Clinical implications and optimal extent of lymphadenectomy for intrahepatic cholangiocarcinoma: A multicenter analysis of the therapeutic index

Abstract

Aims Lymph node metastases (LNM) are associated with lethal prognosis in intrahepatic cholangiocarcinoma (ICC). Lymphadenectomy is crucial for accurate staging and hopes of possible oncological treatment. However, the therapeutic implications and optimal extent of lymphadenectomy remain contentious. Methods To clarify the prognostic value and optimal extent of lymphadenectomy, the therapeutic index (TI) for each lymph node was analyzed for 279 cases that had undergone lymphadenectomy in a multi‐institutional database. Tumor localization was divided into hilar lesions (n = 130), right peripheral lesions (n = 60), and left peripheral lesions (n = 89). In addition, the lymph node station was classified as Level 1 (LV1: hepatoduodenal ligament node), Level 2 (LV2: postpancreatic or common hepatic artery nodes), or Level 3 (LV3: gastrocardiac, left gastric artery, or celiac artery nodes). Results Lymph node metastases were confirmed in 109 patients (39%). Five‐y survival rates were 45.3% for N0 disease, 27.1% for LV1‐LNM, 22.9% for LV2‐LNM, and 7.3% for LV3‐LNM ( P < 0.001). LV3‐LNM were the most frequent and earliest recurrence outcome, including multisite recurrence, followed by LV2, LV1, and N0 disease. The 5‐year TI (5year‐TI) for lymphadenectomy was 7.2 for LV1, 5.5 for LV2, and 1.9 for LV3. Regarding tumor location, hilar lesions showed 5‐year TI >5.0 in LV1 and LV2, whereas bilateral peripheral lesions showed 5‐year TI > 5.0 in LV1. Conclusion The implications and extent of lymphadenectomy for ICC appear to rely on tumor location. In the peripheral type, the benefit of lymphadenectomy would be limited and dissection beyond LV1 should be avoided, while in the hilar type, lymphadenectomy up to LV2 could be recommended.

Intrahepatic cholangiocarcinoma with extensive intraductal extension of high-grade biliary intraepithelial neoplasia: a case report

“…Umeda Y et al reported that hilar lesions exhibited the highest rate of LNM at 44% (57 out of 130). They discussed the therapeutic implications of LND in cases of hilar lesions and suggested extending LND to include postpancreatic head or common hepatic artery nodes [ 23 ].…”

How to interpret the results of clinical studies: “Multicenter cutting‐edge study” or “real‐world big data study”?

“…Umeda et al have proposed the appropriate extent of lymphadenectomy in surgery for intrahepatic cholangiocarcinoma according to tumor location, by a multicenter data analysis of the therapeutic index of 279 patients (DOI:10.1002/ags3.12631). 1 By a multicenter retrospective cohort study of 1,623 patients followed by propensity score matching (PSM), Nakatsutsumi et al have revealed that the prophylactic use of negative‐pressure wound therapy with delayed sutures was associated with a lower incidence of incisional surgical site infection after emergency laparotomy for colorectal perforation. 2 If the number of subjects is large, PSM can be used to adjust background factors and obtain reliable results with scientifically valid analyses.…”