Published online Nov 15, 2023. doi: 10.4251/wjgo.v15.i11.2017
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
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.
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.
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).
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.
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.
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.
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.