肝内胆管癌根治性切除术中淋巴结清扫价值研究

Significance of lymphadenectomy in intrahepatic cholangiocarcinoma with radical resection

目的通过分析海军军医大学东方肝胆外科医院7年间诊断肝内胆管癌(ICC)并接受手术治疗病人的治疗及预后情况,探讨术中淋巴结清扫的意义。方法回顾性分析2010年1月至2017年12月于海军军医大学东方肝胆外科医院经手术治疗的265例ICC病人资料。结果共纳入265例病人,男性175例,女性90例。年龄22~86岁,中位年龄56.5岁。中位随访时间33.5个月。全部病人1、2、3年无瘤存活率分别为50%、29%、20%,中位无瘤生存时间11.9个月;1、2、3年总存活率分别为77%、47%、36%,总中位生存时间22.8个月。COX多因素分析结果显示病人无瘤生存的影响因素包括糖尿病史、术前CA19-9高水平、肿瘤直径≥5 cm、肿瘤周边子灶、淋巴结是否清扫;病人总体生存的影响因素包括术前CA19-9高水平、肿瘤直径≥5 cm、血管侵犯、淋巴结是否清扫。分组对比经倾向评分匹配(PSM)后,淋巴结清扫组及未清扫组各77例。1、2、3年无瘤存活率:清扫组68%、47%、36%vs.未清扫组31%、13%、6%(P<0.05),中位无瘤生存时间:清扫组22.2个月vs.未清扫组9.2个月。1、2、3年总存活率:清扫组91%、75%、56%vs.未清扫组71%、30%、21%(P<0.05),中位总生存时间:清扫组46.8个月vs.未清扫组17.0个月。剔除清扫组淋巴结阳性病人,比较清扫组中淋巴结病理学诊断阴性与未清扫病人生存情况,PSM后:清扫淋巴结阴性组及未清扫组各50例。1、2、3年无瘤存活率:清扫淋巴结阴性组77%、60%、52%vs.未清扫组32%、22%、15%(P<0.05),中位无瘤生存时间:清扫淋巴结阴性组38.1个月vs.未清扫组9.0个月。1、2、3年总存活率:清扫淋巴结阴性组94%、82%、74%vs.未清扫组68%、40%、28%,(P<0.05),中位总生存时间:清扫淋巴结阴性组54.0个月vs.未清扫组18.9个月。病人发生淋巴结转移的影响因素分析显示,肿瘤直径≥5 cm、术前CA19-9高水平是影响病人淋巴结转移的独立危险因素。结论术中淋巴结清扫可改善ICC病人预后。术前无法明确淋巴结转移,但评估肿瘤可行根治性切除的ICC病人,伴随术前CA19-9水平较高、肿瘤直径较大时,术中应积极常规进行淋巴结清扫。

Objective To retrospectively analyze those ICC patients whose tumor got resected during 7 years in Eastern Hepatobiliary Surgery Hospital,to observe the prognosis related influence factors,the significance of routine lymphadenectomy during surgical operation and the influence factors of lymph node metastasis.MethodsThe clinicopathological and follow-up data of 265 cases that were clinical diagnosed as ICC and had been performed surgical operation from January 2010 to December 2017 in Eastern Hepatobiliary Surgery Hospital, Naval Military Medical University were collected and retrospectively analyzed.ResultsThere were 175 male and 90 female cases with a median age of 56.5(22-86)years.The median follow-up time was 33.5 months.Of all the cases,the disease-free survival(DFS)rate was 50%,29% and 20% in the 1,2 and 3 years,and the median DFS time was 11.9 months.The overall survival(OS)rate was 77%,47% and 36% in the 1,2 and 3 years,and the median OS time was 22.8 months. The multivariate analysis(COX)of prognosis showed that diabetes,preoperative CA19-9 level,tumor size≥ 5 cm,son focal,lymphadenectomy were factors affecting on DFS;preoperative CA19-9 level,tumor size≥ 5 cm,vascular invasion,lymphadenectomy were factors affecting on the OS. Two groups had77 cases respectively after PSM compared between groups.(1)Comparison of DFS condition:1,2 and 3 years DFS rate was 68%,47%,36% in lymphadenectomy group vs. 31%,13%,6% in un-lymphadenectomy group,(P<0.05).The median DFS time was 22.2 months in lymphadenectomy group vs. 9.2 months in un-lymphadenectomy group.(2)Comparison of OS condition:1,2 and 3 years overall survival rate was 91%,75%,56% in lymphadenectomy group vs.71%,30%,21% in un-lymphadenectomy group,(P<0.05).The median OS time was 46.8 months in lymphadenectomy group vs. 17.0 months in un-lymphadenectomy group.Then the lymph node positive patients were removed from the lymphadenectomy group,and the survival condition of the patients with negative lymph node and un-lymphadenectomy patients was compared after PSM. Two groups had 50 cases respectively.(1)Comparison of DFS condition:1,2 and 3 years DFS rate was 77%,60%,52% in lymph node negative group vs. 32%,22%,15% in un-lymphadenectomy group,(P<0.05).The median DFS time was 38.1 months in lymph node negative group vs. 9.0 months in un-lymphadenectomy group.(2)Comparison of OS condition:1,2 and 3 years OS rate was 94%,82%,74% in lymph node negative group vs.68%,40%,28% in un-lymphadenectomy group,(P<0.05).The median OS time was 54.0 months in lymph node negative group vs. 18.9 months in un-lymphadenectomy group. In the analysis of the influence factors of lymph node metastasis,tumor diameter≥ 5 cm and preoperative CA19-9 level were independent risk factors affecting on lymph node metastasis.ConclusionRoutine lymphadenectomy may improve the prognosis of ICC patients. For patients who were evaluated can undergo radical resection,especially with high level of preoperative CA19-9 and larger tumor size,routine lymphadenectomy is recommended.