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- 1. Rates, Predictors, and Outcomes of Portal Lymphadenectomy for Resectable Gallbladder Cancer Phillip M. Kemp et-al, Ann Surg Oncol (2021) ORIGINAL ARTICLE – HEPATOBILIARY TUMORS
- 2. Introduction LND - critical component T1b -12–15% T2 - 17–46% T3 - 45.5–53.8% LND - grossly under-utilised No LND -> T1b - 53.2%, ≥T2 - 52.4 % Lee AJ, Chiang YJ, Lee JE, et al. Validation of American Joint Committee on Cancer eighth staging system for gallbladder cancer and its lymphadenectomy guidelines. J Surg Res. 2018
- 3. Introduction Known nodal disease - more likely to receive chemotherapy Omitting LND - decreases chances of receiving adjuvant chemotherapy Lymphadenectomy (LND) recommended ≥ T1b gallbladder Simple cholecystectomy - T1a disease Radical cholecystectomy - ≥ T1b Kemp Bohan PM, Kirby DT, Chick RC, et al. Adjuvant chemotherapy in resectable gallbladder cancer is underutilized despite benefits in node-positive patients. Ann Surg Oncol. 2020
- 4. To describe national trends in LND utilization Identify patient predictors for receipt of LND Impact of LND on overall survival with particular attention to T stage-specific survival and rates of adjuvant chemotherapy Objectives
- 5. Patient and methods De-identified NCDB 2006–2015 Divided into study groups (surgery versus surgery with LND)
- 6. Patient and methods Inclusion Criteria Non-metastatic GBC, Stage T1b - T3 Exclusion criteria Patients with either clinical or pathologic stage coded as 0, 4, or missing Patients who underwent an unknown surgical procedure Local tumor excision/treatment Missing data - pathologic T stage, performance of LND or survival Patients coded solely as pathologic T1 (rather than either pT1a or pT1b)
- 7. Study Profile Patients with gallbladder adenocarcinoma (n=22,441) Patients received surgery with curative intent (n=14,22) Patients with stage I-III disease (n=4,037) Patients with known nodal staging status (n=2,651) Study cohort (n=2,302) Excluded patients who did not undergo surgery (n=7,919) Excluded stage 0, stage IV, or missing stage (n=10,485) Excluded patients with unknown nodal staging (n=1,386) Excluded patients with incomplete survival / T stage (n=349)
- 8. Baseline Characteristics Variable Surgery + LND (1343) Surgery Alone (959) P Value Sex 0.026 Male 421 (31.4) 343 (35.8) Female 922 (68.6) 616 (64.2) Age at diagnosis, mean (SD) 67.5 (11.8) 72.6 (11.9) <0.001 Health Insurance <0.001 Private 462 (35.0) 203 (21.6) Government 829 (62.7) 699 (74.4) Not insured 31 (2.3) 37 (4.0) Type of cancer program <0.001 Community 111 (8.4) 151 (15.8) Comprehensive community 451 (34.1) 444 (46.5) Academic / Research 614 (46.4) 262 (27.4)
- 9. Baseline Characteristics Variables Surgery + LND (1343) Surgery Alone (959) P Value Node-positive <0.001 Yes 634 (47.3) 7 (0.8) No 680 (50.8) 24 (2.5) Not examined 26 (1.9) 916 (96.7) Surgical margin <0.001 Negative 1039 (80.9) 634 (70.1) Microscopic 231 (18.0) 253 (28.0) Macroscopic 14 (1.1) 17 (1.9) Pathologic overall stage <0.001 I (T1 N0 or T1 NX) 228 (17.0) 360 (38.0) II (T2 N0 or T2 NX) 335 (25.0) 408 (43.1) IIIA (T3 N0 or T3 NX) 143 (10.7) 172 (18.2) IIIB (T1-3 N1) 634 (47.3) 7 (0.8)
