Ann Hepatobiliary Pancreat Surg.  2022 May;26(2):168-177. 10.14701/ahbps.21-126.

The prognostic value of the lymph node ratio in patients with distal cholangiocarcinoma after curative intended surgery: A single-center retrospective study

• Oh C
• Kim HJ
• Song SH
• Park EK
• Hur YH
• Koh YS
• Cho CK

• KMID: 2530096
• DOI: http://doi.org/10.14701/ahbps.21-126

Abstract

Backgrounds/Aims
The goal of the present study was to evaluate the prognostic value of lymph node ratio (LNR) in distal cholangiocarcinoma (DCC) after curative intended surgery.
Methods
Clinicopathological data of 162 DCC patients who underwent radical intended surgery between 2012 and 2020 were analyzed retrospectively. Prognostic factors related to overall survival (OS) and disease-free survival (DFS) were evaluated.
Results
Median OS time and DFS time were 41 and 29 months, and 5-year OS rate and DFS rate were 44.7% and 38.1%, respectively. In the univariate analysis, significant prognostic factors for OS were histologic differentiation, American Joint Committee on Cancer (AJCC) stage, positive lymph node count, LNR, R1 resection, and perineural invasion. Preoperative carcinoembryonic antigen, carbohydrate antigen 19-9, infiltrative type, histologic differentiation, AJCC stage, positive lymph node count, LNR, R1 resection, perineural invasion, and lymph-vascular invasion were significant prognostic factors for DFS in the univariate analysis. In the multivariate analysis, histologic differentiation, R1 resection, and LNR were the independent prognostic factors for both OS and DFS. The LNR ≥ 0.2 group had a significantly poor prognosis in terms of OS (hazard ratio, 3.915; p = 0.002) and DFS (hazard ratio, 5.840; p < 0.001).
Conclusions
LNR has significant value as a prognostic factor of DCC related to OS and DFS. LNR has the potential to be used as a modified staging system with furthermore studies.

Keyword

Cholangiocarcinoma; Pancreaticoduodenectomy; Lymph node ratio; Survival

Figure

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  Fig. 1 Cumulative overall survival ratio according to survival time (A), and cumulative disease-free survival according to survival time (B) in the LNR groups. Significant differences of survival in the LNR group were demonstrated. LNR, lymph node ratio.

Reference

1. Gonzalez RS, Bagci P, Basturk O, Reid MD, Balci S, Knight JH, et al. 2016; Intrapancreatic distal common bile duct carcinoma: analysis, staging considerations, and comparison with pancreatic ductal and ampullary adenocarcinomas. Mod Pathol. 29:1358–1369. DOI: 10.1038/modpathol.2016.125. PMID: 27469329. PMCID: PMC5598556.

2. Nakeeb A, Pitt HA, Sohn TA, Coleman J, Abrams RA, Piantadosi S, et al. 1996; Cholangiocarcinoma. A spectrum of intrahepatic, perihilar, and distal tumors. Ann Surg. 224:463–473. discussion 473–475. DOI: 10.1097/00000658-199610000-00005. PMID: 8857851. PMCID: PMC1235406.

3. Launois B, Reding R, Lebeau G, Buard JL. 2000; Surgery for hilar cholangiocarcinoma: French experience in a collective survey of 552 extrahepatic bile duct cancers. J Hepatobiliary Pancreat Surg. 7:128–134. DOI: 10.1007/s005340050166. PMID: 10982604.

4. Murakami Y, Uemura K, Sudo T, Hashimoto Y, Nakashima A, Kondo N, et al. 2011; Prognostic factors after surgical resection for intrahepatic, hilar, and distal cholangiocarcinoma. Ann Surg Oncol. 18:651–658. DOI: 10.1245/s10434-010-1325-4. PMID: 20945107.

5. Kim BH, Kim K, Chie EK, Kwon J, Jang JY, Kim SW, et al. 2017; Long-term outcome of distal cholangiocarcinoma after pancreaticoduodenectomy followed by adjuvant chemoradiotherapy: a 15-year experience in a single institution. Cancer Res Treat. 49:473–483. DOI: 10.4143/crt.2016.166. PMID: 27554480. PMCID: PMC5398409.

6. Strijker M, Belkouz A, Van Der Geest LG, Van Gulik TM, Van Hooft JE, De Meijer VE, et al. 2019; Treatment and survival of resected and unresected distal cholangiocarcinoma: a nationwide study. Acta Oncol. 58:1048–1055. DOI: 10.1080/0284186X.2019.1590634. PMID: 30907207.

7. Hayashi H, Jang JY, Kim KS, Choi JS, Takahara T, Choi SH, et al. 2020; Comparison of pancreaticoduodenectomy and bile duct resection for middle bile duct cancer: a multi-center collaborating study of Japan and Korea. J Hepatobiliary Pancreat Sci. 27:289–298. DOI: 10.1002/jhbp.724. PMID: 32048467. PMCID: PMC7384139.

8. Lee HG, Lee SH, Yoo DD, Paik KY, Heo JS, Choi SH, et al. 2009; Carcinoma of the middle bile duct: is bile duct segmental resection appropriate? World J Gastroenterol. 15:5966–5971. DOI: 10.3748/wjg.15.5966. PMID: 20014461. PMCID: PMC2795184.

