Abstract
Purpose
The aim of this study was to assess the effect of lymphadenectomy on survival in T1/T2 gallbladder cancer (GBC).
Methods
In this retrospective cohort study, patients undergoing surgery for T1/T2 GBC from 2004 to 2014 were identified in the Surveillance, Epidemiology, and End Results database. The effect of lymph node excision (LNE) on survival was assessed using Cox regression and propensity score methods.
Results
A total of 2112 patients were identified: 11.4% had T1a, 18.5% T1b, and 70.1% had T2 tumors. Mean follow-up was 31.3 months. In 48.8% of patients, LNE was performed with a mean of 3.6 ± 4.3 nodes retrieved. Cancer-specific 5-year survival for T1 and T2 stages combined was 49.6% (95% confidence interval (CI), 45.9–53.6%) without LNE compared to 56.2% (95% CI, 52.4–60.4%) if LNE was performed (hazard ratio (HR), 0.75; 95%CI, 0.64–0.86, P < 0.001). Propensity score analyses for both stages combined confirmed this survival benefit with an HR of 0.67 (95% CI, 0.55–0.80) for the LNE group (P < 0.001). Stratified for tumor stages, LNE had no significant effect on cancer-specific survival in T1a (HR, 1.80 (95% CI, 0.76–4.26), P = 0.185) or T1b tumors (HR, 0.95 (95% CI, 0.57–1.58), P = 0.844), whereas it persistently revealed an advantage for patients with T2 tumors (HR 0.68 (95% CI, 0.55–0.83, P < 0.001). No correlation between the number of retrieved lymph nodes and the N+ rate was found (P = 0.134).
Conclusions
LNE is associated with improved survival in T2 GBC. No significant survival benefit was observed in T1a and T1b tumors. The retrieval of even a few lymph nodes reliably predicts the nodal status, which might assist in patient selection for re-resection in T1 GBC.
Similar content being viewed by others
References
Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359–86. doi:https://doi.org/10.1002/ijc.29210.
Tran TB, Nissen NN. Surgery for gallbladder cancer in the US: a need for greater lymph node clearance. J Gastrointest Oncol. 2015;6(5):452–8.
Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK et al. AJCC Cancer Staging Manual. 8th ed. New York: Springer; 2017.
Pawlik TM, Gleisner AL, Vigano L, Kooby DA, Bauer TW, Frilling A et al. Incidence of finding residual disease for incidental gallbladder carcinoma: implications for re-resection. J Gastrointest Surg. 2007;11(11):1478–86; discussion 86-7. doi:https://doi.org/10.1007/s11605-007-0309-6.
Lee SE, Jang JY, Lim CS, Kang MJ, Kim SW. Systematic review on the surgical treatment for T1 gallbladder cancer. World J Gastroenterol. 2011;17(2):174–80. doi:https://doi.org/10.3748/wjg.v17.i2.174.
Duffy A, Capanu M, Abou-Alfa GK, Huitzil D, Jarnagin W, Fong Y et al. Gallbladder cancer (GBC): 10-year experience at Memorial Sloan-Kettering Cancer Centre (MSKCC). J Surg Oncol. 2008;98(7):485–9. doi:https://doi.org/10.1002/jso.21141.
Shih SP, Schulick RD, Cameron JL, Lillemoe KD, Pitt HA, Choti MA et al. Gallbladder cancer: the role of laparoscopy and radical resection. Ann Surg. 2007;245(6):893–901. doi:https://doi.org/10.1097/SLA.0b013e31806beec2.
Cavallaro A, Piccolo G, Di Vita M, Zanghi A, Cardi F, Di Mattia P et al. Managing the incidentally detected gallbladder cancer: algorithms and controversies. Int J Surg. 2014;12 Suppl 2:S108–19. doi:https://doi.org/10.1016/j.ijsu.2014.08.367.
Butte JM, Matsuo K, Gonen M, D'Angelica MI, Waugh E, Allen PJ et al. Gallbladder cancer: differences in presentation, surgical treatment, and survival in patients treated at centers in three countries. J Am Coll Surg. 2011;212(1):50–61. doi:https://doi.org/10.1016/j.jamcollsurg.2010.09.009.
