Endoscopic ultrasound in patients with resectable perihilar cholangiocarcinoma: impact on clinical decision-making

Abstract

Background and study aims Accurate assessment of the lymph node (LN) status is crucial in resectable perihilar cholangiocarcinoma (pCCA) to prevent major surgery in patients with extraregional metastatic LNs (MLNs). This study investigates the added value of preoperative endoscopic ultrasound (EUS) with or without tissue acquisition (TA) for the detection of MLNs in patients with resectable pCCA. Patients and methods In this retrospective, multicenter cohort study, patients with potentially resectable pCCA who underwent EUS preoperatively between 2010-2020, were included. The clinical impact of EUS-TA was defined as the percentage of patients who did not undergo surgical resection due to MLNs found with EUS-TA. Findings of cross-sectional imaging were compared with EUS-TA findings and surgery. Results EUS was performed on 141 patients, of whom 107 (76 %) had suspicious LNs on cross-sectional imaging. Surgical exploration was prevented in 20 patients (14 %) because EUS-TA detected MLNs, of which 17 (85 %) were extraregional. Finally, 74 patients (52 %) underwent surgical exploration followed by complete resection in 40 (28 %). MLNs were identified at definitive pathology in 24 (33 %) patients, of which 9 (38 %) were extraregional and 15 (63 %) regional. Conclusions EUS-TA may be of value in patients with potentially resectable pCCA based on preoperative cross-sectional imaging, regardless of lymphadenopathy at cross-sectional imaging. A prospective study in which a comprehensive EUS investigation with LN assessment and EUS-TA of LNs is performed routinely should confirm this promise.

Conflict of interest statement

Competing interests Dr. Bruno received research funding for industry-initiated studies from Boston Scientific and Cook Medical. He received research funding for investigator initiated studies from Boston Scientific, Cook Medical, Pentax Medical, Interscope, Mylan and ChiRoStim. He is a consultant to Boston Scientific, Cook Medical, and Pentax Medical. Dr. Voermans received research funding for investigator initiated studies from Boston Scientific and Prion Medical. He is a consultant with speakers fee for Boston Scientific.

The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Figures

Fig. 1

Flowchart of patients included in this study. § In 72 patients, because of missing pathology in one patient and one patient with cardiac arrest during surgery, before any resection. Two patients had preoperative confirmation of MLN by EUS-TA and underwent surgery. The first patient underwent a diagnostic laparoscopy which showed locally advanced disease. The second patient underwent left hemi-hepatectomy with regional MLN. These patients are not taken into account.

Fig. 2

Flowchart of patients included in this study, according to imaging findings. § For patients without preoperative confirmation of MLN by EUS-TA.