侵犯第一肝门肝内胆管癌手术的临床价值

Clinical value of surgical resection for hilar type intrahepatic cholangiocarcinoma

背景与目的:侵犯第一肝门肝内胆管癌(HICC)侵袭性强,病理生理复杂。外科手术是首选的治疗方法,但R0切除率低,预后差。本文通过分析接受手术治疗的HICC患者预后情况,探讨其手术治疗的临床价值。方法:回顾性分析2010年11月—2016年6月在东方肝胆外科医院手术治疗98例HICC患者的临床及病理资料。根治手术67例,姑息手术31例,其中R1切除3例,R2切除28例。行根治手术患者中,32例合并肝门血管侵犯(HVI),35例无HVI。结果:全组患者1、3、5年总生存率为46.5%、11.7%、5.8%,中位生存期(mOS)12.0个月。根治手术患者预后优于姑息手术组(m OS:14.0个月vs.7.0个月,P=0.004)。无HVI患者预后优于有HVI患者(mOS:21.0个月vs.9.0个月,P=0.002)及行姑息手术患者(mOS:21.0个月vs.7.0个月,P<0.001)。有HVI的根治手术患者与行姑息手术患者的预后差异无统计学意义(mOS:9.0个月vs.7.0个月,P=0.192)。Cox多因素分析显示,肝门血管受侵(HR=2.02,95%CI=1.19~3.44,P=0.009)及CA19-9高水平(HR=1.89,95%CI=1.05~3.43,P=0.035)是HICC患者根治手术预后的独立危险因素。有HVI与无HVI的患者间比较发现,年龄>60岁及肿瘤直径≥5 cm的患者HVI率更高(均P<0.05)。结论:HICC切除率低,预后差。肝门血管受侵及CA19-9高水平是影响HICC根治术后预后的危险因素,合并HVI的HICC患者术后无生存获益。

Background and Aims:Hilar type intrahepatic cholangiocarcinoma(HICC)is characterized by strong invasion capability and pathophysiological complexity.Surgical resection is the preferred treatment,but the R0 resection rate remains low and the prognosis is poor.This study was conducted to assess the clinical value of surgical treatment of HICC by analyzing the outcomes of HICC patients treated by surgery.Methods:The clinical and pathological data of 98 patients who underwent surgery for HICC in Eastern Hepatobiliary Surgery Hospital from November 2011 to June 2016 were retrospectively analyzed.Of the patients,67 cases underwent radical surgery,and 31 cases were subjected to palliative surgery that included R1 resection in 3 cases and R2 resection in 28 cases.In patients undergoing radical surgery,hilar vascular invasion(HVI)occurred in 32 cases,and HVI did not occur in 35 cases.Results:In the entire group of patients,the overall 1-,3-,and 5-year survival rates were 46.5%,11.7%,and 5.8%,respectively,with a median overall survival(mOS)of 12.0 months.Patients receiving radical surgery had a better prognosis than those undergoing palliative surgery(mOS:14.0 months vs.7.0 months,P=0.004).Patients without HVI showed a better prognosis compared with those with HVI(mOS:21.0 months vs.9.0 months,P=0.002)as well as those undergoing palliative surgery group(mOS:21.0 months vs.7.0 months,P<0.001).There was no difference in prognosis between patients with HVI undergoing radical surgery and those undergoing palliative surgery(mOS:9.0 months vs.7.0 months,P=0.192).Results of multivariate Cox analysis showed that HVI and high CA19-9 level were independent risk factors for the prognosis of HICC patients after radical surgery.Comparison between patients with and without HVI found that the patients with age>60 years and tumor diameter≥5 cm had a higher rate of HVI(both P<0.05).Conclusion:The resection rate of HICC is low and the prognosis is poor.HVI and high CA19-9 level are risk factors for the prognosis of HICC patients after radical resection.Surgery offers no survival benefit to those with HVI.