, but long-term survival is rarely seen with medical therapy alone. Surgical resection offers a survival advantage, but negative oncologic margins are difficult to achieve, recurrence rates are high, and the need for adequate future liver remnant limits the extent of resection. Advances in neoadjuvant and adjuvant treatments have broadened patient treatment options, and these agents are undergoing active investigation, especially in the setting of advanced, initially unresectable disease. For those who are not able to undergo resection, liver transplantation is emerging as a potential curative therapy in certain cases. Patient selection, favorable tumor biology, and a protocolized, multidisciplinary approach are ultimately necessary for best patient outcomes. This review will discuss the current surgical management of locally advanced, liver-limited intrahepatic cholangiocarcinoma as well as the role of liver transplantation for select patients with background liver disease.

Investigation of a Tumor Location-Specific Therapeutic Strategy for Intrahepatic Cholangiocarcinoma

Objective:

An optimal therapeutic strategy for intrahepatic cholangiocarcinoma (ICC) has not yet been determined. Herein we focused on intrahepatic tumor location and retrospectively analyzed tumor characteristics depending on location to elucidate a location-specific therapeutic strategy for ICC.

Methods:

Sixty-five ICC patients were divided into three groups based on the distance between the innermost portion of the tumor and portal vein branches observed on preoperative imaging: peripheral, intermediate and central ICC.

Results:

Median disease-specific survival (DSS) of the peripheral ICC was not reached, whereas median DSS was 32.9 months in intermediate ICC and 25.2 months in central ICC (p <0.05). Vascular invasion was observed in all groups (56-92%). Bile duct invasion to the first branch of the hepatic duct was more commonly observed in central ICC (43%) compared with the peripheral and intermediate ICC (0-8%). Lymph node metastasis was not observed in peripheral ICC, whereas it was frequently observed in intermediate and central ICC (39-44%). A Cox regression analysis revealed sufficient RDI (≥58.3%) of adjuvant chemotherapy (AC) significantly increased the length of DSS (HR: 0.205). Based on these data, we have proposed a location-specific therapeutic strategy as follows: peripheral ICC requires anatomical resection without lymphadenectomy; intermediate ICC requires anatomical resection with lymphadenectomy and sufficient doses of AC; and central ICC requires anatomical resection with extrahepatic bile duct resection, caudate lobectomy, lymphadenectomy, and sufficient doses of AC.

Conclusion:

We propose an intrahepatic tumor location-specific therapeutic strategy for ICC. This information could contribute to the appropriate therapeutic management of patients with ICC.

Recommended Minimal Number of Harvested Lymph Nodes for Intrahepatic Cholangiocarcinoma

BACKGROUND

Lymph node (LN) metastasis is one factor indicating a poor prognosis after radical surgery for intrahepatic cholangiocarcinoma (ICC). Although several guidelines have recommended that LN dissection be strongly considered at the time of ICC surgery, no clear evidence regarding the appropriate number of harvested LNs has been established. Thus, we aimed to identify the minimum number of harvested LNs required for ICC by using a Bayesian Weibull model.

METHODS

Data from 142 patients who underwent radical hepatectomy (R0) for ICC from January 2000 to December 2018 were retrospectively reviewed. A Bayesian Weibull model was developed to analyze the effect of number of harvested LNs on survival of patients without (N0; n = 71) and with (N1; n = 71) metastatic nodes. We also compared the percentage of N1 patients (i.e., the N1 rate) in each of the five subgroups categorized according to the number of harvested LNs (1-4, 5-8, 9-12, 13-16, and ≥ 17).

RESULTS

In patients with 5 or more harvested LNs, the hazard ratio (HR) for LN metastasis was above the reference line (the HR with 5 harvested LNs, 1.95 (1.09-3.45)). The N1 rate of the 1-4 harvested LNs subgroup was lower than that of the other subgroups (e.g., 1-4 vs. 5-8; 16.1% vs. 39.4%, p = 0.014).

CONCLUSION

Our results suggest that at least 5 LNs should be harvested in patients who undergo radical surgery for ICC to promote accurate staging.

Prognostic Value of Lymph Node Dissection for Intrahepatic Cholangiocarcinoma Patients With Clinically Negative Lymph Node Metastasis: A Multi-Center Study From China

Background

The clinical value of lymph-node dissection (LND) for intrahepatic carcinoma (ICC) patients with clinically negative lymph node metastasis (LNM) remains unclear; hence we conducted a multi-center study to explore it.

Methods

Patients who were diagnosed ICC with clinically negative LNM and underwent hepatectomy with or without LND from December 2012 to December 2015 were retrospectively collected from 12 hepatobiliary centers in China. Overall survival (OS) was analyzed using the Kaplan–Meier method, and then subgroup analysis was conducted stratified by variables related to the prognosis.

