Extrahepatic Lymphadenectomy in Intrahepatic Cholangiocarcinoma: Current Evidence and Controversies

Abstract

Lymph node metastasis (LNM) is one of the most adverse prognostic factors in intrahepatic cholangiocarcinoma (iCCA), with five-year overall survival rarely exceeding 15% in node-positive patients. The role and extent of extrahepatic lymphadenectomy in this setting, however, remain controversial. This narrative review synthesizes the current evidence on nodal assessment in iCCA, including prognostic implications of nodal disease, preoperative prediction of LNM, survival benefit of lymphadenectomy, and postoperative morbidity. Prognosis is particularly poor in patients with multiple positive nodes, high lymph node ratio, or metastases beyond the hepatoduodenal ligament. Preoperative imaging with computed tomography (CT) or magnetic resonance imaging (MRI) has limited accuracy for nodal staging, while PET-CT and endoscopic ultrasound with fine-needle aspiration provide improved detection in selected cases. To address this limitation, predictive nomograms have been proposed, which integrate clinical, biochemical, and radiological variables and are available as online calculators for daily practice. From a surgical perspective, adequate lymphadenectomy, defined by retrieval of at least six lymph nodes, remains essential for accurate staging and should be tailored to tumor laterality, involving stations 1, 3, 7, 8, and 12 for left-lobe tumors and stations 8, 12, and 13 for right-lobe tumors. Although its therapeutic role is still debated, a growing number of studies published in recent years suggest that lymphadenectomy may confer a survival benefit, particularly in clinically node-negative patients undergoing R0 resection and in those with less aggressive tumor biology.