title: The prognostic importance of lymphovascular invasion in cholangiocarcinoma above the cystic duct: a new selection criterion for adjuvant therapy?
abstract: OBJECTIVE
  Criteria for selecting patients to receive adjuvant chemotherapy in cases of resected intrahepatic or hilar cholangiocarcinoma (CC) are lacking. Some clinicians advocate the provision of adjuvant therapy in patients with lymph node (LN)-positive disease; however, nodal assessment is often inadequate. The aim of this study was to identify a surrogate criterion based on primary tumour characteristics.
  
  
  METHODS
  All patients who underwent resection for hilar or intrahepatic CC at a single institution between January 2000 and September 2009 were identified from a prospectively maintained database. Pathological factors were recorded. The primary outcome assessed was overall survival (OS).
  
  
  RESULTS
  In total, 69 patients underwent resection for hilar (n=34) or intrahepatic (n=35) CC. Their median age was 66 years and 27 patients (39%) were male. Median follow-up was 22 months and median OS was 17 months. Median tumour size was 5 cm. Overall, 23% of patients had a positive resection margin, 44% had perineural invasion, 32% had lymphovascular invasion (LVI) and 25% had positive LNs. The median number of LNs removed was two and the median number of positive LNs was zero. The presence of LVI was associated with reduced OS (11.9 months vs. 23.1 months; P=0.023). After accounting for all other adverse tumour factors, the presence of LVI persisted as the only negative prognostic factor for OS on multivariate Cox regression.
  
  
  CONCLUSIONS
  In patients who had undergone resection of hilar or intrahepatic CC, the presence of LVI was strongly associated with reduced OS. Thus the finding of LVI may potentially be used as a criterion in the selection of patients for adjuvant chemotherapy.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA.
authors.forename: Sameer H
authors.initials: SH
authors.lastname: Patel
authors.forename: David A
authors.initials: DA
authors.lastname: Kooby
authors.forename: Charles A
authors.initials: CA
authors.lastname: Staley
authors.forename: Juan M
authors.initials: JM
authors.lastname: Sarmiento
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000473:pathology* / Q000628:therapy; D001653:Bile Ducts, Intrahepatic / Q000473:pathology*; D017024:Chemotherapy, Adjuvant; D018281:Cholangiocarcinoma / Q000401:mortality / Q000473:pathology* / Q000628:therapy; D005260:Female; D005845:Georgia; D006801:Humans; D053208:Kaplan-Meier Estimate; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D018579:Patient Selection; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome