A tailored approach in lymph node-positive perihilar cholangiocarcinoma

Abstract

Purpose Extended right hepatectomy is associated with wide surgical margins in PHC and often favored for oncological considerations. However, it remains uncertain whether established surgical principles also apply to the subgroup of node-positive patients. The aim of the present study was to define a tailored surgical approach for patients with perihilar cholangiocarcinoma (PHC) and lymph node metastases. Methods We reviewed the course of all consecutive patients undergoing major hepatectomy for PHC between 2005 and 2015 at the Department of Surgery, Charité – Universitätsmedizin Berlin. Results Two hundred and thirty-one patients underwent major hepatectomy for PHC with 1-, 3-, and 5-year overall (OS) and disease-free survival (DFS) rates of 72%, 48%, and 36%, and 60%, 22%, and 12%, respectively. In lymph node-positive patients (n = 109, 47%), extended left hepatectomy was associated with improved OS and DFS, respectively, when compared to extended right hepatectomy (p = 0.008 and p = 0.003). Interestingly, OS and DFS did not differ between R0 and R1 resections in those patients (both p = ns). Patients undergoing extended left hepatectomy were more likely to receive adjuvant chemotherapy (p = 0.022). This is of note as adjuvant chemotherapy, besides grading (p = 0.041), was the only independent prognostic factor in node-positive patients (p=0.002). Conclusion Patients with node-positive PHC might benefit from less aggressive approaches being associated with lower morbidity and a higher chance for adjuvant chemotherapy. Lymph node sampling might help to guide patients to the appropriate surgical approach according to their lymph node status.

Impact of Positive Lymph Nodes and Resection Margin Status on the Overall Survival of Patients with Resected Perihilar Cholangiocarcinoma: The ENSCCA Registry

“…Previous studies reported comparable differences between the survival rates for patients with and without lymph node involvement [4,6,19]. For patients with locally advanced disease who do not undergo resection, median OS rates of 12 months are reported.…”

Textbook outcome after major hepatectomy for perihilar cholangiocarcinoma — definitions and influencing factors

“…Although R0 status was part of the TO definition in half of the TO studies [13,17,19,20], we decided not to include it in the definition of TO in PHC surgery for several reasons. First, the perihilar region is narrow and R1 resection is not uncommon in PHC surgery [28][29][30] and patients benefit from surgical resection even in case R1 status is obtained. Second, especially in the subset of lymph nodepositive patients which counts up to almost 50%, survival is independent of R status [30].…”

“…First, the perihilar region is narrow and R1 resection is not uncommon in PHC surgery [28][29][30] and patients benefit from surgical resection even in case R1 status is obtained. Second, especially in the subset of lymph nodepositive patients which counts up to almost 50%, survival is independent of R status [30]. Third, PHC surgery is characterized by high perioperative morbidity and mortality.…”

Clinical efficacy of adjuvant treatments for patients with resected biliary tract cancer: a systematic review and network meta-analysis

“…Nineteen studies comprising a total of 5595 patients who received one of the following four different treatments after radical resection—ACT, ART, ACRT and surgical resection alone (observation group)—were included in our analysis. It is worth noting that 34 studies11 41–73 were excluded because of unbalanced or unclear baselines. Of the included patients, 2774 patients received adjuvant treatments following curative-intent resection, and 2821 patients underwent curative-intent resection without adjuvant treatments.…”