Selective lymph node dissection in intrahepatic cholangiocarcinoma may not impair oncological outcomes: A single-center retrospective cohort study

Background 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. Methods 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. Results 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 3.37, 95% CI 1.55–7.41; p = 0.002). The median overall survival was 30.5 months for pN0 patients, 17.4 months for pN1 patients, and 59.1 months for pNx patients (p = 0.034). 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 = 0.335). Patients with pure CCA had worse survival than those with HCC-CCA (HR 1.65, 95% CI 1.01–2.70; p = 0.044). Adequate lymphadenectomy (≥ 6 nodes) was achieved in only 26% of patients who underwent LND. Conclusions Compared with routine lymphadenectomy with negative nodes, selective lymph node dissection based on clinical suspicion does not compromise survival outcomes. 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.