80例胆囊癌诊疗分析
摘要
目的：原发性胆囊癌（primary carcinoma of gallbladder）是胆道系统恶性肿瘤中最常见的恶性肿瘤，约占胆道肿瘤的2/3左右。胆囊癌早期缺乏特征性的症状及体征,早期诊断困难,易与胆囊结石,胆囊息肉样病变,胆囊炎等良性胆囊病变相混淆，当出现上腹痛、纳差、黄疸等临床表现时多属中晚期。其手术切除率低,术后5年生存率低。早期胆囊癌手术预后较好,5年生存率可达到100%。本文重在分析原发性胆囊癌（PCG）的临床特点，探讨与胆囊癌早期临床诊断相关的指标，提高胆囊癌的早期诊断率，改善预后以及探讨胆囊癌的病理分期、手术方式选择与预后的关系。
方法：本文收集2002年1月～2011年1月间，在河北医科大学第二医院肝胆外科进行治疗的胆囊癌患者，排除重复入院，合并其他重大疾病的，随访资料不完整的病人后共有80例。以2010年1月～2011年5月在本院治疗的胆囊结石及胆囊息肉患者随机抽取90例作为对照组。对两组病例进行组间比较及单、多因素Logistic回归分析。
结果：胆囊癌组80例，其中男性45例占56.3％，女性35例占43.8％，最大年龄81岁，最小年龄30岁，大于50的75例占93.75％，平均年龄为64.5岁；对照组90例，其中男性39例占43.33％，女性51例占56.67％，最大年龄85岁，最小年龄19岁，大于50的有51例占56.67％，平均年龄为56岁。两组之间在患病年龄上存在差异（P<0.001）；80例胆囊癌患者中手术参与治疗的有72例，其中单纯胆囊切除术2例，胆囊癌根治术19例，扩大根治术14例，姑息或减黄术27例，因术中探查广泛转移行开关术10例，8例患者放弃治疗；术后病理回报有68例，腺癌56例，占82.4%；鳞癌6例，占8.8%；腺鳞癌2例占2.9%；类癌2例占2.9%；未分化癌2例，占2.9%。病理分期（TNM分期）：0期0例，I期2例，Ⅱ期9例，III期23例，Ⅳ期46例；胆囊癌组腹胀纳差的有59例（59/80），对照组有23例（23/90），两组之间存在差异（P<0.001）；在是否存在胆囊占位方面，胆囊癌组66例（66/80），对照组2例（2/90），两组之间存在差异（P<0.001）；胆囊壁厚方面，胆囊癌组74例（74/80），对照组8例（8/90），两组之间存在差异（P<0.001）；是否存在肿大淋巴结，胆囊癌组65例（65/80），对照组1例（1/90）两组之间存在差异（P<0.001）；是否存在肝内外胆管扩张，胆囊癌组37例（37/80），对照组2例（2/90），两组之间存在差异（P<0.001）；胆囊癌组CA199高于正常值的占65例，CA125高于正常值的有37例，两者与对照组相比均存在差异（P<0.001）；在实验室化验检查方面，胆囊癌组与对照组之间存在差异的有：HGB、TBIL、DBIL、IBIL、ALT、AST、ALP、rGGT、TBA；在影像学检查方面，B超检查诊断符合率为61．29%(38／62)，78例行CT检查，68例术前明确诊断，其诊断准确率为87.18％；46例患者得到了随访，其随访率为57.5％(46／80)，I期患者中2例获得随访，其中1例已存活3年，1例已经存活5年。II期患者中得到随访5例，2例已存活1年，2例存活2年，1例存活5年。Ⅲ期患者中11例患者获得随访，3例存活1年，1例存活2年，1例存活3年，6例1年内死亡。Ⅳ期患者中得到随访的28例，2例存活1年，26例在1年内死亡。
结论：
1原发性胆囊癌的起病隐匿，大多与慢性胆囊炎、胆囊结石、胆囊息肉样病变等疾病有关。
2原发性胆囊癌的临床表现无特异性，综合腹部超声、CT、实验室检查及肿瘤标志物联合检测可提高胆囊癌术前诊断率。
3原发性胆囊癌的首选治疗方式是手术治疗，进展期胆囊癌行根治性手术有助于患者生存率的提高。
4原发性胆囊癌的预后差，控制胆囊癌的高危因素能有效的预防胆囊癌的发生，从而改善预后。对于胆囊癌高危人群的早期筛查是胆囊癌临床治疗的关键。
5胆囊癌的临床分期对胆囊癌的预后影响大。提高胆囊癌早诊率是提高胆囊癌诊治水平的关键。
Objective: The primary carcinoma of gallbladder (PCG), which accountsfor two thirds of the biliary tumor, is the most common one in the malignantdisease of biliary system. It can be easily confused with some benign diseases,such as cholecystolithiasis, gallbladder polyps, cholecystitis and so on, forlacking of characteristic symptoms and signs during its early phase and it isusually in the advanced phase when upper abdominal pain, dyspepsia,jaundice and other symptoms have presented. The resection rate and5-yearsurvival rate of advanced gallbladder carcinoma are low, while the5yearssurvival rate of early gallbladder carcinoma could reach100%. This paperfocuses on analyzing the clinical characters of PCG, exploring the relatedparameters for the diagnosis of early gallbladder carcinoma to improve thediagnostic rate and prognosis and discussing the relationship between theoperation methods and the prognosis.
