# Selective lymph node dissection in intrahepatic cholangiocarcinoma and combined hepatocellular cholangiocarcinoma may not impair oncological outcomes: a single-center retrospective cohort study

## TL;DR

This study suggests that selective lymph node dissection in intrahepatic cholangiocarcinoma and combined hepatocellular-cholangiocarcinoma does not worsen survival outcomes compared to routine dissection.

## Contribution

The study challenges current guidelines by showing that selective lymph node dissection based on clinical judgment does not compromise oncological outcomes in iCCA patients.

## Key findings

- Selective lymph node dissection did not significantly affect overall survival compared to routine dissection.
- Only 30% of patients underwent lymph node dissection, with decisions influenced by preoperative diagnosis of cholangiocarcinoma.
- Patients with pure cholangiocarcinoma had worse survival than those with combined hepatocellular-cholangiocarcinoma.

## Abstract

Current guidelines recommend routine lymph node dissection (LND) for intrahepatic cholangiocarcinoma (iCCA) to achieve adequate staging; however, real-world compliance remains suboptimal. This study evaluated whether, compared with routine approaches, selective lymphadenectomy, on the basis of clinical judgment, compromises oncological outcomes in patients with iCCA.

A retrospective analysis of 179 patients who underwent curative hepatectomy for iCCA between 2014 and 2024 was performed. The cohort included pure cholangiocarcinoma (CCA, n = 102) and combined hepatocellular-cholangiocarcinoma (HCC-CCA, n = 77) patients. Patients were categorized by pathological nodal status: pN0 (LND performed, negative nodes), pN1 (LND performed, positive nodes), and pNx (no LND performed). Logistic regression identified factors influencing LND decisions. Survival outcomes were analyzed via the Kaplan‒Meier method and Cox proportional hazards modeling. Subgroup analysis was performed to explore the outcomes in CCA and HCC-CCA separately.

LND was performed in 54 patients (30%), with significant variation based on tumor characteristics. Preoperative cholangiocarcinoma diagnosis was the primary factor influencing LND decisions (OR 3.33, 95% CI 1.54–7.34; p = 0.002). The median overall survival (OS) was 30.5, 17.4, and 59.1 months (p = 0.007), and median progression-free survival (PFS) was 21.2, 8.4, and 16.6 months (p = 0.042) for pN0, pN1, and pNx, respectively. Subgroup analysis for CCA and HCC-CCA separately showed a similar Kaplan-Meier curve pattern, but the differences were not statistically significant because of the uneven distribution between groups. After adjusting for age, tumor stage, and histology, no significant difference in survival was detected between the pNx and pN0 groups (HR 0.78, 95% CI 0.46–1.30; p = 0.34). Patients with pure CCA had worse survival than those with HCC-CCA (HR 1.68, 95% CI 1.03–2.75; p = 0.040). Adequate lymphadenectomy (≥ 6 nodes) was achieved in only 26% of patients who underwent LND.

This study highlights the low compliance with the guidelines regarding lymph node dissection for intrahepatic cholangiocarcinoma in real-world settings. However, compared to lymphadenectomy with negative nodes, selective lymph node dissection based on clinical suspicion does not compromise the overall survival. These findings support individualized surgical approaches rather than universal lymphadenectomy protocols and challenge current guidelines mandating routine LND for all iCCA patients. Future guidelines should incorporate risk-stratified decision-making in lymph node management.

The online version contains supplementary material available at 10.1186/s12957-025-04034-3.