Meta-Analysis
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Nov 15, 2023; 15(11): 2017-2032
Published online Nov 15, 2023. doi: 10.4251/wjgo.v15.i11.2017
Role of routine lymph node dissection alongside resection of intrahepatic cholangiocarcinoma: Systematic review and meta-analysis
Mo Atif, Aditya Borakati, Vasileios K Mavroeidis
Mo Atif, Department of Colorectal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
Aditya Borakati, Department of HPB and Liver Transplantation Surgery, Royal Free Hospital NHS Foundation Trust, London NW3 2QG, United Kingdom
Vasileios K Mavroeidis, Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom
Vasileios K Mavroeidis, Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
Author contributions: Atif M and Borakati A contributed equally to this work; Atif M and Borakati A did the literature search, acquisition of data, analysis and drafted the original manuscript; Mavroeidis VK conceptualised and supervised the study, and made critical revisions; all authors designed the study, interpreted the data, prepared the final draft and approved the final version.
Conflict-of-interest statement: The authors declare no conflict of interests for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Vasileios K Mavroeidis, MD, MSc, FRCS, FACS, FICS, MFSTEd, MICR, Surgeon, Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Royal Infirmary, Upper Maudlin St, Bristol BS2 8HW, United Kingdom. vasileios.mavroeidis@nhs.net
Received: August 10, 2023
Peer-review started: August 10, 2023
First decision: August 30, 2023
Revised: September 14, 2023
Accepted: October 23, 2023
Article in press: October 23, 2023
Published online: November 15, 2023
Processing time: 96 Days and 20 Hours
ARTICLE HIGHLIGHTS
Research background

Intraoperative lymph node dissection (LND) is increasingly being performed alongside hepatic resection for intrahepatic cholangiocarcinoma (ICCA) to more accurately stage the disease, reduce recurrence, and improve overall survival (OS). While this procedure may result in associated morbidity, there is no consensus or formal guidelines on its role in this setting.

Research motivation

There is a need to better delineate the evidence for performing LND alongside surgical resection of the ICCA in improving prognostication and survival post-resection of ICCA.

Research objectives

To compare curative intent resection of ICCA with LND vs resection without LND with the primary outcome measures of OS and disease-free survival (DFS).

Research methods

A systematic review and meta-analysis was performed per the PRISMA framework and Cochrane Handbook for Systematic Reviews. A systematic literature search was performed using Pubmed, Medline, Embase, and the Cochrane Library, for all studies involving LND, ICCA, and surgical resection. All clinical studies comparing curative intent resection of ICCA with LND vs resection without LND were included from the different academic databases up till early December 2022. The primary outcome measures were set for OS and DFS. Quality assessment was conducted using the ROBINS-I tool. Data were analysed using RStudio (R 4.3.0; R Foundation, Austria) with meta and dmetar packages. Meta-analyses were conducted depending on feasibility.

Research results

In the total of harvested LNs in patients who underwent LND, the incidence of metastases was 27.7%. LND did not significantly improve OS and DFS in patients undergoing resection, however, there may be a trend toward improved OS. The effect of LND on OS showed a degree of variability by geographical region, in Eastern and Western countries. Concomitant neoadjuvant and/or adjuvant chemotherapy with LND did not improve OS. The effect of LND differed depending on tumour morphology with resection of periductal infiltrating tumours being associated with significantly worsened OS and resection of mass-forming tumours with improved OS. Positive lymph nodes (LNs) at lymphadenectomy or retrieval of > 6 LNs were not associated with a difference in survival.

Research conclusions

Overall, the results of this meta-analysis show that LND does not improve OS or DFS in patients with ICCA. However, a significant proportion of patients undergoing LND are found to have LN metastases, suggesting that LND may result in a more accurate staging. Consequently, it may be beneficial for prognostication and stratification of patients to guide adjuvant treatments. Notably, in high-risk patients unlikely to benefit from further treatments, the current evidence would not support the performance of LND as a standard part of the surgical resection of ICCA.

Research perspectives

The fact that LND may result in a more accurate staging and consequently aid the prognostication and stratification of patients to guide adjuvant treatments, may become more important in the future, should more effective chemotherapeutic agents be discovered for this type of cancer, ultimately leading to survival benefit.

There is an urgent clinical need for higher-quality studies to dissect the role of LND further.