Method: Patients with gallbladder carcinoma and being treated in theHepatobiliary Department of the Second Affiliated Hospital of Hebei MedicalUniversity between2002.1to2011.1were involved in this paper.80patientswere excluded for repeated admission, complicating other severe diseases orincomplete following-up data.90patients with cholecystolithiasis orgallbladder polyps treated in our hospital were randomly selected as thecontrol group. And all these cases were analysed with comparison betweengroups and single and multiple logistic regression.
Result: There were80cases in the gallbladder carcinoma group, ofwhich45were male(56.3%),35were female(43.8%), the oldest was81yearsold, the youngest was30years old,75cases were older than75(93.75%) andthe mediate age was64.5years old. There were90cases in the control group,of which39were male (43.33%),51were female(56.67%), the oldest was85years old, the youngest was19years old,51cases were older than50(56.67%) and the mediate age was56years old. Between these two groups, a significantdifference (P<0.001) in suffering age could be found. And there were alsosignificant differences(P<0.001) in that whether the patients were withabdominal distention, dyspepsia (59out of80cases in PCG group and23outof90cases in control group), whether there was space-occupying lesions(SOL) in gallbladder(66out of80cases in PCG group and23out of90casesin control group), whether there was thick gallbladder wall(74out of80casesin PCG group and8out of90cases in control group), whether there wereswelling lymph nodes(65out of80cases in PCG group and1out of90casesin control group), whether there was intra-or extra-hepatic cholangiectasis (37out of80cases in PCG group and2out of90cases in control group).In PCGgroup, patients with abnormal CEA value, CA199value or CA125value wererespectively20,65and37cases, and a significant difference(P<0.001) wasfound when compared with the control group. In laboratory examinations,there were significant differences（P<0.001）in HGB,TBIL, DBIL, IBIL,ALT,AST, ALP, rGGT and TBA between the PGC group and control group;in imaging examination, the preoperative localization accuracy ofB-ultrasonography and computed tomography(CT)Was61.29％(38／62) and87．18％(68／78)．