title: Association of Lymph Node Status With Survival in Patients After Liver Resection for Hilar Cholangiocarcinoma in an Italian Multicenter Analysis.
abstract: The prognostic value of lymph node (LN) assessment after liver resection for hilar cholangiocarcinoma (HC) is still controversial, and the number of LNs required to be removed to obtain adequate staging is not well defined.
  
  
  
  To evaluate the LN status in patients after liver resection for HC and to clarify which prognostic factor (the number of positive LNs or the LN ratio [LNR]) was most accurate for staging and what minimum number of retrieved LNs was required for adequate staging.
  
  
  
  Retrospective multicenter study of patients who underwent resection for HC between January 1, 1992, and December 31, 2007, at 8 hepatobiliary Italian centers. The last follow-up was assessed in July 2014.
  
  
  
  Differences in overall survival (OS) according to the LN status were analyzed. The OS results were defined as actual because all included patients completed a 5-year follow-up.
  
  
  
  One-hundred seventy-five patients with 1133 retrieved LNs were analyzed. The mean (SD) age of the cohort was 63 (10) years, and 42.9% (75 of 175) were female. The median number of LNs examined per patient was 6.5. Forty percent (70 of 175) had LN metastasis. An LNR exceeding 0.20 was associated with significantly lower 5-year OS than an LNR of 0.20 or less (10.6% vs 24.4%; odds ratio, 2.434; 95% CI, 1.020-5.810; P = .04). On multivariable analysis, the LNR was the only independent prognostic factor for OS but was influenced by the total number of retrieved LNs. The LNR was greater than 0.20 in all patients (30 of 30) with 1 to 4 retrieved LNs and in 52.5% (21 of 40) of patients with at least 5 retrieved LNs. Five-year OS in patients with 1 to 5 retrieved LNs was significantly lower than that in those with 6 to 7 retrieved LNs and those with at least 8 retrieved LNs (34.2%, 64.5%, and 62.7%, respectively; P = .047). Five-year OS did not significantly improve when the number of retrieved LNs was greater than 6. These results were confirmed in a receiver operating characteristic curve analysis performed among N0R0 patients, in whom 5 retrieved LNs was the most accurate cutoff to predict 5-year actual OS (area under the curve, 0.624; P = .004).
  
  
  
  An LNR exceeding 0.20 was the only independent prognostic factor for OS in N1 patients after liver resection for HC. However, the LNR was influenced by the total number of retrieved LNs, and removal of more than 5 LNs was the minimum number of LNs required for adequate staging.
authors.affiliation: Hepatobiliary Surgery Unit, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy.
authors.forename: Felice
authors.initials: F
authors.lastname: Giuliante
authors.affiliation: Hepatobiliary Surgery Unit, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Ardito
authors.affiliation: Division of General Surgery A, Department of Surgery, University of Verona, Verona, Italy.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Guglielmi
authors.affiliation: Liver Unit, San Raffaele Hospital, Milan, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Aldrighetti
authors.affiliation: Department of Digestive and Hepatobiliary Surgery, Mauriziano Umberto I Hospital, Turin, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Ferrero
authors.affiliation: Unit of Hepatobiliary Surgery and Liver Transplantation, Cardarelli Hospital, Naples, Italy.
authors.forename: Fulvio
authors.initials: F
authors.lastname: Calise
authors.affiliation: Department of Medical and Surgical Sciences, Surgical Clinic, Brescia University, Brescia, Italy.
authors.forename: Stefano M
authors.initials: SM
authors.lastname: Giulini
authors.affiliation: Department of Surgery, Maggiore Hospital, Bologna, Italy.
authors.forename: Elio
authors.initials: E
authors.lastname: Jovine
authors.affiliation: Hepatobiliary Surgery Unit, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Breccia
authors.affiliation: Hepatobiliary Surgery Unit, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy.
authors.forename: Agostino M
authors.initials: AM
authors.lastname: De Rose
authors.affiliation: Department of Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
authors.forename: Antonio D
authors.initials: AD
authors.lastname: Pinna
authors.affiliation: Hepatobiliary Surgery Unit, A. Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy.
authors.forename: Gennaro
authors.initials: G
authors.lastname: Nuzzo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000473:pathology* / Q000601:surgery*; D018281:Cholangiocarcinoma / Q000556:secondary* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy; D006801:Humans; D007558:Italy; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D012372:ROC Curve; D012189:Retrospective Studies; D015996:Survival Rate