Interobserver variability in lymph node evaluation with endoscopic ultrasonography in perihilar and intrahepatic cholangiocarcinoma

Aims Accurate preoperative lymph node (LN) assessment is crucial for patients with intrahepatic cholangiocarcinoma (iCCA) and perihilar cholangiocarcinoma (pCCA), as the presence of LN metastases significantly reduces survival rates and can contraindicate surgical resection. Endoscopic ultrasound (EUS) provides a reliable method for LN assessment with the advantage of enabling tissue acquisition for pathological confirmation. Although specific LN characteristics have been recognized as important predictive factors for metastatic disease in hepatobiliary disease in general, inter-observer agreement is suggested to be poor. This study aimed to assess the interobserver agreement among endosonographers in evaluating LN characteristics in patients with iCCA and pCCA.

Methods A cross-sectional survey study was conducted among 24 endosonographers. Participants reviewed 42 randomly selected de-identified EUS images from iCCA and pCCA patients, classifying LNs based on six characteristics (demarcation, shape, echogenicity, homogeneity, suspiciousness, and the need to retrieve tissue). Interobserver agreement was determined using Light’s kappa statistics. Diagnostic accuracy, sensitivity and specificity were determined based on a 2x2 table where presumed suspicious/not suspicious (based on EUS characteristics) was plotted against definite benign/malignant (EUS-fine needle aspiration/biopsy or surgical specimen pathology) [1] [2] [3] [4] [5].

Results The overall kappa values indicated moderate to fair agreement on LN characteristics, with Kappa values of 0.24 for demarcation, 0.45 for shape, 0.38 for echogenicity, 0.52 for homogeneity, and 0.36 for suspiciousness. The overall accuracy of endosonographers in correctly identifying malignant LNs was 64% with individual accuracy ranging from 45 to 76%. Sensitivity was 56% (range: 27-91%) and specificity was 68% (range: 28-89%).

Conclusions The endosonographic assessment of LN morphology and characterization demonstrates considerable variability among endosonographers. Thus, there is a clear need for standardization in preoperative LN evaluation. The findings of this study support the justification to biopsy all LNs as carried out in the POELH trial (NCT05678218). Establishing consensus on when to perform tissue acquisition, based on objective criteria such as short-axis diameter, is required to refine and optimize these preoperative EUS for iCCA and pCCA.

 

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Conflicts of Interest

M.J. Bruno serves as a consultant and receives support for industry and investigator-initiated studies from Boston Scientific and Cook Medical and receives support for investigator-initiated studies from Pentax Medical, 3 M, Interscope, and Mylan. W.J. Lammers acts as a consultant/lecturer for Mediglobe. The other authors declare that they have no conflicts of interest.

• References

• 1 Gleeson FC, Rajan E, Levy MJ. et al. EUS-guided FNA of regional lymph nodes in patients with unresectable hilar cholangiocarcinoma. Gastrointest Endosc 2008; 67 (3): 438-443
• 2 de Jong DM, van de Vondervoort S, Dwarkasing RS. et al. Endoscopic ultrasound in patients with resectable perihilar cholangiocarcinoma: impact on clinical decision-making. Endosc Int Open 2023; 11 (2): E162-E168
• 3 de Jong DM, den Hoed CM, Willemssen FEJA. et al. Impact of EUS in liver transplantation workup for patients with unresectable perihilar cholangiocarcinoma. Gastrointestinal Endoscopy 2024; 99 (4): 548-556
• 4 Malikowski T, Levy MJ, Gleeson FC. et al. Endoscopic Ultrasound/Fine Needle Aspiration Is Effective for Lymph Node Staging in Patients With Cholangiocarcinoma Hepatology. 2019; doi:10.1002/hep.31077..
• 5 Schulick RD.. Criteria of unresectability and the decision-making process. HPB (Oxford) 2008; 10 (2): 122-125

Publication History

Article published online:
27 March 2025