Cancer Res Treat.  2020 Apr;52(2):455-468. 10.4143/crt.2019.271.

Validation of the 8th Edition of the American Joint Committee onCancer Staging System for Gallbladder Cancer and Implications forthe Follow-up of Patients without Node Dissection

• Sung YN
• Song M
• Lee JH
• Song KB
• Hwang DW
• Ahn CS
• Hwang S
• Hong SM

• KMID: 2500331
• DOI: http://doi.org/10.4143/crt.2019.271

Abstract

Purpose
The 8th edition of gallbladder cancer staging in the American Joint Committee on Cancer (AJCC) staging system changed the T and N categories.
Materials and Methods
In order to validate the new staging system, a total of 348 surgically resected gallbladder cancers were grouped based on the 8th edition of the T and N categories and compared with patients’ survival.
Results
Significant differences were noted between T1b-T2a (p=0.003) and T2b-T3 (p < 0.001) tumors, but not between Tis-T1a, T1a-T1b, and T2a-T2b tumors. However, significant survival differences were observed both by the overall and pair-wise (T1-T2, T2-T3) comparisons (all, p < 0.001) without dividing T1/T2 subcategories. When cases with ! 6 examined lymph nodes were evaluated, significant survival differences were observed among the entire comparison (p < 0.001) and pair-wise comparisons of N0-N1 (p=0.001) and N1-N2 (p=0.039) lesions. When cases without nodal dissection (NX) were additionally compared, significant survival differences were observed between patients with N0-NX (p=0.001) and NX-N1 (p < 0.001) lesions.
Conclusion
The T category in the 8th edition of the AJCC staging system did not completely stratify the prognosis of patients with gallbladder cancer. Modification by eliminating T subcategories can better stratify the prognosis. In contrast, the N category clearly determines patients’ survival with ! 6 examined lymph nodes. The survival time in patients of gallbladder cancers without nodal dissection is between N0 and N1 cases. Therefore, close postoperative followed up is recommended for those patients.

Keyword

Gallbladder; Cancer; Stage; Survival; Prognosis

Figure

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  Fig. 1. Representative images of the T category of the 8th American Joint Committee on Cancer staging system scheme based on cancer cell infiltration. Cancer cells infiltrate to the lamina propria, T1a (×200) (A), muscle layer, T1b (×100) (B), peritoneal side of the perimuscular connective tissue, T2a (×100) (C), hepatic side of the perimuscular connective tissue, T2b (×100) (D), penetrates the serosa, T3 (×100) (E), to the liver parenchyma, T3 (magnification, ×100) (F).

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  Fig. 2. The overall (OS) and recurrence-free survival (RFS) according to the T categories of the 7th and 8th American Joint Committee on Cancer (AJCC) staging system scheme. The OS (A) and RFS (B) in patients with gallbladder cancer according to the T category of the 7th edition; significant differences were observed in the overall (p < 0.001) and pair-wise comparisons between T1b-T2 (p=0.001) and T2-T3 (p < 0.001) tumors, except for Tis-T1a (p=0.482) and T1a-T1b (p=0.387) lesions. The OS (C) and RFS (D) of patients with gallbladder cancer according to the T category in the 8th edition; significant differences were observed in the OS in overall comparisons (p < 0.001) and pair-wise comparisons between T1b-T2a (p=0.003) and T2b-T3 (p < 0.001) tumors. The OS (E) and RFS (F) of patients with gallbladder cancer according to the T category in the 8th edition without subdivision; significant differences were observed in the OS in overall (p < 0.001) and pair-wise comparisons between T1-T2 (p < 0.001) and T2-T3 (p < 0.001) tumors.

• 

  Fig. 3. The overall (OS) and recurrence-free survival (RFS) according to N categories of the 7th and 8th American Joint Committee on Cancer (AJCC) staging system scheme including patients without lymph node dissection as NX. The OS (A) and RFS (B) of patients with gallbladder cancer according to the N category of the 7th edition including NX. A significant difference was also observed in overall comparisons (p < 0.001) and pair-wise comparisons of N0-N1 (p < 0.001) lesions. The OS (C) and RFS (D) of patients with gallbladder cancer according to the N category in the 8th edition including NX. A significant difference was observed in overall (p < 0.001) and pair-wise comparisons of N0-N1 (p < 0.001), N0-NX (p=0.001), and NX-N1 (p < 0.001).

• 

  Fig. 4. The overall (OS) and recurrence-free survival (RFS) according to N categories of the 7th and 8th editions of the American Joint Committee on Cancer (AJCC) staging system scheme based on number of examined lymph nodes. The OS (A) and RFS (B) in patients with gallbladder cancer according to the N category of the 7th edition scheme with ≥ 6 examined lymph nodes. A significant difference was observed in overall (p < 0.001) and pair-wise comparisons of N0-N1 (p < 0.001) lesions. The OS (C) and RFS (D) of patients with gallbladder cancer according to the N category of the 8th edition scheme with ≥ 6 examined lymph nodes. A significant difference was noted in OS in overall (p < 0.001) and pair-wise comparisons of N0-N1 (p=0.001) and N1-N2 (p=0.039) lesions. The OS (E) and RFS (F) of patients with gallbladder cancer according to the N category of the 7th edition in a subgroup with 1-5 examined lymph nodes. A significant difference was observed in overall (p < 0.001) and pair-wise comparisons of N0-N1 (p < 0.001). The OS (G) and RFS (H) of patients with gallbladder cancer according to the N category of the 8th edition in a subgroup with 1-5 examined lymph nodes. A significant difference in the OS was observed in overall (p < 0.001) and pair-wise comparisons of N0-N1 (p < 0.001).

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  Fig. 5. The overall (OS) and recurrence-free survival (RFS) according to stage grouping of the 7th and 8th editions of the American Joint Committee on Cancer (AJCC) staging system. The OS (A) and RFS (B) of patients with gallbladder cancer according to the stage grouping of the 7th edition scheme; significant differences in the OS were observed in overall comparisons (p < 0.001) and the pair-wise comparisons of stages II and IIIA (p=0.009). The OS (C) and RFS (D) of patients with gallbladder cancer according to the stage grouping of the 8th edition scheme; significant differences in the OS were observed in overall (p < 0.001) and the pair-wise comparisons between stage IIB and IIIA (p=0.018).

Reference

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