- 10. Baseline Characteristics Variables Surgery + LND (1343) Surgery Alone (959) P Value Adjuvant chemo <0.001 Yes 582 (46.2) 229 (26.6) No 677 (53.8) 632 (73.4) Chemotherapy type <0.001 None 570 (51.1) 573 (74.0) Single agent 311 (27.9) 100 (12.9) Multi agent 234 (21. 101 (13.1) Type of surgery <0.001 Simple/Partial removal of primary site 267 (19.9) 235 (24.5) Total surgical removal of primary site 813 (60.5) 673 (70.2) Surgery stated to be ‘‘debulking’’ 13 (1.0) 6 (0.6) Radical surgical resection 250 (18.6) 45 (4.7)
- 11. Variables Surgery + LND (1343) Surgery Alone (959) P Value Pathologic T stage <0.001 p1A 31 (2.3) 52 (5.4) p1B 101 (7.5) 116 (12.1) p2 684 (50.9) 496 (51.7) p3 527 (39.3) 295 (30.8) Radiation <0.001 Yes 403 (30.2) 134 (14.1) No 932 (69.8) 815 (85.9) Timing of chemotherapy <0.001 None 677 (54.5) 632 (75.7) Neoadjuvant 21 (1.7) 5 (0.6) Adjuvant chemo 536 (43.1) 197 (23.6) Baseline Characteristics
- 12. 0 18 35 53 70 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Patients receiving LND (%) Rates of LND for each year included in the study cohort Rates of LND for each year
- 13. Multivariable regression - independent risk factors OR (95% CL) P Value Age at diagnosis 0.97 (0.96, 0.98) < 0.001 Male versus Female 0.78 (0.62, 0.98) 0.03 Health insurance Private versus not insured 3.06 (1.65, 5.69) < 0.001 Government versus not insured 2.66 (1.43, 4.95) 0.002 Type of cancer program Community versus academic/research 0.35 (0.24, 0.50) < 0.001 Comprehensive community versus academic/research 0.48 (0.38, 0.62) < 0.001 Integrated network cancer program versus academic/research 0.57 (0.39, 0.82) 0.002 Surgical margin Macroscopic versus negative 0.22 (0.09, 0.53) < 0.001 Microscopic versus negative 0.49 (0.37, 0.64) < 0.001
- 14. Multivariable regression - independent risk factors OR (95% CL) P Value Adjuvant chemo Yes versus no 1.43 (1.08, 1.89) 0.01 Type of surgery Simple/partial removal of primary site versus radical surgical resection 0.34 (0.21, 0.54) < 0.001 Total surgical removal of primary site versus radical surgical resection 0.34 (0.22, 0.52) < 0.001 Pathologic T stage p2 versus p1A 2.28 (1.31, 3.95) 0.003 p3 versus p1A 2.62 (1.46, 4.69) 0.001 Radiation Yes versus no 1.92 (1.38, 2.68) < 0.001
- 15. LND According to Treatment Facility Variables Community cancer program (262) Comprehensive community cancer program (895) Academic /research (876) Integrated network (244) Lymphadenectomy <0.001 No 151 (57.6) 444 (49.6) 262 (29.9) 98 (40.2) Yes 111 (42.4) 451 (50.4) 614 (70.1) 146 (59.8) Pathologic T stage 0.002 p1A 11 (4.2) 30 (3.3) 35 (4.0) 7 (2.9) p1B 25 (9.5) 101 (11.3) 70 (8.0) 20 (8.2) p2 134 (51.2) 492 (55.0) 427 (48.7) 111 (45.5) p3 92 (35.1) 272 (30.4) 344 (39.3) 106 (43.4) Type of surgery <0.001 Simple/partial removal of primary site 56 (21.4) 194 (21.7) 198 (22.6) 49 (20.1) Total surgical removal of primary site 186 (71.0) 615 (68.7) 510 (58.2) 160 (65.6) Surgery stated to be ‘‘debulking’’ 2 (0.7) 6 (0.7) 10 (1.2) 1 (0.4) Radical surgical resection 18 (6.9) 80 (8.9) 158 (18.0) 34 (13.9)
- 16. Variables Community cancer program (262) Comprehensive community cancer program (895) Academic /research (876) Integrated network (244) Surgical margin 0.01 Negative 174 (69.6) 660 (77.1) 648 (79.2) 173 (72.4) Microscopic 69 (27.6) 186 (21.7) 159 (19.5) 64 (26.8) Macroscopic 7 (2.8) 10 (1.2) 11 (1.3) 2 (0.8) Node positive <0.001 Yes 56 (21.7) 213 (24.0) 284 (32.6) 77 (31.6) No 56 (21.7) 243 (27.3) 325 (37.3) 71 (29.1) Not examined 146 (56.6) 433 (48.7) 262 (30.1) 96 (39.3) Timing of chemotherapy Neoadjuvant 1 (0.5) 6 (0.8) 17 (2.1) 1 (0.4) Adjuvant chemo 73 (32.7) 274 (34.2) 278 (34.6) 98 (43.4) Treatment characteristics based on facility type
