Immunohistochemically demonstrated lymph node micrometastasis and prognosis in patients with gallbladder carcinoma

Lymph node metastatic status could predict the prognosis of intracholecystic papillary neoplasm of gallbladder

Intracholecystic papillary neoplasm (ICPN) is a non-invasive epithelial tumor that presents as a grossly identifiable mass arising in the mucosa and protruding into the lumen. ICPN is associated with invasive carcinoma. There are few studies on the clinicopathological features of ICPN, including that with invasive carcinoma. We evaluated the clinicopathological characteristics of 42 ICPNs and 41 conventional gallbladder adenocarcinomas (cGBAs). Subserosa or deeper (≥ss) invasion was significantly lower in ICPN (61.9%) than that in cGBA (90.2%) (P = 0.004). Cox regression analysis revealed that lymph node metastasis (hazard ratio [HR] [95% confidence interval (CI)]: 2.610 [1.131, 6.024], P = 0.025) and positive margin (HR [95% CI]: 5.143 [2.113, 12.516], P < 0.001), but not ≥ss invasion (HR [95% CI]: 1.541 [0.479, 4.959], P = 0.469), were independent prognostic factors. In addition, there was a significant interaction between histological type and lymph node metastasis (HR [95% CI]: 0.191 [0.042, 0.983], P = 0.033). In cGBA, the presence or absence of lymph node metastasis did not affect prognosis; however, ICPN without lymph node metastasis had better prognosis. Therefore, the histological classification of ICPN and cGBA and the pathological evaluation of lymph node metastasis in ICPN are crucial for determining prognosis.

Effect of Different Liver Resection Modalities on the Prognosis of Patients with Hepatocellular Carcinoma on the Left Lateral Lobe

Purpose

To investigate the effect of different liver resection modalities on the prognosis of left lateral lobe hepatocellular carcinoma (HCC) patients.

Methods

315 patients with HCC on left lateral lobe were divided into open left lateral lobectomy (LLL) group (n=249) and open left hepatectomy (LH) group (n=66). The differences in long-term prognosis between two groups were compared.

Results

The results showed that narrow resection margin (Hazard Ratio (HR):1.457, 95% Confidential Interval (CI): 1.038-2.047; HR:1.415, 95% CI: 1.061-1.887), tumor diameter > 5 cm (1.645, 1.161-2.330; 1.488, 1.123-1.971), multiple tumors (2.021, 1.330-3.073; 1.987, 1.380-2.861), and microvascular invasion (MVI) (1.753, 1.253-2.452; 1.438, 1.087-1.902) are independent risk factors for overall survival (OS) and tumor recurrence (TR), while liver resection modality is not. After propensity score matching, liver resection modality is not an independent risk factor for OS and TR. Further analysis revealed that wide resection margins were achieved in all patients in the LH group but only 59.0% patients in the LLL group. The OS and TR rates were not significantly different between wide patients with resection margins in LLL group and LH group (P=0.766 and 0.919, respectively), but significantly different between patients with narrow resection margins in LLL group and LH group (P=0.012 and 0.017, respectively).

Conclusion

Liver resection modality is not an independent risk factor for the prognosis of patients with HCC on the left lateral lobe as long as wide margins are obtained. Nevertheless, with narrow margins, patients who underwent LH rather than LLL did better.

Removing different number of regional lymph nodes affects survival outcomes of operable patients at stage IIA non-small cell lung cancer (according to the 8th edition staging)

Background

Surgery combined with chemotherapy (CT) is the best treatment for tumor patients at stage I to IIIA. But there are only few studies specifically evaluated the survival benefits of removing different number of regional lymph nodes (RLNs) for patients with stage IIA non-small cell lung cancer (NSCLC). The objective of this study is to discuss the effect of removing different number of RLNs on survival outcomes in operable patients at stage IIA NSCLC.

Methods

Through the use of the Surveillance, Epidemiology, and End Results (SEER) registry, satisfactory patients at stage IIA NSCLC, who had complete clinical information from 2004 to 2015, were identified. Lung cancer-specific survival (LCSS) and overall survival (OS) were compared by the Kaplan-Meier analysis and Cox regression analyses to determine the impact of the confounding factors on the survival outcomes. LCSS and OS as the primary endpoints were compared among patients with different number of RLNs removed.

Results

A total of 3,362 patients at stage IIA NSCLC met our criteria, including 173 (5.1%), 486 (14.5%), 2,703 (80.4%) patients without RLNs removed, with 1 to 3 RLNs removed and with greater than or equal to 4 RLNs removed, respectively. Kaplan-Meier survival analyses and Univariate Cox regression analyses revealed that there was a statistically significant difference on survival curve (log rank P<0.001) among the stage IIA NSCLC patients with different number of RLNs removed. Furthermore, multivariable Cox regression analyses on LCSS showed that the hazard ratio (HR) and 95% confidence interval (95% CI) of the 1 to 3 RLNs removed group and greater than or equal to 4 RLNs removed group were 0.622 (0.484-0.800, P<0.001) and 0.545 (0.437-0.680, P<0.001), respectively, compared to without any RLNs removed group.

Conclusions

This study illustrated that removing different number of RLNs can affect survival outcomes of operable patients at stage IIA NSCLC. Whether more radical lymphadenectomy is beneficial to patients at stage IIA NSCLC still needs to be researched.

Robotic versus open extended cholecystectomy for T1a-T3 gallbladder cancer: A matched comparison

BACKGROUND

The feasibility and safety of robotic extended cholecystectomy (REC) are still uncertain. This study was performed to compare the short- and long-term outcomes of REC with those of open extended cholecystectomy (OEC) for T1a-T3 gallbladder cancer.

METHODS

From January 2015 to April 2022, 28 patients underwent REC in our center. To minimize any confounding factors, a 1:2 propensity score-matching analysis was conducted based on the patients' demographics, liver function indicators, T stage, and symptoms. The data regarding demographics, perioperative outcomes, and long-term oncologic outcomes were reviewed.

