Bartsch Fabian, Hahn Felix, Müller Lukas, Baumgart Janine, Hoppe-Lotichius Maria, Kloeckner Roman, Lang Hauke
Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst. 1, 55131, Mainz, Germany.
Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
BMC Surg. 2020 Apr 15;20(1):75. doi: 10.1186/s12893-020-00730-x.
Intrahepatic cholangiocarcinoma (ICC) is often diagnosed at an advanced stage resulting in a low resectability rate. Even after potentially curative resection the risk for tumor recurrence is high. Although the extent and value of lymphadenectomy is part of ongoing discussion, the role of preoperative imaging for assessment of suspicious lymph nodes (suspLN) has only been studied modestly. Aim of this study is to demonstrate the influence of suspicious lymph nodes in preoperative imaging on resectability, recurrence, and long-term outcome.
All patients who underwent exploration for ICC between January 2008 and June 2018 were included. Preoperative imaging (CT or MRI) was analysed with focus on suspLN at the hepatoduodenal ligament, lesser curvature, interaortocaval, and superior to the diaphragm; suspLN were classified according to the universally accepted RECIST 1.1 criteria; histopathology served as gold standard.
Out of 187 patients resection was performed in 137 (73.3%), in 50 patients the procedure was terminated after exploration. Overall, suspLN were found preoperatively in 73/187 patients (39%). Comparing patients who underwent resection and exploration only, suspLN were significantly more common in the exploration group (p = 0.011). Regarding lymph node stations, significant differences could be shown regarding resectability: All tumors with suspLN superior to the diaphragm were irresectable. Preoperative imaging assessment showed a strong correlation with final histopathology, especially of suspLN of the hepatoduodenal ligament and the lesser curvature. Sensitivity of suspLN was 71.1%, specificity 90.8%. Appearance of tumor recurrence was not affected by suspLN (p = 0.289). Using a short-axis cut-off of <> 1 cm, suspLN had significant influence on recurrence-free survival (RFS, p = 0.009) with consecutive 1-, 3-, and 5-year RFS of 41, 21, and 15% versus 29, 0, and 0%, respectively. Similarly, 1-, 3- and 5-year overall survival (OS) was 75, 30, and 18% versus 59, 18, and 6%, respectively (p = 0.040).
Suspicious lymph nodes in preoperative imaging are predictor for unresectability and worse survival. Explorative laparoscopy should be considered, if distant suspicious lymph nodes are detected in preoperative imaging. Nevertheless, given a sensitivity of only 71.1%, detection of suspicious lymph nodes in the preoperative imaging alone is not sufficient to allow for a clear-cut decision against a surgical approach.
肝内胆管癌（ICC）常于晚期被诊断出来，导致可切除率较低。即使在进行了可能治愈性切除术后，肿瘤复发风险仍很高。尽管淋巴结清扫的范围和价值仍是正在讨论的一部分，但术前影像学检查对可疑淋巴结（suspLN）评估的作用仅得到了有限的研究。本研究的目的是证明术前影像学检查中可疑淋巴结对可切除性、复发及长期预后的影响。
纳入所有在2008年1月至2018年6月期间因ICC接受探查的患者。对术前影像学检查（CT或MRI）进行分析，重点关注肝十二指肠韧带、小弯侧、主动脉腔间隙及膈上的可疑淋巴结；可疑淋巴结根据普遍接受的RECIST 1.1标准进行分类；组织病理学检查作为金标准。
187例患者中，137例（73.3%）进行了切除手术，50例患者在探查后终止了手术。总体而言，73/187例（39%）患者术前发现了可疑淋巴结。仅比较接受切除手术和仅接受探查的患者，可疑淋巴结在探查组中更为常见（p = 0.011）。关于淋巴结部位，在可切除性方面可显示出显著差异：所有膈上有可疑淋巴结的肿瘤均不可切除。术前影像学评估与最终组织病理学检查显示出很强的相关性，尤其是肝十二指肠韧带和小弯侧的可疑淋巴结。可疑淋巴结的敏感性为71.1%，特异性为90.8%。肿瘤复发的出现不受可疑淋巴结的影响（p = 0.289）。使用短轴截断值<> 1 cm时，可疑淋巴结对无复发生存期（RFS，p = 0.009）有显著影响，连续1年、3年和5年的RFS分别为41%、21%和15%，而对照组分别为29%、0%和0%。同样，1年、3年和5年的总生存率（OS）分别为75%、30%和18%，而对照组分别为59%、18%和6%（p = 0.040）。
术前影像学检查中的可疑淋巴结是不可切除性及较差生存率的预测指标。如果术前影像学检查发现远处有可疑淋巴结，应考虑进行探索性腹腔镜检查。然而，鉴于敏感性仅为71.1%，仅通过术前影像学检查发现可疑淋巴结不足以明确决定放弃手术治疗。
