0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Association of Lymph Node Status With Survival in Patients After Liver Resection for Hilar Cholangiocarcinoma in an Italian Multicenter Analysis ONLINE FIRST

Felice Giuliante, MD1; Francesco Ardito, MD1; Alfredo Guglielmi, MD2; Luca Aldrighetti, MD3; Alessandro Ferrero, MD4; Fulvio Calise, MD5; Stefano M. Giulini, MD6; Elio Jovine, MD7; Claudio Breccia, MD1; Agostino M. De Rose, MD1; Antonio D. Pinna, MD8; Gennaro Nuzzo, MD1
[+] Author Affiliations
1Hepatobiliary Surgery Unit, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy
2Division of General Surgery A, Department of Surgery, University of Verona, Verona, Italy
3Liver Unit, San Raffaele Hospital, Milan, Italy
4Department of Digestive and Hepatobiliary Surgery, Mauriziano Umberto I Hospital, Turin, Italy
5Unit of Hepatobiliary Surgery and Liver Transplantation, Cardarelli Hospital, Naples, Italy
6Department of Medical and Surgical Sciences, Surgical Clinic, Brescia University, Brescia, Italy
7Department of Surgery, Maggiore Hospital, Bologna, Italy
8Department of Surgery and Transplantation, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
JAMA Surg. Published online August 24, 2016. doi:10.1001/jamasurg.2016.1769
Text Size: A A A
Published online

Importance  The prognostic value of lymph node (LN) assessment after liver resection for hilar cholangiocarcinoma (HC) is still controversial, and the number of LNs required to be removed to obtain adequate staging is not well defined.

Objectives  To evaluate the LN status in patients after liver resection for HC and to clarify which prognostic factor (the number of positive LNs or the LN ratio [LNR]) was most accurate for staging and what minimum number of retrieved LNs was required for adequate staging.

Design, Setting, and Participants  Retrospective multicenter study of patients who underwent resection for HC between January 1, 1992, and December 31, 2007, at 8 hepatobiliary Italian centers. The last follow-up was assessed in July 2014.

Main Outcome and Measures  Differences in overall survival (OS) according to the LN status were analyzed. The OS results were defined as actual because all included patients completed a 5-year follow-up.

Results  One-hundred seventy-five patients with 1133 retrieved LNs were analyzed. The mean (SD) age of the cohort was 63 (10) years, and 42.9% (75 of 175) were female. The median number of LNs examined per patient was 6.5. Forty percent (70 of 175) had LN metastasis. An LNR exceeding 0.20 was associated with significantly lower 5-year OS than an LNR of 0.20 or less (10.6% vs 24.4%; odds ratio, 2.434; 95% CI, 1.020-5.810; P = .04). On multivariable analysis, the LNR was the only independent prognostic factor for OS but was influenced by the total number of retrieved LNs. The LNR was greater than 0.20 in all patients (30 of 30) with 1 to 4 retrieved LNs and in 52.5% (21 of 40) of patients with at least 5 retrieved LNs. Five-year OS in patients with 1 to 5 retrieved LNs was significantly lower than that in those with 6 to 7 retrieved LNs and those with at least 8 retrieved LNs (34.2%, 64.5%, and 62.7%, respectively; P = .047). Five-year OS did not significantly improve when the number of retrieved LNs was greater than 6. These results were confirmed in a receiver operating characteristic curve analysis performed among N0R0 patients, in whom 5 retrieved LNs was the most accurate cutoff to predict 5-year actual OS (area under the curve, 0.624; P = .004).

Conclusions and Relevance  An LNR exceeding 0.20 was the only independent prognostic factor for OS in N1 patients after liver resection for HC. However, the LNR was influenced by the total number of retrieved LNs, and removal of more than 5 LNs was the minimum number of LNs required for adequate staging.

Figures in this Article

Figures

Place holder to copy figure label and caption
Figure 1.
Five-Year Overall Survival in Patients With Lymph Node Metastasis According to the Lymph Node Ratio (LNR)

An LNR exceeding 0.20 was associated with significantly lower 5-year overall survival than an LNR of 0.20 or less (10.6% vs 24.4%, P = .04).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Association of the Total Lymph Node Count With Overall Survival and Receiver Operating Characteristic Curve Analysis

A, Five-year overall survival in patients with 1 to 5 retrieved lymph nodes (LNs) was significantly lower than that in patients with 6 to 7 retrieved LNs and in patients with 8 or more retrieved LNs (34.2%, 64.5%, and 62.7%, respectively; P = .047). B, Five retrieved LNs was the most accurate cutoff to predict 5-year actual overall survival (area under the curve, 0.624; P = .004).

Graphic Jump Location

Tables

References

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

159 Views
0 Citations
×

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
brightcove.createExperiences();