RESULTS

The visual analogue scale score was significantly lower in the REC than OEC group immediately postoperatively (3.68 ± 2.09 vs. 4.73 ± 1.85, P = 0.008), on postoperative day 1 (2.96 ± 1.75 vs. 3.69 ± 1.41, P = 0.023), and on postoperative day 2 (2.36 ± 1.55 vs. 2.92 ± 1.21, P = 0.031). In addition, the REC group exhibited a shorter time to first ambulation (P = 0.043), a shorter time to drainage tube removal (P = 0.038), and a shorter postoperative stay (P = 0.037), but hospital costs were significantly higher in the REC group (P < 0.001). However, no statistically significant difference was found in the operation time (P = 0.134), intraoperative blood loss (P = 0.467), or incidence of postoperative morbidity (P = 0.227) or mortality (P = 0.289) between the REC and OEC groups. In regard to long-term outcomes, the 3-year disease-free survival rate was comparable between the OEC and REC groups (43.1% vs. 57.2%, P = 0.684), as was the 3-year overall survival rate (62.8% vs. 75.0%, P = 0.619).

CONCLUSION

REC can be an effective and safe alternative to OEC for selected patients with T1a-T3 gallbladder cancer with respect to short- and long-term outcomes.

Effect of lymphadenectomy on the prognosis for N0 gallbladder carcinoma patients: A study based on SEER database

Background

It remains unclear whether lymph node dissection is necessary for patients with N0 gallbladder carcinoma (GBC). The objective of this study was to evaluate the effect of lymphadenectomy on the prognosis for N0 GBC patients. The secondary objective was to establish a prognostic model of survival for N0 GBC patients being founded on the large samples.

Methods

Patient data were obtained from the database named SEER (Surveillance, Epidemiology, and End Results database) between 2010 and 2014. Analyses of Kaplan–Meier survival and multivariate Cox regression were performed in subgroups based on regional lymph nodes removal (LNR) to calculate the excess risk of cause‐specific death. A prognosis nomogram was constructed build on the results of a multivariate analysis to predict the specific survival time (CSS) rates of N0 GBC patients.

Result

A total of 1406 N0 GBC patients were included in this research. The majority of N0 GBC patients undergoing cancer‐directed surgery did not undergo LNR (64.5%). The results showed that LNR can improve the survival of N0 GBC patients, including those at the T1a and T1b stages, and a wider range of lymph node dissection (LNR2) compared to LNR1 was more conducive to the prognosis. Furthermore, multivariate regression analysis showed that LNR was an independent favorable prognostic factor of N0 GBC. Finally, a nomogram was constructed to accurately predict the prognosis of N0 gallbladder cancer patients.

Conclusion

This study demonstrated a significant survival benefit for extended lymph nodes removed in N0 GBC patients. These results recommend that an extended lymph node dissection strategy is needed for N0 GBC patients.

Surgical strategies for hepatocellular carcinoma located in the left lateral lobe: A propensity score-matched and prognostic nomogram study

PURPOSE

For hepatocellular carcinoma (HCC) located in the left lateral lobe, the optimal surgical procedure is still controversial. This study aimed to optimize surgical strategies and to construct a nomogram to predict the postoperative survival of patients with HCC.

METHODS

Between 1 January 2005 and 30 September 2018, a total of 493 patients were enrolled. Propensity score matching (PSM) was performed between the left lateral lobectomy (LLL) and left hepatectomy (LH) groups (1:1). The study endpoints were overall survival (OS), recurrence-free survival (RFS), and safety. A nomogram was generated using a multivariate Cox proportional hazards model. The discriminative ability and calibration of the nomogram were evaluated using C-statistics and calibration plots.

RESULTS

After matching, 87 pairs were included. The LH group had better 1-, 3-, and 5-year OS rates than the LLL group (88%, 73%, and 69% vs. 73%, 57%, and 49%, respectively; p = 0.017). The 1-, 3-, and 5-year RFS rates of the LH group were similar to those of the LLL group (64%, 49%, and 46% vs. 63%, 51%, and 42%, respectively; p = 0.652). There were no significant differences in postoperative complications. Eight factors were integrated into the nomogram and it had good discriminative ability and calibration.

CONCLUSION

Our data revealed that compared to LLL, LH may result in better OS and have similar postoperative complications for HCC. The nomogram may serve as a practical tool for the individual prognostic evaluation of patients with HCC.

Clinical Significance of Lymph Node Micrometastasis in pN0 Gastric Cancer Patients

Purpose

To investigate the relationship between lymph node micrometastasis (LNMM) and clinicopathological factors and to evaluate the prognostic effects of LNMM in pN0 gastric cancer (GC) patients.

Methods

One hundred and seventy-two GC patients who received radical gastrectomy with D2 lymph node dissection were enrolled in the present study. 1371 negative lymph nodes from level 2 station confirmed by pathology were examined. The LNMM was diagnosed by telomeric repeat amplification protocol/enzyme-linked immunosorbent assay (TRAP-ELISA). The relationship between clinicopathological factors and LNMM was investigated by multivariate analysis. Survival analysis was performed to evaluate the effects of LNMM on prognosis.

Results

LNMM was detected in 423 lymph nodes from 72 patients. The results showed that invasion depth (OR = 3.755, P = 0.004), TNM staging (OR = 3.152, P = 0.002), lymphatic invasion (OR = 2.178, P = 0.009), and tumor differentiation (OR = 1.266, P = 0.013) were independent risk factors associated with LNMM. Survival analysis showed that patients with LNMM had significantly worse 5-year survival compared with those without LNMM (42% vs. 76.4%, P < 0.05). Multivariate analysis demonstrated that LNMM, tumor size, Lauren type, invasion depth, and lymphatic invasion (P < 0.05) were independently factors associated with 5-year survival.

Conclusions

The findings showed that tumor invasion depth, TNM staging, lymphatic invasion, and tumor differentiation were independent risk factors associated with LNMM occurrence. Moreover, LNMM is a clinically negative prognostic factor in pN0 GC patients.

Survival Prediction in Gallbladder Cancer Using CT Based Machine Learning

Objective

To establish a classifier for accurately predicting the overall survival of gallbladder cancer (GBC) patients by analyzing pre-treatment CT images using machine learning technology.

Methods

This retrospective study included 141 patients with pathologically confirmed GBC. After obtaining the pre-treatment CT images, manual segmentation of the tumor lesion was performed and LIFEx package was used to extract the tumor signature. Next, LASSO and Random Forest methods were used to optimize and model. Finally, the clinical information was combined to accurately predict the survival outcomes of GBC patients.

Results

Fifteen CT features were selected through LASSO and random forest. On the basis of relative importance GLZLM-HGZE, GLCM-homogeneity and NGLDM-coarseness were included in the final model. The hazard ratio of the CT-based model was 1.462(95% CI: 1.014–2.107). According to the median of risk score, all patients were divided into high and low risk groups, and survival analysis showed that high-risk groups had a poor survival outcome (P = 0.012). After inclusion of clinical factors, we used multivariate COX to classify patients with GBC. The AUC values in the test set and validation set for 3 years reached 0.79 and 0.73, respectively.

