Defining when to offer operative treatment for intrahepatic cholangiocarcinoma: A regret-based decision curves analysis

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• 作者：Fabio Bagante ; MD^a ; Gaya Spolverato ; MD^a ; Alessandro Cucchetti ; MD^b ; Faiz Gani ; MBBS^a ; Irinel Popescu ; MD^c ; Andrea Ruzzenente ; MD^d ; Hugo P. Marques ; MD^e ; Luca Aldrighetti ; MD^f ; T. Clark Gamblin ; MD^g ; Shishir K. Maithel ; MD^h ; Charbel Sandroussi ; MDⁱ ; Todd W. Bauer ; MD^j ; Feng Shen ; MD^k ; George A. Poultsides ; MD^l ; James Wallis Marsh ; MD^m ; Alfredo Guglielmi ; MD^d ; Timothy M. Pawlik ; MD ; MPH ; PhD ; FACS^a ; ^{tpawlik1@jhmi.edu" class="auth_mail" title="E-mail the corresponding author}
• 刊名：Surgery
• 出版年：2016
• 出版时间：July 2016
• 年：2016
• 卷：160
• 期：1
• 页码：106-117
• 全文大小：621 K

文摘

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).