- 18. Largest contemporary analysis of the performance and impact of LND in GBC LND increased slightly over the study period, LND for patients with GBC remains vastly underutilized Only 59.1% of patients with pT1b–T3 disease received a LND LND - improved survival in T1b, T2, and T3 disease LND - highest at academic/ research centers- Survival benefit Discussion
- 19. OS - T2 and T3 sub- groups was higher with LND Results highlight the importance of treatment at an academic/research center, as both rates of LND and OS were higher Rates of adjuvant chemotherapy administration were relatively high at academic/research centers Inexperienced surgeons - refer to an academic center Discussion
- 20. Number of nodes retrieved - critical prognostic information Retrieval of 4? lymph nodes 6? lymph nodes and 8? lymph nodes have each been recommended as adequate for staging in various studies AJCC 8th edition - 6 lymph nodes, and distinguishes between 1–3 positive nodes (N1) and 4 positive nodes (N2) disease Discussion
- 21. Question Study Type of study? Retrospective Single centre or multi centre? Multicentre Sample size ? 2302 Patient population? Well defined Intervention? well defined Critical Appraisal
- 22. Question Study Is the question asked clinically relevant? Yes Comparison criteria? Well defined Outcome parameters? Well defined Study question? Relevant Does the study question get answered? Yes Are there similar studies answering the same question? Yes Critical Appraisal
- 23. • Multicentre study • Large sample size • Analyses large number of parameters Merits of the study
- 24. Limitations Retrospective study - 10 Years data Practice patterns and treatment algorithms may have changed during this time period Did not evaluate the number of lymph nodes retrieved during LND to determine adequacy AJCC 8th edition was not published during this cohort’s study period
- 25. Portal LND remains significantly underutilized LND - survival benefit for patients with pT2 and pT3 GBC Failure to perform LND can result in under-staging of patients, which decreases the likelihood of receiving adjuvant chemotherapy Highest rates of LND and highest rates of OS occurred at academic centers, despite patients at academic centers also treating higher stage disease LND for ≥ T1b - early referral to academic centers Conclusion
- 26. Review Articles
- 27. 3796 (2004 to 2016) HQS - cholecystectomy with partial hepatectomy, lymph node harvest≥6, and negative margins 364 (9.6%) met HQS criteria, and 3432 (90.4%) did not achieve HQS - improved median O.S (55.1 vs. 25.5 months, P<.001) Adjuvant chemotherapy (AC) was not able to rescue LQS with poorer survival compared to HQS without AC (27.9 vs 55.1 months, P<.001)
- 28. N = 1245 (2010 - 2021) T1b - 76 patients Conclusion: Nodal positivity for T1b - 21% Radical surgery with complete periportal lymphadenectomy should be considered as standard of care European Journal of Surgical Oncology 48 (2022)
- 29. N = 147 T2 GBC (2003 - 2012), T2a - 40 (27.2%) & T2b -107 (72.8%) Two groups A/T tumor location (T2a vs. T2b) Three groups A/T surgery (simple cholecystectomy, cholecystectomy with lymph node dissection and extended cholecystectomy) Comparison - OS & DFS according to T2 subgroups and surgery 5 Yr OS & DFS T2a - 75.0% vs 73.8% (p-0.653), T2b - 72.5% vs 70.1% (p-0.49) Surgical Oncology 40 (2022)