Conclusion

GBC survival outcomes could be predicted by radiomics based on LASSO and Random Forest.

Surgical treatment of gallbladder cancer: An eight-year experience in a single center

BACKGROUND

Gallbladder cancer (GBC) is the most common biliary malignancy and has the worst prognosis, but aggressive surgeries [e.g., resection of the extrahepatic bile duct (EHBD), major hepatectomy and lymph node (LN) dissection] may improve long-term survival. GBC may be suspected preoperatively, identified intraoperatively, or discovered incidentally on histopathology.

AIM

To present our data together with a discussion of the therapeutic strategies for GBC.

METHODS

We retrospectively investigated nineteen GBC patients who underwent surgical treatment.

RESULTS

Nearly all symptomatic patients had poor outcomes, while suspicious or incidental GBCs at early stages showed excellent outcomes without the need for two-stage surgery. Lymph nodes around the cystic duct were reliable sentinel nodes in suspicious/incidental GBCs. Intentional LN dissection and EHBD resection prevented metastases or recurrence in early-stage GBCs but not in advanced GBCs with metastatic LNs or invasion of the nerve plexus. All patients with positive surgical margins (e.g., the biliary cut surface) showed poor outcomes. Hepatectomies were performed in sixteen patients, nearly all of which were minor hepatectomies. Metastases were observed in the left-sided liver but not in the caudate lobe. We may need to reconsider the indications for major hepatectomy, minimizing its use except when it is required to accomplish negative bile duct margins. Only a few patients received neoadjuvant or adjuvant chemoradiation. There were significant differences in overall and disease-free survival between patients with stages ≤ IIB and ≥ IIIA disease. The median overall survival and disease-free survival were 1.66 and 0.79 years, respectively.

CONCLUSION

Outcomes for GBC patients remain unacceptable, and improved therapeutic strategies, including neoadjuvant chemotherapy, optimal surgery and adjuvant chemotherapy, should be considered for patients with advanced GBCs.

Prognostic Evaluation for Patients over 45 Years Old with Gallbladder Adenocarcinoma Resection: A SEER-Based Nomogram Analysis

Gallbladder adenocarcinoma is the main histopathological type of gallbladder cancer (GBC), so it is particularly important to understand its biological characteristics. Due to the low incidence of this type of cancer, there are few studies with large sample sizes. The log of positive lymph nodes (LODDS) has been evaluated by many scholars as a lymph node stage that may play a better role than the 8^th edition of the American Joint Committee on Cancer (AJCC) lymph node staging system in many cancers. However, the effect of LODDS has not been proven in gallbladder adenocarcinoma. Our research aimed to identify independent prognostic factors that are closely related to overall survival (OS) in patients with gallbladder adenocarcinoma over 45 years of age using data from the Surveillance, Epidemiology and, End Results (SEER) database. All patients were randomly divided into a modeling cohort and an internal validation cohort. Seven independent prognostic factors associated with OS—age, marital status, grade, tumor size, AJCC 8^th edition T stage and M stage, and LODDS—were used to build a nomogram to predict 1-, 3-, and 5-year survival. The C-index of our nomogram was 0.735 (95% CI, 0.716 to 0.754), and together with the calibration curve and ROC curve validation, the results confirmed the prediction effect of our nomogram. We believe that our nomogram will be an accurate and convenient method for patient prognosis assessment in the future.

Phase 2 Trial of Adjuvant Chemotherapy With S - 1 for Node-Positive Biliary Tract Cancer (N-SOG 09)

BACKGROUND

Nodal metastasis is a leading attributable factor of poor survival in biliary tract cancer (BTC), and adjuvant chemotherapy targeting this high-risk feature has not been attempted to date. This study aimed to test the efficacy of adjuvant S - 1 for patients with node-positive BTC.

METHODS

This single-arm multicenter phase 2 trial enrolled patients who underwent resection for histologically proven node-positive BTC. In this trial, S - 1 was administered at a dose of 80-120 mg/day on 14 days of a tri-weekly cycle for 6 months. The primary end point of the trial was 3-year overall survival (OS), in which the result would be promising if the 90% confidence interval (CI) surpassed a threshold of 30% (alpha error, 0.1; beta error, 0.2). The secondary end points were relapse-free survival (RFS), feasibility, and toxicity.

RESULTS

The trial included 50 patients with perihilar (n = 23) or distal (n = 20) cholangiocarcinoma, or gallbladder cancer (n = 7). The median numbers of positive lymph nodes and examined lymph nodes were respectively 2 and 15. The 3-year OS and RFS were respectively 50% (90% CI, 40.9-59.1%) and 32.0% (95% CI, 19.1-44.9%), with median survival times of 34.6 months (95% CI, 19.3-49.8 months) and 18.4 months (95% CI, 11.9-24.9 months). Although hematologic toxicity often occurred, grades 3 and 4 toxicity were rare. The completion rate of the test therapy was 64%, and the median relative dose intensity was 87.5% (interquartile range, 50-100%).

CONCLUSION

Adjuvant chemotherapy with S - 1 may be promising for patients with node-positive BTC.

Positive relationship between number of negative lymph nodes and duration of gallbladder cancer cause-specific survival after surgery

Background

Although the prognostic implications of negative lymph nodes (NLNs) has been reported for a variety of tumors, little information has been published about the NLNs in gallbladder cancer (GBC).

Patients and methods

In this study, clinicopathological characteristics and survival times of patients who had undergone surgery for GBC were collected from the Surveillance, Epidemiology, and End Results Program-registered TNM stage database and analyzed. Univariate and multivariate Cox proportional hazards models were used to identify the predictors of survival.

Results

It was found that a cutoff of one to two NLNs is optimal when assessing the association with survival, survival rates being consistently better with two or more NLNs than with fewer than two. This optimal cutoff value of 2 was identified as an independent prognostic factor by univariate and multivariate analyses (all P<0.001). Specifically, patients with two or more NLNs had better 5-year gallbladder cancer cause-specific survival than those with fewer than NLNs examined for stage I/II, stage III/IV, and all TNM stages (all P<0.001).

Conclusion

Our findings indicate that the number of NLNs is an independent prognostic factor after GBC surgery, and, together with the number of positive lymph nodes, this will provide better prognostic information than the number of positive lymph nodes alone.