Kasumova GG, Tabatabaie O, Najarian RM, Callery MP, Ng SC, Bullock AJ et al. Surgical Management of Gallbladder Cancer: Simple Versus Extended Cholecystectomy and the Role of Adjuvant Therapy. Ann Surg. 2017. doi:https://doi.org/10.1097/sla.0000000000002385.
Muszynska C, Lundgren L, Lindell G, Andersson R, Nilsson J, Sandstrom P et al. Predictors of incidental gallbladder cancer in patients undergoing cholecystectomy for benign gallbladder disease: Results from a population-based gallstone surgery registry. Surgery. 2017;162(2):256–63. doi:https://doi.org/10.1016/j.surg.2017.02.009.
Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York: Springer; 2010.
Hundal R, Shaffer EA. Gallbladder cancer: epidemiology and outcome. Clin Epidemiol. 2014;6:99–109. doi:https://doi.org/10.2147/clep.s37357.
Agarwal AK, Kalayarasan R, Javed A, Gupta N, Nag HH. The role of staging laparoscopy in primary gall bladder cancer--an analysis of 409 patients: a prospective study to evaluate the role of staging laparoscopy in the management of gallbladder cancer. Ann Surg. 2013;258(2):318–23. doi:https://doi.org/10.1097/SLA.0b013e318271497e.
Mekeel KL, Hemming AW. Surgical management of gallbladder carcinoma: a review. J Gastrointest Surg. 2007;11(9):1188–93. doi:https://doi.org/10.1007/s11605-007-0115-1.
Aloia TA, Jarufe N, Javle M, Maithel SK, Roa JC, Adsay V et al. Gallbladder cancer: expert consensus statement. HPB. 2015;17(8):681–90. doi:https://doi.org/10.1111/hpb.12444.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Hepatobiliary Cancers. Version 2.2018. www.nccn.org. Accessed 25.07.2018.
Lammert F, Neubrand MW, Bittner R, Feussner H, Greiner L, Hagenmueller F et al. S3-guidelines for diagnosis and treatment of gallstones. German society for digestive and metabolic diseases and German society for surgery of the alimentary tract. Z Gastroenterol. 2007(45):971–1001.
Valle JW, Borbath I, Khan SA, Huguet F, Gruenberger T, Arnold D. Biliary cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2016;27(suppl 5):v28-v37. doi:https://doi.org/10.1093/annonc/mdw324.
Foster JM, Hoshi H, Gibbs JF, Iyer R, Javle M, Chu Q et al. Gallbladder cancer: Defining the indications for primary radical resection and radical re-resection. Ann Surg Oncol. 2007;14(2):833–40. doi:https://doi.org/10.1245/s10434-006-9097-6.
SEER. National Cancer Institute, Surveillance Epidemiology and End Results. http://seer.cancer.gov. Accessed 23.07.2018 2018.
Adamo M, Dickie L, Ruhl J.(2016). SEER Program Coding and Staging Manual 2016. Bethesda: National Cancer Institute; 2016.
Grambsch PM, Therneau TM. Proportional hazards tests and diagnostics based on weighted residuals. Biometrika. 1994;81(3):515–26. doi:https://doi.org/10.1093/biomet/81.3.515.
Joffe MM, Rosenbaum PR. Invited commentary: propensity scores. Am J Epidemiol. 1999;150(4):327–33.
Rosenbaum PR. Model-based direct adjustment. J Am Stat Assoc. 1987;82:387–94.
Rubin DB. Estimating causal effects from large data sets using propensity scores. Ann Intern Med. 1997;127(8 Pt 2):757–63.
Hansen BB, Klopfer SO. Optimal full matching and related designs via network flows. J Comput Graph Statist. 2006;15:609–27.
Ho DE, Imai K, King G, Elizabeth AS. MatchIt: nonparametric preprocessing for parametric causal inference. J Stat Softw. 2011;42:1–28.
Coburn NG, Cleary SP, Tan JC, Law CH. Surgery for gallbladder cancer: a population-based analysis. J Am Coll Surg. 2008;207(3):371–82. doi:https://doi.org/10.1016/j.jamcollsurg.2008.02.031.
Kohn N, Maubach J, Warschkow R, Tsai C, Nussbaum D, Candinas D et al. High rate of positive lymph nodes in T1a gallbladder cancer does not translate to decreased survival: a population-based, propensity score adjusted analysis. HPB. 2018;08:08.
