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Lymphadenectomy in Gallbladder Adenocarcinoma: Are We Doing Enough?
Marianna V. Papageorge, Susanna W. de Geus, Alison P. Woods, Sing Chau Ng, Andrea Merrill, Michael R. Cassidy, David McAneny, Jennifer F. Tseng, Teviah E. Sachs
Department of Surgery, Boston Medical Center, Boston, Massachusetts, United States

Objective: Current American Joint Committee on Cancer (AJCC) guidelines recommend that ≥6 lymph nodes be evaluated at the time of gallbladder cancer resection but real world data demonstrate that this number is rarely achieved. We sought to determine the extent of lymphadenectomy among patients with gallbladder adenocarcinoma and its impact on staging and survival.

Design: Retrospective cohort study.

Setting: National population-based study.

Patients: Patients with clinical stage T1b or greater gallbladder adenocarcinoma who underwent resection were identified from the National Cancer Database (2004-2015). Propensity scores were created for the odds of sufficient lymphadenectomy (≥6 lymph nodes) and were matched 1:1 based on sex, age, co-morbidity status, insurance status and facility type.

Main Outcome Measures: Primary outcome: number of lymph nodes removed. Secondary outcome: overall survival (OS).

Results: Overall, 3713 patients were identified: 63.5% had N0 disease and 36.5% had N1-2 disease. The median number of lymph nodes evaluated in N0 patients was 1 (IQR 0-3), versus 2 lymph nodes in N1-2 disease (IQR 1-5) (p<0.0001). A sufficient lymphadenectomy was performed in twice as many patients with N1-2 disease as compared to N0 disease (21.9% v 11.1%, p<0.0001). In patients with N0 disease, sufficient lymphadenectomy was associated with a significant survival benefit: OS 92.2 months versus 33.5 months (log-rank, p<0.0001).

Conclusions: The majority of patients with gallbladder adenocarcinoma do not undergo dissection of the recommended number of lymph nodes. As a result, many patients with N0 disease are likely under-staged. This discordance is associated with a significant survival disadvantage. Insufficient lymphadenectomy may promote this survival disadvantage by allowing local tumor recurrence or by negatively influencing decisions regarding adjuvant therapy.

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