Assessment of nodal status for perihilar cholangiocarcinoma: does the extent of lymphadenectomy make a difference?

Over the last several decades aggressive surgical resection has changed the prognosis for perihilar cholangiocarcinoma, transforming an unresectable tumor with certain mortality to a curable disease with almost 50% 5-year survival in high volume centers with R0N0 resections (1). The field continues to evolve, pushing boundaries and improving outcomes by extending resection to include vascular resections and pancreaticoduodenectomy to achieve negative margins. The Nagoya group has been instrumental in advocating an aggressive approach to this disease and is considered one of the most experienced and aggressive surgical centers for treatment of cholangiocarcinoma. However, no matter how aggressive the surgery, the risk of lymph node metastases at the time of resection remains 24-50% (2) and lymph node involvement remains one of the most significant negative prognostic factors for recurrence and survival after resection after margin status.