72out of80cases in the PCG group underwent operationtreatment;2patients were performed laproscopic cholecystectomy alone；19patients were performed radical surgery；14patients were performed extendedradical gallbladder surgery；10patients were performed open-shut operationfor extensive metastasis．Pathological types：56cases of adenocarcinoma(82.4％)，6cases of squamous cell carcinoma(8.8%)，2cases ofadenosquamous carcinoma(2.9%),2cases of carcinoid tumers(2.9%),2casesof undifferentiated carcinoma(2.9%)．Pathological stage(in accordance withthe International Union Against Cancer(UICC) released TNM stagingcriteria)：0stage of0case，I stage of2cases，II stage of9cases，III stage of23cases，IV stage46cases．46patients have been followed-up with thefollowing-up rate of57.5％(46／80)．5patients with II stage have beenfollowed—up，including2cases survived1year,2cases survived2years,1 cases survived5years.11patients with III stage have been followed—up，including3cases survived1year,2cases survived3years，6cases deadwithin1year.28patients with IV stage have been followed-up，including2cases survived1year,26cases dead within1year. The overall1-year survivalrate was30.43％(14／46) and5-year survival rate was4.35％(2／46)．
Conclusion:1. Primary gallbladder carcinoma is mostly related tochronic cholecystitis, cholecystolithiasis and gallbladder polyps with insidiousonset.2. There are no characteristic clinical manifestations for primarygallbladder carcinoma while the abdominal ultrasonography, computerizedtomography and laboratory examinations including tumor marker detectioncould benefit the preoperative diagnosis.3. Surgery is the first choice for PCGand the survival rate of the patients with advanced gallbladder carcinomacould be improved by radical surgery.4.Controlling the risk factors couldimprove the prognosis, which is not good, by preventing the occurrence ofgallbladder carcinoma. Early screening of the high risk population ofgallbladder carcinoma is the key point to the clinical treatment.5. The clinicalstage of gallbladder carcinoma greatly influence the prognosis. And improvingthe early dignostic rate is the key point to improve the diagnostic andtreatment level.
方法：本文收集2002年1月～2011年1月间，在河北医科大学第二医院肝胆外科进行治疗的胆囊癌患者，排除重复入院，合并其他重大疾病的，随访资料不完整的病人后共有80例。以2010年1月～2011年5月在本院治疗的胆囊结石及胆囊息肉患者随机抽取90例作为对照组。对两组病例进行组间比较及单、多因素Logistic回归分析。
