Combined portal vein resection in the treatment of hilar cholangiocarcinoma: A systematic review and meta-analysis

Objective

To analyse the efficacy and safety of portal vein resection for hilar cholangiocarcinoma (HCCA).

Methods

A thorough search of PubMed, the Cochrane Library, Embase, the Chinese BioMedical Literature (CBM), and the Chinese Medical Current Contents (CMCC) databases was performed to identify comparative studies concerning combined portal vein resection (PVR) versus surgery without portal vein resection (Without PVR) and no surgical tumour resection (NR) in the treatment of HCCA.

Results

Thirteen studies with a total of 1921 HCCA cases were included. The results of the meta-analysis revealed that PVR was associated with a poorer overall survival than Without PVR (HR = 1.90; 95%CI 1.59–2.28; P < 0.00001) but was significantly better than NR (HR = 0.33; 95%CI 0.26–0.41; P < 0.00001). The PVR group exhibited significantly higher rates of advanced disease and a higher proportion of lymph node metastasis (OR = 1.50; 95%CI 1.06–2.13; P = 0.02) and perineural invasion (OR = 2.95; 95%CI 1.80–4.84; P < 0.0001), and the PVR group exhibited a lower curative resection rate (OR = 0.65; 95%CI 0.46–0.91; P = 0.01). No significant differences were found between the two groups with respect to postoperative mortality and morbidity.

Conclusions

Combined PVR is safe and feasible in the treatment of HCCA when the portal vein is grossly involved. For advanced HCCA when the portal vein is grossly involved, surgical resection including PVR can benefit the overall survival in certain patients. However, further randomised controlled trials are necessary to determine the prognostic effects of the addition of PVR to the surgical procedure.     

腹腔镜与开腹肝门部胆管癌根治术疗效比较的Meta分析

目的:系统评价腹腔镜肝门部胆管癌根治术(laparoscopic radical resection for hilar cholangiocarcinoma, LRRHC)与开腹肝门部胆管癌根治术(open radical resection for hilar cholangiocarcinoma, ORRHC)两种手术方式的临床疗效。方法:以laparoscopy、laparoscopic、laparotomy、open surgery、bile duct neoplasms、hilar cholangiocarcinoma、腹腔镜手术、开腹手术、胆管癌、肝门部胆管癌为检索词,检索PubMed、Embase、the Cochrane Library、CBM、CNKI、VANFUN数据库。检索时间为1960年01月至2020年12月。根据Cochrane系统评价原则,由两名研究者独立筛选文献并提取数据,进行质量评价后使用Review Manager 5.3版进行统计分析。计量资料采用均数差(MD)及其95%可信区间(95%CI)表示,计数资料采用比值比(OR)及其95%CI表示。采...     

局部晚期肝门部胆管癌根治术后放射治疗

目的回顾性分析及评价肝门部胆管癌根治性术后放射治疗的结果.方法 1992年3月～1997年12月76例肝门部胆管癌患者接受根治性手术,其中47例术后病理显示切缘有镜下残留(R1组),47例中28例接受术后放射治疗(S RT组),6～15MV X线外照射,靶区剂量达45～62Gy,中位剂量52Gy.术后中位随访期30个月(4～113个月).结果(n=47)总5年生存率28%,中位生存期19.6个月.S RT组(n=28)5年生存率、中位生存期显著高于S组(n=19),分别为34%、29个月和14%、10.0个月(P=0.0141).结论根治性手术结合放射治疗可明显延长切缘阳性患者的生存期;早、晚期放射反应可以耐受.     

Clinical outcome after resection of early-stage hilar cholangiocarcinoma

BackgroundLiver transplantation in patients with unresectable early-stage (<3 cm, node negative) hilar cholangiocarcinoma has been recently reported to be associated with longer survival compared to liver resection and therefore suggested as potential treatment option also in resectable disease. Here, we investigated the outcome of resection in early-stage tumours as the standard of care in an experienced European centre.MethodsPatients with de novo resectable hilar cholangiocarcinomas who underwent liver resection between mid-2009 and December 2017 were classified as early-stage (<3 cm and node negative) or later-stage tumours (≥3 cm and/or node positive), and were investigated with respect to clinical outcome.ResultsFifty-six patients were analyzed of whom 17 had early-stage tumours and 39 had later-stage tumours. The sex ratio (m:f) was 30:26. The median age was 65 years (range 33–80). The median follow-up was 17.0 months (range 0.7–92.4). 5-year overall survival (OS) rates were 82% in patients with early-stage tumours and 23% in patients with later-stage tumours, respectively. Median OS was 89.9 months and 27.6 months, respectively (HR 0.25 (95% CI 0.08–0.84), P = 0.024).ConclusionsIn an experienced European centre, 5-year survival rates after liver resection for early-stage hilar cholangiocarcinoma are comparable with reported outcomes after transplantation. The results of this study question the value of liver transplantation in this setting, especially with respect to the shortage of transplantable organs worldwide.     