- 30. No survival difference among T2a gallbladder cancer A/T surgery T2b - extended cholecystectomy showed a better overall survival than simple cholecystectomy and cholecystectomy with lymph node dissection groups (p = 0.043 and p = 0.003 respectively) Conclusion: no difference in OS & DFS A/T location of T2 GBC Extended cholecystectomy increases OS in T2b Surgical Oncology 40 (2022)
- 31. ? Optimal categorization of nodal metastasis status Anatomical location of positive nodes (AJCC 7th N staging) Number of metastatic lymph nodes (NMLN) Log odds of metastatic LNs (LODDS) - natural logarithm of the ratio of the probability of metastatic to non-metastatic LNs Lymph node ratio (LNR) - Ratio of NMLN and total number of lymph nodes examined (TNLE)
- 32. N = 226 patients (2008-2013) Discriminative abilities assessed Most important factor - NMLN Conclusion NMLN was the optimal LN staging system in evaluating prognosis of GBC
- 33. N = 4760, pT1b-T3 GBC (2004 - 2017) 16.7% - sufficient lymphadenectomy Survival benefit - N0 (median OS 140.8 vs. 44.4 months; p < 0.0001) N1-2 disease (median OS 27.7 versus 17.7 months; p < 0.0001) Conclusion - majority of patients do not undergo recommended nodal dissection The American Journal of Surgery 224 (2022)
- 34. THANK YOU
Editor's Notes
- LND is a critical component of surgical intervention for patients with GBC. The likelihood of nodal metastases increases with T stage, reported as 12–15% in T1b disease, 17–46% in T2 disease, and at least 45.5–53.8% in T3 disease. Despite the prevalence of nodal metastases, population-wide studies have demonstrated that LND is grossly under-utilised. As many as 53.2% of patients with T1b disease, and 52.4% of patients with ≥ T2 disease, do not undergo LND.
- Patients with known nodal disease are significantly more likely to receive chemotherapy than patients with either confirmed node- negative disease or unknown nodal status.Therefore, omitting LND decreases the chance that a patient will receive adjuvant chemotherapy, which may be particularly detrimental if the patient has undiagnosed node-positive disease Current guidelines recommend surgery according to tumor (T) stage: simple cholecystectomy for T1a disease, and radical cholecystectomy (with hepatic resec- tion of the gallbladder fossa) with portal lymphadenectomy (LND) for T1b or greater.
- The primary objectives of this study are to describe national trends in LND utilization and identify patient predictors for receipt of LND. Additionally, we seek to comprehensively determine the impact of LND on overall survival (OS), with particular attention given to T stage-specific survival and rates of adjuvant chemotherapy.
- Patient and methods The data utilized in this study originated from a de-identified NCDB 2006–2015 To isolate a cohort of patients who underwent surgery with presumably curative intent for non-metastatic GBC,
- Patients with either clinical or pathologic stage coded as 0, 4, or missing were excluded (patients with pathologic T4 disease were excluded as well as this represented patho- logic stage IV disease). Patients who underwent an unknown surgical procedure or who underwent a local tumor excision/treatment (codes 20-29) were excluded. Patients with missing data related to pathologic T stage, the performance of a LND, or survival were all excluded. Finally, in order to distinguish between T1a and T1b patients more accurately, patients coded solely as patho- logic T1 (rather than either pT1a or pT1b) were excluded.