结果：胆囊癌组80例，其中男性45例占56.3％，女性35例占43.8％，最大年龄81岁，最小年龄30岁，大于50的75例占93.75％，平均年龄为64.5岁；对照组90例，其中男性39例占43.33％，女性51例占56.67％，最大年龄85岁，最小年龄19岁，大于50的有51例占56.67％，平均年龄为56岁。两组之间在患病年龄上存在差异（P<0.001）；80例胆囊癌患者中手术参与治疗的有72例，其中单纯胆囊切除术2例，胆囊癌根治术19例，扩大根治术14例，姑息或减黄术27例，因术中探查广泛转移行开关术10例，8例患者放弃治疗；术后病理回报有68例，腺癌56例，占82.4%；鳞癌6例，占8.8%；腺鳞癌2例占2.9%；类癌2例占2.9%；未分化癌2例，占2.9%。病理分期（TNM分期）：0期0例，I期2例，Ⅱ期9例，III期23例，Ⅳ期46例；胆囊癌组腹胀纳差的有59例（59/80），对照组有23例（23/90），两组之间存在差异（P<0.001）；在是否存在胆囊占位方面，胆囊癌组66例（66/80），对照组2例（2/90），两组之间存在差异（P<0.001）；胆囊壁厚方面，胆囊癌组74例（74/80），对照组8例（8/90），两组之间存在差异（P<0.001）；是否存在肿大淋巴结，胆囊癌组65例（65/80），对照组1例（1/90）两组之间存在差异（P<0.001）；是否存在肝内外胆管扩张，胆囊癌组37例（37/80），对照组2例（2/90），两组之间存在差异（P<0.001）；胆囊癌组CA199高于正常值的占65例，CA125高于正常值的有37例，两者与对照组相比均存在差异（P<0.001）；在实验室化验检查方面，胆囊癌组与对照组之间存在差异的有：HGB、TBIL、DBIL、IBIL、ALT、AST、ALP、rGGT、TBA；在影像学检查方面，B超检查诊断符合率为61．29%(38／62)，78例行CT检查，68例术前明确诊断，其诊断准确率为87.18％；46例患者得到了随访，其随访率为57.5％(46／80)，I期患者中2例获得随访，其中1例已存活3年，1例已经存活5年。II期患者中得到随访5例，2例已存活1年，2例存活2年，1例存活5年。Ⅲ期患者中11例患者获得随访，3例存活1年，1例存活2年，1例存活3年，6例1年内死亡。Ⅳ期患者中得到随访的28例，2例存活1年，26例在1年内死亡。
结论：
1原发性胆囊癌的起病隐匿，大多与慢性胆囊炎、胆囊结石、胆囊息肉样病变等疾病有关。
2原发性胆囊癌的临床表现无特异性，综合腹部超声、CT、实验室检查及肿瘤标志物联合检测可提高胆囊癌术前诊断率。
3原发性胆囊癌的首选治疗方式是手术治疗，进展期胆囊癌行根治性手术有助于患者生存率的提高。
4原发性胆囊癌的预后差，控制胆囊癌的高危因素能有效的预防胆囊癌的发生，从而改善预后。对于胆囊癌高危人群的早期筛查是胆囊癌临床治疗的关键。
5胆囊癌的临床分期对胆囊癌的预后影响大。提高胆囊癌早诊率是提高胆囊癌诊治水平的关键。
Objective: The primary carcinoma of gallbladder (PCG), which accountsfor two thirds of the biliary tumor, is the most common one in the malignantdisease of biliary system. It can be easily confused with some benign diseases,such as cholecystolithiasis, gallbladder polyps, cholecystitis and so on, forlacking of characteristic symptoms and signs during its early phase and it isusually in the advanced phase when upper abdominal pain, dyspepsia,jaundice and other symptoms have presented. The resection rate and5-yearsurvival rate of advanced gallbladder carcinoma are low, while the5yearssurvival rate of early gallbladder carcinoma could reach100%. This paperfocuses on analyzing the clinical characters of PCG, exploring the relatedparameters for the diagnosis of early gallbladder carcinoma to improve thediagnostic rate and prognosis and discussing the relationship between theoperation methods and the prognosis.
Method: Patients with gallbladder carcinoma and being treated in theHepatobiliary Department of the Second Affiliated Hospital of Hebei MedicalUniversity between2002.1to2011.1were involved in this paper.80patientswere excluded for repeated admission, complicating other severe diseases orincomplete following-up data.90patients with cholecystolithiasis orgallbladder polyps treated in our hospital were randomly selected as thecontrol group. And all these cases were analysed with comparison betweengroups and single and multiple logistic regression.
