肝门部胆管癌神经浸润特征的临床病理学分析

Clinical pathology of perineural invasion in hilar cholangiocarcinoma

目的:总结肝门部胆管癌神经浸润的方式和规律,探讨肿瘤浸润神经的途径和机制.方法:光镜观察73例肝门部胆管癌患者1082张组织病理切片,总结归纳肿瘤浸润神经的方式和规律;分析肿瘤浸润神经与肿瘤分化程度、肿瘤浸润范围、肿瘤标志物水平等临床病理学因素的关系;通过免疫组织化学CD34、D2-40染色分别显示肿瘤浸润神经与微血管和微淋巴管的关系.结果:肝门部胆管癌神经浸润率为91.78%,高、中、低分化腺癌组肿瘤神经浸润发生率之间的差异无统计学意义(P>0.05).Logistic回归分析显示肿瘤浸润胆管壁全层与神经浸润间的相关性具有统计学意义(P<0.01).高分化腺癌与中、低分化组微血管密度之间的差异有统计学意义(P<0.05).肿瘤浸润神经有五种方式,肿瘤可以发生微血管和微淋巴管的侵犯,未发现肿瘤通过血管、淋巴管途径浸润神经.结论:肝门部胆管癌神经浸润率高;肿瘤侵犯胆管壁全层后直接浸润神经,而不是经过血管和淋巴管途径;行根治性切除时应紧贴血管外膜仔细剥除其周围神经纤维组织.

AIM： To elucidate the characteristics and mechanism of perineural invasion in hilar cholangiocarcinoma. METHODS： A clinicopathologic study was conducted on tissue sections from 73 patients with hilar cholangiocarcinoma to observe the incidence and modes of perineural invasion. Clinicopathologic factors, such as tumor differentiation and pathologic stage, were analyzed when perineural invasion was observed in the sections. Immunohistochemical staining for CD34 and D2-40 in cancer tissue samples was performed to clarify the association of perineural invasion with vessels. RESULTS： The overall incidence of perineural invasion was 91.78% （67 of 73 patients）. However, the incidence of perineural invasion did not show any remarkable difference in various differentiated adenocarcinomas. Logistic regression analysis identified that penetration of bile duct was significantly correlated with perineural invasion （P 〈 0.01）. The microvessel density （MVD） was significantly lower in well-differentiated adenocarcinomas than in moderately- and poor- lydifferentiated adenocarcinomas （P 〈 0.05）. Five patterns were observed as the tumor cells invaded nerve fibers. Although tumor cells were found to invade microvessels and microlymphatics, immunohistochemical staining for CD34 and D2-40 respectively showed no association between perineural invasion and lymphatic or vascular invasion. CONCLUSION： Perineural invasion is common in hilar cholangiocarcinoma and does not develop via the lymphatic or vascular network, but is a continuous extension from the primary tumor. Nerve plexus around the membrana adventitia should be completely divested during radical excision of hilar cholangiocarcinoma.