术前CT血管造影不同后处理方法对肝门部胆管细胞癌血管侵犯的诊断价值

目的:探讨术前256层螺旋CT血管造影（256-slice spiral CT angiography,256-SCTA）常用后处理方法在肝门部胆管细胞癌肝动脉、门静脉侵犯评估中的诊断价值。方法:回顾性纳入2015年3月至2017年8月西安交通大学第一附属医院35例经病理证实的肝门部胆管细胞癌患者,所有患者术前均行256层螺旋CT血管造影检查,并采用动态容积扫描及Philip EBW后处理工作站对肝动脉及门静脉行容积再现（volume rendering,VR）、最大密度投影（maximum intensity projection,MIP）及多平面重组（multi-planar-reformatting,MPR）重建,在相应后处理图像中评估肿瘤周围血管有无受侵,以术中探查结果作为金标准,分别计算三种后处理方法的灵敏度、特异度、准确率并行Kappa检验以比较三种后处理方法的诊断效能。结果:判断肝动脉有无受侵时,诊断效能以MPR最佳,其诊断灵敏度、特异度、准确性分别为92.3%、86.4%、88.6%,阳性预测值80.0%,阴性预测值95.0%,Kappa值0.763（P＜0.001）,ROC曲线下面积0.893（P＜0.01）。判断门静脉有无受侵时,诊断效能同样以MPR最佳,其诊断灵敏度、特异度、准确性分别为94.4%、100.0%、97.1%,阳性预测值100%,阴性预测值94.4%,Kappa值0.943（P＜0.001）,ROC曲线下面积0.972（P＜0.01）。结论:256-SCTA三种常用后处理方法在判断肝门部胆管细胞癌血管有无受侵时以MPR诊断效能最高,VR及MIP次之。因此,在日常影像后处理工作中应合理应用这些后处理方法以便为临床术前血管评估提供更准确的信息。     

Extended right hepatectomy for hilar cholangiocarcinoma with resection of the left hepatic duct prior to hepatic resection

Extended hepatectomy for hilar cholangiocarcinoma results in high operative or in-hospital mortality rates despite of the recent progress in perioperative management. As a new procedure to prevent postoperative hepatic failure in hilar cholangiocarcinoma infiltrating predominantly the right hepatic duct, we devised a combination of extended right lobectomy plus caudal lobectomy with resection of the left hepatic duct prior to hepatic resection by utilizing intraoperative cholangiography, and applied the procedure to a 70-year-old patient. He had a favorable postoperative course and remains recurrence-free at 4 years after operation. This is a procedure for confining the extent of hepatectomy to the minimum necessary, aiming at curative resection of hilar cholangiocarcinoma.     

