Lymph Node Dissection Impact on Staging and Survival of Extrahepatic Cholangiocarcinomas, Based on U.S. Population Data



Cholangiocarcinomas (CC) frequently demonstrate lymphatic spread. We investigated lymph node (LN) counts after resection of extrahepatic CC and survival based on the SEER 1973–2004 database. Out of 20,068 CC patients, 1,518 individuals were selected based on M0 stage and at least one LN examined. Primary cancer sites included gallbladder (29%), extrahepatic bile ducts (26%), and intrapancreatic/ampullary bile ducts (45%); 42% of patients were LN-positive. The median number of LNs examined was four (range 1–39). Median survival was 37 months for LN-negative and 16 months for LN-positive cancers. Multivariate prognostic variables were the number of positive LNs, primary site, age (all at p < 0.0001), gender (p = 0.002), size (p = 0.005), T category (p = 0.009), and total LN count (or number of negative LNs obtained, p = 0.01). The impact of total LN counts was seen in LN-negative (median survival, 1 vs 10 or more LNs examined: 27 vs 51 months, p = 0.002) and LN-positive disease (10 vs 22 months, p < 0.0001). Survival prediction of extrahepatic CCs is strongly influenced by total LN counts and numbers of negative LNs obtained. Although the resulting incremental benefit is small, dissection and examination of 10 or more LNs should be considered for curative intent resections.


Extrahepatic cholangiocarcinoma Lymph node count Gallbladder cancer Ampullary cancer Lymphadenectomy Survival 