- Of this cohort, 1,343 patients (58.3%) underwent LND, while 959 (41.7%) did not receive a nodal staging procedure. The majority of patients in both groups were female (66.8%). Compared with patients who did not receive LND, patients who underwent lymphadnectomy were more likely to be younger (67.5 versus 72.6 years; p\ 0.001), have private health insurance (35.0% versus 21.6%; p \ 0.001), and be treated at an academic/research cancer program (46.4% versus 27.4%; p \ 0.001)
- Patients who underwent LND were found to have higher rates of nodal disease (47.3% versus 0.8%) and higher pathologic stage disease (stage IIIa–IIIb 57.9% versus 18.7%, p \ 0.001), more frequently underwent radical resection (18.6% versus 4.7%, p \ 0.001), and more fre- quently had negative surgical margins (80.9% versus 70.1%; p \ 0.001). Patients who underwent LND were more likely to receive any type of chemotherapy (46.2% versus 26.6%, p \ 0.001), multi-agent chemotherapy (21.0% versus 13.1%, p \ 0.001), and radiation therapy (30.2% versus 14.1%, p \ 0.001) relative to patients who did not ungero formal nodal staging.
- Other
- There was an increase in the frequency of LND over the study period (51.6% in 2006 versus 64.2% in 2015), with patients in 2015 significantly more likely to receive a LND than patients in 2006
- The strongest patient-related factor independently predictive of LND was private insurance (OR 3.06, CI 1.65–5.69), with younger age and female sex was also found to be significant predictors. Treatment at an academic center was independently predictive of LND when compared with treatment at any other site, with the greatest difference in likelihood seen when compared with community centers specifically (OR 2.86, CI 2.00–4.17). Surgical outcomes, including negative margins (OR 4.55, CI 1.89–11.11 compared with a macroscopically positive surgical margin) and radical surgery (OR 2.94, CI 4.76–1.85 compared with simple excision of the primary site), were also found to be associated with LND. Finally, patients with higher pathologic T-stage tumors were more likely to receive LND (pT3 versus pT1a, OR 2.62, CI 1.46–4.69).
- To further evaluate utilization by facility type, patients were grouped by facility type and rates of LND were compared. Frequency of LND was highest at academic centers among the entire cohort of patients (70.1%, all other facilities B 59.8%; p \ 0.001) and for each patho- logic T-stage subgroup except pT3 (highest rate at integrated network cancer programs) (Fig. 1). Patients treated at academic centers more frequently underwent radical surgery (p \ 0.001), received a margin-negative resection (p = 0.01),
- Patients treated at academic centers more frequently underwent radical surgery (p \ 0.001), received a margin-negative resection (p = 0.01), and were more frequently found to be node positive (p \ 0.001) (Table 3). There were no differences in overall rates of chemotherapy or radiation utilization (p = 0.10 and p = 0.32 overall, respectively), though academic centers more frequently gave neoadjuvant therapy (2.1%, all others B 0.8%, p = 0.03) and multiagent chemotherapy (21.3%, all others B 19.2%, p = 0.002).
- Kaplan–Meier analysis including all patients in the cohort compared the survival of three groups: patients who did not undergo LND, patients who underwent LND and were node negative, and patients who underwent LND and were node positive (Fig. 2a). Patients who underwent LND and were found to have no nodal disease had the best overall survival, while the survival curves of patients with node- positive disease and patients who did not undergo LND had similarly worse surviva Kaplan–Meier survival analysis overall (a) comparing patients who did not receive LND, patients who were node positive, and patients who were node negative. Patients were then stratified by T stage: b T1b, c T2, and d T3, and survival was compared between patients who received LND and patients who did not receive LND. LND lymphadenectomy. analysis was then performed after stratifying patients by T stage. Kaplan–Meier analyses were per- formed for each T stage and compared patients who received LND with those who did not. LND was associated with improved survival for T1b (p = 0.02; Fig. 2b), T2 (p\ 0.001; Fig. 2c), and T3 (p\0.001; Fig. 2d) disease, but not for T1a disease (p = 0.13). On Cox proportional hazards modeling (Table 5), patients with T2 disease who under- went LND had a 33% reduction in risk of death (HR 0.67, CI 0.56–0.81; p \ 0.001) and patients with T3 disease had a 27% reducion in risk of death (HR 0.73, CI 0.60–0.88; p\ 0.001) relative to those who did not receive a formal nodal staging procedure.