Result: There were80cases in the gallbladder carcinoma group, ofwhich45were male(56.3%),35were female(43.8%), the oldest was81yearsold, the youngest was30years old,75cases were older than75(93.75%) andthe mediate age was64.5years old. There were90cases in the control group,of which39were male (43.33%),51were female(56.67%), the oldest was85years old, the youngest was19years old,51cases were older than50(56.67%) and the mediate age was56years old. Between these two groups, a significantdifference (P<0.001) in suffering age could be found. And there were alsosignificant differences(P<0.001) in that whether the patients were withabdominal distention, dyspepsia (59out of80cases in PCG group and23outof90cases in control group), whether there was space-occupying lesions(SOL) in gallbladder(66out of80cases in PCG group and23out of90casesin control group), whether there was thick gallbladder wall(74out of80casesin PCG group and8out of90cases in control group), whether there wereswelling lymph nodes(65out of80cases in PCG group and1out of90casesin control group), whether there was intra-or extra-hepatic cholangiectasis (37out of80cases in PCG group and2out of90cases in control group).In PCGgroup, patients with abnormal CEA value, CA199value or CA125value wererespectively20,65and37cases, and a significant difference(P<0.001) wasfound when compared with the control group. In laboratory examinations,there were significant differences（P<0.001）in HGB,TBIL, DBIL, IBIL,ALT,AST, ALP, rGGT and TBA between the PGC group and control group;in imaging examination, the preoperative localization accuracy ofB-ultrasonography and computed tomography(CT)Was61.29％(38／62) and87．18％(68／78)．72out of80cases in the PCG group underwent operationtreatment;2patients were performed laproscopic cholecystectomy alone；19patients were performed radical surgery；14patients were performed extendedradical gallbladder surgery；10patients were performed open-shut operationfor extensive metastasis．Pathological types：56cases of adenocarcinoma(82.4％)，6cases of squamous cell carcinoma(8.8%)，2cases ofadenosquamous carcinoma(2.9%),2cases of carcinoid tumers(2.9%),2casesof undifferentiated carcinoma(2.9%)．Pathological stage(in accordance withthe International Union Against Cancer(UICC) released TNM stagingcriteria)：0stage of0case，I stage of2cases，II stage of9cases，III stage of23cases，IV stage46cases．46patients have been followed-up with thefollowing-up rate of57.5％(46／80)．5patients with II stage have beenfollowed—up，including2cases survived1year,2cases survived2years,1 cases survived5years.11patients with III stage have been followed—up，including3cases survived1year,2cases survived3years，6cases deadwithin1year.28patients with IV stage have been followed-up，including2cases survived1year,26cases dead within1year. The overall1-year survivalrate was30.43％(14／46) and5-year survival rate was4.35％(2／46)．
