肝门部胆管癌手术切除疗效及预后影响因素分析
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摘要
目的探讨肝门部胆管癌(HCCA)手术切除的临床疗效及预后影响因素。方法回顾性分析2009年1月至2013年12月在解放军福州总医院行手术切除的52例HCCA患者临床资料。其中男31例,女21例;年龄34～80岁,中位年龄63岁。患者均签署知情同意书,符合医学伦理学规定。观察患者生存、肿瘤复发及转移情况。生存分析及预后单因素分析采用Kaplan-Meier法和Logrank检验,多因素分析采用Cox比例风险回归模型。结果随访期间45例患者死于复发、转移,1例死于上消化道出血。52例患者总体中位生存时间为21个月,1、3、5年生存率分别为69.2%、30.8%、11.5%。单因素分析结果显示肿瘤直径、肿瘤根治程度、淋巴结转移、TNM分期、肿瘤分化程度是HCCA手术切除患者预后的影响因素(χ~2=3.902,8.820,8.926,4.245,6.071;P<0.05)。多因素分析结果显示肿瘤R0切除、淋巴结阴性、TNM分期Ⅰ～Ⅱ期、肿瘤高分化为HCCA手术切除患者预后的独立保护因素(HR=0.364,0.379,0.546,0.498;95%CI:0.178～0.743,0.190～0.756,0.303～0.984,0.263～0.942;P<0.05)。结论 HCCA患者预后差,根治性切除、规范淋巴结清扫和肿瘤恶性程度为影响外科手术疗效的关键因素。
Objective To investigate the clinical efficacy of surgical resection for hilar cholangiocarcinoma(HCCA) and the impact factors for the prognosis. Methods Clinical data of 52 patients with HCCA who underwent surgical resection in Fuzhou General Hospital of PLA from January 2009 to December 2013 were retrospectively analyzed. Among them, 31 patients were male and 21 were female, aged from 34 to 80 years, with a median age of 63 years. The informed consents of all patients were obtained and the local ethical committee approval was received. The survival, tumor recurrence and metastasis of the patients were observed. Survival ananlysis and univariate analysis of the prognosis was conducted with Kaplan-Meier method and Log-rank test. The multivariate analysis was conducted with Cox's proportional hazard model. Results During the follow-up period, 45 patients died of tumor recurrence and metastasis, and 1 died of the upper gastrointestinal bleeding. The overall median survival time of 52 patients was 21 months, and the 1-, 3-, and 5-year survival rates were 69.2%, 30.8% and 11.5%, respectively. Univariate analysis indicated that tumor diameter, degree of radical resection of tumor, lymph node metastasis, TNM stage and tumor differentiation degree were the impact factors for the prognosis of HCCA patients after surgical resection(χ~2=3.902, 8.820, 8.926, 4.245, 6.071; P<0.05). Multivariate analysis revealed that R0 resection, negative lymph node, TNM stage Ⅰ-Ⅱ and high differentiation of tumor were the independent protective factors for the prognosis of HCCA patients after surgical resection(HR=0.364, 0.379, 0.546, 0.498; 95%CI: 0.178-0.743, 0.190-0.756, 0.303-0.984, 0.263-0.942; P<0.05). Conclusions The prognosis of HCCA patients is poor. Radical resection, standardized lymph node dissection and tumor malignancy are the key factors affecting the surgical efficacy.