Lymph node micrometastasis in gallbladder cancer

BACKGROUND

Prognosis of gallbladder cancer (GBC) is grim even after curative surgery. Lymph node metastasis is the most important prognostic factor, but distant relapses occurring in their absence point towards additional factor. Lymph node micrometastasis could be one. The present study aimed to evaluate the incidence and clinical significance of lymph node micrometastasis.

METHODS

This is a prospective study of patients undergoing curative surgery for GBC from 1 March 2013 to 30 April 2015, at our institute. All lymph nodes were examined with hematoxylin and eosin and immunohistochemistry against CK7. The incidence of lymph node and its relation to other clinicopathological parameters, recurrence, and survival was evaluated.

RESULTS

Out of 589 lymph nodes retrieved from 40 patients, metastasis was seen in 13 (2.20%) nodes from 8 (20%) patients and micrometastasis in 4 (0.68%) nodes from 3 (7.5%) patients. Micrometastases were absent in pT1 tumors (0/10 in pT1 vs. 3/30 in pT2-4) and more common in patients with nodal metastasis (13% vs. 6%). Though the presence of micrometastasis would have upstaged the disease, it did not statistically relate to clinicopathological parameters, recurrence, and survival.

CONCLUSIONS

Incidence of lymph node micrometastasis in GBC was low and did not correlate with other clinicopathological parameters, recurrence, and survival.

Indications for major hepatectomy and combined procedures for advanced gallbladder cancer

Background

The clinical impact of major hepatectomy for advanced gallbladder cancer is currently unclear.

Methods

Patients who underwent resection for stage II, III or IV gallbladder cancer were enrolled. The surgical outcomes of patients who underwent major hepatectomy were compared with those of patients treated with minor hepatectomy and those with unresectable gallbladder cancer. The clinical impact of major hepatectomy and combined advanced procedures such as portal vein resection or pancreatoduodenectomy for advanced gallbladder cancer were evaluated.

Results

A total of 96 patients were enrolled; 29 patients underwent major and 67 had minor hepatectomy. The overall morbidity rate was higher in the major hepatectomy group (55 versus 27 per cent; P = 0·022). There were no deaths after major hepatectomy. Overall survival was better in the major hepatectomy group than in the group of 15 patients with unresectable disease (median survival 17·7 versus 11·4 months; P = 0·003). In a subgroup analysis of the major hepatectomy group, liver metastasis (P = 0·038) and hepatic arterial invasion (P = 0·017) were independently associated with overall survival. Overall survival in patients with liver metastasis (P = 0·572) or hepatic arterial invasion (P = 0·776) was comparable with that in the unresectable group. However, overall survival among patients with lymph node metastasis (P = 0·062) or following portal vein resection (P = 0·054) or pancreatoduodenectomy (P = 0·011) was better than in the unresectable group.

Conclusion

Major hepatectomy combined with portal vein resection or pancreatoduodenectomy, if necessary, may be considered in the treatment of advanced gallbladder cancer, especially in selected patients without liver metastasis or hepatic arterial invasion.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Lymph Node Micrometastases are Associated with Worse Survival in Patients with Otherwise Node-Negative Hilar Cholangiocarcinoma

Background

Lymph node metastases on routine histology are a strong negative predictor for survival after resection of hilar cholangiocarcinoma. Additional immunohistochemistry can detect lymph node micrometastases in patients who are otherwise node negative, but the prognostic value is unsure. The objective of this study was to assess the effect on survival of immunohistochemically detected lymph node micrometastases in patients with node-negative (pN0) hilar cholangiocarcinoma on routine histology.

Methods

Between 1990 and 2010, a total of 146 patients underwent curative-intent resection of hilar cholangiocarcinoma with regional lymphadenectomy at two university medical centers in the Netherlands. Ninety-one patients (62 %) without lymph node metastases at routine histology were included. Micrometastases were identified by multiple sectioning of all lymph nodes and additional immunostaining with an antibody against cytokeratin 19 (K19). The association with overall survival was assessed in univariable and multivariable analysis. Median follow-up was 48 months.

Results

Micrometastases were identified in 16 (5 %) of 324 lymph nodes, corresponding to 11 (12 %) of 91 patients. There were no differences in clinical variables between K19 lymph node-positive and -negative patients. Five-year survival rates in patients with lymph node micrometastases were significantly lower compared to patients without micrometastases (27 vs. 54 %, P = 0.01). Multivariable analysis confirmed micrometastases as an independent prognostic factor for survival (adjusted Hazard ratio 2.4, P = 0.02).

Conclusions

Lymph node micrometastases are associated with worse survival after resection of hilar cholangiocarcinoma. Immunohistochemical detection of lymph node micrometastases leads to better staging of patients who were initially diagnosed with node-negative (pN0) hilar cholangiocarcinoma on routine histology.

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

Backgrounds/Aims

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

Methods

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

Results

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

Conclusions

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

Prognostic implications of SLIT and ROBO1 expression in gallbladder cancer

SLIT, a secretory glycoprotein, and its receptor roundabout (ROBO) are expressed in several types of cancer and have been implicated in tumor angiogenesis. The purpose of this study was to determine the prognostic implications of SLIT and ROBO1 expression and their association with clinicopathologic characteristics in gallbladder cancer. A retrospective analysis of 109 consecutive patients who underwent primary gallbladder cancer resection was conducted. Univariate and multivariate models were used to analyze the effect of clinicopathologic factors on survival. Expression of SLIT and ROBO1 was evaluated by immunohistochemistry, and their association with clinicopathologic characteristics was analyzed using mean testing. Multivariate linear regression analysis was also applied to investigate the independent predictors of ROBO1 expression. Seventy-five patients were included in the post-resection survival analysis, with 1-year and 3-year overall survival rates of 60 and 40 %, respectively. Univariate analysis revealed that pN classification, pT classification, pM classification, liver involvement, perineural invasion, TNM staging, Nevin staging, and microscopic resection margins affect prognosis. Multivariate analysis confirmed that pN classification, liver involvement, and perineural invasion are independent prognostic factors. In the mean tests of 109 cases, the mean difference of SLIT immunoreactivity was significant according to the presence of gallstones (P = 0.003) and liver involvement (P = 0.005), while the mean difference of ROBO1 immunoreactivity was significant according to liver involvement (P < 0.001), TNM staging (P < 0.001), and Nevin staging (P < 0.001). Multivariate analysis of ROBO1 immunoreactivity showed that SLIT immunoreactivity and TNM stage (adjusted R (2) = 0.203) or SLIT immunoreactivity and Nevin stage (adjusted R (2) = 0.195) were independent predictors of ROBO1 expression. pN classification, liver involvement, perineural invasion, and pathologic stage are significant prognostic factors for gallbladder cancer survival. SLIT expression is associated with cholelithiasis and liver involvement, and ROBO1 expression is associated with liver involvement and pathologic stage. In addition, SLIT expression and pathologic stage predict ROBO1 expression independently.