Conclusion:1. Primary gallbladder carcinoma is mostly related tochronic cholecystitis, cholecystolithiasis and gallbladder polyps with insidiousonset.2. There are no characteristic clinical manifestations for primarygallbladder carcinoma while the abdominal ultrasonography, computerizedtomography and laboratory examinations including tumor marker detectioncould benefit the preoperative diagnosis.3. Surgery is the first choice for PCGand the survival rate of the patients with advanced gallbladder carcinomacould be improved by radical surgery.4.Controlling the risk factors couldimprove the prognosis, which is not good, by preventing the occurrence ofgallbladder carcinoma. Early screening of the high risk population ofgallbladder carcinoma is the key point to the clinical treatment.5. The clinicalstage of gallbladder carcinoma greatly influence the prognosis. And improvingthe early dignostic rate is the key point to improve the diagnostic andtreatment level.
引文
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1Kayahara M，Nagakawa T. Recent trends of gallbladder cancer in Japan：an analysis of4770patients［J］. Cancer，2007，11O(3)：572-580
2Kumar JR，Tewari M，Rai A，et a1．An objective assessment ofdemography of gallbladder cance［rJ］. J Surg Oncol，2006，93(8)：610-614
3邹声泉,张林.全国胆囊癌临床流行病学调查报告[J].中国实用外科杂志,2000,20(1)∶43-46
4Donohue J H,Stewart AK,Menck HR. The national cancer data basereport on carcinoma of the gallbladder,1989-1995[J]. Cancer,1998,83(12)∶2618-2628
5Levy AD,Murakata LA,Rohrmann CA J r.Gallbladder carcinoma:radiologic-pathologic correlation[J]. Radiographics,2001,21(2)∶295-314
6Chijiiwa K,Sumiyoshi K,Nakayama F. Impact of recent advance inhepatobiliary imaging techniques on the preoperative diagnosis ofcarcinoma of the gallbladder [J]. World J Surg,1991,15(3)∶322-327
7石景森.我国胆囊癌的发病情况及外科处理[J].肝胆胰外科杂志,1999,11(1):51-52
8Wood R, Fraser LA, Brewster DH, et al. Epidemiology of gallbladdercancer and trends in cholecystectomy rates in Scotland,1968-1998. Eur JCancer,2003,39(14):2080-2086
9PandeyM, Shukla VK. Lifestyle, parity, menstrual and reproductivefactors and risk of gallbladder cancer. Eur J Cancer Prev,2003,12(4):269-272
10上海市疾病预防控制中心.2005年上海市市区恶性肿瘤发病率.肿瘤，2007,27(7):634
11Lowenfels AB,Walker AM,Althaus DP,etal. Gallstone growth, size,and risk of gallbladder cancer:an interracial study[J]. Int J Epidermal,1989,18(1)∶50-54
12Diehl AK. Gallstone size and the risk of gallbladder cancer[J]. JAMA,1983,250(17)∶2323-2326
13焦兴元，黎东明.细胞核仁形成区酸性非组蛋白在胆囊癌诊断与监测中的价值［J］.中华普通外科杂志，2002，17（10）：602-604
14周孝思.胆囊癌与胆囊良性病变的关系［J］.中国实用外科杂志，1997，17(9)：524
15Ootani T，Shirai Y，Tsukada K，et a1. Relationship between gallbladdercarcinoma and the segmental type of adenomyomatosis of the gallbladder［J］. Cancer，1992，69(11)：2647-2652
16Kwon W, Jang JY, Lee SE, et al. Clinicopathologic features of polypoidlesions of the gallbladder and risk factors of gallbladder cancer［J］. JKorean Med Sci,2009,24(3):481-487
17李非,王悦华.胆囊息肉手术适应证再讨论［J］.中国实用外科杂志,2008,28(2):84-86
18Hasumi A，Sugaya H，Aoki H，et a1．Pancreaticobiliary maljunction andbiliary duct cancer［J］．Bil tract Pancr，1995，16(8)：753-757
19卢乐,孙学军,石景森.胆囊癌临床分期研究的临床意义[J].中华肝胆外科杂志,2009,15(1):72-75
20石景森.原发性胆囊癌的诊治进展[J].中国医师进修杂志,2006,29(4):8-11
21Pandey M, Sood BP, Shukla RC, et al. Carcinoma of t he Gall-bladder:role of sonography in diagnosis and staging [J].J Clin Ult rasound,2000;28(5):227-232
