EUS-guided FNA of regional lymph nodes in patients with unresectable hilar cholangiocarcinoma

Background: The clinical impact of EUS-guided FNA (EUS-FNA) in regional lymph-node staging in patients with unresectable hilar cholangiocarcinoma before liver transplantation has yet to be determined. Objectives: To determine the frequency of regional lymph-node detection, identify EUS features predictive of benign or malignant lymph nodes, compare EUS lymph-node detection rates to CT/magnetic resonance imaging and exploratory laparotomy and evaluate the impact of EUS-FNA on patient selection for liver transplantation. Design: Retrospective case series. Setting: Tertiary referral EUS unit. Patients: Clinical, radiographic, EUS, cytologic, and surgical data of 47 patients with unresectable hilar cholangiocarcinoma before liver transplantation were evaluated. Interventions: EUS-FNA. Main Outcome Measurements: Lymph-node morphology and echo features. Results: EUS identified lymph nodes in all patients. FNA of 70 lymph nodes identified metastases in 9 nodes of 8 patients (17%), who were then precluded from transplantation before a staging laparotomy. Identified lymph nodes, irrespective of malignant involvement, were typically oval and geographic in shape, of mixed echogenicity with a hypoechoic border. There were no morphologic criteria or echo features to correlate with nodal malignancy The EUS finding of absent regional lymph-node metastases was confirmed in 20 of 22 by a subsequent exploratory staging laparotomy. Limitations: Single institution, retrospective analysis. Conclusions: EUS identified lymph nodes in all patients, and confirmation of malignant lymph nodes detected by FNA precluded 17% of patients from transplantation. EUS-FNA of visualized lymph nodes irrespective of appearance is advised because morphology and echo features do not predict malignant involvement.