改良T分期系统在肝门部胆管癌诊断和治疗中的应用价值

Value of modified T staging system in the diagnosis and treatment of hilar cholangiocarcinoma

目的探讨改良T分期系统在肝门部胆管癌诊断和治疗中的应用价值。方法回顾性分析1995年12月至2010年1月中山大学孙逸仙纪念医院收治的95例肝门部胆管癌患者的临床资料，根据影像学检查结果，按照改良T分期系统标准进行术前分期。比较不同T分期患者的手术疗效和预后。计数资料组间比较采用x^2检验和Fisher确切概率法，生存曲线采用Kaplan—Meier法绘制，生存情况比较采用Logrank检验。结果超声联合MRCP检查的确诊率为93％（37／40），超声联合CT或螺旋CT检查的确诊率为66％（23／35），超声联合CT或螺旋CT和ERCP检查的确诊率为14／15，超声联合CT或螺旋CT和MRCP检查的确诊率为15／15。95例肝门部胆管癌患者中，44例行手术治疗（根治性切除术28例、姑息性切除术16例），35例行单纯性内外引流术，16例行剖腹探查。其中T1、T2、T3期患者肿瘤切除率分别为71％（30／42）、50％（12／24）和7％（2／29），3者比较，差异有统计学意义（x^2=30．182，P〈0．05）。T1、T1期患者的切缘阴性率分别为77％（23／30）和5／12，T，期的2例患者切缘均发现癌细胞残留，3期患者根治性切除率比较，差异有统计学意义（x^2：8．204，P〈0．05）。44例行手术治疗的患者中，联合肝切除率为68％（30／44）；T1、T2期患者联合肝切除率分别为70％（21／30）、9／12，两者比较，差异无统计学意义（x^2=0．101，P〉0．05）；单纯肿瘤切除率为32％（14／44）。两者的并发症发生率分别为53％（16／30）和5／14，围手术期病死率分别为10％（3／30）和1／14，上述指标比较，差异无统计学意义（x^2=1．188，0．094，P〉0．05）。联合肝切除的患者中位生存时间为29个月，长于单纯肿瘤切除患者的19个月（x^2=11．317，P〈0．05）。本组患者随访率为91％（86／95），中位随访时间为15．6个月（3—70个月）。T1、T2、T3期患者的1年累积生存率分别为73．8％、58．0％和9．2％，3年累积生存率分别为33．5％、12．1％和0；T1、T2、T3期患者的中位生存时间分别为24、16、7个月；随着T分期增加，患者预后变差（X2=37．07，P〈0．05）。结论改良T分期系统对肝门部胆管癌患者有较好的术前评估作用，联合肝切除有利于提高患者根治性切除率和延长术后生存时间。

Objective To investigate the value of modified T staging system in the diagnosis and treatment of hilar cholangiocarcinoma （HCCA）. Methods The clinical data of 95 patients with HCCA who were admitted to the Memorial Sun Yat-Sen Hospital from December 1995 to January 2010 were retrospectively analyzed. Based on the results of imaging examination, preoperative staging was determined according the modified T staging system. The prognosis of the patients in difference T stages were compared. The data were analyzed by using the chi-square test and Fisher exact test. The survival curve was drawn by Kaplan-Meier method and the survival rate was compared by using the Log-rank test. Results The diagnostic rates of ultrasound ＋ magnetic resonance cholangiopancreatography （MRCP） , ultrasound ＋ computed tomography （CT） or spiral CT were 93% （37/40） and 66% （23/35） , respectively. The diagnostic rates of ultrasound ＋ CT or spiral CT and endoscopic retrograde cholangiopancreatography （ERCP） , ultrasound ＋ CT or spiral CT and MRCP were 14/15 and 15/15, respectively. Of the 95 patients, 44 received operation （ including 28 cases of radical resection and 16 cases of palliative resection）, 16 received exploratory laparotomy, and 35 received simple internal or external drainage. For patients in T1, T2 and T3 stages, the resection rates were 71% （30/42） , 50% （12/24） and 7% （2/29）, respectively, with significant differences （ X2 = 30. 182, P 〈 0.05 ）. The negative rates of the resection margins of patients in T1 and T2 stages were 77% （23/30） and 5/12, respectively, 2 patients in T3 stage were found with tumor residuals at the resection margin. There was a significant difference in the radical resection rate among patients in different T stages （ X2 = 8. 204, P 〈 0.05）. Of the 44 patients who received surgical treatment, 30 （68%） received concomitant partial hepatectomy. The ratios of patients in T1 and T2 stages who received concomitant partial hepatectomy were 70% （21/30） and 9/12, respectively, with no significant difference （X2 = 0. 101, P 〉 0.05 ）. Fourteen （32%） patients received tumor resection. The incidences of complications and perioperative mortalities were 53% （16/30） and 10% （3/30） for patients who received concomitant partial hepatectomy, and 5/14 and 1/14 for patients who received tumor resection, with no significant differences between the 2 groups （X2 = 1. 188, 0. 094, P 〉 0.05）. The median survival time of patients who received concomitant partial hepatectomy was 29 months, which was significantly longer than 19 months of patients who received tumor resection （X2 = 11. 317, P 〈0.05）. Eighty-six patients were followed up, and the median time of follow up was 15.6 months （range, 3-70 months）. The 1-year cumulative survival rates of patients in Tt , T2 and T3 stages were 73.8% , 58.0% and 9.2%, respectively, and the 3-year cumulative survival rates of patients in T1 , T2 and T3 stages were 33.5% , 12.1% and 0, respectively. The median survival time of patients in Ti, T2 and T3 stages were 24, 16 and 7 months, respectively. The prognosis of patients was getting poor as the increase of the T stages （ X2 = 37.07, P 〈 0.05 ）. Conclusions The modified T-staging system is beneficial to preoperative evaluation of patients with HCCA. Concomitant partial hepatectomy could improve the radical resection rate and prolong the median survival time of HCCA patients.