基于实际解剖部位命名的肝内胆管细胞癌新分型的临床价值

A new classification of intrahepatic cholangiocarcinoma based on actual anatomy:a series of 135 cases

目的探讨可切除性肝内胆管细胞癌(IHCC)根据实际解剖部位进行分型的可行性及临床价值。方法回顾性分析2011年11月至2020年11月浙江大学医学院附属第二医院肝胆胰外科收治的经多学科协作团队讨论后计划行根治性切除的135例IHCC患者的病例资料。男性77例,女性58例,中位年龄61岁(范围:26~86岁),其中合并血管侵犯38例。本次新分型由两名肝胆外科医师独立进行,首先根据肿瘤所在位置进行初步分类,再根据血管侵犯情况最终分型。所有患者均采用电话随访,随访截至2020年11月。生存时间定义为接受手术后至末次随访时间或死亡时间。采用Log-rank检验对比患者中位无复发生存及总体生存时间。采用Cox比例风险模型分析肝内胆管癌患者总体生存时间的预后因素。结果135例患者中,R0切除129例,R1切除6例。根据实际解剖部位分型:段型28例(20.7%),支型43例(31.9%),叶型64例(47.4%)。所有患者的中位生存时间为35.2个月(95%CI:21.3~70.5个月),1年累积生存率为75.1%,3年累积生存率为45.8%,5年累积生存率为39.0%。根据分型分组后,段型患者的中位生存时间为36.9个月(超过50%患者达到中位生存期),支型患者的中位生存时间为33.8个月(95%CI:16.8~38.5);叶型患者的中位生存时间为25.0个月(95%CI:13.6~58.7)。组间Log-rank检验结果提示,段型患者的中位生存时间优于支型和叶型患者(HR=2.03,95%CI:1.24~3.64,P=0.006);而支型和叶型两组患者的中位生存未见明显差异(P=0.685)。Cox风险比例模型多因素分析结果提示,实际解剖部位分型(HR=2.32,95%CI:1.10~4.92,P=0.028)及术后病理学检查结果证实的淋巴结转移(HR=2.06,95%CI:1.24~3.45,P=0.005)是IHCC患者根治术后生存的独立预后因素。结论采用实际解剖部位对可切除IHCC进行分型简单、便捷,可用于初步判断患者预后,为临床提供了一种可行的分型方案。

Objective To explore the feasibility and clinical value of a new classification for resectable intrahepatic cholangiocarcinoma(IHCC)according to the actual anatomy.Methods The data of 135 patients with IHCC who were admitted to the Department of Hepatopancreatobiliary Surgery,Second Affiliated Hospital of Zhejiang University School of Medicine from November 2011 to November 2020 after discussion by a multidisciplinary team and planned to undergo radical resection were analyzed retrospectively.There were 77 males and 58 females,with a median age of 61 years(range:26 to 86 years),of which 38 cases had vascular invasion.This new classification was carried out independently by two hepatobiliary surgeons.First,a preliminary classification was made based on the location of the tumor,and then the final classification was based on vascular invasion.All patients were followed up by telephone,and the follow-up was as of November 2020.Survival time is defined as the time after surgery to follow-up or death.Log-rank test was used to compare patients′median recurrence-free survival and overall survival time.The Cox proportional hazard model was used to analyze the prognosis factors of the overall survival time of patients with IHCC.Results Among the 135 patients,129 underwent R0 resection and 6 underwent R1 resection.According to the actual anatomy,28 cases(20.7%)belonged to segmental type,43 cases(31.9%)belonged to branch type,64 cases(47.4%).The median survival time of all patients was 35.2 months(95%CI:21.3 to 70.5 months),the 1-year cumulative survival rate was 75.1%,the 3-year cumulative survival rate was 45.8%,and the 5-year cumulative survival rate was 39.0%.After grouping according to the classification,the median survival time of segmental patients was 36.9 months(more than 50%of patients reached the median survival time),and the median survival time of branched patients was 33.8 months(95%CI:16.8 to 38.5);The median survival time of lobe patients was 25.0 months(95%CI:13.6 to 58.7).The result of Log-rank test between groups indicated that the median survival time of patients with segmental type was better than that of patients with branch and lobe type(HR=2.03,95%CI:1.24 to 3.64,P=0.006);There was no significant difference in survival time between patients with branch type and lobe type(P=0.685).The results of the multivariate analysis of the Cox risk ratio model suggested that the actual anatomical location classification(HR=2.32,95%CI:1.10 to 4.92,P=0.028)and the postoperative lymph node metastasis rate(HR=2.06,95%CI:1.24 to 3.45,P=0.005)were independent factors related to survival after radical resection of IHCC patients.Conclusion It is simple and convenient to classify resectable IHCC by actual anatomy,which can be used to preliminarily judge the prognosis of patients and provide a feasible classification scheme for the clinic.