Background The role of routine lymphadenectomy (LD) among patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC) remains poorly defined. This study aimed to evaluate the role of ...routine LD as well as to quantify the impact of not assessing nodal station on disease-specific survival (DSS) among patients undergoing liver surgery for ICC. Study Design Using data from 12 major hepatobiliary centers, 561 patients undergoing liver surgery for ICC between 1990 and 2012 were identified. The association between nodal status and DSS was assessed using Cox proportional and Aalen's linear hazards models. Results Among the 272 (48.5%) patients who underwent LD, 123 (45.2%) had lymph node metastasis (N1). Although differences in DSS were noted between N0 and Nx patients within the first 18 months after surgery (DSS at 18 months: N0 vs Nx, 70.2% vs 60.6%, respectively, p = 0.019) among patients who had survived to 18 months, the DSS at 60 months of Nx patients was comparable to that of N0 patients (p = 0.48). Conversely, although the DSS of N1 and Nx patients was comparable in the short-term (DSS at 18 months: p = 0.13), among patients who had survived to 18 months, N1 patients had a lower DSS compared with Nx patients (DSS at 60 months among patients who had survived to 18 months: N1 vs Nx, 15.2% vs 45.8%, respectively, p < 0.001; all p values were based on the log-rank test comparing 2 survival curves). Conclusions Although Nx patients and N1 patients had comparable DSS in the short-term, Nx patients who survived past 18 months had a survival comparable to that of N0 patients. Lack of nodal staging may lead to heterogeneous and potentially incorrect prognostic classification of patients with ICC.
Background Patients with advanced gastrointestinal stromal tumors (GIST) are at high risk for recurrence after surgery. The aim of this study was to characterize outcomes of advanced GIST treated ...with surgery from a large multi-institutional database in the tyrosine kinase inhibitor (TKI) era. Study Design Patients who underwent surgery for an advanced GIST from 1998 through 2012 were identified. Demographic, clinicopathologic, perioperative, and survival data were collected and analyzed. Results There were 87 patients with locally advanced GIST and 71 patients with recurrent/metastatic GIST. The vast majority (95%) of patients with locally advanced GIST required a multivisceral resection; most patients (87%) underwent a microscopically complete (R0) resection. Although 82% of patients had high-risk tumors according to modified NIH criteria or had recurrent/metastatic disease, only 56% of patients received adjuvant TKI therapy. Among patients with locally advanced GIST, 3-year recurrence-free survival and overall survival rates were 65% and 87%, respectively. In contrast, 3-year recurrence-free survival and overall survival rates among patients with recurrent/metastatic GIST were 49% and 82%, respectively. On multivariate analysis, predictors of worse outcomes included high mitotic rate and male sex for patients with locally advanced GIST, and age and lack of adjuvant TKI therapy were associated with adverse outcomes among patients with recurrent/metastatic GIST (all p < 0.05). Conclusions Resection of advanced GIST can be safely accomplished with high rates of R0 resection. Among patients with advanced GIST, TKI therapy was underused. Barriers to the use of TKI therapy in this population should be explored.
Background The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) risk-adjustment model for patients who require hepatic resection does not include metrics of ...underlying chronic liver disease. The applicability of the current risk adjustment model is under debate. This study aims to assess the impact of chronic liver disease on the ACS NSQIP estimates of postoperative morbidity and mortality. Study design This retrospective cohort study included all cases of hepatic resection at our quaternary referral institution between 2006 and 2013. Metrics of chronic liver disease were abstracted and linked with the ACS NSQIP risk-adjustment model estimated probabilities of morbidity and mortality for each case. Sequential general linear models were used to estimate differences in ACS NSQIP probabilities of morbidity and mortality associated with measures of underlying chronic liver disease. Results A total of 522 hepatic resections were performed during the study period. The patient cohort included 91 patients with fibrosis (17%) and 38 patients with cirrhosis (7%). The mean ACS NSQIP estimated probability of morbidity was 0.24 ± 0.11 and probability of mortality was 0.02 ± 0.02. Fibrosis was associated with increased probability of morbidity (0.26 ± 0.11; P = .019); cirrhosis was also associated with increased probability of morbidity (0.27 ± 0.10; P = .059). Parenchymal liver disease was not associated with increased probability of mortality (all P ≥ .62). Increased probabilities of mortality were associated with diagnosis and extent of resection (both P < .001). Conclusions In patients selected for hepatectomy, metrics of chronic liver disease were associated with differences in ACS NSQIP estimated probability of morbidity. Incorporation of metrics of chronic liver disease into the ACS NSQIP targeted hepatectomy modules should improve estimates of risk after hepatic resection.
Background Regret-based decision curve analysis (DCA) is a framework that assesses the medical decision process according to physician attitudes (expected regret) relative to disease-based factors. ...We sought to apply this methodology to decisions around the operative management of intrahepatic cholangiocarcinoma (ICC). Methods Utilizing a multicentric database of 799 patients who underwent liver resection for ICC, we developed a prognostic nomogram. DCA tested 3 strategies: (1) perform an operation on all patients, (2) never perform an operation, and (3) use the nomogram to select patients for an operation. Results Four preoperative variables were included in the nomogram: major vascular invasion (HR = 1.36), tumor number (multifocal, HR = 1.18), tumor size (>5 cm, HR = 1.45), and suspicious lymph nodes on imaging (HR = 1.47; all P < .05). The regret-DCA was assessed using an online survey of 50 physicians, expert in the treatment of ICC. For a patient with a multifocal ICC, largest lesion measuring >5 cm, one suspicious malignant lymph node, and vascular invasion on imaging, the 1-year predicted survival was 52% according to the nomogram. Based on the therapeutic decision of the regret-DCA, 60% of physicians would advise against an operation for this scenario. Conversely, all physicians recommended an operation to a patient with an early ICC (single nodule measuring 3 cm, no suspicious lymph nodes, and no vascular invasion at imaging). Conclusion By integrating a nomogram based on preoperative variables and a regret-based DCA, we were able to define the elements of how decisions rely on medical knowledge (postoperative survival predicted by a nomogram, severity disease assessment) and physician attitudes (regret of commission and omission).
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