Abstract
Background
The TNM classification for distal cholangiocarcinoma was first introduced in the 7th edition, which was published in 2009; however, prognostic accuracy compared with the 5th and 6th editions has not yet been evaluated and requires validation.
Methods
A prospective histological database of patients with distal bile duct cancer was analyzed, and histological parameters and stage of the distal cholangiocarcinoma were assessed according to the 5th, 6th, and 7th editions of the TNM classification.
Results
Between 1994 and 2012, a total of 516 patients underwent pancreatic head resection, of whom 59 patients (11.4 %) experienced histologically confirmed distal cholangiocarcinoma. The median overall survival time was 22.2 months (13.1–31.4). Tumor recurrence occurred in 23 patients after a median disease-free survival time of 14.1 months. The 7th edition showed a monotonicity of all gradients, with a stepwise increase of mortality related to a stepwise increase of tumor stage (log-rank test; p < 0.05) demonstrating best discrimination of all tested editions [area under the receiver operating characteristic curve (AUC) 0.82; 95 % CI 0.70–0.95; p = 0.012]. The discrimination rate was low for the 5th (AUC 0.67; 95 % CI 0.42–0.91; p = 0.18) and 6th editions (AUC 0.70; 95 % CI 0.47–0.93; p = 0.11), while the log-rank test did not reach statistical significance. On multivariate analysis, lymph node involvement and positive resection margins were positive and independent predictors of inferior survival (p < 0.05).
Conclusions
The 7th edition of the TNM classification was favorable in terms of predicting outcome, and generated a monotonicity of all grades. Strikingly, the 7th edition, but not the 5th and 6th editions, was of prognostic significance to predict outcome.
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Acknowledgment
Felix Krenzien was supported by the German Research Foundation (KR 4362/2-1). None of the authors have received any financial benefit.
Conflicts of interest
Georg Wiltberger, Felix Krenzien, Christian Benzing, Georgi Atanasov, Fritz Klein, Hans-Michael Hau, Linda Feldbrügge, Johann Pratschke, Moritz Schmelzle, and Sven Jonas declare no conflicts of interest.
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Georg Wiltberger and Felix Krenzien contributed equally to this work and are co-first authors.
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10434_2015_4999_MOESM1_ESM.tif
Survival curves according different pathological characteristics. The absence of residual Tumor (A), the absence of lymph node metastasis (B), a well/moderately differentiated tumor (C) showed survival benefit for patients who underwent partial pancreaticoduodenectomy (p<0.05). Log Rank test was used to compare survival curves.Survival curves according different pathological characteristics. The absence of residual Tumor (A), the absence of lymph node metastasis (B), a well/moderately differentiated tumor (C) showed survival benefit for patients who underwent partial pancreaticoduodenectomy (p<0.05). Log Rank test was used to compare survival curves. (TIFF 1233 kb)
10434_2015_4999_MOESM2_ESM.tif
Survival curves according different pathological characteristics. Invasion of small lymphatic vessels (A), vessel invasion (B), perineural invasion (C), distant metastasis (D), pancreas infiltration (E) and duodenal infiltration (F) did not statistically affect patient outcome. Log Rank test was used to compare survival curves. (TIFF 1662 kb)
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Wiltberger, G., Krenzien, F., Benzing, C. et al. Prognostic Accuracy of the Seventh Edition of the TNM Classification Compared with the Fifth and Sixth Edition for Distal Cholangiocarcinoma. Ann Surg Oncol 23, 1320–1326 (2016). https://doi.org/10.1245/s10434-015-4999-9
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DOI: https://doi.org/10.1245/s10434-015-4999-9