Results

A total of 380 patients were eligible including 106 (27.9%) in the LND group and 274 (72.1%) in the non-LND group. Median OS in the LND group was slightly longer than that in the non-LND group (24.0 vs. 18.0 months, P = 0.30), but a significant difference was observed between the two groups (24.0 vs. 14.0 months, P = 0.02) after a well-designed 1:1 propensity score matching without increased severe complications. And, LND was identified to be one of the independent risk factors of OS (HR = 0.66, 95%CI = 0.46–0.95, P = 0.025). Subgroup analysis in the matched cohort showed that patients could benefit more from LND if they were male, age <60 years, had no HBV infection, with ECOG score <2, CEA ≤5 ug/L, blood loss ≤400 ml, transfusion, major hepatectomy, resection margin ≥1 cm, tumor size >5 cm, single tumor, mass-forming, no satellite, no MVI, and no perineural invasion (all P < 0.05). Furthermore, only patients with pathologically confirmed positive LNM were found to benefit from postoperative adjuvant therapy (P < 0.001).

Conclusion

With the current data, we concluded that LND would benefit the selected ICC patients with clinically negative LNM and might guide the postoperative management.

An immunostaining panel of C-reactive protein, N-cadherin, and S100 calcium binding protein P is useful for intrahepatic cholangiocarcinoma subtyping

This study aimed to establish an immunohistochemical panel useful for subclassification of intrahepatic cholangiocarcinoma (iCCA) into small- and large-duct types. Fifty surgical cases of iCCA consisting of small- (n = 31) and large-duct types (n = 19) were examined. To imitate liver needle biopsies, tissue microarrays were constructed using three tissue cores (2 mm in diameter) obtained from one representative paraffin block of each case. Immunostaining for C-reactive protein (CRP), N-cadherin, tubulin beta-III (TUBB3), neural cell adhesion molecule (NCAM), and S100 calcium binding protein P (S100P) was conducted. Most cases of small-duct iCCA were immunoreactive to CRP and N-cadherin, whereas expressions of these markers were markedly less common in large-duct iCCA (CRP, 97% vs. 5%, P < 0.001; N-cadherin, 87% vs. 16%, P < 0.001). TUBB3 and NCAM were also more frequently expressed in small-duct iCCA (65% vs. 32%, P = 0.006; 58% vs. 5%, P < 0.001), but their sensitivities were lower than those of CRP and N-cadherin. S100P was more commonly expressed in large-duct iCCA than in small-duct iCCA (95% vs. 29%, P < 0.001), and diffuse expressions were observed in 17 of 19 cases of large-duct iCCA (90%). All cases with a CRP+/S100P- immunophenotype were of small-duct type, whereas all but one case with a CRP-/S100P+ immunophenotype were of large-duct type. Of 10 cases with a double-positive or double-negative immunophenotype, 7 were appropriately classified based on immunoreactivity to N-cadherin. In conclusion, CRP, N-cadherin, and S100P form a useful immunohistochemical panel for iCCA subclassification, and correct subclassification was possible in 92% of cases based on a proposed, simple algorithm.

Risk of malignancy in Caroli disease and syndrome: A systematic review

BACKGROUND

Congenital intrahepatic bile duct dilatation without fibrosis is called Caroli disease (CD), and is called Caroli syndrome (CS) when it has fibrotic and cirrhotic liver morphology. The development of intrahepatic carcinoma is described in both conditions, but the reported incidence varies extensively. Potential risk factors for the malignant transformation were not described. Furthermore, conservative or surgical treatment is performed depending on the extent of cystic malformation, hepatic dysfunction and structural hepatic changes, but little is known about which treatment should be offered to patients with CD or CS and cancer.

AIM

To further investigate the malignant transformation in these conditions.

METHODS

A systematic review of the current literature until January 2019 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A search using Medline (PubMed) was performed using a combination of Medical Subject Headings terms “caroli disease”, “caroli syndrome”, “tumor”, “malignant”, and “cholangiocarcinoma”. Only human studies published in English were used for this systematic review. The following parameters were extracted from each article: year of publication, type of study, number of patients, incidence of malignant tumor, duration of symptoms, age, sex, diagnostics, identification of tumor, surgical therapy, survival and tumor recurrence.