9. Schreuder AM, Engelsman AF, Van Roessel S, Verheij J, Besselink MG, Van Gulik TM, et al. 2019; Treatment of mid-bile duct carcinoma: local resection or pancreatoduodenectomy? Eur J Surg Oncol. 45:2180–2187. DOI: 10.1016/j.ejso.2019.06.032. PMID: 31279596.

10. Akita M, Ajiki T, Ueno K, Tsugawa D, Tanaka M, Kido M, et al. 2020; Benefits and limitations of middle bile duct segmental resection for extrahepatic cholangiocarcinoma. Hepatobiliary Pancreat Dis Int. 19:147–152. DOI: 10.1016/j.hbpd.2020.01.002. PMID: 32037277.

11. Komaya K, Ebata T, Shirai K, Ohira S, Morofuji N, Akutagawa A, et al. 2017; Recurrence after resection with curative intent for distal cholangiocarcinoma. Br J Surg. 104:426–433. DOI: 10.1002/bjs.10452. PMID: 28138968.

12. Ercolani G, Dazzi A, Giovinazzo F, Ruzzenente A, Bassi C, Guglielmi A, et al. 2015; Intrahepatic, peri-hilar and distal cholangiocarcinoma: three different locations of the same tumor or three different tumors? Eur J Surg Oncol. 41:1162–1169. DOI: 10.1016/j.ejso.2015.05.013. PMID: 26095704.

13. Sakata J, Wakai T, Matsuda Y, Ohashi T, Hirose Y, Ichikawa H, et al. 2016; Comparison of number versus ratio of positive lymph nodes in the assessment of lymph node status in extrahepatic cholangiocarcinoma. Ann Surg Oncol. 23:225–234. DOI: 10.1245/s10434-015-4609-x. PMID: 25994208.

14. Kim HJ, Kim CY, Hur YH, Koh YS, Kim JC, Kim HJ, et al. 2014; Prognostic factors for survival after curative resection of distal cholangiocarcinoma: perineural invasion and lymphovascular invasion. Surg Today. 44:1879–1886. DOI: 10.1007/s00595-014-0846-z. PMID: 24535697.

15. Kawai M, Tani M, Kobayashi Y, Tsuji T, Tabuse K, Horiuchi T, et al. 2010; The ratio between metastatic and examined lymph nodes is an independent prognostic factor for patients with resectable middle and distal bile duct carcinoma. Am J Surg. 199:447–452. DOI: 10.1016/j.amjsurg.2009.01.019. PMID: 19596119.

16. Kiriyama M, Ebata T, Aoba T, Kaneoka Y, Arai T, Shimizu Y, et al. 2015; Prognostic impact of lymph node metastasis in distal cholangiocarcinoma. Br J Surg. 102:399–406. DOI: 10.1002/bjs.9752. PMID: 25611179.

17. Murakami Y, Uemura K, Hayashidani Y, Sudo T, Ohge H, Sueda T. 2007; Pancreatoduodenectomy for distal cholangiocarcinoma: prognostic impact of lymph node metastasis. World J Surg. 31:337–342. discussion 343–344. DOI: 10.1007/s00268-006-0224-0. PMID: 17006609.

18. Andrianello S, Paiella S, Allegrini V, Ramera M, Pulvirenti A, Malleo G, et al. 2015; Pancreaticoduodenectomy for distal cholangiocarcinoma: surgical results, prognostic factors, and long-term follow-up. Langenbecks Arch Surg. 400:623–628. DOI: 10.1007/s00423-015-1320-0. PMID: 26134446.

19. Lyu S, Li L, Zhao X, Ren Z, Cao D, He Q. 2020; Prognostic impact of lymph node parameters in distal cholangiocarcinoma after pancreaticoduodenectomy. World J Surg Oncol. 18:262. DOI: 10.1186/s12957-020-02040-1. PMID: 33032609. PMCID: PMC7545845.

20. Byrling J, Andersson R, Sasor A, Lindell G, Ansari D, Nilsson J, et al. 2017; Outcome and evaluation of prognostic factors after pancreaticoduodenectomy for distal cholangiocarcinoma. Ann Gastroenterol. 30:571–577. DOI: 10.20524/aog.2017.0169. PMID: 28845114. PMCID: PMC5566779.

21. Li X, Lin H, Sun Y, Gong J, Feng H, Tu J. 2019; Prognostic significance of the lymph node ratio in surgical patients with distal cholangiocarcinoma. J Surg Res. 236:2–11. DOI: 10.1016/j.jss.2018.10.044. PMID: 30694756.

22. Oshiro Y, Sasaki R, Kobayashi A, Murata S, Fukunaga K, Kondo T, et al. 2011; Prognostic relevance of the lymph node ratio in surgical patients with extrahepatic cholangiocarcinoma. Eur J Surg Oncol. 37:60–64. DOI: 10.1016/j.ejso.2010.10.011. PMID: 21094016.

23. You Y, Shin YC, Choi DW, Heo JS, Shin SH, Kim N, et al. 2020; Proposed modification of staging for distal cholangiocarcinoma based on the lymph node ratio using Korean Multicenter Database. Cancers (Basel). 12:762. DOI: 10.3390/cancers12030762. PMID: 32213853. PMCID: PMC7140100.

24. Ito K, Ito H, Allen PJ, Gonen M, Klimstra D, D'Angelica MI, et al. 2010; Adequate lymph node assessment for extrahepatic bile duct adenocarcinoma. Ann Surg. 251:675–681. DOI: 10.1097/SLA.0b013e3181d3d2b2. PMID: 20224368.