Hepatobiliary Surgery Unit, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy.
Division of General Surgery A, Department of Surgery, University of Verona, Verona, Italy.
JAMA Surg. 2016 Oct 1;151(10):916-922. doi: 10.1001/jamasurg.2016.1769.
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.
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.
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.
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).
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.
肝门部胆管癌（HC）肝切除术后淋巴结（LN）评估的预后价值仍存在争议，并且为获得充分分期所需切除的 LN 数量也尚未明确。
评估 HC 肝切除术后患者的 LN 状态，并阐明哪种预后因素（阳性 LN 数量或 LN 比[LNR]）对分期最准确，以及需要获取多少个 LN 才能进行充分分期。
设计、地点和参与者：对 1992 年 1 月 1 日至 2007 年 12 月 31 日期间在意大利 8 个肝胆中心行 HC 切除术的患者进行回顾性多中心研究。最后一次随访评估于 2014 年 7 月进行。
根据 LN 状态分析总生存率（OS）的差异。OS 结果被定义为实际结果，因为所有纳入的患者都完成了 5 年随访。
对 175 例患者的 1133 个 LN 进行了分析。队列的平均（SD）年龄为 63（10）岁，42.9%（75/175）为女性。每位患者检查的平均 LN 数量为 6.5。40%（70/175）存在 LN 转移。LNR 超过 0.20 与 0.20 或更低的 5 年 OS 显著相关（10.6%比 24.4%；比值比，2.434；95%CI，1.020-5.810；P=0.04）。多变量分析显示，LNR 是 OS 的唯一独立预后因素，但受总 LN 数量的影响。在总 LN 数量为 1 至 4 个和至少 5 个的所有患者（30/30）和 52.5%（21/40）的患者中，LNR 均大于 0.20。在总 LN 数量为 1 至 5 个的患者中，5 年 OS 明显低于总 LN 数量为 6 至 7 个和至少 8 个的患者（分别为 34.2%、64.5%和 62.7%；P=0.047）。当获取的 LN 数量大于 6 时，5 年 OS 并未显著提高。在 N0R0 患者中进行的接受者操作特征曲线分析中证实了这些结果，在这些患者中，5 个 LN 是预测 5 年实际 OS 的最佳截断值（曲线下面积，0.624；P=0.004）。
LNR 超过 0.20 是肝切除术后 HC 患者 N1 患者 OS 的唯一独立预后因素。然而，LNR 受总 LN 数量的影响，并且获取 5 个以上的 LN 是进行充分分期所需的最小 LN 数量。