肝部分切除与肝十二指肠韧带骨髂化治疗肝门部胆管癌

Objective To summarize the surgical experience of partial hepatectomy with skeletonization of the hepatoduodenal ligament in the treatment of hilar cholangiocarcinoma.Methods Between Jan.1999 and Dec,2001,67 consecutive patients with hilar cholangiocarcinoma underwent surgical exploration at the Second Military Medical University,Eastern Hepatobiliary Surgery Hospital.The clinical data of these patients were reviewed.Results Of the 67 patients,65(97%) underwent surgical resection.Fourty-nine patients(73%) received curative resection:22 skeletonization resection(SR) and 27 SR combined with partial hepatectomy.In 16 patients(9%) with curative resection the tumor margin was histologically postive and the resection was therefore considered palliative.The tumors were classified according to Bismuth with SR was type Ⅱ(17cases),various types of partial hepatectomy with SR was type Ⅲ and type IV.Right lobectomy with right caudate lobectomy was indicated in type Ⅲ(6cases),left lobectomy with complete caudate lobectomy in type Ⅲb(15cases),right loobectomy with complete caudate lobectomy(3 cases),left lobectomy with complete caudate lobectomy(9 cases) and quadrate lobectomy(2 cases)in type IV.SR and left lobectomy with complete caudate lobectomy was successfully performed in 2 patients(3%) who had undergone palliative biliary resection and cholangiojejunostomy before.Eight patients(12%) had local resecton of the tumor with Roux-en-Y hepaticojejunostomy reconstruction using intrahepatic stents.Two patients(3%) had palliative biliary drainage.Combined portal vein resection was performed in 13 patients(20%) and hepatic artery resection in 27 patients(40%) .Twenty-four atients(36%) had no postoperative complication,23 patients(34%) had minor complications only ,and the remaining 20 patients(30%) had major complications.Of the 20 patients with major complications,14 recovered,the remaining 6 patients died from hepatorenal failure with other organ failures,from myocardial infarction or from intraabdominal or gastrointestianl bleeding 7,12,14,42,57 or 89 days after surgery.The 30-day operative mortality was 4.5%.The mean survival of the patient with curative resecton was 16 months(range 1-32 months);for those undergong palliative resection mean survival was 7 months(range 1-14months).Conlusion Partial hepatectomy with SR for hilar cholangiocarcinoma can be performed with acceptable morbidity and mortality.For curative treatmet of hilar cholangiocarcinoma,caudate lobectomy is always recommended in Bismuth Ⅲ/IV.     

肝门胆管癌神经周围侵袭的研究进展

肿瘤的神经周围侵袭(perineural invasion,PNI)是一种特殊的恶性肿瘤转移方式,与肝门胆管癌及胰腺癌等多种恶性肿瘤的不良预后相关.肝门胆管癌肿瘤细胞与神经之间的相互作用主要包括细胞形态改变和分子间相互作用.其微环境中的多种分子包括M3毒蕈碱乙酰胆碱受体、趋化因子、神经营养因子-β、MicroRNA及L...     

47例肝门部胆管癌的相关预后影响因素分析

目的探讨影响肝门部胆管癌的预后因素。方法回顾性分析2006年1月至2009年1月47例肝门部胆管癌患者的临床资料,分析肝门部胆管癌的预后影响因素。结果全组患者的1年生存率为63.6%,3年生存率为18.2%,5年生存率为6.8%。Cox回归模型分析显示肿瘤分期和局部浸润与转移是影响肝门部胆管癌患者预后的独立风险因素。结论肝门部胆管癌的预后与肿瘤分期和局部浸润与转移密切相关,选择适宜的治疗方式,有望获得良好的近远期治疗效果。     

不可切除肝门胆管癌的光动力学治疗现状

肝门胆管癌是一种少见的起源于胆管上皮细胞的恶性肿瘤。目前肝门胆管癌的主要治疗方式为:手术切除、放疗、化疗、光动力疗法（photodynamic therapy ,PDT ）。 根治性手术切除是目前可能治愈肝门胆管癌并最大限度延长生存期的唯一方法,然而超过一半的患者在确诊时已属肿瘤晚期而丧失手术机会。放疗和化疗能否延长患者生存期仍缺少可靠大数据研究的支持。多数无法行手术治疗的患者为解除胆道梗阻只能行胆道支架置入术,但无法延长生存期。PDT 是新兴的一种可以治疗多种恶性肿瘤的方法,已有多项临床研究表明其具有局部消融肿瘤的能力。因此,PDT 在治疗不可切除肝门胆管癌有着广阔的应用前景。      

Clinical outcomes for hilar and extrahepatic cholangiocarcinoma with adjuvant,definitive, or liver transplant-based neoadjuvant chemoradiotherapy strategies: a single-center experience

