辅助放化疗在胆囊癌综合治疗中的作用和地位

正由于胆囊的解剖学特点,胆囊肿瘤易侵犯肌层周围富含血管和淋巴的结缔组织,容易发生扩散,因此胆囊癌比较早期就可能出现转移。胆囊壁较薄,胆囊癌可以直接侵犯肝、胃、十二指肠或结肠,发生腹膜播散,区域淋巴结转移或远处转移。胆囊癌术后局部复发率和远处转移率高,术后辅助治疗在胆囊癌综合治疗中应该有一定的作用。本文就胆囊癌术后辅助化疗、辅助放疗及辅助放化疗进行阐述,并就新辅助治疗做一简单介绍。1辅助化疗     

CXCR4与CCR5在胆囊癌中的表达及其意义

目的探讨CXCR4与CCR5在胆囊癌中的表达及其意义。方法采用免疫组化方法检测31例胆囊癌和作为对照的15例胆囊息肉组织中CXCR4与CCR5的表达。结果胆囊癌中CXCR4、CCR5表达阳性率高于胆囊息肉,差异有统计学意义(P0.05);胆囊癌患者中女性、有淋巴和(或)远处脏器转移及侵犯周围组织者CXCR4表达阳性率分别明显高于男性、无淋巴和(或)远处脏器转移及未侵犯周围组织者(P0.05);年龄≥61岁、有淋巴和(或)远处脏器转移及侵犯周围组织者CCR5阳性表达率分别明显高于年龄61岁、无淋巴和(或)远处脏器转移及未侵犯周围组织者(P0.05);CXCR4和CCR5表达与患者术前血清CA199、CA242和CEA值均无明显相关性(P0.05);Spearman等级相关分析显示CXCR4和CCR5表达无相关性(r=0.066,P0.05)。结论 CXCR4与CCR5表达可能是胆囊癌发生、发展、侵袭、转移的重要生物学标记物。     

胆囊癌外科治疗的共识与分歧

<正>胆囊癌是胆道系统最常见的恶性肿瘤之一,其发病率在消化道恶性肿瘤中位列第5位并有逐渐上升趋势~([1-3])。胆囊癌的恶性程度高,早期即可能出现淋巴和血行转移并有腹膜播散的倾向,进展迅速。由于胆囊癌的临床表现缺乏特异性,早期诊断困难,患者就诊时常常已是晚期~([4]);另外,胆囊及周围解剖结构的特点使其容易侵犯周围器官和组织,缺乏有效治疗方式,因而胆囊癌总体预后极     

联合肝叶及部分胰头、十二指肠切除治疗Nevin Ⅴ期胆囊癌六例

原发性胆囊癌是胆系常见的一种高度恶性肿瘤,本病早期多无症状,一旦临床发现多属晚期,易发生肝脏直接浸润和周围脏器侵犯,并易于发生淋巴结转移,手术切除率低,预后及5年生存率差。近年来,随着对胆囊癌转移方式研究的深入,以及现代外科综合技术的不断发展,晚期胆囊癌的手术切除     

CT在原发性胆囊癌诊治中的价值探讨

目的　探讨原发性胆囊癌ＣＴ的表现特征、病期判断和临床应用价值。方法　对经手术病理证实的３７ 例原发性胆囊癌与ＣＴ扫描结果进行了回顾性对比分析。结果　原发性胆囊癌根据ＣＴ表现分为：腔内型、厚壁型、肿块型。胆囊癌的主要转移形式是直接侵犯肝脏和淋巴结转移。结论　（１）临床上中晚期胆囊癌具有特异的ＣＴ表现，对良恶性胆囊疾患鉴别有一定意义；（２）ＣＴ对胆囊癌壁外侵犯与转移的判定具有一定敏感度，且特异性较高，尤其肝脏直接侵犯和淋巴结转移，应做为胆囊癌术前常规检查以指导治疗；（３）ＣＴ对胆囊癌手术前评估具有一定价值。     

扩大胆囊切除术治疗胆囊癌

胆囊癌是一种致死性很高的疾病,因其可侵犯周围重要脏器,可切除率低.因胆囊结石行胆囊切除术,偶尔可发现早期胆囊癌,这类病人可长期存活.因诊断技术的改进,术前确诊为胆囊癌的病例日趋增多.当肿瘤尚未突破肌层时,单纯胆囊切除术即可达到治疗目的.对已扩散的胆囊癌则应行扩大的胆囊切除术:完全的胆囊切除术、胆囊床楔形肝切除术、局部淋巴结清除术.作者报道227例胆囊癌,其中158例行切除术,66例为扩大胆囊切除术.根据有无淋巴结转移、侵犯被膜、腹膜种植、肝转移、侵犯肝脏和胆管等,胆囊癌分为4期.根据大体形态特征分为8型:乳头型、结节型、乳头侵犯型、结节侵犯型、侵犯型、填充型、巨块型和特殊型.     

