A more detailed lymph node metastasis classification for patients with cholangiocarcinoma (CCA) could determine the survival prognosis more accurately, according to a study recently published in Cancer Medicine.

“Consistent with the eighth edition of AJCC recommendations, in this study, the novel nodal classification could not stratify prognosis between the N1 and N2 groups among patients who had NELN <6, indicating that adequate pathologic staging can only be obtained by the retrieval of at least 6 LNs,” the authors wrote.

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This observational study included 1028 patients previously diagnosed with intrahepatic CCA, of whom the majority (63.4%) underwent surgical tumor resection with lymph node dissection. Among these cases, 32.5% had histologically confirmed lymph node metastasis. 

Notably, there was no difference in survival between patients that underwent lymph node dissection and those who did not. Regardless, participants with confirmed lymph node metastasis exhibited lower overall survival and cancer-specific survival rates than those without lymph node involvement or who did not have a lymph node staging procedure. 

Moreover, the proportion of positive lymph nodes for metastasis directly correlated with survival rates. The researchers further proposed a lymph node involvement classification: N0 for no metastasis, N1 for 1 to 2 positive nodes, and N3 for 3 or more positive nodes. Both the overall survival and cancer-specific survival rates markedly decreased as the classification was higher.

For example, the median overall survival was 46, 21, and 14 for those in stages N0, N1, and N2, respectively. Likewise, the median cancer-specific survival was 50, 22, and 14 for each case. Further multivariable analysis revealed that a greater nodal stage is an independent survival prognostic tool. 

These results confirm the importance of dissecting lymph nodes in patients undergoing a surgical procedure for CCA while also questioning the classification system.

“In the era of personalized medicine, this simplistic binary classification for N staging bears limited prognostic value to guide clinical practice,” the authors concluded.


Zhu J, Liu C, Li H, et al. Adequate lymph node dissection is essential for accurate nodal staging in intrahepatic cholangiocarcinoma: a population-based study. Cancer Med. Published online January 16, 2023. doi:10.1002/cam4.5620