Brief Article
Copyright ©2013 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Gastroenterol. Aug 21, 2013; 19(31): 5150-5158
Published online Aug 21, 2013. doi: 10.3748/wjg.v19.i31.5150
Radical lymph node dissection and assessment: Impact on gallbladder cancer prognosis
Gui-Jie Liu, Xue-Hua Li, Yan-Xin Chen, Hui-Dong Sun, Gui-Mei Zhao, San-Yuan Hu
Gui-Jie Liu, San-Yuan Hu, Department of General Surgery, Qilu Hospital, Shandong University, Jinan 250012, Shandong Province, China
Gui-Jie Liu, Xue-Hua Li, Yan-Xin Chen, Hui-Dong Sun, Gui-Mei Zhao, Department of Hepatobiliary Surgery, Liaocheng People’s Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng 252000, Shandong Province, China
Author contributions: Liu GJ and Hu SY conceived the study and drafted the manuscript; Chen YX, Sun HD and Zhao GM performed chart review and follow-up of the study; Li XH helped to draft the manuscript and performed statistical analyses; Hu SY was responsible for the whole study and participated in its coordination; all authors read and approved the final manuscript.
Correspondence to: San-Yuan Hu, MD, PHD, Department of General Surgery, Qilu Hospital, Shandong University, 107 Wenhua West Road, Jinan 250012, Shandong Province, China.
Telephone: +86-635-8272383 Fax: +86-635-8272383
Received: March 20, 2013
Revised: May 24, 2013
Accepted: July 4, 2013
Published online: August 21, 2013

AIM: To investigate the lymph node metastasis patterns of gallbladder cancer (GBC) and evaluate the optimal categorization of nodal status as a critical prognostic factor.

METHODS: From May 1995 to December 2010, a total of 78 consecutive patients with GBC underwent a radical resection at Liaocheng People’s Hospital. A radical resection was defined as removing both the primary tumor and the regional lymph nodes of the gallbladder. Demographic, operative and pathologic data were recorded. The lymph nodes retrieved were examined histologically for metastases routinely from each node. The positive lymph node count (PLNC) as well as the total lymph node count (TLNC) was recorded for each patient. Then the metastatic to examined lymph nodes ratio (LNR) was calculated. Disease-specific survival (DSS) and predictors of outcome were analyzed.

RESULTS: With a median follow-up time of 26.50 mo (range, 2-132 mo), median DSS was 29.00 ± 3.92 mo (5-year survival rate, 20.51%). Nodal disease was found in 37 patients (47.44%). DSS of node-negative patients was significantly better than that of node-positive patients (median DSS, 40 mo vs 17 mo, χ2 = 14.814, P < 0.001), while there was no significant difference between N1 patients and N2 patients (median DSS, 18 mo vs 13 mo, χ2 = 0.741, P = 0.389). Optimal TLNC was determined to be four. When node-negative patients were divided according to TLNC, there was no difference in DSS between TLNC < 4 subgroup and TLNC ≥ 4 subgroup (median DSS, 37 mo vs 54 mo, χ2 = 0.715, P = 0.398). For node-positive patients, DSS of TLNC < 4 subgroup was worse than that of TLNC ≥ 4 subgroup (median DSS, 13 mo vs 21 mo, χ2 = 11.035, P < 0.001). Moreover, for node-positive patients, a new cut-off value of six nodes was identified for the number of TLNC that clearly stratified them into 2 separate survival groups (< 6 or ≥ 6, respectively; median DSS, 15 mo vs 33 mo, χ2 = 11.820, P < 0.001). DSS progressively worsened with increasing PLNC and LNR, but no definite cut-off value could be identified. Multivariate analysis revealed histological grade, tumor node metastasis staging, TNLC and LNR to be independent predictors of DSS. Neither location of positive lymph nodes nor PNLC were identified as an independent variable by multivariate analysis.

CONCLUSION: Both TLNC and LNR are strong predictors of outcome after curative resection for GBC. The retrieval and examination of at least 6 nodes can influence staging quality and DSS, especially in node-positive patients.

Keywords: Gallbladder neoplasms, Lymphatic metastasis, Lymph node excision, Lymph node ratio, Prognosis

Core tip: The presence or absence of lymph node metastasis is an important prognostic factor in patients with curatively resected gallbladder cancer (GBC). The present study evaluates the prognostic impact of number, location and ratio of involved lymph nodes, in addition to well described prognostic parameters, in patients with curatively resected GBC. The results demonstrate that total lymph node count and lymph node ratio are more appropriate to stratify GBC patients with regards to prognosis; removal and pathological examination of at least six lymph nodes can influence staging quality and disease-specific survival especially in node-positive patients.