191例手术治疗肝门部胆管癌患者预后的多因素分析
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摘要
目的探讨肝门部胆管癌手术治疗后影响患者生存的危险因素。方法回顾性分析2003年1月至2017年5月在我院诊断并接受手术治疗的191例患者的生存情况,选择性别、年龄、肿瘤Bismuth-Corlette分型、手术方式、手术切缘肿瘤残留状况、淋巴结转移、术前总胆红素水平、术前CA19-9水平、术前白蛋白水平、血管侵犯、肿瘤病理分化程度、神经侵犯情况及术后化疗等潜在的影响预后因素进行单因素分析,再通过COX回归模型进行多因素分析。结果单因素分析显示单纯行引流手术、非R0切除、存在淋巴结转移、术前总胆红素水平≧171mmol/l、病理分化程度较差的患者预后较差(P <0. 05);多因素分析表明,对行肿瘤切除的患者,存在淋巴结转移(HR=1. 796,P=0. 008)、术前总胆红素水平≧171mmol/l(HR=1. 766,P=0. 021)和非R0切除(HR=1. 585,P=0. 030)是影响肝门部胆管癌术后生存的独立危险因素。对于非R0切除及存在淋巴结转移的患者,术后辅助化疗可以延长该类患者的生存时间。结论手术切除肿瘤能延长肝门部胆管癌患者的生存时间。肝门部胆管癌切除术后的预后受手术切缘、淋巴结转移、术前总胆红素水平、病理分化程度等多种因素影响。在联合肝叶切除的基础上,联合尾状叶切除可延长患者术后生存时间,对于非R0切除及局部淋巴结转移的患者,术后辅助化疗可以延长该类患者的生存时间。
Objective Hilar Cholangiocarcinoma is a common malignant tumor in biliary system with poor prognosis. The study aims to explore the prognosis factors of hilar cholangiocarcinoma after Surgery. Methods One hundred and ninety-one cases of patients with hilar cholangiocarcinoma after surgery in Sun Yat-sen memorial hospital of Sun Yat-sen University from January 2003 to May 2017 were selected and analyzed retrospectively. Univariate analysis was performed to assess potential prognosis factors including patients' gender,age,Bismuth-Corlette classification,surgical method,condition of incisal margin,lymph node metastasis,preoperative total bilirubin,preoperative CA 19-9 level,preoperative albumin level,vessel invasion,classification of tumor differentiation,nerve invasion and postoperative chemotherapy. Multivariate analysis was performed by Cox proportional hazards regression model. Results: Univariate analysis revealed that the survival of patients with simple drainage,positive incisal margin,lymph node metastasis,high preoperative total bilirubin(≧ 171 mmol/l),poor differentiation was significant worse(P < 0. 05). Multivariate analysis revealed that lymph node metastasis(HR = 1. 796,P = 0. 008),high preoperative total bilirubin(≧ 171 mmol/l)(HR = 1. 766,P = 0. 021) and positive incisal margin(HR = 1. 585,P = 0. 030) were the independent risk factors for patients with hilar cholangiocarcinoma after resection. Chemotherapy could improve the survival time of patients with and positive incisal margin and lymph node metastasis. Conclusion: Resection of the tumor is critical for the survival of patients with hilar cholangiocarcinoma. Incisal margin,lymph node metastasis,preoperative total bilirubin and classification of tumor differentiation were the prognosis factors of hilar cholangiocarcinoma after surgery. Combined resection of the caudate lobe could improve the survival time. Chemotherapy could improve the survival time of patients with positive incisal margin and lymph node metastasis.
Objective Hilar Cholangiocarcinoma is a common malignant tumor in biliary system with poor prognosis. The study aims to explore the prognosis factors of hilar cholangiocarcinoma after Surgery. Methods One hundred and ninety-one cases of patients with hilar cholangiocarcinoma after surgery in Sun Yat-sen memorial hospital of Sun Yat-sen University from January 2003 to May 2017 were selected and analyzed retrospectively. Univariate analysis was performed to assess potential prognosis factors including patients' gender,age,Bismuth-Corlette classification,surgical method,condition of incisal margin,lymph node metastasis,preoperative total bilirubin,preoperative CA 19-9 level,preoperative albumin level,vessel invasion,classification of tumor differentiation,nerve invasion and postoperative chemotherapy. Multivariate analysis was performed by Cox proportional hazards regression model. Results: Univariate analysis revealed that the survival of patients with simple drainage,positive incisal margin,lymph node metastasis,high preoperative total bilirubin(≧ 171 mmol/l),poor differentiation was significant worse(P < 0. 05). Multivariate analysis revealed that lymph node metastasis(HR = 1. 796,P = 0. 008),high preoperative total bilirubin(≧ 171 mmol/l)(HR = 1. 766,P = 0. 021) and positive incisal margin(HR = 1. 585,P = 0. 030) were the independent risk factors for patients with hilar cholangiocarcinoma after resection. Chemotherapy could improve the survival time of patients with and positive incisal margin and lymph node metastasis. Conclusion: Resection of the tumor is critical for the survival of patients with hilar cholangiocarcinoma. Incisal margin,lymph node metastasis,preoperative total bilirubin and classification of tumor differentiation were the prognosis factors of hilar cholangiocarcinoma after surgery. Combined resection of the caudate lobe could improve the survival time. Chemotherapy could improve the survival time of patients with positive incisal margin and lymph node metastasis.