Lymph node metastases in patients undergoing surgery for a gallbladder cancer. Extension of the lymph node dissection and prognostic value of the lymph node ratio

BACKGROUND

Lymph node (LN) status is one of the strongest prognostic factors after gallbladder cancer (GBC) resection. The adequate extension of LN dissection and the stratification of the prognosis in N+ patients have been debated. The present study aims to clarify these issues.

METHODS

A total of 112 consecutive patients who underwent operations for GBC with LN dissection were analyzed. Twenty-five patients (22.3%) had D1 dissection (hepatic pedicle), and 87 (77.7%) had D2 dissection (hepatic pedicle, celiac and retro-pancreatic area). The LN ratio (LNR) was computed as follows: number of metastatic LNs/number of retrieved LNs.

RESULTS

The median number of retrieved LNs was 7 (1-35). Fifty-nine patients (52.7%) had LN metastases (22 N2). D2 dissection allowed the retrieval of more LNs (8 vs. 3, p = 0.0007), with similar short-term outcomes. Common bile duct (CBD) resection (n = 41) did not increase the number of retrieved LNs. In five patients, D2 dissection identified skip LN metastases that otherwise would have been missed. LN metastases negatively impacted survival (5-years survival 57.2% if N0 vs. 12.4% if N+, p < 0.0001), but N1 and N2 patients had similar survival rates. The number of LN+ (1-3 vs. ≥4) did not impact prognosis. An LNR = 0.15 stratified the prognosis of N+ patients: 5-years survival 32.7% if LNR ≤ 0.15 vs. 10.3% if LNR > 0.15 (multivariate analysis p = 0.007).

CONCLUSIONS

A D2 LN dissection is recommended in all patients, because it allows for better staging. CBD resection does not improve LN dissection. An LNR = 0.15, not the site of metastatic LNs, stratified the prognoses of N+ patients.

Pathology report assessment of incidental gallbladder carcinoma diagnosed from cholecystectomy specimens: results of a French multicentre survey

AIMS

To assess the accuracy of pathology reports on gallbladder specimens from patients operated on for incidental gallbladder carcinoma.

METHODS

Demographic data, details on pathological reports including gross and microscopic features section were recorded in 100 selected patients with incidental gallbladder carcinoma diagnosed from 2004 to 2007.

RESULTS

Pathology reports had a conventional format in 93% of cases, without any standardization. Turnaround time ranged from 1 to 35 days. Frozen sections were performed in 20% of cases. The reports failed to give information on prognostic histological factors: exact tumour site (missing in 55% of cases), depth of tumour infiltration within the gallbladder wall (missing in 10%), surgical margins (missing in 40% for the cystic duct margin), tumour differentiation (missing in 28%), vascular invasion (missing in 52%) and perineural invasion (missing in 51%). Lymph node status could be assessed in 44% of cases. Distances between the tumour and the cystic duct and circumferential margins were not specified in 68% and 84% of cases. Only 29% of the reports clearly stated the pTNM stage in the conclusion section. The pT stage with margin status and tumour site was only mentioned in 30% of the reports.

CONCLUSION

Pathology reports on gallbladder carcinoma from participating centres frequently lacked important information on key prognostic histological factors.

Key factors influencing prognosis in relation to gallbladder cancer

INTRODUCTION

The 5-year survival of patients with gallbladder cancer remains low. However, patients can be stratified into prognostic categories based on established factors such as T, N, and R status. New concepts regarding prognostic significance of lymph node disease, the importance of residual gallbladder fossa disease, and the gravity of presentation with jaundice are reviewed. In addition, a number of new prognostic factors proposed in recent years are considered.

METHODS

PubMed was searched for "gallbladder cancer" with builder "date-completion" 2008 to present. A total of 1,490 articles were screened from which 168 were retrieved. From this, 40 articles specifically related to prognosis form the basis for this review.

DISCUSSION

Key factors of prognostic significance remain T and N stage and R0 resection. Residual disease either in the gallbladder fossa, lymph nodes, or cystic duct margin dictates hepatectomy, lymphadenectomy and bile duct resection, respectively. Adequate lymphadenectomy requires removal of six nodes, and hepatectomy must be sufficient to achieve R0. Subtleties regarding lymph node ratio, significance of pathological features such as dedifferentiation, and budding may hold value for stratifying patients with early stage disease, but require further investigation.

Prognostic factors for gallbladder cancer in the laparoscopy era

PURPOSE

Hepatobiliary surgery has changed dramatically in recent decades with the advent of laparoscopic techniques. The aim of this retrospective study was to compare survival rates according to stages, adjusting for important prognostic factors.

METHODS

A retrospective study of a 17-year period from January 1994 to April 2011 was carried out. The cases studied were divided into two time period cohorts, those treated in the first 9-years (n = 109) and those treated in the last 7-years (n = 109).

RESULTS

An operation with curative intent was performed on 218 patients. The 5-year survival rates according to the depth of invasion were 86% (T1), 56% (T2), 45% (T3), and 5% (T4). The number of cases of incidental gallbladder cancer found during 3,919 laparoscopic cholecystectomies was 96 (2.4%). Incidental gallbladder cancer revealed a better survival rate (P = 0.003). Iatrogenic bile spillage was found in 20 perforations of the gallbladder during laparoscopic cholecystectomies, 16 preoperative percutaneous transhepatic gallbladder drainages and 16 percutaneous transhepatic biliary drainages; only percutaneous transhepatic biliary drainage patients showed a significantly lower survival rate than patients without iatrogenic bile spillage (P < 0.034). Chemoradiation appeared to improve overall survival (P < 0.001). Multivariate analysis also revealed that time period, type of surgery, surgical margin, lymphovascular invasion, lymph node involvement, and chemoradiation therapy had significant effects.

CONCLUSION

This study found that the prognosis of gallbladder cancer is still determined by the stage at presentation due to the aggressive biology of this tumor. Early diagnosis, radical resection and appropriate adjuvant therapy can increase overall survival.

