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LYMPH NODE STATUS IN INCIDENTAL GALLBLADDER CANCER: CYSTIC DUCT LYMPH NODE, LYMPH NODE DISSECTION AND NUMBER OF METASTATIC LYMPH NODE
Eduardo A. Vega*1,2, Eduardo Vinuela2,3, Gabriel Cavada4, Marcel P. Sanhueza2,3, Claudius Conrad1
1Surgical Oncology, MD Anderson Cancer Center, Houston, TX; 2Department of Digestive Surgery Hepato-Bilio-Pancreatic Surgery Unit, Sotero Del Rio Hospital, Santiago, Region Metropolitana, Chile; 3Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Region Metropolitana, Chile; 4Epidemiology, Faculty of Medicine, Andes University of Chile, Santiago, Region Metropolitana, Chile
Background: Incidental gallbladder cancer (IGBC) is the most common diagnosis of gallbladder cancer today. Calot’s lymph node (pN12c) is frequently removed during the index cholecystectomy, but it remains unclear whether pN12c status can predict the status of D2 lymph nodes (LNS) to guide whether an oncologic extended resection (OER) is required. The aim of this study is to determine the prognostic impact of pN12c status for lymph nodes in D2 distribution and the need for extended lymph node dissection.
Methods: Outcomes after OER for IGBC performed between January 1999 and June 2015 from two referral centers at both low-incidence (USA) and high-incidence countries (Chile) were analyzed. Prognostic performance of pN12c was analyzed separately from pN1 status. The LNS was correlated with disease specific survival.
Results: Of 187 patients with a median age of 60 (32-81). Twelve patients (6%) had a D0 dissection, twenty-seven patients (14.4%) had D1 dissection, and 148 patients (79%) had a dissection of D2. A total of 1261 LNs were retrieved, with a median of 6.7 LN per patient. Seventy-five (40%) patients had N12c retrieved. Common bile duct (CBD) resection (n = 48) did not increase the number of retrieved LNs. OER with D2 dissection identified skip LN metastases in 24 patients (12.8%). If the N12c was positive, the dissection of the hepatic pedicle was positive with OR 22,78 (p = 0.023), but there was no correlation with status of stations 8 (p = 0.412), 13 (p = 0.789) or16 (p = 0.0639) The hazard ratio (HR) of having a N12c+ before OER was 2.09 CI [1.09-4.01] but if the OER negative for residual cancer the HR decrease to 1.5 CI [0.64-3.66] and there was no significant difference in DSS between pN0 and pN12c (p = 0.337). The HR of having a + D1 dissection was 6.7 vs + D2 dissection 15.81. The 3 year OS for entire cohort 68.9% CI [60.3-76.1] and stratified by N status was, N0 81% CI [71.5-87.6], N1 37% [16-59] p = 0.001 and N2 18% [28.5-44.1] p < 0.001. The presence of 3 or more LN+ dramatically reduced the median disease specific survival (DSS) 3 year OS of 73% vs not reached. In the multivariate analysis the LNR did not stratified the prognosis.
Conclusions: Calot’s lymph node status can predict LNS of the hepatoduodenal ligament only, but not more advance lymphadenopathy. Moreover, in the appropriate clinical context DSS of pN0 and pN12c+ may even be similar and therefore pN12c status cannot substitute for OER. Our data shows that D2 LN dissection is needed for more accurate staging and therefore is recommend for all patients undergoing OER. D2 LN dissection, however, allows for subgroup stratification of <3 and ≧ 3, which stratifies patients according to DSS.
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