引文
1 Klatskin G.Adenocarcinoma of the Hepatic Duct at Its Bifurcation within the Porta Hepatis.An Unusual Tumor withDistinctive Clinical and Pathological Features.Am J Med1965;38:241-56.
2中华医学会外科学分会胆道外科学组,解放军全军肝胆外科专业委员会.肝门部胆管癌诊断及治疗指南(2013版).中华外科杂志,2013,51(10):865-871.
3 Fairweather M,Balachandran VP,D’Angelica MI.Surgical management of biliary tract cancers.Chin Clin Oncol,2016,5(5):63.
4 Kevin C.Soares,Ihab Kamel,et al.Hilar cholangiocarcinoma:diagnosis,treatment options,and management.Hepatobiliary Surgery and Nutrition.2014,3(2):19-34
5 Traian D,et al.Resection for Hilar Cholangiocarcinoma:Analysis of Prognostic Factors and the Impact of Systemic Inflammation on Longterm Outcome.J Gastrointest Surg(2013)17:913-924
6 Peizhan C,Bin L et al,Establishment and validation of a prognostic nomogram for patients with resectable perihilar cholangiocarcinoma,Oncotarget,2016,7(24):37319-37330
7 Suarez-Munoz MA,Fernandez-Aguilar JL,Sanchez-Perez B,et al.Risk factors and classifications of hilar cholangiocarcinoma.World JGastrointest Oncol 2013,5:132-138.
8 Choi JY,Kim MJ,Lee JM,et al.Hilar cholangiocarcinoma:role of preoperative imaging with sonography,MDCT,MRI,and direct cholangiography.AJR Am J Roentgenol 2008,191:1448-1457.
9窦科峰,王德盛.不能切除的肝门部胆管癌治疗方法的选择.中国实用外科杂志,2007(5):370-372.
10 Zengwei T,Yuan Y,Wenbo M,Xun Li,Best option for preoperative biliary drainage in Klatskin tumor:A systematic review and meta-analysis.Medicine,2017,96:43
11 Bismuth H,Nakache R,Diamond T.Management strategies in resection for hilar cholangiocarcinoma,Ann Surg,1992,215(1):31-38
12吴力群,邱法波等,原发性肝细胞癌R0切除标准的探讨.中国实用外科杂志,2011,31(11):1027-1030
13高纪东.肝细胞癌肝切除术后预后影响因素分析.中华肝胆外科杂志,2005 11(8):515-517.
14 Cho MS,Kim SH,Park SW,et al.Surgical outcomes and predicting factors of curative resection in patients with hilar cholangiocarcinoma:10-year single-institution experience.J Gastrointest Surg 2012,16:1672-1679.
15 Nuzzo G,Giuliante F,Ardito F,et al.Improvement in perioperative and long-term outcome after surgical treatment of hilar cholangiocarcinoma:results of an Italian multicenter analysis of 440 patients.Arch Surg 2012,147:26-34.
16 De Oliveira ML,Cunningham SC,Cameron JL,et al.Cholangiocarcinoma:thirty-one-year experience with 564 patients at a single institution.Ann Surg 2007;245(5):755-762.
17 Aoba T,Ebata T,Yokoyama Y,et al.Assessment of node status for perihilar cholangiocarcinoma:location,number,or ratio of involved nodes.Ann Surg 2013;257(4):718-725.
18 Guglielmi A,Ruzzenente A,Campagnaro T,et al.Patterns and prognostic significance of lymph node dissection for surgical treatment of perihilar and intrahepatic cholangiocarcinoma.J Gastrointest Surg2013;17(11):1917-1928.
19 Amin MB,Edge SB,Greene FL,et al.AJCC Cancer Staging Manual.8th ed.New York:Springer,2017
20毛谅,陈骏等,美国癌症联合委员会肝门部胆管癌分期系统(第8版)更新解读中国实用外科杂志.2017,37(5):510-513
21 Ito K,Ito H,Allen P J,et al.Adequate lymph node assement for extrahepatic bile duct adenocarcinoma,Ann Surg.2010,251(4):675-681
22 Ruys AT,Kate FJ,Busch OR,et al.Metastatic lymph nodes in hilar cholangiocarcinoma:does size matter?HPB(Oxford),2011;13(12):881-886.
23 Murakami Y,Uemura K,Sudo T,et al.Prognostic factors after surgical resection for intrahepatic,hilar,and distal cholangiocarcinoma.Ann Surg Oncol 2011,18:651-658.
24 Murakami Y,Uemura K,Sudo T,et al.Gemcitabine-based adjuvant chemotherapy improves survival after aggressive surgery for hilar cholangiocarcinoma.J Gastrointest Surg 2009,13:1470-1479.