22Li D,Dong BW,Wu YL,et al. Imagedirected and color Doppler studies ofgallbladder tumors[J]. J Chin Utrasoun d,1994,22:551-555
23Weedon D. Pathology of the gallbladder[M]. New York:MassonPublishing USA,1984.225-230
24季福.胆囊癌的综合治疗[J].肝胆胰外科杂志,2007,19(2):70-72
25张宝善.现代胆道镜技术的进展[J].内镜外科杂志,1994,1:9
26Duarte I,Llanos O,Domke H,et al. Metaplasia and precursor lesions ofgallbladder carcinoma. Frequency, distribution, and proba-bility ofdetection in routine histologic samples [J]. Cancer,1993,72(6)∶1878-1884
27王海连等. CEA、CA1929、CA50、CA125监测在胆囊癌早期诊断和预后判断中的应用[J].中国误诊学杂志,2009;9(3):577-578
28陈国蓉，艾开兴.意外胆囊癌的外科治疗进展［J］.中国肿瘤临床，2008，35（19）：1135-1138
2Kumar JR，Tewari M，Rai A，et a1．An objective assessment ofdemography of gallbladder cancer[J]. J Surg Oncol，2006，93(8)：610-614
3邹声泉,张林.全国胆囊癌临床流行病学调查报告[J].中国实用外科杂志,2000,20(1)∶43-46
4Donohue J H,Stewart AK,Menck HR. The national cancer data base repo-rt on carcinoma of the gallbladder,1989-1995[J]. Canc-er,1998,83(12)∶2618-2628
5Levy AD,Murakata LA,Rohrmann CA J r.Gallbladder carcinoma:radiolo-gic-pathologic correlation[J].Radiographics,2001,21(2):295-314
6Chijiiwa K,Sumiyoshi K,Nakayama F. Impact of recent advance in hepato-biliary imaging techniques on the preoperative diagnosis of carcinoma ofthe gallbladder [J]. World J Surg,1991,15(3)∶322-327
7石景森.我国胆囊癌的发病情况及外科处理[J].肝胆胰外科杂志,
1999,11(1):51-52
8Wood R, Fraser LA, Brewster DH, et al. Epidemiology of gall-bladdercancer and trends in cholecystectomy rates in Scotland,1968-1998. Eur JCancer,2003,39(14):2080-2086
9PandeyM, Shukla VK. Lifestyle, parity, menstrual and repro-ductivefactors and risk of gallbladder cancer. Eur J Cancer Prev,2003,12(4):269-272
10Lowenfels AB,Walker AM,Althaus DP,etal. Gallstone growth, size, andrisk of gallbladder cancer:an interracial study[J]. Int J. Epidermal,1989,18(1)∶50-54
11Diehl AK. Gallstone size and the risk of gallbladder cancer [J].JAMA,1983,250(17)∶2323-2326
12焦兴元，黎东明.细胞核仁形成区酸性非组蛋白在胆囊癌诊断与监测中的价值［J］.中华普通外科杂志，2002，17（10）：602-604
13周孝思.胆囊癌与胆囊良性病变的关系［J］.中国实用外科杂志，1997，17(9)：524
14Ootani T，Shirai Y，Tsukada K，et a1. Relationship between gallbladdercarcinoma and the segmental type of adenomyomatosis of thegallbladder[J]. Cancer，1992，69(11)：2647-2652
15Kwon W, Jang JY, Lee SE, et al. Clinicopathologic features of polypoidlesions of the gallbladder and risk factors of gallbladder cancer[J].J KoreanMed Sci,2009,24(3):481-487
16李非,王悦华.胆囊息肉手术适应证再讨论［J］.中国实用外科杂志,2008,28(2):84-86
17Pandey M, Sood BP, Shukla RC, et al. Carcinoma of t he gallbladder:role of sonography in diagnosis and staging [J].J Clin Ult rasound,2000;
28(5):227-232
18于跃利，石景森等．原发性胆囊癌的早期诊断．中华肝胆外科杂志，2004，10：781-782
19斯东锋，全志伟．胆囊癌的分期与手术治疗．国际外科学杂志，2006，33(3)：175-177
20Yoshimitsu K，Honda H．et a1．Helical CT of the local spread of car-cinoma of the galIbladder：evaluation according to the TNM system inpatients who underwent surgical resection．AJR，2002，179(2)：423-428
21季福.胆囊癌的综合治疗[J].肝胆胰外科杂志,2007,19(2):70-72
22秦净，王炳生等．上海市胆囊癌诊治现状分析．中华普通外科杂志，2005，9：584-586
23陈国蓉，艾开兴.意外胆囊癌囊癌诊治现状分析．中华普通外科杂志，2005，9：584-586.的外科治疗进展［J］.中国肿瘤临床，2008，35（19）：1135-1138
