Value of lymph node dissection in intrahepatic cholangiocarcinoma: a systematic review and meta-analysis

"Biological R2" resection for intrahepatic cholangiocarcinoma: identification of patients at risk for poor oncologic outcomes after curative-intent resection

INTRODUCTION

We sought to define a cohort of patients with "biological R2" (bR2) resection, defined as recurrence within 12 weeks, following curative-intent resection for intrahepatic cholangiocarcinoma (ICC). In addition, we sought to identify factors associated with bR2 risk.

METHODS

Patients who underwent upfront curative-intent surgery for ICC were identified from an international, multi-institutional database. The weighted beta-coefficients of preoperative risk factors were used to construct an online tool to predict bR2.

RESULTS

Among 1138 patients, 106 (9.3 %) patients had a bR2 resection. Patients with bR2 were more likely to be younger (OR 0.97) and non-White (OR 2.19), as well as more often had cirrhosis (OR 2.11), a higher neutrophil-to-lymphocyte ratio (OR 1.07), a higher tumor burden score (OR 1.16), and metastatic nodal disease on preoperative imaging (OR 1.92). Patients categorized as low-risk had a 3.2 % risk of bR2, intermediate-risk patients had an 11.1 % risk of bR2, whereas patients in the high-risk category had a 27.6 % risk of bR2 (p < 0.001). An online tool was made available at https://junkawashima.shinyapps.io/bR2_ICC/, https://junkawashima.shinyapps.io/CRLMfollwingchemotherapy/.

CONCLUSIONS

Approximately one in ten patients with resectable ICC had a bR2 resection. An online calculator can may help clinicians identify patients with ICC at highest risk of a bR2 resection.

[Preliminary results of fluorescent lymphography in patients with biliary cancer undergoing liver resection]

OBJECTIVE

To evaluate the diagnostic capability of intraoperative fluorescence lymphography (FLG) in detecting of sentinel lymph nodes (SLN) and lymph outflow pathways in patients with biliary cancer (BC).

MATERIAL AND METHODS

From April 2023 till March 2024, ten liver resections for BC were performed using FLG. We carried out the standard lymph node dissection with additional removal of lymph nodes (LN) that have accumulated indocyanine green (ICG). The lymphatic outflow pathways in all patients and frequency of SLN invasion were evaluated.

RESULTS

Ten patients were included: five patients had been diagnosed with intrahepatic cholangiocarcinoma (IHCC), two - with perichilar tumor (PT), the last three ones had gallbladder cancer (GBC). SLN No. 1 were detected in eight patients, the accumulation of ICG was detected in the following groups of LN: No. 8 (n=2), No. 13 (n=1), No. 12b (n=2), cystic lymph node (n=2), and No. 7 (n=1). SLN No. 2 was detected in seven patients. In three cases LN No. 13 were stained, in one - LN No. 12a, in another - LN No. 8. In two patients, staining of vesicular LN was noted. The combined morphological assessment of SLN No. 1 and SLN No. 2 made it possible to predict the presence of LN metastases in all patients (100%, n=3). Fluorescence of third-order LN was detected in four patients. In one case, the staining of LN No. 13 was noted. Another patient revealed accumulation of ICG in LN No. 3. In two cases, at the third stage, fluorescence of LN No. 7 was noted, while metastatic invasion of LN No. 7 was detected in one patient with IHCC.

CONCLUSION

Using FLG, it was possible to determine an alternative lymph flow outpath to LN No. 7 in three patients. The method allowed to identify and remove metastatic LN No. 7 in one case. 100% sensitivity was shown in the determination of SLN in BC in a small group of patients. It is advisable to study the sensitivity of the method in large-scale studies.

Prognostic impact of lymph node dissection in intrahepatic cholangiocarcinoma: a propensity score analysis

PURPOSE

The clinical significance of lymph node dissection (LND) in patients with peripheral type intrahepatic cholangiocarcinoma (ICC) remains unclear. Although LND is usually performed for perihilar type ICC, there is no consensus on whether routine LND should be performed for peripheral type ICC. This study aimed to investigate the prognostic significance of LND in patients who underwent hepatectomy for peripheral type ICC.

METHODS

This study included consecutive patients who underwent macroscopically curative initial hepatectomy for ICC at our hospital from 2000 to 2018. Among them, peripheral type ICCs with the macroscopic appearance of mass-forming (MF) or MF + periductal infiltrating (PI) types were analyzed. Propensity score analyses (1:1 matching and inverse probability treatment weighting) were adopted to adjust confounding variables. Overall survival (OS) and disease-free survival (DFS) were compared between the LND and no LND (NLND) groups.

RESULTS

During the study period, 201 patients underwent hepatectomy for ICC. The number of peripheral ICC patients with MF type or MF + PI type was 142. The LND group comprised 94 patients and the NLND group comprised 48 patients. The N1 group showed significantly poorer OS and DFS than the N0 and NLND groups (P < 0.001). After propensity score adjustment, there were no significant differences in OS and DFS between the LND and NLND groups.

CONCLUSIONS

The prognostic impact of lymph node metastasis was significant; however, the therapeutic effect of LND was not demonstrated in peripheral type ICC. The indication of LND should be carefully considered on an individual patient basis.