- Rates of adjuvant chemotherapy were higher among those who underwent LND. OS of patients without LND mirrored survival of node-positive patients. On subgroup analysis, LND was associated with improved survival in patients with T1b, T2, and T3 disease, though only those with T2 and T3 disease derived independent OS benefit. Finally, rates of LND were highest at academic/ research centers, and patients treated at these centers showed independent survival benefit.
- The current study demonstrates that OS within the T2 and T3 sub- groups was higher in the group of patients that underwent LND, and that patients who did not receive LND had survival similar to patients who were found to be node- positive. In this study, the performance of LND associated with a greater survival benefit in the current analysis than the receipt of adjuvant chemotherapy. This finding is likely multifactorial but generally reflects the fact that LND is a gateway to adjuvant therapy and a surrogate for quality of care, with the survival benefit seen in patients undergoing LND secondary to appropriate staging and increased like- lihood of appropriate adjuvant chemotherapy delivery Our results highlight the importance of treatment at an academic/research center, as both rates of LND and OS were higher. Concurrently, rates of adjuvant chemotherapy administration were relatively high at academic/research centers. As data gathered from a LND often influence the decision to give adjuvant chemotherapy, surgeons who are not comfortable performing a portal LND should consider referring these patients to an academic center.
- Recent studies have also shown that the number of nodes retrieved provides critical prognostic information as well. Retrieval of 4? lymph nodes,21 6? lymph nodes,22 and 8? lymph nodes23 have each been recommended as adequate for staging. Currently, the AJCC 8th edition recommends retrieval of at least 6 lymph nodes, and dis- tinguishes between 1–3 positive nodes (N1) and 4? positive nodes (N2) disease.24 Our study did not evaluate the effects of number of nodes retrieved during LND because the nodal count was not consistently recorded for all patients, and a prior study using NCDB data demon- strated that only 12.4% of eligible patients received a LND that included six or more lymph nodes.1 Similarly, in our study, only 23.9% of eligible patients received an adequate lymphadenectomy. Thus, we will not comment on the importance of retrieving six lymph nodes, but instead recommend a focus on wide dissemination of the need for any LND prior to focusing on improving the lymph node yields.
- There are a number of important limitations to our study. First, this study is retrospective and utilizes a dataset that includes cases from over a 10-year time period. Practice patterns and treatment algorithms may have changed during this time period. However, the NCDB captures a sufficient number of cases to represent national trends. Additionally, we did not evaluate the number of lymph nodes retrieved during LND to determine adequacy. As the AJCC 8th edition was not published during this cohort’s study period, we felt that retrospectively judging adequacy of LND by a standard unavailable at that time would be inequitable. However, the determination of adequate nodal resection warrants further consideration in the future and may also prove to be a useful benchmark for quality-of-care comparisons between centers.