Clinical significance of wall invasion pattern of subserosa-invasive gallbladder carcinoma

We have previously classified wall invasion patterns of gallbladder carcinoma (GBC) cases into two groups, i.e., the infiltrative growth type (IG type) and destructive growth type (DG type). The DG type was significantly associated with poor differentiation, aggressive infiltration and decreased postoperative survival in terms of its histological differentiation, lymphatic invasion, venous invasion, lymph node status, neural invasion and mode of subserosal infiltration. In the present study, we analyzed 42 surgically-resected subserosal invasive gallbladder adenocarcinomas, invading the perimuscular connective tissue (pT2). The cumulative 5-year survival rate in the series was 48.7%. Lymphatic invasion (p=0.021), venous invasion (p=0.020), mode of subserosal infiltration (p<0.001), histological differentiation (p=0.030) and biliary infiltration (p=0.007) were noted, respectively, at a significantly higher incidence in more aggressive infiltration or poor differentiation in the DG type. The cumulative 5-year survival rate of curative resection cases was lower in patients with the DG type than in those with the IG type (68.9 versus 20.2%, respectively, p=0.006, log-rank test). On Cox’s proportional hazard regression modeling, the low degree of venous/perineural invasion and IG type of wall invasion pattern were associated with a significant improvement in overall survival. Our data suggest that the wall invasion pattern is an independent predictor of survival in subserosal invasive GBC. Regarding the clinical application of our concept, on the classification of patients with subserosal invasive GBC based on a combination of the wall invasion pattern and lymph node status, the overall survival rate in patients with the DG type and/or N2 metastasis (n=21) was lower than in patients with the IG type and N0, 1 metastasis (n=21) (p=0.0023, log-rank test). The wall invasion pattern could contribute to decision-making concerning curative resection for subserosal invasive GBC.

Invasion of the hepatic artery is a crucial predictor of poor outcomes in gallbladder carcinoma

BACKGROUND

In the present study we undertook a retrospective analysis of gallbladder carcinoma to assess whether histologically determined hepatic artery (HA) invasion and portal vein (PV) invasion can be considered prognostic factors.

METHODS

Seventy-one patients who had undergone radical resection for gallbladder carcinoma between 1995 and 2008 at University of Tsukuba were selected from the database for analysis. Patients who required extended surgery for para-aortic lymph node metastasis were also included. Correlation between invasion of the HA and the PV and prognosis and other clinicopathologic factors were analyzed.

RESULTS

There were two postoperative deaths among the 71 patients. Pathological invasion of the HA was confirmed in 16 (22.5%) cases and PV invasion was confirmed in 15 patients. Patients with invasion of the HA had a significantly poorer prognosis than those without HA invasion (P < 0.0001). Additionally, in univariate analysis, gender (male), positive para-aortic lymph node metastasis, PV invasion, and HA invasion were identified as significant poor prognostic factors. In multivariate analysis, only HA invasion was an independent prognostic factor (Odds Ratio 0.323; P = 0.029).

CONCLUSIONS

Invasion of the HA is a crucial prognostic factor in patients with gallbladder carcinoma.

Clinical significance of lymph node micrometastasis in gastric cancer

Recently, the existence of lymph node micrometastasis (LNM), including isolated tumor cells, has been focused on during the development of molecular diagnostic tools for lymph node metastasis in various malignant neoplasms. In particular, immunohistochemistry and reverse transcription-polymerase chain reaction have been reported to be available for the detection of LNM in gastric cancer. However, at present, the clinical significance of LNM remains unclear in patients with gastric cancer. Therefore, we cannot strategically make light of this issue in clinical management. Currently, minimally invasive treatments, such as endoscopic submucosal dissection and laparoscopic surgery with personalized lymphadenectomy, are widely performed in consideration of postsurgical quality of life (QOL). However, it is important to maintain the balance between QOL and curability when selecting surgical treatments for patients with gastric cancer. If minimally invasive surgery based on LNM status was established for patients with early gastric cancer, it could be performed safely. We reviewed the clinical significance of LNM as an important strategic target in patients with gastric cancer.

Adenocarcinoma da vesícula biliar: avaliação dos fatores prognósticos em 100 casos ressecados no Brasil

RACIONAL: A despeito da sua relativa raridade, o adenocarcinoma de vesícula biliar é neoplasia que apresenta comportamento biológico agressivo. O único tratamento curativo tem sido a ressecção cirúrgica radical com margem livre. Fatores prognósticos têm sido estudados por serem importantes para identificar pacientes que podem se beneficiar de ressecção cirúrgica agressiva. OBJETIVO: Avaliar preditores prognósticos em longo prazo de pacientes com câncer da vesícula biliar. MÉTODOS: Foram identificados e retrospectivamente revisados os prontuários médicos de todos os doentes submetidos a tratamento cirúrgico que apresentavam diagnóstico histológico confirmado de adenocarcinoma de vesícula biliar durante período de 14 anos. Os dados foram submetidos à análise estatística uni e multivariada. RESULTADOS: A amostra total foi de 100 doentes. A mediana de idade foi de 71 anos (34 a 93). Houve 17 mulheres e 83 homens. A distribuição das lesões de acordo com o sistema de estadiamento TNM foi: I (n=22), II (n=59), III (n=6), IV (n=4) e desconhecido (n=9). Cinquenta e dois doentes foram submetidos à ressecção radical (R0) enquanto 48 à cirurgia paliativa (R1-R2). A morbidade global foi de 14% enquanto que a mortalidade pós-operatória (até 30º dia do pós-operatório) foi de 12 %. A taxa de sobrevida em cinco anos foi de 28% enquanto a mediana de sobrevida foi de 10 meses. A análise multivariada identificou seis fatores prognósticos: estádio T, nível sérico de CA 19.9, perfuração da vesícula biliar, embolização linfática, coorte cirúrgico histórico e linfadenectomia hilar. CONCLUSÃO: O tratamento do câncer de vesícula biliar apresenta alta morbimortalidade. Os fatores prognósticos foram: estádio T, nível sérico de CA 19.9, perfuração da vesícula biliar, embolização linfática, coorte cirúrgico histórico e linfadenectomia hilar.

T-category reflects the histopathologic characteristics of gallbladder cancer

AIMS

Gallbladder (GB) cancer is a relatively uncommon gastrointestinal malignancy and is known to often result in unfavorable outcomes. Recent advances in aggressive surgical resection have improved the overall survival rate of patients with GB cancer. We aimed to evaluate the outcomes and prognostic factors of GB cancer following a surgical resection with curative intent.

