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LYMPH NODE STAGING IN PATIENTS UNDERGOING HEPATECTOMY FOR INTRAHEPATIC CHOLANGIOCARCINOMA: AN INTERNATIONAL MULTICENTRIC ANALYSIS
Fabio Bagante^*1, Gaya Spolverato¹, Matthew J. Weiss², Sorin Alexandrescu³, Luca Aldrighetti⁴, Shishir Maithel⁵, Carlo Pulitano⁶, Todd W. Bauer⁷, Feng Shen⁸, George A. Poultsides⁹, Oliver Soubrane¹⁰, Guillaume Martel¹¹, B. Groot Koerkamp¹², Alfredo Guglielmi¹, Endu Itaru¹³, Timothy M. Pawlik^14
1G. B. Rossi Hospital, University of Verona, Verona, Italy; ²Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; ³Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania; ⁴Department of Surgery, Ospedale San Raffaele, Milan, Italy; ⁵Emory University, Atlanta, GA; ⁶Department of Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; ⁷Department of Surgery, University of Virginia, Charlottesville, VA; ⁸Department of Surgery, Eastern Hepatobiliary Surgery Hospital, Shanghai, China; ⁹Department of Surgery, Stanford University, Stanford, CA; ¹⁰Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France; ¹¹Department of Surgery, University of Ottawa, Ottawa, ON, Canada; ¹²HPB and Abdominal Transplant, Erasmus University Medical Center, Rotterdam, Netherlands; ¹³Yokohama City University School of Medicine, Yokohama , Japan; ¹⁴Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH

Introduction: The role of routine lymphadenectomy for intrahepatic cholangiocarcinoma (ICC) is still controversial and there is no standard approach to assessing regional nodal status. The newly released AJCC 8^th edition staging system recommends a minimum number of 6 harvested lymph nodes (HLN) for adequate nodal staging. We sought to define outcome and risk of death among patients who were staged with ≥ 6 HLN vs. < 6 HLN.
Materials and Methods: Patients undergoing liver surgery for ICC between 1990 and 2015 at one of 14 major hepatobiliary centers were identified. Data on clinicopathological characteristics, operative details, HLN and pathological LN status were collected and analyzed.
Results: Among 1,154 patients undergoing hepatectomy for ICC, 515 (44.6%) had a lymphadenectomy. The median number of HLN was 4 (IQR, 2-8) and 217 (42.1%) patients had ≥6 HLN. On final pathology, among the 1,154 patients, 200 (17.3%) patients had metastatic lymph node (MLN) disease while 315 (27.3%) had no evidence of nodal (NLN) disease. Among the 200 patients with MLN, 110 (55.0%) patients had 1 MLN, 65 (32.5%) 2-5 MLN and 25 (12.5%) >5 MNL. The 5-year OS of patients with NLN was 44.4% (IQR, 36.9-51.6) vs. 15.2% (IQR, 8.7-23.4) for patients with MLN (HR 2.42, 95% CI 1.88-3.13; p<0.001). Among the 315 patients with NLN, HLN was associated with 5-year OS (≥6 HLN, 54.9% (IQR, 41.6-66.3) vs. <6 HLN: 39.4% (IQR, 30.6-48.1); p=0.098). In contrast, HLN did not impact 5-year OS among patients with MLN (≥6 HLN: 17.9% (IQR, 8.6-29.9) vs. <6 HLN: 12.5% (IQR, 4.7-24.2); p=0.71). Rather, the number of MLN was associate with 5-year OS (1 MLN, 22.9% (IQR, 13.2-34.1) vs. 2-5 MLN 10.5% (IQR, 5.1-3.2) vs. >5 MNL 0%; p=0.02). Of note, among the 217 patients with ≥ 6 HLN survival of N0 patients (54.9%, IQR, 41.6-66.3) was almost 3-fold better than N1 patients (17.9%, IQR, 8.6-29.9)(HR 2.91, 95% CI 1.92-4.42; p<0.001).
Conclusion: Only one-fifth of patients undergoing liver resection for ICC had adequate nodal staging according to the AJCC 8^th edition staging system. While the 6 HLN cut-off value impacted prognosis of patients staged as N0, the number of MLN rather than the total HLN was associated with long-term survival among patients with N1 disease.

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