- Portal LND remains significantly underutilized nation- wide for resectable GBC. When performed, LND appears to provide independent survival benefit for patients with pT2 and pT3 GBC. Failure to perform LND can result in under-staging of patients, which decreases the likelihood of receiving adjuvant chemotherapy. Finally, the highest rates of LND and highest rates of OS occurred at academic centers, despite patients at academic centers also treating higher stage disease. Based on these findings, we would continue to advocate for LND for all T1b and higher dis- ease, with early referral to academic centers if necessary to complete appropriate staging
- Methods The NCDB was queried for patients diagnosed with stage I–III (T1b-T3) GBC undergoing curative-intent surgery from 2004 to 2016. These patients were divided into two groups based on receiving high quality surgery (HQS) or not; HQS was defned as cholecystectomy with partial hepatectomy, lymph node harvest≥6, and negative margins. Logistic regression and Kaplan–Meier survival analyses were performed Results A total of 3796 patients met inclusion criteria; only 364 (9.6%) met HQS criteria, and 3432 (90.4%) did not achieve HQS and were deemed low-quality surgery (LQS). HQS was associated with improved median overall survival (55.1 vs. 25.5 months, P<.001). Adjuvant chemotherapy (AC) was not able to rescue LQS with poorer survival compared to HQS without AC (27.9 vs 55.1 months, P<.001). Factors associated with HQS included private insurance (OR 1.809, P<.001), higher income (OR 1.380, P=.038), urban/rural residence (vs metropolitan) (OR 1.641, P=.001), higher education (OR 1.342, P=.031), Medicaid expansion states (OR 1.405, P=.005), stage 3 GBC (OR 1.642, P=.020), and reresection (OR 2.685, P<.001). Factors associated with LQS included older age (OR 0.974, P<.001), comorbidities (OR 0.701, P=.004), and laparoscopic approach (0.579, P<.001). Facility type incrementally improved HQS rate (integrated cancer network vs. comprehensive community, 9.8% vs. 6.1%, OR 1.694, P=.003; academic/research center vs. integrated cancer network, 14.9% vs. 9.8%, OR 1.599, P=.003) Conclusion While HQS for GBC strongly improves survival, it is infrequently practiced. The newly identifed factors that improve survival for GBC, such as centralization, open approach, and insurance coverage, are modifable and, therefore, should be considered to achieve optimal outcomes
- Methodology: A retrospective review of a prospectively maintained database of GBC patients operated at our institute from March 2010 to March 2021 was conducted. Only patients with proven gallbladder adenocarcinoma on final histopathology report were included. Results: A total of 1245 patients of suspected GBC who underwent surgery during this period with 76 patients of T1b stage were analysed. We divided the group into a node positive cohort (n ¼ 16, 9 received neoadjuvant treatment due to uptake in periportal nodes and 7 patients were pN1) and a node negative cohort (n ¼ 60). The median nodal harvest was 8 nodes (2e24 nodes). Considering the radiological and pathological parameters, the rate of lymph node positivity was 21% (16/76). The overall major morbidity was 5.2% and there was no mortality. After a median follow up of 47.5 months, 3-year OS and DFS of the node negative and positive cohort was 96.7%, 91.7% and 75% and 62.5% (p ¼ 0.058). The node positive cohort had 43% recurrences whereas the node negative cohort had 8.3% with all recurrences limited to periportal lymph nodes, distant nodes or liver metastasis. Conclusion: Nodal positivity for T1b gall bladder cancer ranges around 21% and radical surgery with complete peri eportal lymphadenectomy should be considered as standard of care
- Methods: We retrospectively reviewed electronic medical records of 147 patients who underwent surgical resection for pathologically confirmed T2 gallbladder cancer between 2003 and 2012. Patients were categorized into two groups according to the tumor location (T2a vs. T2b) and three groups according to surgery method (simple cholecystectomy, cholecystectomy with lymph node dissection, and extended cholecystectomy). We compared the overall and disease-free survival rates according to T2 subgroups and surgery Results: The 5-year overall and disease-free survival rates were 75.0% vs. 73.8% (p = 0.653) and 72.5% vs. 70.1% (p = 0.479) in T2a and T2b gallbladder cancers, respectively.
- There was no difference in the survival rate among T2a gallbladder cancer according to the surgery method. However, in T2b gallbladder cancer, extended cholecystectomy showed a better overall survival than simple cholecystectomy and cholecystectomy with lymph node dissection groups (p = 0.043 and p = 0.003, respectively). Conclusions: There is no difference in overall and disease-free survival rates according to the location of T2 gallbladder cancers Extended cholecystectomy increases overall survival rate, especially in T2b gallbladder cancers.