BackgroundWe report our experience with 3 strategies for treating hilar and extrahepatic cholangiocarcinoma (CCA) including chemoradiotherapy: neoadjuvant chemoradiotherapy (nCRT) and orthotopic liver transplant, surgical resection and adjuvant chemoradiotherapy (aCRT), and definitive chemoradiotherapy (dCRT).MethodsWe included patients treated from 1998 through 2019. Kaplan-Meier estimates, log-rank testing, and univariate/multivariate Cox models were used to assess outcomes (local progression-free survival, disease-free survival, and overall survival).ResultsSixty-five patients (nCRT, n=20; aCRT, n=16; dCRT, n=29) met inclusion criteria [median (range) age 65 years (27–84 years)]. Median posttreatment follow-up was 19.1 months (0.8–164.8 months) for all patients and 38.6, 24.3, and 9.0 months for the nCRT, aCRT, and dCRT groups, respectively. At 3 and 5 years, overall survival was 78% and 59% for the nCRT group; 47% and 35%, aCRT group; and 11% and 0%, dCRT group. Compared with the dCRT group, the nCRT group (hazard ratio =0.13, 95% CI: 0.05–0.33) and the aCRT group (hazard ratio =0.29, 95% CI: 0.14–0.64) had significantly improved overall survival (P<0.001). The 5-year local progression-free survival (50% nCRT vs. 30% aCRT vs. 0% dCRT, P<0.001) and 5-year disease-free survival (61% nCRT vs. 30% aCRT vs. 0% dCRT, P=0.01) were significantly better for strategies combined with surgery.ConclusionsOutcomes for patients with extrahepatic CCA were superior for those who underwent nCRT/orthotopic liver transplant or postsurgical aCRT than for patients treated with dCRT. The excellent outcomes after nCRT/orthotopic liver transplant provide additional independent data supporting the validity of this strategy. The poor survival of patients treated with dCRT highlights a need for better therapies when surgery is not possible.     

The prognostic potential and oncogenic effects of PRR11 expression in hilar cholangiocarcinoma

PRR11 is a newly identified oncogene in lung cancer, yet its role in others tumors remains unclear. Gastrointestinal tissue microarrays were used to evaluate PRR11 expression and its association with clinical outcome was analyzed in patients with hilar cholangiocarcinoma. Overexpression of PRR11 was observed in esophageal, gastric, pancreatic, colorectal, and hilar cholangiocarcinoma. Expression of PRR11 correlated with lymph node metastasis and CA199 level in two HC patient cohorts. After an R0 resection, a high level of PRR11 expression was found to be an independent indicator of recurrence (P = 0.001). In cell culture, PRR11 silencing resulted in decreased cellular proliferation, cell migration, tumor growth of QBC939 cells. Microarray analysis revealed that several genes involved in cell proliferation, cell adhesion, and cell migration were altered in PRR11-knockout cells, including: vimentin (VIM), Ubiquitin carboxyl-terminal hydrolase 1 (UCHL1), early growth response protein (EGR1), and System A amino acid transporter1 (SNAT1). Silencing PRR11 inhibited the expression of UCHL1, EGR1, and SNAT1 proteins, with immunoassays revealing a significant correlation among the levels of these four proteins. These results indicate that PRR11 is an independent prognostic indicator for patients with HC.     

彩色多普勒超声诊断肝门部胆管癌的临床价值

目的:探讨肝门部胆管癌的彩色多普勒超声图像特征,评价其术前定性临床价值。方法:回顾性分析 58例经手术病理证实为肝门部胆管癌的彩色多普勒声像图表现。结果:58例肝门部胆管癌中,术前超声诊断为49 例,诊断符合率 84.48%,漏误诊率为 15.52%。肝门部胆管癌的声像图多表现为肝门部肿块、胆管壁增厚伴管腔狭窄,梗阻部近端肝内胆管扩张等,可作为诊断肝门部胆管癌的主要声像图表现。诊断的关键是受侵胆管壁的厚度。结论:彩色多普勒超声对肝门部胆管癌诊断准确率较高,定位准确,可作为诊断肝门部胆管癌的首选方法。     

三维可视化技术在肝门部胆管癌术前评估中的应用

  目的  探讨三维可视化技术在肝门部胆管癌术前评估中的应用价值。  方法  收集2014年3月至2016年4月蚌埠医学院第一附属医院38例肝门部胆管癌手术患者临床资料,将所有患者分为两组,对照组术前未行三维可视化重建（n=20）,观察组术前行三维可视化重建（n=18）。分析两组术前诊断结果与术中实际情况的相符程度,并比较两组相关手术指标。  结果  在肿瘤纵向和门静脉、肝动脉垂直方向侵犯评估中,观察组和对照组都具有较高的准确率,二者无显著性差异。而在肝门部解剖分型上,观察组中所有患者分型与术中实际吻合,吻合率高于对照组（100% vs. 70%,P＜0.05）,同时对肝体积的预估和实测更加精确（r=0.986,P＜0.001）。此外,与对照组相比,观察组平均术中出血量、手术时间明显减少（P＜0.05）,R0切除率无明显差异。  结论  三维可视化技术能精准完成肝门部胆管癌术前评估。