  1. 1.
    American Cancer Society. Cancer facts & figures. Atlanta: American Cancer Society 2006.Google Scholar
  2. 2.
    Donohue JH, Stewart AK, Menck HR. The National Cancer Data Base report on carcinoma of the gallbladder, 1989–1995. Cancer 1998;83(12):2618–2628.PubMedCrossRefGoogle Scholar
  3. 3.
    Yalcin S. Diagnosis and management of cholangiocarcinomas: A comprehensive review. Hepatogastroenterology 2004;51(55):43–50.PubMedGoogle Scholar
  4. 4.
    Jang JY, Kim SW, Park DJ, et al. Actual long-term outcome of extrahepatic bile duct cancer after surgical resection. Ann Surg 2005;241(1):77–84.PubMedGoogle Scholar
  5. 5.
    Kitagawa Y, Nagino M, Kamiya J, et al. Lymph node metastasis from hilar cholangiocarcinoma: Audit of 110 patients who underwent regional and paraaortic node dissection. Ann Surg 2001;233(3):385–392.PubMedCrossRefGoogle Scholar
  6. 6.
    Kondo S, Nimura Y, Hayakawa N, Kamiya J, Nagino M, Uesaka K. Regional and para-aortic lymphadenectomy in radical surgery for advanced gallbladder carcinoma. Br J Surg 2000;87(4):418–422.PubMedCrossRefGoogle Scholar
  7. 7.
    Onoyama H, Ajiki T, Takada M, Urakawa T, Saitoh Y. Does radical resection improve the survival in patients with carcinoma of the gallbladder who are 75 years old and older? World J Surg 2002;26(11):1315–1318.PubMedCrossRefGoogle Scholar
  8. 8.
    Yoshida T, Matsumoto T, Sasaki A, Morii Y, Aramaki M, Kitano S. Prognostic factors after pancreatoduodenectomy with extended lymphadenectomy for distal bile duct cancer. Arch Surg 2002;137(1):69–73.PubMedCrossRefGoogle Scholar
  9. 9.
    Araida T, Yoshikawa T, Azuma T, Ota T, Takasaki K, Hanyu F. Indications for pancreatoduodenectomy in patients undergoing lymphadenectomy for advanced gallbladder carcinoma. J Hepatobiliary Pancreat Surg 2004;11(1):45–49.PubMedCrossRefGoogle Scholar
  10. 10.
    Yeo CJ, Cameron JL, Lillemoe KD, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: Randomized controlled trial evaluating survival, morbidity, and mortality. Ann Surg 2002;236(3):355–366; discussion 366–368.PubMedCrossRefGoogle Scholar
  11. 11.
    Smith DD, Schwarz RR, Schwarz RE. Impact of total lymph node count on staging and survival after gastrectomy for gastric cancer: Data from a large US-population database. J Clin Oncol 2005;23(28):7114–7124.PubMedCrossRefGoogle Scholar
  12. 12.
    Schwarz RE, Smith, DD. Extent of lymph node retrieval and pancreatic cancer survival: Information from a large U.S. population database. Ann Surg Oncol 2006;13(9):1189–1200.PubMedCrossRefGoogle Scholar
  13. 13.
    Surveillance, epidemiology and end results (SEER) program: Public use data (1973–2004). Retrieved April 2005, from
  14. 14.
    Greene FL, Page DL, Fleming ID, et al. American joint committee on cancer staging manual (6th ed.). New York: Springer, 2002.Google Scholar
  15. 15.
    Cox DR. Regression models and life tables. J R Stat Assoc 1972;29:187–220.Google Scholar
  16. 16.
    Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. Am Stat Assoc 1958;53:457–481.CrossRefGoogle Scholar
  17. 17.
    Peto R, Pike MC. Conservatism in the approximation E(0-E)2/E in the log rank test for survival data or tumor incidence data. Biometrics 1973;29:579–584.PubMedCrossRefGoogle Scholar
  18. 18.
    Pawlik TM, Abdalla EK, Barnett CC, et al. Feasibility of a randomized trial of extended lymphadenectomy for pancreatic cancer. Arch Surg 2005;140(6):584–589; discussion 9–91.PubMedCrossRefGoogle Scholar
  19. 19.
    Schwarz RE, Zagala-Nevarez K. Recurrence patterns after radical gastrectomy for gastric cancer: Prognostic factors and implications for postoperative adjuvant therapy. Ann Surg Oncol 2002;9(4):394–400.PubMedCrossRefGoogle Scholar
  20. 20.
    Gervasoni JE, Jr., Taneja C, Chung MA, Cady B. Biologic and clinical significance of lymphadenectomy. Surg Clin North Am 2000;80(6):1631–1673.PubMedCrossRefGoogle Scholar
  21. 21.
    Cserni G, Vinh-Hung V, Burzykowski T. Is there a minimum number of lymph nodes that should be histologically assessed for a reliable nodal staging of T3N0M0 colorectal carcinomas? J Surg Oncol 2002;81(2):63–69.PubMedCrossRefGoogle Scholar
  22. 22.
    Cuschieri A, Weeden S, Fielding J, et al. Patient survival after D1 and D2 resections for gastric cancer: Long-term results of the MRC randomized surgical trial. Surgical Co-operative Group. Br J Cancer 1999;79(9–10):1522–1530.PubMedCrossRefGoogle Scholar
  23. 23.
    Hartgrink HH, Van De Velde CJ, Putter H, et al. Extended lymph node dissection for gastric cancer: Who may benefit? Final results of the randomized Dutch gastric cancer group trial. J Clin Oncol 2004;22(11):2069–2077.PubMedCrossRefGoogle Scholar
  24. 24.
    Pedrazzoli S, DiCarlo V, Dionigi R, et al. Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: A multicenter, prospective, randomized study. Lymphadenectomy Study Group. Ann Surg 1998;228(4):508–517.PubMedCrossRefGoogle Scholar
  25. 25.
    Yeo CJ, Cameron JL, Sohn TA, et al. Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: Comparison of morbidity and mortality and short-term outcome. Ann Surg 1999;229(5):613–622; discussion 622–624.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  1. 1.Division of Surgical OncologyThe Cancer Institute of New JerseyNew BrunswickUSA
  2. 2.Division of BiostatisticsCity of Hope Cancer CenterDuarteUSA
  3. 3.Department of Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical SchoolThe Cancer Institute of New JerseyNew BrunswickUSA

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