Birnbaum David Jérémie, Viganò Luca, Russolillo Nadia, Langella Serena, Ferrero Alessandro, Capussotti Lorenzo
Department of HPB and Digestive Surgery, Ospedale Mauriziano "Umberto I", Largo Turati 62, 10128, Turin, Italy.
Ann Surg Oncol. 2015 Mar;22(3):811-8. doi: 10.1245/s10434-014-4044-4. Epub 2014 Sep 9.
Lymph node (LN) status is one of the strongest prognostic factors after gallbladder cancer (GBC) resection. The adequate extension of LN dissection and the stratification of the prognosis in N+ patients have been debated. The present study aims to clarify these issues.
A total of 112 consecutive patients who underwent operations for GBC with LN dissection were analyzed. Twenty-five patients (22.3%) had D1 dissection (hepatic pedicle), and 87 (77.7%) had D2 dissection (hepatic pedicle, celiac and retro-pancreatic area). The LN ratio (LNR) was computed as follows: number of metastatic LNs/number of retrieved LNs.
The median number of retrieved LNs was 7 (1-35). Fifty-nine patients (52.7%) had LN metastases (22 N2). D2 dissection allowed the retrieval of more LNs (8 vs. 3, p = 0.0007), with similar short-term outcomes. Common bile duct (CBD) resection (n = 41) did not increase the number of retrieved LNs. In five patients, D2 dissection identified skip LN metastases that otherwise would have been missed. LN metastases negatively impacted survival (5-years survival 57.2% if N0 vs. 12.4% if N+, p < 0.0001), but N1 and N2 patients had similar survival rates. The number of LN+ (1-3 vs. ≥4) did not impact prognosis. An LNR = 0.15 stratified the prognosis of N+ patients: 5-years survival 32.7% if LNR ≤ 0.15 vs. 10.3% if LNR > 0.15 (multivariate analysis p = 0.007).
A D2 LN dissection is recommended in all patients, because it allows for better staging. CBD resection does not improve LN dissection. An LNR = 0.15, not the site of metastatic LNs, stratified the prognoses of N+ patients.
淋巴结（LN）状态是胆囊癌（GBC）切除术后最强的预后因素之一。淋巴结清扫的适当范围以及N+患者预后的分层一直存在争议。本研究旨在阐明这些问题。
对112例连续接受GBC手术并进行淋巴结清扫的患者进行分析。25例患者（22.3%）行D1清扫（肝蒂），87例（77.7%）行D2清扫（肝蒂、腹腔干和胰后区域）。淋巴结转移率（LNR）计算如下：转移淋巴结数/获取淋巴结数。
获取淋巴结的中位数为7个（1 - 35个）。59例患者（52.7%）有淋巴结转移（22例为N2）。D2清扫能获取更多淋巴结（8个对3个，p = 0.0007），短期结局相似。胆总管（CBD）切除（n = 41）未增加获取淋巴结的数量。在5例患者中，D2清扫发现了跳跃性淋巴结转移，否则这些转移会被漏诊。淋巴结转移对生存有负面影响（N0患者5年生存率为57.2%，N+患者为12.4%，p < 0.0001），但N1和N2患者的生存率相似。阳性淋巴结数量（1 - 3个对≥4个）不影响预后。LNR = 0.15可对N+患者的预后进行分层：LNR≤0.15时5年生存率为32.7%，LNR > 0.15时为10.3%（多因素分析p = 0.007）。
建议对所有患者行D2淋巴结清扫，因为其能更好地进行分期。CBD切除并不能改善淋巴结清扫效果。LNR = 0.15而非转移淋巴结的部位可对N+患者的预后进行分层。