Objective To investigate the clinical efficacy of surgical resection for hilar cholangiocarcinoma(HCCA) and the impact factors for the prognosis. Methods Clinical data of 52 patients with HCCA who underwent surgical resection in Fuzhou General Hospital of PLA from January 2009 to December 2013 were retrospectively analyzed. Among them, 31 patients were male and 21 were female, aged from 34 to 80 years, with a median age of 63 years. The informed consents of all patients were obtained and the local ethical committee approval was received. The survival, tumor recurrence and metastasis of the patients were observed. Survival ananlysis and univariate analysis of the prognosis was conducted with Kaplan-Meier method and Log-rank test. The multivariate analysis was conducted with Cox's proportional hazard model. Results During the follow-up period, 45 patients died of tumor recurrence and metastasis, and 1 died of the upper gastrointestinal bleeding. The overall median survival time of 52 patients was 21 months, and the 1-, 3-, and 5-year survival rates were 69.2%, 30.8% and 11.5%, respectively. Univariate analysis indicated that tumor diameter, degree of radical resection of tumor, lymph node metastasis, TNM stage and tumor differentiation degree were the impact factors for the prognosis of HCCA patients after surgical resection(χ~2=3.902, 8.820, 8.926, 4.245, 6.071; P<0.05). Multivariate analysis revealed that R0 resection, negative lymph node, TNM stage Ⅰ-Ⅱ and high differentiation of tumor were the independent protective factors for the prognosis of HCCA patients after surgical resection(HR=0.364, 0.379, 0.546, 0.498; 95%CI: 0.178-0.743, 0.190-0.756, 0.303-0.984, 0.263-0.942; P<0.05). Conclusions The prognosis of HCCA patients is poor. Radical resection, standardized lymph node dissection and tumor malignancy are the key factors affecting the surgical efficacy.
引文
[1]中国抗癌协会.肝门部胆管癌规范化诊治专家共识(2015)[J].中华肝胆外科杂志,2015,21(8):501-511.
[2]Xiong J,Nunes QM,Huang W,et al.Major hepatectomy in Bismuth typesⅠandⅡhilar cholangiocarcinoma[J].J Surg Res,2015,194(1):194-201.
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[7]Pork KE,Pawlik TM,Weiss MJ.Perioperative management of hilar cholangiocarcinoma[J].J Gastrointest Surg,2015,19(10):1889-1899.
[8]Soare KC,Kamel I,Cosgrove DP,et al.Hilar cholangiocarcinoma:diagnosis,treatment options,and management[J].Hepatobiliary Surg Nutr,2014,3(1):18-34.
[9]Buettner S,Margonis GA,Kim Y,et al.Conditional probability of long-term survival after resection of hilar cholangiocarcinoma[J].HPB,2016,18(6):510-517.
[10]殷晓煜,刘鑫,粱力建,等.肝门部胆管癌手术切除的远期疗效及预后因素分析[J].中华消化外科杂志,2016,15(4):329-334.
[11]Ebata T,Kosuge T,Hirano S,et al.Proposal to modify the International Union Against Cancer staging system for perihilar cholangiocarcinomas[J].Br J Surg,2014,101(2):79-88.
[12]Matsuo K,Rocha FG,Ito K,et al.The Blumgart preoperative staging system for hilar cholangiocarcinoma:analysis of respectability and outcomes in 380 patients[J].J Am Coll Surg,2012,215(3):343-355.
[13]Hartog H,Ijzermans JN,van Gulik TM,et al.Resection of perihilar cholangiocarcinoma[J].Surg Clin North Am,2016,96(2):247-267.
[14]Mao K,Liu J,Sun J,et al.Patterns and prognostic value of lymph node dissection for resected perihilar cholangiocarcinoma[J].J Gastroenterol Hepatol,2016,31(2):417-426.
[15]Kambakamba P,Linecker M,Slankamenac K,et al.Lymph node dissection in resectable perihilar cholangiocarcinoma:a systematic review[J].Am J Surg,2015,210(4):694-701.
[16]Giuliante F,Ardito F,Guglielmi A,et al.Association of lymph node status with survival in patients after liver resection for hilar cholangiocarcinoma in an Italian multicenter analysis[J].JAMASurgery,2016,151(10):916-922.
[17]房龙.《2016年欧洲肿瘤内科学会胆管癌诊断、治疗与随访临床实践指南》摘译[J].临床肝胆病杂志,2017,33(2):238-243.
[18]Hemming AW,Mekeel K,Khanna A,et al.Portal vein resection in management of hilar cholangiocarcinoma[J].J Am Coll Surg,2011,212(4):604-613.
[19]Chen W,Ke K,Chen YL.Combined portal vein resection in the treatment of hilar cholangiocarcinoma:a systematic review and metaanalysis[J].Eur J Surg Oncol,2014,40(5):489-495.
[20]Hartog H,Ijzerrmans JN,van Gulik TM,etal.Resection of perihilar cholangiocarcinoma[J].Surg Clin North Am,2016,96(2):247-267.
