title: Discordance between conventional and detailed lymph node analysis in resected biliary carcinoma at or above the cystic duct: are we understaging patients?
abstract: BACKGROUND
  Analysis of portal lymph node (LN) metastases following resection of biliary carcinomas at or above the cystic duct (BC) is used to select patients for adjuvant therapy, but no guidelines exist and LN yield is low. Some consider analysis of 7 LNs necessary for accurate staging. Conventional LN analysis may understage patients.
  
  
  METHODS
  Portal LNs from 38 node-negative patients following resection of BC from 2000 to 2008 were re-examined in detail for occult metastases (OM) using a modified Weaver protocol. Outcomes measured were discordance in LN positivity and patient survival.
  
  
  RESULTS
  On detailed examination, 5 of 38 patients had OM. There was no difference in survival between patients with and without OM (24 vs 17 months; p = .382). There was no association between OM and patient demographics or adverse tumor characteristics. The median LN yield was 3. Of the 27 patients with <7 LNs retrieved, 1 had OM, compared with 4 of 11 patients with ≥7 LNs retrieved (p = .030). OM in these well-staged patients were associated with reduced survival (9 vs 41 months; p = .032).
  
  
  CONCLUSIONS
  There is discordance between conventional and detailed LN analysis in resected BC. LN yield ≥7 was associated with OM. The presence of OM may be associated with decreased survival. Conventional LN analysis may understage patients with resected BC.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Lee M
authors.initials: LM
authors.lastname: Ocuin
authors.forename: Pelin
authors.initials: P
authors.lastname: Bağci
authors.forename: Sarah B
authors.initials: SB
authors.lastname: Fisher
authors.forename: Sameer H
authors.initials: SH
authors.lastname: Patel
authors.forename: David A
authors.initials: DA
authors.lastname: Kooby
authors.forename: Juan M
authors.initials: JM
authors.lastname: Sarmiento
authors.forename: Kenneth
authors.initials: K
authors.lastname: Cardona
authors.forename: Maria C
authors.initials: MC
authors.lastname: Russell
authors.forename: Charles A
authors.initials: CA
authors.lastname: Staley
authors.forename: N
authors.initials: N
authors.lastname: Volkan Adsay
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001661:Biliary Tract Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery; D003549:Cystic Duct / Q000473:pathology* / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D011446:Prospective Studies; D015996:Survival Rate