Endoscopic ultrasound with tissue acquisition of lymph nodes in patients with resectable distal cholangiocarcinoma

Lymph node (LN) involvement is a negative prognostic factor for patients with distal cholangiocarcinoma (dCCA). Therefore, preoperative assessment of the LN status could potentially aid therapy decision making. Endoscopic ultrasound (EUS) is often used to obtain a tissue diagnosis of the primary tumor, but can also be used to sample suspicious LN. The aim of this study was to evaluate the impact of EUS for suspicious LN in patients with presumed resectable dCCA. In this multicenter cohort study, patients with potentially resectable dCCA who underwent preoperative EUS between 2010 and 2020 were retrospectively included. Impact of EUS was defined as the percentage of patients who were precluded from surgical exploration due to pathologically confirmed LN metastasis found with EUS tissue acquisition (EUS-TA). A total of 149 patients were included. In the 187 EUS procedures performed, a total of 58 LN among 43 patients were described. Among five patients (3.6%), EUS-TA of LN confirmed malignancy in six of the 20 LN (30%). In four patients (2.7%), surgical exploration was withheld due to nodal involvement (extraregional in two, regional in two). Finally, 109 patients (73.2%) underwent surgical exploration. During exploration or at surgical pathology specimens, malignant regional LN was identified in 58 patients (53.2%). Preoperative EUS had a limited but clinically important yield for nodal staging in patient with presumed resectable dCCA but was not executed in systematic fashion. Further prospective studies should investigate whether systematic nodal staging with EUS could improve preoperative decision making.