24Albores-Saavedra J,Corke D.The precursor lesione of invasive gallbladdercarcinoma. Cancer1980;45(3):919
25刘颖斌，王许安等．胆囊癌扩大根治术的意义和评价．中国实用外科杂志，2008，9：718-720
1Kayahara M，Nagakawa T. Recent trends of gallbladder cancer in Japan：an analysis of4770patients［J］. Cancer，2007，11O(3)：572-580
2Kumar JR，Tewari M，Rai A，et a1．An objective assessment ofdemography of gallbladder cance［rJ］. J Surg Oncol，2006，93(8)：610-614
3邹声泉,张林.全国胆囊癌临床流行病学调查报告[J].中国实用外科杂志,2000,20(1)∶43-46
4Donohue J H,Stewart AK,Menck HR. The national cancer data basereport on carcinoma of the gallbladder,1989-1995[J]. Cancer,1998,83(12)∶2618-2628
5Levy AD,Murakata LA,Rohrmann CA J r.Gallbladder carcinoma:radiologic-pathologic correlation[J]. Radiographics,2001,21(2)∶295-314
6Chijiiwa K,Sumiyoshi K,Nakayama F. Impact of recent advance inhepatobiliary imaging techniques on the preoperative diagnosis ofcarcinoma of the gallbladder [J]. World J Surg,1991,15(3)∶322-327
7石景森.我国胆囊癌的发病情况及外科处理[J].肝胆胰外科杂志,1999,11(1):51-52
8Wood R, Fraser LA, Brewster DH, et al. Epidemiology of gallbladdercancer and trends in cholecystectomy rates in Scotland,1968-1998. Eur JCancer,2003,39(14):2080-2086
9PandeyM, Shukla VK. Lifestyle, parity, menstrual and reproductivefactors and risk of gallbladder cancer. Eur J Cancer Prev,2003,12(4):269-272
10上海市疾病预防控制中心.2005年上海市市区恶性肿瘤发病率.肿瘤，2007,27(7):634
11Lowenfels AB,Walker AM,Althaus DP,etal. Gallstone growth, size,and risk of gallbladder cancer:an interracial study[J]. Int J Epidermal,1989,18(1)∶50-54
12Diehl AK. Gallstone size and the risk of gallbladder cancer[J]. JAMA,1983,250(17)∶2323-2326
13焦兴元，黎东明.细胞核仁形成区酸性非组蛋白在胆囊癌诊断与监测中的价值［J］.中华普通外科杂志，2002，17（10）：602-604
14周孝思.胆囊癌与胆囊良性病变的关系［J］.中国实用外科杂志，1997，17(9)：524
15Ootani T，Shirai Y，Tsukada K，et a1. Relationship between gallbladdercarcinoma and the segmental type of adenomyomatosis of the gallbladder［J］. Cancer，1992，69(11)：2647-2652
16Kwon W, Jang JY, Lee SE, et al. Clinicopathologic features of polypoidlesions of the gallbladder and risk factors of gallbladder cancer［J］. JKorean Med Sci,2009,24(3):481-487
17李非,王悦华.胆囊息肉手术适应证再讨论［J］.中国实用外科杂志,2008,28(2):84-86
18Hasumi A，Sugaya H，Aoki H，et a1．Pancreaticobiliary maljunction andbiliary duct cancer［J］．Bil tract Pancr，1995，16(8)：753-757
19卢乐,孙学军,石景森.胆囊癌临床分期研究的临床意义[J].中华肝胆外科杂志,2009,15(1):72-75
20石景森.原发性胆囊癌的诊治进展[J].中国医师进修杂志,2006,29(4):8-11
21Pandey M, Sood BP, Shukla RC, et al. Carcinoma of t he Gall-bladder:role of sonography in diagnosis and staging [J].J Clin Ult rasound,2000;28(5):227-232
22Li D,Dong BW,Wu YL,et al. Imagedirected and color Doppler studies ofgallbladder tumors[J]. J Chin Utrasoun d,1994,22:551-555
23Weedon D. Pathology of the gallbladder[M]. New York:MassonPublishing USA,1984.225-230
24季福.胆囊癌的综合治疗[J].肝胆胰外科杂志,2007,19(2):70-72
25张宝善.现代胆道镜技术的进展[J].内镜外科杂志,1994,1:9
26Duarte I,Llanos O,Domke H,et al. Metaplasia and precursor lesions ofgallbladder carcinoma. Frequency, distribution, and proba-bility ofdetection in routine histologic samples [J]. Cancer,1993,72(6)∶1878-1884
27王海连等. CEA、CA1929、CA50、CA125监测在胆囊癌早期诊断和预后判断中的应用[J].中国误诊学杂志,2009;9(3):577-578
28陈国蓉，艾开兴.意外胆囊癌的外科治疗进展［J］.中国肿瘤临床，2008，35（19）：1135-1138