肝内胆管细胞癌淋巴结清扫范围探讨及预后危险因素分析

To study the extent of lymph mode dissection and prognostic factors in patients with intrahepatic cholangiocarcinoma

目的探讨肝内胆管细胞癌(ICC)患者行手术切除术中,未行淋巴结清扫、阴性淋巴结清扫、阳性淋巴结清扫、淋巴结清扫范围的差异,及部分预后相关因素对ICC患者临床预后的影响。方法回顾性分析郑州大学附属肿瘤医院2014年6月至2019年10月期间收治的行手术切除并经术后病理结果确诊为ICC的162例患者的临床资料。依据淋巴结清扫程度分为3组:未清扫组(n=68)、N0清扫组(预防性清扫)(n=41)和N1清扫组(阳性清扫)(n=53)。共有94例行淋巴结清扫,其中仅行第1站清扫者23例,纳入为常规清扫组(n=23);行联合清扫者71例,纳入为扩大清扫组(n=71)。采用Kaplan-Meier法构建生存曲线;Cox回归分析筛选影响患者生存预后的独立因素。结果162例患者中男性87例,女性75例,中位年龄60岁。162例ICC患者中位生存期为10个月,术后1、3、5年累积生存率分别为37.6%、16.5%、7.9%。N0清扫组术后1、3、5年累积生存率分别为52.1%、31.7%、25.4%,优于未清扫组的34.2%、12.7%、3.4%,也优于N1清扫组的30.3%、11.4%、0,差异具有统计学意义(P<0.05)。扩大清扫组、常规清扫组相比,术后生存情况差异无统计学意义(P>0.05)。术前肿瘤糖类抗原(CA)19-9>50 U/ml(RR=1.425,95%CI:0.962~2.112)、肿瘤最大径>5 cm(RR=0.672,95%CI:0.456~0.989)、淋巴结未清扫(RR=1.715,95%CI:1.140~2.580)、切缘阳性(RR=0.591,95%CI:0.390~0.897)、术后无辅助治疗(RR=0.663,95%CI:0.504~0.872)为影响患者术后生存的独立危险因素(P<0.05)。结论ICC患者术中行预防性淋巴结清扫可提高生存率,但扩大清扫并不能改善患者预后。术前CA19-9水平、肿瘤最大径、淋巴结清扫、切缘状态、术后辅助治疗是影响患者预后的独立危险因素。

Objective To study the impact of patients with intrahepatic cholangiocellular carcinoma(ICC)who underwent surgical resection with or without lymph node dissection(LND),negative or positive lymph node metastasis detected by LND,different extents of LND,and prognostic factors on long-term prognosis of these patients.Methods The clinical data of 162 patients who were admitted to the Affiliated Cancer Hospital of Zhengzhou University from June 2014 to October 2019 and underwent surgical resection with postoperative histopathological results confirming ICC were retrospectively analyzed.According to the degree of LND,these patients were divided into three groups:the undissected group(n=68),N0 dissected group(prophylactic dissection)(n=41)and N1 dissected group(positive dissection,n=53).Of 94 patients who underwent LND,23 patients underwernt the first station LND(the routine dissection group,n=23),and 71 patients underwent extended LND(the extended dissection group,n=71).The Kaplan-Meier method was used to construct survival curves.Cox regression analysis was used to detect independent factors affecting survival and long-term prognosis of patients.Results In this study,there were 87 males and 75 females,with a median age of 60 years.The median survival time of these 162 ICC patients was 10 months.The cumulative survival rates at 1-,3-and 5-year after surgery were 37.6%,16.5%and 7.9%,respectively.The 1-,3-and 5-year cumulative survival rates of the N0 dissection group were 52.1%,31.7%and 25.4%,respectively,which were significantly better than those of the undissected group(34.2%,12.7%,3.4%),and the N1 dissection group(30.3%,11.4%,0)(P<0.05).There were no significant differences in postoperative survival between the extended dissection group and the routine dissection group(P>0.05).Preoperative CA19-9>50 U/ml(RR=1.425,95%CI:0.962-2.112),maximum tumor diameter>5 cm(RR=0.672,95%CI:0.456-0.989),without LND(RR=1.715,95%CI:1.140-2.580),positive margin(RR=0.591,95%CI:0.390-0.897),and without postoperative adjuvant therapy(RR=0.663,95%CI:0.504-0.872)were independent risk factors affecting postoperative survival(P<0.05).Conclusions LND in ICC patients improved long-term survival outcomes.However,extended LND did not improve prognosis of these patients.The preoperative CA19-9 level,maximum tumor diameter,lymph node dissection,surgical margin status,and postoperative adjuvant therapy were independent risk factors affecting long-term prognosis of these patients.