Lee SE, Jang JY, Kim SW, Han HS, Kim HJ, Yun SS et al. Surgical Strategy for T1 Gallbladder Cancer: A Nationwide Multicenter Survey in South Korea. Ann Surg Oncol. 2014;21(11):3654–60.
Goetze TO, Paolucci V. [Immediate radical re-resection of incidental T1b gallbladder cancer and the problem of an adequate extent of resection (results of the German Registry “Incidental Gallbladder Cancer”)]. Zentralbl Chir. 2014;139 Suppl 2:e43–8.
Downing SR, Cadogan KA, Ortega G, Oyetunji TA, Siram SM, Chang DC et al. Early-stage gallbladder cancer in the surveillance, epidemiology, and end results database: Effect of extended surgical resection. Arch Surg. 2011;146(6):734–8.
Betge J, Harbaum L, Pollheimer MJ, Lindtner RA, Kornprat P, Ebert MP et al. Lymph node retrieval in colorectal cancer: determining factors and prognostic significance. Int J Colorectal Dis. 2017;32(7):991–8. doi:https://doi.org/10.1007/s00384-017-2778-8.
Warschkow R, Widmann B, Beutner U, Marti L, Steffen T, Schiesser M et al. The More the Better-Lower Rate of Stage Migration and Better Survival in Patients With Retrieval of 20 or More Regional Lymph Nodes in Pancreatic Cancer: A Population-Based Propensity Score Matched and Trend SEER Analysis. Pancreas. 2017;46(5):648–57. doi:https://doi.org/10.1097/mpa.0000000000000784.
Ito M, Mishima Y, Sato T. An anatomical study of the lymphatic drainage of the gallbladder. Surg Radiol Anat. 1991;13(2):89–104.
Shirai Y, Yoshida K, Tsukada K, Ohtani T, Muto T. Identification of the regional lymphatic system of the gallbladder by vital staining. Br J Surg. 1992;79(7):659–62.
Uesaka K, Yasui K, Morimoto T, Torii A, Yamamura Y, Kodera Y et al. Visualization of routes of lymphatic drainage of the gallbladder with a carbon particle suspension. J Am Coll Surg. 1996;183(4):345–50.
Liu GJ, Li XH, Chen YX, Sun HD, Zhao GM, Hu SY. Radical lymph node dissection and assessment: Impact on gallbladder cancer prognosis. World J Gastroenterol. 2013;19(31):5150–8. doi:https://doi.org/10.3748/wjg.v19.i31.5150.
Shirai Y, Sakata J, Wakai T, Ohashi T, Ajioka Y, Hatakeyama K. Assessment of lymph node status in gallbladder cancer: location, number, or ratio of positive nodes. World J Surg Oncol. 2012;10:87. doi:https://doi.org/10.1186/1477-7819-10-87.
Ito H, Ito K, D'Angelica M, Gonen M, Klimstra D, Allen P et al. Accurate staging for gallbladder cancer: implications for surgical therapy and pathological assessment. Ann Surg. 2011;254(2):320–5.
Mayo SC, Shore AD, Nathan H, Edil B, Wolfgang CL, Hirose K et al. National trends in the management and survival of surgically managed gallbladder adenocarcinoma over 15 years: a population-based analysis. J Gastrointest Surg. 2010;14(10):1578–91.
Acknowledgements
This study arose from a Master of Science in Public Health project report proposal at the London School of Hygiene and Tropical Medicine. The authors thank the National Cancer Institute for providing the Surveillance, Epidemiology, and End Results (SEER) data set and Lydia Widmann and Rachelle Miner for the English language editing.
Author information
Authors and Affiliations
Contributions
Contributions to the conception or design of the work: T.S., I.T., B.W.
Acquisition, analysis, or interpretation of data for the work: T.S., B.W.
Drafting the work and revising it critically: T.S., S.E., B.W.
Final approval of the version to be published: T.S., I.T., B.W.
Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: T.S., B.W.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflicts of interest.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Steffen, T., Ebinger, S.M., Tarantino, I. et al. Prognostic Impact of Lymph Node Excision in T1 and T2 Gallbladder Cancer: a Population-Based and Propensity Score-Matched SEER Analysis. J Gastrointest Surg 24, 633–642 (2020). https://doi.org/10.1007/s11605-019-04175-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11605-019-04175-3