Lymph node metastasis of intrahepatic cholangiocarcinoma: the present and prospect of detection and dissection

Intrahepatic cholangiocarcinoma (ICC) ranks as the second most primary liver cancer that often goes unnoticed with a high mortality rate. Hepatectomy is the main treatment for ICC, but only 15% of patients are suitable for surgery. Despite advancements in therapeutic approaches, ICC has an unfavorable prognosis, largely due to lymph node metastasis (LNM) that is closely linked to the elevated recurrence rates. Consequently, the identification of precise and suitable techniques for the detection and staging of LNM assumes paramount importance for ICC therapy. While preoperative imaging plays a crucial role in ICC diagnosis, its efficacy in accurately diagnosing LNM remains unsatisfactory. The inclusion of lymph node dissection as part of the hepatectomy procedures is significant for the accurate pathological diagnosis of LNM, although it continues to be a topic of debate. The concept of sentinel lymph node in ICC has presented a novel and potentially valuable approach for diagnosing LNM. This review aims to explore the current state and prospects of LNM in ICC, offering a promising avenue for enhancing the clinical diagnosis and treatment of ICC to improve patient prognosis.

Probability of Lymph Node Metastases in Patients Undergoing Adequate Lymphadenectomy during Surgery for Intrahepatic Cholangiocarcinoma: A Retrospective Multicenter Study

Introduction: Nodal metastases (lymph node metastasis [LNM]) are one of the major determinants of prognosis following surgery for intrahepatic cholangiocarcinoma (ICC). Previous studies investigating the correlation between clinical-radiological features and the probability of LNM include patients undergoing inadequate nodal sampling. Aim of this study was to develop a model to predict the risk of LNM in patients undergoing adequate lymphadenectomy using preoperative clinical and radiological features. Methods: Patients undergoing radical surgery for ICC with adequate lymphadenectomy at seven Italian Centers between 2000 and 2023 were collected and divided into a derivation and a validation cohort. Logistic regression and dominance analysis were applied in the derivation cohort to identify variables associated with LNM at pathology. The final coefficients were derived from the model having the highest c-statistic in the derivation cohort with the lowest number of variables included (parsimony). The model was then tested in the external validation cohort, and the linear predictor was divided into quartiles to generate four risk categories. Results: A total of 693 patients were identified. Preoperative CA 19-9, clinically suspicious lymph nodes at radiology, patients’ age, and tumor burden score were significantly associated with LNM. These factors were included in a model (<ext-link ext-link-type="uri" xlink:href="https://aicep.website/calculators/" xmlns:xlink="http://www.w3.org/1999/xlink">https://aicep.website/calculators/</ext-link>) showing a c-statistic of 0.723 (95% CI: 0.680, 0.766) and 0.771 (95% CI: 0.699, 0.842) in the derivation and validation cohort, respectively. A progressive increase of pathological lymph node positivity across risk groups was observed (29.9% in low-risk, 45.1% in intermediate-low risk, 51.5% in intermediate-high risk, and 87.3% in high-risk patients; p = 0.001). Conclusions: A novel model that combines preoperative CA 19-9, clinically suspicious lymph nodes at radiology, patients’ age, and tumor burden score was developed to predict the risk of LNM before surgery. The model exhibited high accuracy and has the potential to assist clinicians in the management of patients who are candidate to surgery.

Impact of Lymph Node Dissection for Patients With Clinically Node-Negative Intrahepatic Cholangiocarcinoma: A Multicenter Cohort Study

Background

Lymph node status is a prominent prognostic factor for intrahepatic cholangiocarcinoma (ICC). However, the prognostic value of performing lymph node dissection (LND) in patients with clinical node-negative ICC remains controversial. The aim of this study was to evaluate the clinical value of LND on long-term outcomes in this subgroup of patients.

Methods

We retrospectively analyzed patients who underwent radical liver resection for clinically node-negative ICC from three tertiary hepatobiliary centers. The propensity score matching analysis at 1:1 ratio based on clinicopathological data was conducted between patients with and without LND. Recurrence-free survival (RFS) and overall survival (OS) were compared in the matched cohort.

Results

Among 303 patients who underwent radical liver resection for ICC, 48 patients with clinically positive nodes were excluded, and a total of 159 clinically node-negative ICC patients were finally eligible for the study, with 102 in the LND group and 57 in the non-LND group. After propensity score matching, two well-balanced groups of 51 patients each were analyzed. No significant difference of median RFS (12.0 vs. 10.0 months, P = 0.37) and median OS (22.0 vs. 26.0 months, P = 0.47) was observed between the LND and non-LND group. Also, LND was not identified as one of the independent risks for survival. Among 51 patients who received LND, 11 patients were with positive lymph nodes (lymph node metastasis (LNM) (+)) and presented significantly worse outcomes than those with LND (-). On the other hand, postoperative adjuvant therapy was the independent risk factor for both RFS (hazard ratio (HR): 0.623, 95% confidence interval (CI): 0.393 - 0.987, P = 0.044) and OS (HR: 0.585, 95% CI: 0.359 - 0.952, P = 0.031). Furthermore, postoperative adjuvant therapy was associated with prolonged survivals of non-LND patients (P = 0.02 for RFS and P = 0.03 for OS).

Conclusions

Based on the data, we found that LND did not significantly improve the prognosis of patients with clinically node-negative ICC. Postoperative adjuvant therapy was associated with prolonged survival of ICC patients, especially in non-LND individuals.