[21]Matsuyama R,Mori R,Ota Y,et al.Significance of vascular resection and reconstruction in surgery for hilar cholangiocarcinoma:with special reference to hepatic arterial resection and reconstruction[J].Ann Surg Oncol,2016,23 Suppl 4:475-484.
[2]Xiong J,Nunes QM,Huang W,et al.Major hepatectomy in Bismuth typesⅠandⅡhilar cholangiocarcinoma[J].J Surg Res,2015,194(1):194-201.
[3]隋鑫磊,汤恢焕,肖广发,等.322例肝门部胆管癌的临床疗效及预后因素分析[J].中华消化外科杂志,2017,16(4):391-397.
[4]Mansour JC,Aloia TA,Crane CH,et al.Hilar cholangiocarcinoma:expert consensus statement[J].HPB,2015,17(8):691-699.
[5]Weiss MJ,Cosgrove D,Herman JM,et al.Multimodal treatment strategies for advanced hilar cholangiocarcinoma[J].Langenbecks Ach Surg,2014,399(6):679-692.
[6]Tiapun A,Pugkhem A,Luvira V,et al.Outcome of curative resection for perihilar cholangiocarcinoma in Northeast Thailand[J].World JGastrointest Oncol,2015,7(12):503-512.
[7]Pork KE,Pawlik TM,Weiss MJ.Perioperative management of hilar cholangiocarcinoma[J].J Gastrointest Surg,2015,19(10):1889-1899.
[8]Soare KC,Kamel I,Cosgrove DP,et al.Hilar cholangiocarcinoma:diagnosis,treatment options,and management[J].Hepatobiliary Surg Nutr,2014,3(1):18-34.
[9]Buettner S,Margonis GA,Kim Y,et al.Conditional probability of long-term survival after resection of hilar cholangiocarcinoma[J].HPB,2016,18(6):510-517.
[10]殷晓煜,刘鑫,粱力建,等.肝门部胆管癌手术切除的远期疗效及预后因素分析[J].中华消化外科杂志,2016,15(4):329-334.
[11]Ebata T,Kosuge T,Hirano S,et al.Proposal to modify the International Union Against Cancer staging system for perihilar cholangiocarcinomas[J].Br J Surg,2014,101(2):79-88.
[12]Matsuo K,Rocha FG,Ito K,et al.The Blumgart preoperative staging system for hilar cholangiocarcinoma:analysis of respectability and outcomes in 380 patients[J].J Am Coll Surg,2012,215(3):343-355.
[13]Hartog H,Ijzermans JN,van Gulik TM,et al.Resection of perihilar cholangiocarcinoma[J].Surg Clin North Am,2016,96(2):247-267.
[14]Mao K,Liu J,Sun J,et al.Patterns and prognostic value of lymph node dissection for resected perihilar cholangiocarcinoma[J].J Gastroenterol Hepatol,2016,31(2):417-426.
[15]Kambakamba P,Linecker M,Slankamenac K,et al.Lymph node dissection in resectable perihilar cholangiocarcinoma:a systematic review[J].Am J Surg,2015,210(4):694-701.
[16]Giuliante F,Ardito F,Guglielmi A,et al.Association of lymph node status with survival in patients after liver resection for hilar cholangiocarcinoma in an Italian multicenter analysis[J].JAMASurgery,2016,151(10):916-922.
[17]房龙.《2016年欧洲肿瘤内科学会胆管癌诊断、治疗与随访临床实践指南》摘译[J].临床肝胆病杂志,2017,33(2):238-243.
[18]Hemming AW,Mekeel K,Khanna A,et al.Portal vein resection in management of hilar cholangiocarcinoma[J].J Am Coll Surg,2011,212(4):604-613.
[19]Chen W,Ke K,Chen YL.Combined portal vein resection in the treatment of hilar cholangiocarcinoma:a systematic review and metaanalysis[J].Eur J Surg Oncol,2014,40(5):489-495.
[20]Hartog H,Ijzerrmans JN,van Gulik TM,etal.Resection of perihilar cholangiocarcinoma[J].Surg Clin North Am,2016,96(2):247-267.
[21]Matsuyama R,Mori R,Ota Y,et al.Significance of vascular resection and reconstruction in surgery for hilar cholangiocarcinoma:with special reference to hepatic arterial resection and reconstruction[J].Ann Surg Oncol,2016,23 Suppl 4:475-484.