Abstract

Presenter: Ken Meredith MD | Florida State University, Sarasota Memorial Hospital Background: Extra-hepatic cholangiocarcinomas (EHC) are low-incidence cancers that are difficult to diagnose and associated with a dismal prognosis. Surgery remains the only option to improve survival. We sought to examine the accuracy of clinical nodal staging for extra-hepatic cholangiocarcinoma and evaluate outcomes with surgery and adjuvant therapies. Methods: Utilizing the National Cancer Database we identified patients who underwent resection for EHC. We then stratified by T stage, N stage (clinical (C), pathologic (P) and adjuvant therapy (chemo(AC) or chemoradiation(CRT). Baseline comparisons of patient characteristics were made using Mann-Whitney U, Kruskal Wallis and Pearson’s Chi-square test as appropriate. Survival analyses were performed using the Kaplan-Meier method. Multivariable cox proportional hazard models (MVA) were developed to identify predictors of survival. All statistical tests were two-sided and p <0.05 was considered significant. Results: We identified 3106 patients diagnosed with EHC and a median age of 68 (20-90) years. There were 1976 (63.6%) males and 1130 (36.4%) females, p<0.001. The median tumor size was 2.2 cm (1.5-3) and 1562 (50.5%) were node positive. Of those undergoing portal lymphadenectomy (PL), the median nodes removed was 11 (5-19) and mean nodes positive were 1.5 ± 2.6. R0 resections were performed in 2269 (73.1%). Adjuvant therapy was administered in 1627 (52.4%) of patients (AC =722 (23.2%), CRT=905 (29.2%). Of those whose clinical node status was N0, 37.3% were pN+. Those patients whose nodal status was unknown cNX, 59.6% were pN+. Patients with cN+ subsequently were pN+ 95.6%. Median and 5 year survival for those pN0 vs pN+ patients was 41.7 mo and 37% vs 25 mo and 23%, p<0.001. Adjuvant therapy improved overall and 5 year survival compared to those who did not receive subsequent therapy (none= 31.5 mo and 30% vs AC 28.9 mo and 24% vs CRT 34.8 mo and 33%), p=0.02. There was no benefit seen in node negative patients, p=0.14. However in node positive patients median and 5 year survival was benefited by AC and CRT (none= 21.3 mo and 21% vs AC 25 mo and 19% vs CRT 27.8 mo and 27%), p=0.002. Additionally, portal lymphadenectomy substantially improved median and 5 year survival (no PL=23.2 mo and 29% vs PL=43.1 mo and 37%), p=0.003. Conclusion: Clinical accuracy of nodal staging for extra-hepatic cholangiocarcinoma remains dismal. Surgery to include portal lymphadenectomy significantly improves survival. Adjuvant therapy improves survival in node positive patients, and in patients with R1 resections.

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