Brauer David G, Fields Ryan C, Tan Benjamin R, Doyle M B Majella, Hammill Chet W, Hawkins William G, Colditz Graham A, Chapman William C
Department of Surgery, Washington University School of Medicine, Alvin J. Siteman Cancer Center, St Louis, MO, USA.
Division of Oncology, Department of Medicine, Washington University School of Medicine, Alvin J. Siteman Cancer Center, St Louis, MO, USA.
HPB (Oxford). 2018 May;20(5):470-476. doi: 10.1016/j.hpb.2017.11.010. Epub 2018 Jan 20.
Lymph node (LN) status is an important predictor of overall survival for resected IHCC, yet guidelines for the extent of LN dissection are not evidence-based. We evaluated whether the number of LNs resected at the time of surgery is associated with overall survival for IHCC.
Patients undergoing curative-intent (R0 or R1) resection for IHCC between 2004 and 2012 were identified within the US National Cancer Database. LN thresholds were evaluated using maximal chi-square testing and five-year overall survival was modeled using Kaplan-Meier and Cox regressions.
57% (n = 1,132) of 2,000 patients had one or more LNs resected and pathologically examined. In the 631 patients undergoing R0 resection with pN0 disease, maximal chi-square testing identified ≥3 LNs as the threshold most closely associated with overall survival. Only 39% of resections reached this threshold. On multivariable survival analysis, no threshold of LNs was associated with overall survival, including ≥3 LNs (p = 0.186) and the current American Joint Committee on Cancer recommendation of ≥6 LNs (p = 0.318).
In determining the extent of lymphadenectomy at the time of curative-intent resection for IHCC, surgeons should carefully consider the prognostic yield in the absence of overall survival benefit.
淋巴结（LN）状态是切除的肝内胆管癌（IHCC）总体生存的重要预测指标，但淋巴结清扫范围的指南并非基于证据。我们评估了手术时切除的淋巴结数量是否与肝内胆管癌的总体生存相关。
在美国国家癌症数据库中识别出2004年至2012年间接受根治性（R0或R1）切除的肝内胆管癌患者。使用最大卡方检验评估淋巴结阈值，并使用Kaplan-Meier和Cox回归对五年总体生存进行建模。
2000例患者中有57%（n = 1132）切除了一个或多个淋巴结并进行了病理检查。在631例接受R0切除且病理分期为N0的患者中，最大卡方检验确定≥3个淋巴结为与总体生存最密切相关的阈值。只有39%的切除术达到该阈值。在多变量生存分析中，没有淋巴结阈值与总体生存相关，包括≥3个淋巴结（p = 0.186）和美国癌症联合委员会目前推荐的≥6个淋巴结（p = 0.318）。
在确定肝内胆管癌根治性切除时的淋巴结清扫范围时，外科医生应在缺乏总体生存获益的情况下仔细考虑预后收益。
