肝门部胆管癌神经浸润及围肝门神经丛的分布

Perineural invasion in hilar cholangiocarcinoma and distribution of nerve plexuses around porta hepatis

目的了解肝门部胆管癌（HCCA）神经浸润（PNI）的发生率，明确PNI发生与血管、淋巴管的关系，以及围肝门神经丛的分布特征。方法通过检索PubMed数据库，总结文献中关于HCCA的PNI发生率；光镜下观察75例HCCA患者组织病理切片，明确PNI的发生率；通过免疫组织化学CD34、D2-40染色分别显示PNI与微血管和微淋巴管的关系；观察5例尸检标本正常肝十二指肠韧带不同层面组织切片，总结围肝门神经丛分布特点。结果文献报道的HCCA中PNI发生率为59．2％～100％。本研究中，PNI发生率为92．0％（69／75），病理诊断中未报告PNI者28例。高、中、低分化组及不同Bismuth—Corlette分型组间PNI发生率的差异无统计学意义（P〉0．05）。肿瘤可以发生微血管和微淋巴管侵犯，但未发现肿瘤通过血管、淋巴管途径浸润神经。肝十二指肠韧带与一、二级肝管所在的Glisson鞘内分布的神经丛主要有3丛，均围绕大血管分布。结论HCCA中PNI发生率高，未报告率高；外科医生行根治性切除时应注意对围肝门神经丛的清扫。

Objective To explore the incidence of perineural invasion （PNI） in hilar cholangiocarcinoma （HCCA） and summarize the distribution pattern of nerve plexuses around porta hepatis. Methods Reported series on PNI in HCCA were systematically reviewed. A clinicopathological study was conducted on sections from 75 HCCA patients to summarize the incidence and modes of PNI. Immunohistochemical stains for CD34 and D2-40 in tumor tissue were performed to clarify the association of PNI with microvessel and lymphoduct. Sections of different decks of hepatoduodenal ligament from 5 autopsy cases were scanned and computerized to display the distribution of nerve plexuses around porta hepatis. Results The incidence of PNI in HCCA in literature ranged from 59. 2% to 100%. In the present study, the overall incidence of PNI was 92. 0% （69/75）. However, the incidence of PNI showed no remarkable differences among various differentiated groups and Bismuth-Corlette classification groups. Tumor cells could invade microvessels and lymphoducts in HCCA. But no invasion of nerves occurred via microvessels or lymphoducts as demonstrated by immunohistochemistry. Three nerve plexuses in hepatoduodenal ligament and Glisson＇s sheath were classified and they all surrounded great vessels very closely. Conclusion PNI is generally underreported in HCCA. A surgeon should handle diligently the nerve plexuses around porta hepatis.