A tailored approach in lymph node-positive perihilar cholangiocarcinoma

Abstract

Purpose: Extended right hepatectomy is associated with wide surgical margins in PHC and often favored for oncological considerations. However, it remains uncertain whether established surgical principles also apply to the subgroup of node-positive patients. The aim of the present study was to define a tailored surgical approach for patients with perihilar cholangiocarcinoma (PHC) and lymph node metastases.

Methods: We reviewed the course of all consecutive patients undergoing major hepatectomy for PHC between 2005 and 2015 at the Department of Surgery, Charité - Universitätsmedizin Berlin.

Results: Two hundred and thirty-one patients underwent major hepatectomy for PHC with 1-, 3-, and 5-year overall (OS) and disease-free survival (DFS) rates of 72%, 48%, and 36%, and 60%, 22%, and 12%, respectively. In lymph node-positive patients (n = 109, 47%), extended left hepatectomy was associated with improved OS and DFS, respectively, when compared to extended right hepatectomy (p = 0.008 and p = 0.003). Interestingly, OS and DFS did not differ between R0 and R1 resections in those patients (both p = ns). Patients undergoing extended left hepatectomy were more likely to receive adjuvant chemotherapy (p = 0.022). This is of note as adjuvant chemotherapy, besides grading (p = 0.041), was the only independent prognostic factor in node-positive patients (p=0.002).

Conclusion: Patients with node-positive PHC might benefit from less aggressive approaches being associated with lower morbidity and a higher chance for adjuvant chemotherapy. Lymph node sampling might help to guide patients to the appropriate surgical approach according to their lymph node status.

Keywords: Long-term survival; Lymph node positive perihilar cholangiocarcinoma; Major hepatectomy; Postoperative complications.

Fig. 1

Overall survival according to lymph node and R status. Kaplan Meier curves of overall survival. A All resected patients with perihilar cholangiocarcinoma with and without lymph node metastases (N0 and N+) according to R status. B All resected patients with perihilar cholangiocarcinoma with and without lymph node metastases (N0 and N+) excluding 90-day mortality according to R status. C Resected patients with perihilar cholangiocarcinoma without lymph node metastases (N0) according to R status. D Resected patients with perihilar cholangiocarcinoma without lymph node metastases (N0) excluding 90-day mortality according to R status. E Resected patients with perihilar cholangiocarcinoma with lymph node metastases (N+) according to R status

Fig. 2

Disease-free survival according to lymph node and R status. Kaplan Meier curves of disease-free survival. A All resected patients with perihilar cholangiocarcinoma with and without lymph node metastases (N0 and N+) according to R status. B All resected patients with perihilar cholangiocarcinoma with and without lymph node metastases (N0 and N+) excluding 90-day mortality according to R status. C Resected patients with perihilar cholangiocarcinoma without lymph node metastases (N0) according to R status. D Resected patients with perihilar cholangiocarcinoma without lymph node metastases (N0) excluding 90-day mortality according to R status. E Resected patients with perihilar cholangiocarcinoma with lymph node metastases (N+) according to R status. F Resected patients with perihilar cholangiocarcinoma with lymph node metastases (N+) excluding 90-day mortality according to R status

Fig. 3

Overall and disease-free survival of patients with lymph node positive perihilar cholangiocarcinoma according to side of hepatic resection. Kaplan Meier curves of patients with lymph node metastases and resected perhilar cholangiocarcinoma according to side of hepatic resection. A. Overall survival. B. Overall survival excluding 90-day mortality. C. Disease-free survival. D. Disease-free survival excluding 90-day mortality. E. Overall survival after propensity score matching excluding 90-day mortality. F. Disease-free survival after propensity score matching excluding 90-day mortality.

Fig. 4

Suggested therapy algorithm in resectable perihilar cholangiocarcinoma Suggested tailored approach in patients diagnosed with resectable perihilar cholangiocarcinoma without distant metastases (Figure created with Biorender.com)