Retroperitoneal Lymph Node Metastasis in Gallbladder Cancer: As Bad as Distant Metastasis

Abstract

Ashish Singh

Background Regarding gallbladder cancer (GBC) there is conflicting evidence in the literature whether retroperitoneal lymph nodal metastases (RLNM) should be considered as regional nodal metastasis or as distant metastasis (DM) and the jury is out on radical curative surgery in presence of RLNM. This is an analysis of GBC patients, to see the effect of RLNM on survival and to compare with that of patients with DMs.

Methods A retrospective analysis of a prospective database of patients of GBC with RLNM (interaortocaval and paraaortic) or DM on frozen section biopsy at surgery, between January 2013 and December 2018. Data was analyzed using the Statistical Package for the Social Sciences software (version 22.0). Survival in these two groups (RLNM and DM) was compared with log-rank test. A p-value of < 0.05 was considered significant.

Results A total of 235 patients with ostensibly resectable GBC underwent surgical exploration. The planned curative resection was abandoned in 91 (39%) patients because of RLNM (n = 20, 9%) or DM (n = 71, 30%) on frozen section biopsy. Demographic profile and blood parameters were similar. The median survival for RLNM and DM groups were 5 (range 2–26) and 6 (range 2–24) months, respectively, with no significant difference on log-rank test (p = 0.64). There was no 3-year or longer survivor in either group.

Conclusion Due to similar poor survival in presence of RLNM or DM, RLNM should be considered as the equivalent of DM. This study strengthens evidence to avoid curative surgery in patients with RLNM. These lymph nodes should be sampled preoperatively, if suspicious on imaging, for fine-needle aspiration cytology and at surgery, as a routine for frozen section histological examination before initiating curative resection to avert a futile exercise.

Keywords

gallbladder cancer - retroperitoneal lymph node metastasis - interaortocaval lymph node metastasis - para-aortic lymph-node metastasis - distant metastasis

• References

• 1 American Cancer Society. Cancer Facts & Figures. Atlanta, GA: American Cancer Society; 2016
• 2 Rückert JC, Rückert RI, Gellert K, Hecker K, Müller JM. Surgery for carcinoma of the gallbladder. Hepatogastroenterology 1996; 43 (09) 527-533
• 3 Shimada H, Endo I, Togo S, Nakano A, Izumi T, Nakagawara G. The role of lymph node dissection in the treatment of gallbladder carcinoma. Cancer 1997; 79 (05) 892-899
• 4 Chijiiwa K, Kai M, Nagano M, Hiyoshi M, Ohuchida J, Kondo K. Outcome of radical surgery for stage IV gallbladder carcinoma. J Hepatobiliary Pancreat Surg 2007; 14 (04) 345-350
• 5 Murakami Y, Uemura K, Sudo T. et al. Is para-aortic lymph node metastasis a contraindication for radical resection in biliary carcinoma?. World J Surg 2011; 35 (05) 1085-1093
• 6 Ishikawa T, Horimi T, Shima Y. et al. Evaluation of aggressive surgical treatment for advanced carcinoma of the gallbladder. J Hepatobiliary Pancreat Surg 2003; 10 (03) 233-238
• 7 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 (04) 418-422
• 8 Kondo S, Nimura Y, Hayakawa N, Kamiya J, Nagino M, Uesaka K. Extensive surgery for carcinoma of the gallbladder. Br J Surg 2002; 89 (02) 179-184
• 9 Kondo S, Nimura Y, Kamiya J. et al. Five-year survivors after aggressive surgery for stage IV gallbladder cancer. J Hepatobiliary Pancreat Surg 2001; 8 (06) 511-517
• 10 Nishio H, Nagino M, Ebata T, Yokoyama Y, Igami T, Nimura Y. Aggressive surgery for stage IV gallbladder carcinoma; what are the contraindications?. J Hepatobiliary Pancreat Surg 2007; 14 (04) 351-357
• 11 Amemiya T, Yokoyama Y, Oda K. et al. A patient with gallbladder cancer with paraaortic lymph node and hepatic metastases who has survived for more than 13 years after the primary extended radical operation. J Hepatobiliary Pancreat Surg 2008; 15 (06) 648-651
• 12 Shinkai H, Kimura W, Sata N, Muto T, Nagai H. A case of gallbladder cancer with para-aortic lymph node metastasis who has survived more than seven years after the primary extended radical operation. Hepatogastroenterology 1996; 43 (11) 1370-1376
• 13 Ohtani T, Shirai Y, Tsukada K, Muto T, Hatakeyama K. Spread of gallbladder carcinoma: CT evaluation with pathologic correlation. Abdom Imaging 1996; 21 (03) 195-201
• 14 Agarwal AK, Kalayarasan R, Javed A, Sakhuja P. Role of routine 16b1 lymph node biopsy in the management of gallbladder cancer: an analysis. HPB (Oxford) 2014; 16 (03) 229-234
• 15 Kluge R, Schmidt F, Caca K. et al. Positron emission tomography with [(18)F]fluoro-2-deoxy-D-glucose for diagnosis and staging of bile duct cancer. Hepatology 2001; 33 (05) 1029-1035