Abstract
Objectives: In our study, we evaluated and compared the prognostic value and performance of the 6th, 7th, and 8th editions of the American Joint Committee on Cancer (AJCC) staging system in patients undergoing surgery for perihilar cholangiocarcinoma (PHC). Methods: Patients undergoing liver surgery with curative intention for PHC between 2002 and 2019 were identified from a prospective database. Histopathological parameters and stage of the PHC were assessed according to the 6th, 7th, and 8th editions of the tumor node metastasis (TNM) classification. The prognostic accuracy between staging systems was compared using the area under the receiver operating characteristic curve (AUC) model. Results: Data for a total of 95 patients undergoing liver resection for PHC were analyzed. The median overall survival time was 21 months (95% CI 8.1–33.9), and the three- and five-year survival rates were 46.1% and 36.2%, respectively. Staging according to the 8th edition vs. the 7th edition resulted in the reclassification of 25 patients (26.3%). The log-rank p-values for the 7th and 8th editions were highly statistically significant (p ≤ 0.01) compared to the 6th edition (p = 0.035). The AJCC 8th edition staging system showed a trend to better discrimination, with an AUC of 0.69 (95% CI: 0.52–0.84) compared to 0.61 (95% CI: 0.51–0.73) for the 7th edition. Multivariate survival analysis revealed male gender, age >65 years, positive resection margins, presence of distant metastases, poorly tumor differentiation, and lymph node involvement, such as no caudate lobe resection, as independent predictors of poor survival (p < 0.05). Conclusions: In the current study, the newly released 8th edition of AJCC staging system showed no significant benefit compared to the previous 7th edition in predicting the prognosis of patients undergoing liver resection for perihilar cholangiocarcinoma. Further research may help to improve the prognostic value of the AJCC staging system for PHC—for instance, by identifying new prognostic markers or staging criteria, which may improve that individual patient’s outcome.
Highlights
Perihilar cholangiocarcinoma (PHC) is a relatively uncommon disease, but the treatment of this cancer is still challenging
Nonanatomic factors have been introduced into the staging of some cancers, with reference to PHC, the 6th, 7th, and 8th editions of the American Joint Committee on Cancer (AJCC) staging system have all adhered to the anatomic extent of the tumor, as in all other hepatobiliary and pancreatic cancers [11,23]
Despite recently encouraging results reported by Ebata et al at a large Eastern hepatobiliary center, who attempted to improve the staging and prognosis of PHC patients, the results of our retrospective study of 95 resected PHC patients indicate that the newly released 8th edition of the AJCC staging system does not provide a better ability to stratify the prognosis and predict the clinical outcomes of patients with PHC when compared with the previous 6th and 7th editions
Summary
Perihilar cholangiocarcinoma (PHC) is a relatively uncommon disease, but the treatment of this cancer is still challenging. Various treatment options and combinations consisting of chemotherapy and/or radiotherapy did not result in marked improvements in long-term patient outcomes, and operative resection remains the only possible curative therapy for these patients [1,2]. Due to complex anatomy and tumor configuration, surgery for PHC can be technically ambitious and may represent a surgical challenge for hepato-pancreato-biliary surgeons. Recent studies have reported five-year survival rates following curative-intent liver resection varying from 25% to 40% [1,3,6,7,8]. Due to clinically inapparent tumor progress, many patients show metastatic or locally advanced disease at first clinical presentation and, do not profit from resection [9,10,11,12,13]
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