肝门部胆管癌的外科治疗和预后相关因素分析

目的 探讨肝门部胆管癌的外科治疗策略及预后相关因素.方法 对1990年1月至2005年12月144例行手术切除治疗的肝门部胆管癌患者的临床资料进行回顾性分析.144例患者中,男性102例,女性42例;年龄36～74岁,平均63岁.根治性切除(R0组)86例(59.7%),镜下切缘阳性(R1组)34例(23.6%),肉眼切缘阳性(R2组)24例(16.7%).R0组和R1组的120例患者中,Bismuth-Corlette分型Ⅰ型28例(23.3%),Ⅱ型49例(40.8%),ⅢA型10例(8.3%),ⅢB型19例(15.8%),Ⅳ型14例(11.7%);TNM分期Ⅰ期19例(15.8%),Ⅱ期80例(66.7%),Ⅲ期16例(13.3%),Ⅳ期5例(4.2%);组织病理学分级:高分化(G1)41例(34.2%),中低分化(G2、G3、G4)79例(65.8%);无淋巴结转移者(N0)62例(51.7%),有淋巴结转移者(N1、N2)58例(48.3%);T1分期42例,T2～3分期78例;无血管侵犯者86例,有血管侵犯者34例.R0组和R1组120例患者均施行伴部分肝切除+区域淋巴结清扫术.结果 中位生存期:R0组46.8个月,R1组18.3个月,R2组11.2个月.生存率:R0组和R1组的120例患者术后1、3、5年总生存率分别为60.2%、36.1%、29.4%,R0组预后好于R1组(P<0.01),R1组预后好于R2组(P=0.031);高分化癌患者预后较好(P=0.003);有淋巴结转移患者预后极差(P<0.01);T1期患者的预后好于T2～3分期患者(P=0.030).有血管侵犯者预后较差(P=0.047).结论 肝门部胆管癌的病理类型、临床分期以及是否行根治性切除是影响预后的主要因素.联合不同范围的肝切除及淋巴结清扫术对提高肝门部胆管癌的根治率和生存率有重要的意义.

Analysis of the surgical outcome and prognostic factors for hilar cholangiocarcinoma

Objective To assess the therapeutic strategies and prognostic factors which influence on clinical outcome of hilar cholangiocarcinoma. Methods A total of 144 patients with hilar cholangiocarcinoma underwent operation between January 1990 and December 2005 were analyzed,including 102 males and 42 females with 36-74 years old. All patients underwent resection among which 86 cases (59.7% ) had an R0 resection (negative histologic margins), 34 cases (23.6%) had an R1 resection (positive histologic margins) ,24 cases(16. 7%) had an R2 resection. The Biamuth-Corlette classification of group R0 and R1:28 cases(23.3% )in type Ⅰ ,49 cases(40. 8%)in type Ⅱ ,10 cases(8.3%) in type Ⅲ A, 19 cases(15.8%) in type Ⅲ B and 14 cases(11.7%) in type Ⅳ. The TNM stages of group R0 and R1: 19 cases(15.8%) in stage Ⅰ ,80 cases in stage Ⅱ (66.7%),16 cases in stage Ⅲ(13.3%),5 cases in stage Ⅳ(4.2%). In group R0 and R1, there were 41 cases with well differentiated and 79 cases with moderately and poorly differentiated,62 cases(51.7%) with negative lymph nodes and 58 cases(48.3%) with positive lymph nodes, 42 cases in stage T1 and 78 cases in stage T2-3,86 cases with negative blood vessel metastasis and 34 cases with positive blood vessel metastasis. Results The median survival time was 46.8 months after R0 resection, 18.3 months after R1 resection,and 11.2 months after R2 resection. The 1-, 3- and 5-year cumulative survival rates of the patients were 60.2% ,36.1% and 29.4%. Survival rates after resection in patients with negative lymph nodes (n=62) were significantly longer than that in those with positive lymph nodes (n=58) (P<0.01). The T stage system predicted respectability and the likelihood of an R0 resection and correlated with survival (P=0.030). Patients requiring portal vein resection had a worse prognosis than those without vascular resection (P=0.047) but still survived longer than patients who were unresectable(P<0.01). Conclusions Negative histologic margins, concomitant partial hepatectomy, and well-differentiated tumor histology are associated with improved outcome after all hilar cholangiocarcinoma resections. In patients who underwent an R0 resection, concomitant partial hepatectomy is the only independent predictor of long-term survival.