METHODS

Between March 2001 and March 2009, 89 patients with GB cancer underwent surgical resection with curative intent at the National Cancer Center of Korea. We then conducted a retrospective analysis of clinicopathologic data.

RESULTS

Nineteen patients underwent simple cholecystectomy and 70 patients underwent extended cholecystectomy. Tumor-free resection margins were obtained in 84 cases. The 1-, 3- and 5-year disease-specific survival rates in the 89 patients were 85.8%, 68.0% and 64.1%, respectively. By multivariate analysis, only the T-category was significant (p < 0.001). The T-category showed a close correlation with all of the other histopathologic factors which were significant in univariate analysis.

CONCLUSION

The T-category of GB cancer represents not only the depth of the primary tumor but also the aggressiveness of its histopathologic nature.

Incidentally-discovered gallbladder cancer: When, why and which reoperation?

Cancer of the gallbladder, a rare entity with a poor prognosis, is often discovered incidentally during or after cholecystectomy. It tends to disseminate early via lymphatic, peritoneal, endobiliary, and hematogenous pathways. Diagnosis is made intra-operatively in only a quarter of cases, by examination of the opened cholecystectomy specimen in the operating room by the surgeon; this procedure should be routine. For incidentally-discovered cancers, survival was 28% at five years. Prognostic factors include age, TNM stage, gallbladder perforation during cholecystectomy and less-than-optimal resection at re-operation. Whether the laparoscopic route for the initial cholecystectomy has an impact on survival remains a subject of debate. R0 surgery is the only potentially curative treatment: simple cholecystectomy with clear margins is adequate resection for stage T1a tumors; extended cholecystectomy with lymphadenectomy and possibly resection of the bile duct is required for more advanced stages. After curative resection, neo-adjuvant or adjuvant chemotherapy and radiotherapy have not, so far, proven effective. Improvement of surgical practices (systematic review of cholecystectomy specimens in the OR, prevention of gallbladder perforation with bile spillage during surgery, early re-intervention for optimal resection) could improve the prognosis of these cancers.

Gender-Specific Prognostic Markers of Patients with Gallbladder Cancer after Surgical Resection

The aim of this study was to elucidate gender-specific markers for postresectional long-term survival of gallbladder cancer (GBC) based on a cohort of Chinese patients. Clinicopathological records of 81 patients (27 males and 54 females) after surgical resection for GBC were reviewed retrospectively. The influence of each variable on survival was determined using the Kaplan-Meier method and log-rank test. For females, Cox regression analysis was also adopted. Univariate analysis showed that the absence of lymph node and distant metastases, differentiation grade, and curative resection were associated with prolonged survival for all males, whereas tumor size, differentiation grade, and the presence of lymph node metastases influenced the overall or disease-free survival of patients after curative resection (all P < 0.05). On the other hand, Nevin stage was an independent marker for both overall survival for all females and overall and disease-free survival for female patients who underwent curative resection. Additionally, resection type and differentiation grade were of independent prognostic significance for different subgroups of females (all P < 0.05). Our data suggested that tumor-related factors affect prognosis of both male and female patients with GBC after resection. Of these factors, tumor differentiation status might be more significant for males, but Nevin stage had a stronger predictive potential for females.

Invasive micropapillary variant of the gallbladder adenocarcinoma and its aggressive potential for lymph node metastasis

An invasive micropapillary variant (IMPV) has recently been described in several organs but has not been reported in the gallbladder. It has been mentioned to have aggressive behavior with a high propensity for lymphovascular invasion, lymph node metastasis and poor clinical outcome. We analyzed the clinicopathologic findings of IMPV and compared them with those of a conventional adenocarcinoma in the gallbladder to clarify the highly aggressive potential of IMPV of gallbladder carcinoma. Ninety consecutive cases of surgically resected gallbladder carcinomas were studied for age, gender, type, depth of invasion and lymph node and distant metastases. Histologically, IMPV of gallbladder carcinoma was characterized by a small cluster of tumor cells lying within clear stromal spaces. This pattern mimicked extensive lymphatic invasion, but the cluster of tumor cells showed a distinctive retraction artifact from the surrounding stroma. In total, 20 (22.2%) cases had foci of IMPV, which ranged from 5% to 10% of the primary tumor tissue. Of those 20 cases, 17 (85.0%) carcinomas with IMPV also included lymph node metastasis, which was more frequent than in conventional carcinoma (32.8%, P < 0.001). Carcinomas with IMPV had a more advanced tumor status and showed severe lymphatic invasion (P = 0.001, P < 0.001, respectively). A multivariate regression analysis demonstrated that the presence of IMPV is an independent predictor of regional nodal metastasis (Odds ratio: 9.995, 95% confidence interval: 1.996-50.052, P = 0.005). IMPV is a useful predictor of regional lymph node metastasis in gallbladder adenocarcinoma.

Number of positive lymph nodes independently determines the prognosis after resection in patients with gallbladder carcinoma

BACKGROUND

This study was designed to compare the prognostic power of the location of positive lymph nodes with that of the number of positive lymph nodes in gallbladder carcinoma.

METHODS

A retrospective analysis was conducted of 116 consecutive patients who underwent an R0 radical resection for gallbladder carcinoma. A total of 2,406 lymph nodes taken from the patients were examined histologically. The location of positive regional nodes was classified according to the Japanese staging system. The number of positive regional nodes was recorded for each patient.

RESULTS

Nodal disease was found in 49 patients, of whom 19 survived for more than 5 years after resection. Univariate analysis revealed that both the location (P < 0.0001) and the number (P < 0.0001) of positive nodes were significant prognostic factors. Multivariate analysis revealed that the number of positive nodes was an independent prognostic factor (P < 0.001), whereas the location of positive nodes failed to remain as an independent variable. The cumulative 5-year survival rates were 81% for patients without regional nodal disease, 62% for patients with a single positive node, 43% for patients with 2-3 positive nodes, and 15% for patients with > or =4 positive nodes (P < 0.0001).

CONCLUSIONS

The number, not the location, of positive lymph nodes independently determines the prognosis after resection in gallbladder carcinoma. No nodal disease or a single positive node indicates a favorable outcome after resection, whereas radical lymph node dissection is effective for selected patients with multiple positive nodes, provided that an R0 resection is feasible.

Prognostic impact of para-aortic lymph node micrometastasis in patients with regional node-positive biliary cancer

BACKGROUND

The presence of para-aortic lymph node metastasis in biliary cancer has a negative impact on prognosis. The relevance of para-aortic lymph node micrometastasis is unknown.