- Controversy exists regarding optimal categorization of nodal metastasis status, including anatomical location of positive nodes (AJCC 7th N staging), number of metastatic lymph nodes (NMLN), log odds of metastatic LNs (LODDS) - LODDS is the natural logarithm of the ratio of the probability of metastatic to non-metastatic LNs, and lymph node ratio (LNR) - The LNR is the rate of NMLN and total number of lymph nodes examined (TNLE) Methods Patients who underwent curative-intent resection for GBC from six Chinese tertiary hospitals between 2008 and 2013 were analyzed retrospectively. The relative discriminative abilities of the different LN staging systems were assessed by different models including the tree-augmented naïve Bayesian (TAN) model, Cox proportional hazards regression model, and binary logistic regression model. Results A total of 226 patients were involved in this cohort. Based on the TAN model and composite importance measures, the most important factor affecting the prognosis in the different LN staging systems was NMLN. Among the four TAN models which were built with 4 metastatic LN markers and baseline variables, the accuracy of the NMLN-based prognostic model was 88.15%, higher than 7th N staging (86.44%), LNR (87.34%), and LODDS (85.19%). The Cox model based on NMLN (C-index: 0.763, AIC: 1371.62) had a higher fitness than the others (7th N staging C-index: 0.756, AIC: 1375.51; LNR C-index: 0.759, AIC: 1378.82; LODDS C-index 0.748, AIC: 1390.99). The AUCs of different staging binary logistic regression models were NMLN (0.872), LNR (0.872), 7th N staging (0.869) and LODDS (0.856), respectively. Conclusions NMLN was the optimal LN staging system in evaluating prognosis of GBC
- Patients who underwent curative-intent resection for GBC from six Chinese tertiary hospitals between 2008 and 2013 were analyzed retrospectively. The relative discriminative abilities of the different LN staging systems were assessed by different models including the tree-augmented naïve Bayesian (TAN) model, Cox proportional hazards regression model, and binary logistic regression model. Results A total of 226 patients were involved in this cohort. Based on the TAN model and composite importance measures, the most important factor affecting the prognosis in the different LN staging systems was NMLN. Among the four TAN models which were built with 4 metastatic LN markers and baseline variables, the accuracy of the NMLN-based prognostic model was 88.15%, higher than 7th N staging (86.44%), LNR (87.34%), and LODDS (85.19%). The Cox model based on NMLN (C-index: 0.763, AIC: 1371.62) had a higher fitness than the others (7th N staging C-index: 0.756, AIC: 1375.51; LNR C-index: 0.759, AIC: 1378.82; LODDS C-index 0.748, AIC: 1390.99). The AUCs of different staging binary logistic regression models were NMLN (0.872), LNR (0.872), 7th N staging (0.869) and LODDS (0.856), respectively. Conclusions NMLN was the optimal LN staging system in evaluating prognosis of GBC
- Methods: Patients with resected pT1b-T3 gallbladder adenocarcinoma were identified (2004–2017). Propensity scores were created for the odds of sufficient lymphadenectomy (≥6 nodes), patients were matched 1:1 and survival was analyzed using the Kaplan-Meier method. Results: Overall, 4760 patients were identified from the NCDB 16.7% underwent sufficient lymphadenectomy, which was predictive of nodal disease (OR 1.77, 95%CI 1.51–2.08) and demonstrated a survival benefit in N0 (median OS 140.8 versus 44.4 months; p < 0.0001) and N1-2 disease (median OS 27.7 versus 17.7 months; p < 0.0001) after matching. Conclusions: The majority of patients with gallbladder adenocarcinoma do not undergo the recommended nodal dissection, resulting in a survival disadvantage, likely due to understaging, decisions regarding adjuvant therapy and local tumor recurrence.