title: Prognostic Implications of Lymph Node Status for Patients With Gallbladder Cancer: A Multi-Institutional Study.
abstract: Although the American Joint Committee on Cancer (AJCC) classification is the most accepted lymph node (LN) staging system for gallbladder adenocarcinoma (GBA), other LN prognostic schemes have been proposed. This study sought to define the performance of the AJCC LN staging system relative to the number of metastatic LNs (NMLN), the log odds of metastatic LN (LODDS), and the LN ratio (LNR).
  
  
  
  Patients who underwent curative-intent resection for GBA between 2000 and 2015 were identified from a multi-institutional database. The prognostic performance of various LN staging systems was compared by Harrell's C and the Akaike information criterion (AIC).
  
  
  
  Altogether, 214 patients with a median age of 66.7 years (interquartile range [IQR] 56.5-73.1) were identified. A total of 1334 LNs were retrieved, with a median of 4 (IQR 2-8) LNs per patient. Patients with LN metastasis had an increased risk of death (hazard ratio [HR] 1.87; 95 % confidence interval [CI] 1.24-2.82; P = 0.003) and recurrence (HR 2.28; 95 % CI 1.37-3.80; P = 0.002). In the entire cohort, LNR, analyzed as either a continuous scale (C-index, 0.603; AIC, 803.5) or a discrete scale (C-index, 0.609; AIC, 802.2), provided better prognostic discrimination. Among the patients with four or more LNs examined, LODDS (C-index, 0.621; AIC, 363.8) had the best performance versus LNR (C-index, 0.615; AIC, 368.7), AJCC LN staging system (C-index, 0.601; AIC, 373.4), and NMLN (C-index, 0.613; AIC, 369.5).
  
  
  
  Both LODDS and LNR performed better than the AJCC LN staging system. Among the patients who had four or more LNs examined, LODDS performed better than LNR. Both LODDS and LNR should be incorporated into the AJCC LN staging system for GBA.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Neda
authors.initials: N
authors.lastname: Amini
authors.affiliation: Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Yuhree
authors.initials: Y
authors.lastname: Kim
authors.affiliation: Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Ana
authors.initials: A
authors.lastname: Wilson
authors.affiliation: Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Georgios Antonios
authors.initials: GA
authors.lastname: Margonis
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Cecilia G
authors.initials: CG
authors.lastname: Ethun
authors.affiliation: Department of Surgery, Stanford University Medical Center, Stanford, CA, USA.
authors.forename: George
authors.initials: G
authors.lastname: Poultsides
authors.affiliation: Department of Surgery, Stanford University Medical Center, Stanford, CA, USA.
authors.forename: Thuy
authors.initials: T
authors.lastname: Tran
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
authors.forename: Kamran
authors.initials: K
authors.lastname: Idrees
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
authors.forename: Chelsea A
authors.initials: CA
authors.lastname: Isom
authors.affiliation: Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Fields
authors.affiliation: Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: Bradley
authors.initials: B
authors.lastname: Krasnick
authors.affiliation: Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
authors.forename: Sharon M
authors.initials: SM
authors.lastname: Weber
authors.affiliation: Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Salem
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA.
authors.forename: Robert C G
authors.initials: RC
authors.lastname: Martin
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA.
authors.forename: Charles
authors.initials: C
authors.lastname: Scoggins
authors.affiliation: Department of Surgery, Wake Forest University, Winston-Salem, NC, USA.
authors.forename: Perry
authors.initials: P
authors.lastname: Shen
authors.affiliation: Department of Surgery, Wake Forest University, Winston-Salem, NC, USA.
authors.forename: Harveshp D
authors.initials: HD
authors.lastname: Mogal
authors.affiliation: Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
authors.forename: Carl
authors.initials: C
authors.lastname: Schmidt
authors.affiliation: Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
authors.forename: Eliza
authors.initials: E
authors.lastname: Beal
authors.affiliation: Department of Surgery, New York University, New York, NY, USA.
authors.forename: Ioannis
authors.initials: I
authors.lastname: Hatzaras
authors.affiliation: Department of Surgery, New York University, New York, NY, USA.
authors.forename: Rivfka
authors.initials: R
authors.lastname: Shenoy
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
authors.affiliation: Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA. tpawlik1@jhmi.edu.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology* / Q000601:surgery; D000368:Aged; D005260:Female; D005706:Gallbladder Neoplasms / Q000473:pathology* / Q000601:surgery; D006801:Humans; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009367:Neoplasm Staging; D011379:Prognosis; D016896:Treatment Outcome