METHODS

A total of 546 para-aortic lymph nodes from 49 patients with biliary cancer with positive regional nodes and negative para-aortic nodes were immunostained with epithelial marker CAM5.2 (specific for cytokeratins 7 and 8). Immunostained tumour foci were classified as micrometastases or isolated tumour cells (ITCs) according to their size (larger or smaller than 0.2 mm).

RESULTS

CAM5.2-positive occult carcinoma cells in para-aortic lymph nodes were detected in nine (18 per cent) of 49 patients and in 18 (3.3 per cent) of 546 para-aortic nodes. There was no difference in postoperative survival between patients with and without CAM5.2-positive para-aortic nodes (P = 0.978), but survival for five patients with micrometastases was significantly worse than that for four patients with only ITCs (P = 0.047).

CONCLUSION

In patients with regional node-positive and para-aortic node-negative biliary cancer, and occult cancer cells in para-aortic lymph nodes, prognosis was significantly worse in those with micrometastases than in patients with only ITCs. An efficient method of intraoperative detection of para-aortic lymph node micrometastases larger than 0.2 mm is needed.

Histological features of lymph node metastasis in patients with biliary tract cancer

BACKGROUND AND OBJECTIVES

The presence of lymph node (LN) metastases is an important prognostic factor in patients with biliary cancers. The aim of this study was to characterize systematically the morphological features of metastatic LNs in biliary cancers.

METHODS

Four hundred ninety-six LNs (including 112 para-aortic LNs) dissected from 47 patients with biliary cancer were examined. The diameter of the long axis (size) and the percent metastatic area relative to whole-node area were measured from histologic specimens.

RESULTS

The average size of metastatic LNs (9.5 mm) was significantly larger than those without metastasis (6.5 mm; P < 0.01). The optimum cut-off size for positive LNs was >7.5 mm, but the sensitivity of this predictor of metastasis was low (60.8%). In general, metastatic area correlated significantly with the size of metastatic LNs (P = 0.023). Para-aortic LNs contained metastasis in 7.1% of cases, and only 25% of para-aortic LNs with a high ratio of metastatic area could be evaluated from preoperative CT scans.

CONCLUSIONS

Although large LNs are highly suggestive of metastasis, poor detection of many small LNs with a low percentage of metastatic area can increase risk in patients with biliary tract cancer.

Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment

The only curative treatment in biliary tract cancer is surgical treatment. Therefore, the suitability of curative resection should be investigated in the first place. In the presence of metastasis to the liver, lung, peritoneum, or distant lymph nodes, curative resection is not suitable. No definite consensus has been reached on local extension factors and curability. Measures of hepatic functional reserve in the jaundiced liver include future liver remnant volume and the indocyanine green (ICG) clearance test. Preoperative portal vein embolization may be considered in patients in whom right hepatectomy or more, or hepatectomy with a resection rate exceeding 50%–60% is planned. Postoperative complications and surgery-related mortality may be reduced with the use of portal vein embolization. Although hepatectomy and/or pancreaticoduodenectomy are preferable for the curative resection of bile duct cancer, extrahepatic bile duct resection alone is also considered in patients for whom it is judged that curative resection would be achieved after a strict diagnosis of its local extension. Also, combined caudate lobe resection is recommended for hilar cholangiocarcinoma. Because the prognosis of patients treated with combined portal vein resection is significantly better than that of unresected patients, combined portal vein resection may be carried out. Prognostic factors after resection for bile duct cancer include positive surgical margins, especially in the ductal stump; lymph node metastasis; perineural invasion; and combined vascular resection due to portal vein and/or hepatic artery invasion. For patients with suspected gallbladder cancer, laparoscopic cholecystectomy is not recommended, and open cholecystectomy should be performed as a rule. When gallbladder cancer invading the subserosal layer or deeper has been detected after simple cholecystectomy, additional resection should be considered. Prognostic factors after resection for gallbladder cancer include the depth of mural invasion; lymph node metastasis; extramural extension, especially into the hepatoduodenal ligament; perineural invasion; and the degree of curability. Pancreaticoduodenectomy is indicated for ampullary carcinoma, and limited operation is also indicated for carcinoma in adenoma. The prognostic factors after resection for ampullary carcinoma include lymph node metastasis, pancreatic invasion, and perineural invasion.

Computed tomography evaluation of regional lymph node metastases in patients with biliary cancer

BACKGROUND

Identification of lymph node metastases in biliary cancer is important for determining prognosis and surgical planning, but the effectiveness of computed tomography (CT) in diagnosing node metastases of the hepatoduodenal ligament (peribiliary and retroportal nodes) or around the common hepatic artery is unknown.

METHODS

CT scans and pathological results from 146 patients who had undergone regional lymphadenectomy for biliary carcinoma were reviewed. To evaluate the regional lymph nodes, long- and short-axis diameters of lymph nodes were measured and axial ratios calculated (short-axis diameter/long-axis diameter). Nodes were considered round if the axial ratio exceeded 0.7. Internal lymph node structures were also evaluated.

RESULTS

The presence of a round node with a short-axis diameter exceeding 16 mm had a positive predictive value (PPV) of 56 per cent for the presence of metastatic foci, and node heterogeneity had a PPV of 64 per cent. The highest PPV (67 per cent) was obtained for round nodes greater than 18 mm in short-axis diameter, but nodes of this size and character were rare.

CONCLUSION

CT is not useful for predicting regional lymph nodal metastases in biliary carcinoma.

Micrometastases in cervical lymph nodes from patients with squamous carcinoma of the head and neck: should they be actively sought? Maybe

Techniques are now being developed, which allow ever smaller metastatic deposits in regional lymph nodes to be detected; the question is, should they be sought, or does their presence convey no additional information for treatment of head and neck carcinoma patients at this time? Preliminary findings have suggested that the presence of micrometastases may carry with it some prognostic information, and as a consequence, the search for micrometastases would, for the foreseeable future, appear to be a fertile ground for investigation. To bring some uniformity to this project, it is suggested that these definitions be adopted: a micrometastasis measures greater than 0.2 mm but less than 2.0 mm in diameter, and smaller deposits should be designated as isolated tumor cells, which, in turn, are subdivided into those isolated tumor cells detected by light microscopy, immunohistochemistry, or molecular methods. At this juncture, the import of such micrometastases remains in the realm of the clinical investigator--it remains an open question whether the identification of micrometastases (however they may ultimately come to be defined) will prove to have an impact on the care of head and neck cancer patients.