25 Dumitrascu T,Chirita D,Ionescu M,et al.Resection for hilar cholangiocarcinoma:analysis of prognostic factors and the impact of systemic inflammation on long-term outcome.J Gastrointest Surg2013;17:913-924.
26 Valle J,Wasan H,Palmer DH,et al.Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer.N Engl J Med 2010;362:1273-1281.
2中华医学会外科学分会胆道外科学组,解放军全军肝胆外科专业委员会.肝门部胆管癌诊断及治疗指南(2013版).中华外科杂志,2013,51(10):865-871.
3 Fairweather M,Balachandran VP,D’Angelica MI.Surgical management of biliary tract cancers.Chin Clin Oncol,2016,5(5):63.
4 Kevin C.Soares,Ihab Kamel,et al.Hilar cholangiocarcinoma:diagnosis,treatment options,and management.Hepatobiliary Surgery and Nutrition.2014,3(2):19-34
5 Traian D,et al.Resection for Hilar Cholangiocarcinoma:Analysis of Prognostic Factors and the Impact of Systemic Inflammation on Longterm Outcome.J Gastrointest Surg(2013)17:913-924
6 Peizhan C,Bin L et al,Establishment and validation of a prognostic nomogram for patients with resectable perihilar cholangiocarcinoma,Oncotarget,2016,7(24):37319-37330
7 Suarez-Munoz MA,Fernandez-Aguilar JL,Sanchez-Perez B,et al.Risk factors and classifications of hilar cholangiocarcinoma.World JGastrointest Oncol 2013,5:132-138.
8 Choi JY,Kim MJ,Lee JM,et al.Hilar cholangiocarcinoma:role of preoperative imaging with sonography,MDCT,MRI,and direct cholangiography.AJR Am J Roentgenol 2008,191:1448-1457.
9窦科峰,王德盛.不能切除的肝门部胆管癌治疗方法的选择.中国实用外科杂志,2007(5):370-372.
10 Zengwei T,Yuan Y,Wenbo M,Xun Li,Best option for preoperative biliary drainage in Klatskin tumor:A systematic review and meta-analysis.Medicine,2017,96:43
11 Bismuth H,Nakache R,Diamond T.Management strategies in resection for hilar cholangiocarcinoma,Ann Surg,1992,215(1):31-38
12吴力群,邱法波等,原发性肝细胞癌R0切除标准的探讨.中国实用外科杂志,2011,31(11):1027-1030
13高纪东.肝细胞癌肝切除术后预后影响因素分析.中华肝胆外科杂志,2005 11(8):515-517.
14 Cho MS,Kim SH,Park SW,et al.Surgical outcomes and predicting factors of curative resection in patients with hilar cholangiocarcinoma:10-year single-institution experience.J Gastrointest Surg 2012,16:1672-1679.
15 Nuzzo G,Giuliante F,Ardito F,et al.Improvement in perioperative and long-term outcome after surgical treatment of hilar cholangiocarcinoma:results of an Italian multicenter analysis of 440 patients.Arch Surg 2012,147:26-34.
16 De Oliveira ML,Cunningham SC,Cameron JL,et al.Cholangiocarcinoma:thirty-one-year experience with 564 patients at a single institution.Ann Surg 2007;245(5):755-762.
17 Aoba T,Ebata T,Yokoyama Y,et al.Assessment of node status for perihilar cholangiocarcinoma:location,number,or ratio of involved nodes.Ann Surg 2013;257(4):718-725.
18 Guglielmi A,Ruzzenente A,Campagnaro T,et al.Patterns and prognostic significance of lymph node dissection for surgical treatment of perihilar and intrahepatic cholangiocarcinoma.J Gastrointest Surg2013;17(11):1917-1928.
19 Amin MB,Edge SB,Greene FL,et al.AJCC Cancer Staging Manual.8th ed.New York:Springer,2017
20毛谅,陈骏等,美国癌症联合委员会肝门部胆管癌分期系统(第8版)更新解读中国实用外科杂志.2017,37(5):510-513
21 Ito K,Ito H,Allen P J,et al.Adequate lymph node assement for extrahepatic bile duct adenocarcinoma,Ann Surg.2010,251(4):675-681
22 Ruys AT,Kate FJ,Busch OR,et al.Metastatic lymph nodes in hilar cholangiocarcinoma:does size matter?HPB(Oxford),2011;13(12):881-886.
23 Murakami Y,Uemura K,Sudo T,et al.Prognostic factors after surgical resection for intrahepatic,hilar,and distal cholangiocarcinoma.Ann Surg Oncol 2011,18:651-658.
24 Murakami Y,Uemura K,Sudo T,et al.Gemcitabine-based adjuvant chemotherapy improves survival after aggressive surgery for hilar cholangiocarcinoma.J Gastrointest Surg 2009,13:1470-1479.
25 Dumitrascu T,Chirita D,Ionescu M,et al.Resection for hilar cholangiocarcinoma:analysis of prognostic factors and the impact of systemic inflammation on long-term outcome.J Gastrointest Surg2013;17:913-924.
26 Valle J,Wasan H,Palmer DH,et al.Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer.N Engl J Med 2010;362:1273-1281.