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Adequate Lymph Node Assessment

for Extrahepatic Bile Duct

Adenocarcinoma

Kaori Ito, MD, Hiromichi Ito, MD, Peter J. Allen, MD,

Mithat Gonen, PhD

Memorial Sloan-Kettering Cancer Center, New York, NY.

Annals of Surgery April 2010


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Introduction Extrahepatic bile duct cancer (EHBDCA)

(adenocarcinoma)

Hilar cholangiocarcinoma (HCCA)

arising from the biliary confluence or from the

right or left hepatic ducts

Distal bile duct adenocarcinoma (DBDCA, excluding

gallbladder cancer )

arising from the bile duct distal to the insertionof the cystic duct.


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United States incidence of 1 to 2/100,000/yr

5-year survival rate after resection : 20% to 45%

Nodal metastasis is one of the most significantindependent prognostic outcome variables.

The current American Joint Committee on Cancer

(AJCC) staging system 6th

(2002) analysis of a minimum of 3 regional LNs

absence (N0) or presence (N1) of regional LN metastasis

However, this minimum extent of lymphadenectomy isnot supported by recent studies.

In 2007, a report using the SEER database, analyzing20,068 patients with gallbladder cancer, ampullary cancer,and EHBDCA suggested that at least 10 LNs should beexamined for the accurate LN staging . -- Schwarz RE,Smith DD. J Gastrointest Surg. 2007;11:158 165.


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METHODS

257 patients (144 HCCA and 113 DBDCA) who underwentcurative intent resection for EHBDCA at Memorial Sloan-Kettering Cancer Center between 1987 and 2007.

Hilar tumors : partial hepatectomy, bile duct resection,and porta hepatis lymphadenectomy en bloc.

from the level of the common hepatic artery on the left andthe retroduodenal area on the right and extending upwardsto the base of the liver

Distal tumors : pancreaticoduodenectomy, either

standard or pylorus preserving with en bloc regionallymphadenectomy

periduodenal, peripancreatic, cystic duct, and common bileduct nodes


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RESULTS


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Impact ofLNMetastasis on Survival

The same analyses were performed in HCCA

patients and DBDCA patients separately, and

the results were remarkably similar.


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When focusing only on the 138 EHBDCA

patients who underwent an R0 resection andwere classified as N0, a linear positive

correlation between TLNC and DSS was

observed using local regression for censored

data.

EHBDCA HCCA DBDCA


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TLNC cut-off value for 206 EHBDCA patients

who underwent R0 resection (including bothN0 and N1 )

Based on the maximal X2 test, the optimal TLNC

was determined to be 11.


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HCCA : 7

DBDCA : 11


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Influence ofNodal Stage on

Decision Making for

Adjuvant Therapy After R0 Resection Forty-five patients (17.5%) received

chemotherapy and/or chemoradiation therapy in

the adjuvant setting after surgery. R0 resections (n = 206) received adjuvant therapy

N0 : 14/138, 10.1%

N1 : 18/68, 26.5%

However, there were no difference in DSSbetween patients who received adjuvant therapyand those who did not (31.5 6.0 vs. 38.5 4.7months, respectively, P =0.304).


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DISCUSSION

Recommendations for the minimum number

of LNs to be examined in gastric, Colorectal,

and pancreatic cancer resection specimens are

established.

Although the AJCC recommendation for

EHBDCA suggests that at least 3 LNs should be

examined, the rationale for this statement isunclear.


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Nodal metastasis is an independent predictor

of worse survival.

In patients staged as N0, the TLNC correlates

with DSS.

the optimum cut-off TLNC EHBDCA : 11

HCCA : 7

DBDCA : 11


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The possibility of a therapeutic effect of the

lymphadenectomy ??

The clinical benefits of lymphadenectomy for

EHBDCA are likely to be small, if any.

Kitagawa Y et al (Ann Surg. 2001;233:385392)

110 patients with HCCA underwent both regional andparaaortic lymphadenectomy

A median 24 LNs were retrieved

The DSS of patients with paraaortic LN metastasis was

similar to M1 patients Survival is not influenced by the extent of

lymphadenectomy but rather by the presence of

metastatic disease.


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Lymphadenectomy staging post-

resection treatment outcome ?? No prospective randomized trial has shown a

benefit of adjuvant therapy

Not because of a lack of effective agents

Several phase II studies have documented the

activity of a number of systemic regimens

the rarity of the disease and the difficulty of

completing an adequately powered study

Disease stage could impact treatment

recommendations and referral for such treatment.


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CONCLUSION

AJCC recommendations results in understaging

of EHBDCA.

AJCC should reconsider recommendations

regarding the optimal lymph node harvest.

AJCC should consider hilar cholangiocarcinoma

and distal bile duct adenocarcinoma separately.


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THANKS FOR YOUR ATTENSION

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