RESULTS

Twelve retrospective studies reporting the courses of 561 patients (53% females) were included in this systematic review. With a mean age of 41.6 years old (range 23 to 56 years old), patients were younger than other populations undergoing liver surgery. Depending on the size of the study population the incidence of cholangiocarcinoma varied from 2.7% to 37.5% with an overall incidence of 6.6%. There were only few detailed reports about preoperative diagnostic work-up, but a multimodal work-up including ultrasound of the liver, computed tomography, magnetic resonance imaging and endoscopic retrograde cholangiopancreatography was used in most studies. Disease duration was variable with up to several years. Most patients had episodes of cholangitis, sepsis, fever or abdominal pain. Tumor detection was an incidental finding of the surgical specimen in most cases because it is currently often impossible to detect tumor manifestation during preoperative diagnostics. Liver resection or liver transplantation was performed depending on the extent of the biliary pathology and additional alterations of the liver structure or function. No postoperative adjuvant chemotherapy was reported, but chemotherapy was administered in selected cases of tumor recurrence. Overall survival rates after one year were low at 36% and a high recurrence rate of up to 75% during the observation period.

CONCLUSION

Only few retrospective studies reported a low tumor incidence. Despite the high rate of mortality and tumor recurrence, definite surgical treatment should be offered as soon as possible.

Preoperative leukocytosis and the resection severity index are independent risk factors for survival in patients with intrahepatic cholangiocarcinoma

PURPOSE

The incidence of intrahepatic cholangiocarcinoma is increasing worldwide. Despite advances in surgical and non-surgical treatment, reported outcomes are still poor and surgical resection remains to be the only chance for long-term survival of affected patients. The identification and validation of prognostic factors and scores, such as the recently introduced resection severity index, for postoperative morbidity and mortality are essential to facilitate optimal therapeutic regimens.

METHODS

This is a retrospective analysis of 269 patients undergoing resection of histologically confirmed intrahepatic cholangiocarcinoma between February 1996 and September 2018 at a tertiary referral center for hepatobiliary surgery. Regression analyses were performed to evaluate potential prognostic factors, including the resection severity index.

RESULTS

Median postoperative follow-up time was 22.93 (0.10-234.39) months. Severe postoperative complications (≥ Clavien-Dindo grade III) were observed in 94 (34.9%) patients. The body mass index (p = 0.035), the resection severity index (ASAT in U/l divided by Quick in % multiplied by the extent of liver resection graded in points; p = 0.006), additional hilar bile duct resection (p = 0.005), and number of packed red blood cells transfused during operation (p = 0.036) were independent risk factors for the onset of severe postoperative complications. Median Kaplan-Meier survival after resection was 27.63 months. Preoperative leukocytosis (p = 0.003), the resection severity index (p = 0.005), multivisceral resection (p = 0.001), and T stage ≥ 3 (p = 0.013) were identified as independent risk factors for survival.

CONCLUSION

Preoperative leukocytosis and the resection severity index are useful variables for preoperative risk stratification since they were identified as significant predictors for postoperative morbidity and mortality, respectively.

Cholangiocarcinoma as an Indication for Liver Transplantation in the Era of Transplant Oncology

Cholangiocarcinoma (CCA) arises from the biliary tract epithelium and accounts for 10-15% of all hepatobiliary malignancies. Depending on anatomic location, CCA is classified as intrahepatic (iCCA), perihilar (pCCA) and distal (dCCA). The best treatment option for pCCA is liver resection and when a radical oncological surgery is obtained, 5-year survival rate are around 20-40%. In unresectable patients, following a specific protocol, liver transplantation (LT) for pCCA showed excellent long-term disease-free survival rates. Fewer data are available for iCCA in LT setting. Nevertheless, patients with very early unresectable iCCA appear to achieve excellent outcomes after LT. This review aims to evaluate existing evidence to define the current role of LT in the management of patients with CCA.

Oncological Resection for Liver Malignancies: Can the Laparoscopic Approach Provide Benefits?

: Laparoscopic surgery has become an increasingly popular alternative approach to open surgery, resulting in a paradigm shift in liver surgery. Although laparoscopic liver resection (LLR) was initially indicated for small benign and peripheral tumors, at present more than half of LLRs are performed in malignant tumors. Several studies have reported the feasibility of LLR in malignant disease and suggested various short-term benefits compared to open liver resection, including decreased blood loss and postoperative complications and a shorter hospital stay. Although these benefits are important to surgeons, patients, and providers, the main goal of surgery for malignancies is to achieve a maximum oncologic benefit.The relevance of the laparoscopic approach must be assessed in relation to the possibility of respecting basic oncological rules and the expertise of the center. Easy LLRs can be safely performed by most surgeons with minimum expertise in liver surgery and laparoscopy, and can therefore probably provide an oncological benefit. On the other hand, intermediate or difficult LLRs require technical expertise and an oncological benefit can only be achieved in expert centers. Technical standardization is the only way to obtain an oncological benefit with this type of resection, and many problems must still be solved.