联合肝叶及部分胰头、十二指肠切除治疗Nevin V期胆囊癌六例

原发性胆囊癌是胆系常见的一种高度恶性肿瘤，本病早期多无症状，一旦临床发现多属晚期，易发生肝脏直接浸润和周围脏器侵犯，并易于发生淋巴结转移，手术切除率低，预后及5年生存率差。近年来，随着对胆囊癌转移方式研究的深入，以及现代外科综合技术的不断发展，晚期胆囊癌的手术切除率和术后生存期均有明显的提高。[第一段]     

血管内皮细胞因子在胆囊腺瘤及不同Nevin分期胆囊癌的表达

本文检测血管内皮生长因子 (ＶＥＧＦ)在胆囊癌、胆囊腺瘤中的表达 ,以探讨其对胆囊癌Ｎｅｖｉｎ分期的影响。材料与方法　　 1.临床资料从我院 1990年～ 2 0 0 0年 110例胆囊癌和 80例胆囊腺瘤手术病人中随机选择 44例 ,其中胆囊癌 2 4例 (病理检测结果表明 ,13例有远处转移 ,其中 5例转移至肝脏 ,8例淋巴血行转移中 ,4例肝十二指肠韧带、胃右动脉旁和主动脉淋巴结转移 ,4例转移至胰腺 ,一例腹腔广泛转移 ,一例转移至大网膜 ) ,胆囊腺瘤 2 0例 ,根据临床资料 (肿瘤浸润的层次 ,侵犯的范围等 ) ,胆囊癌作Ｎｅｖｉｎ分期 ,Ⅰ、Ⅱ、Ⅲ期 11例 …     

乳腺癌伴胰腺转移1例

乳腺癌是女性最常见的恶性肿瘤之一,随着乳腺癌发病率的增加,晚期乳腺癌也随之增加,其诊断、治疗已成为乳腺专科医师关注的问题。乳腺癌常见的转移部位包括：骨、肝、肺、脑的脏器,罕见胰腺转移。恶性肿瘤的胰腺转移,占胰腺恶性肿瘤的5%。恶性肿瘤侵犯胰腺常见于周围脏器的直接侵犯,如胃、肝、脾脏等。血行转移和淋巴转移常见于肾癌和肺癌。而结肠癌、甲状腺癌、乳腺癌、皮肤癌、食管癌、胃癌、胆囊癌、膀胱癌、子宫内膜癌和卵巢癌的胰腺转移较少见。现报告乳腺癌并胰腺转移1例。     

原发性胆囊癌CT表现与手术对照分析

目的 探讨原发性胆囊癌ＣＴ表现特征、病期判断和临床应用价值。方法 对３７例原发性胆囊癌的手术病理结果与ＣＴ扫描结果进行了回顾性对比分析。结果 原发性胆囊癌根据ＣＴ表现分为腔内型，壁厚型、肿块型。胆囊癌主要转移形式是直接侵犯肝脏和淋巴结转移。结论（１）ＣＴ检查对良恶性胆囊疾患鉴别有一定肿块型。（２）ＣＴ对胆囊癌壁外侵犯与转移的判定具有一定敏感度，且特异性较高，应作为胆囊癌术前常规检查。（３）ＣＴ对术     

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??Anatomical features of gallbladder and invasion and metastasis route of gallbladder cancer CHEN Ya-jin. Department of Hepatobiliarypancreatic Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou 510120, China
Abstract The invasion and metastasis of gallbladder cancer (GBCA) is closely related with the gallbladder anatomical features. The gallbladder sits are just beneath the liver, with thin submucosal muscle, multi-directional lymphatic flow and rich innervation. The gallbladder vein directly joins the portal vein and the gallbladder keeps close anatomical relationship with surrounding organs. Liver and lymph node invasion are the most common metastasis ways of GBCA, and bile duct metastasis is often accompanied by neural invasion. Surrounding organs invasion, peritoneal dissemination and distant metastasis may occur in advanced GBCA. Grasping the invasion and metastasis properties from the perspective of anatomy and pathophysiology will facilitate the understanding of clinical manifestations, treatment and prognosis of GBCA with different locations, types and advanced stages.     

Kidney metastasis from gallbladder cancer

A case of kidney metastasis from primary gallbladder cancer is presented. Five years after operation for gallbladder cancer, a 73-year-old woman exhibited hematuria. Imaging disclosed a 5×4cm solid mass in the right kidney and enlarged lymph nodes behind the inferior vena cava adjacent to the right renal vein. The right kidney and adjacent tissues, including retroperitoneum and regional lymph nodes, were resected en bloc. The renal tumor was diagnosed as a metastasis from the primary adenocarcinoma of the gallbladder, based on histological similarities, absence of other primary adenocarcinoma, and fluctuations in CA19-9 levels during the progress and after the resection of the metastatic tumor. The initial operation had been an extended cholecystectomy with wedge resection of the liver bed, plus regional lymphadenectomy. The excised gallbladder had a 2.3 ×1.2cm nodular tumor in the fundus. Histological examination indicated the gallbladder tumor to be a moderately differentiated tubular adenocarcinoma invading the subserosal layer. Mild lymphatic invasion was recognized in the gallbladder wall, although lymph node metastasis was negative. We believe this patient represents the first case of kidney metastasis from gallbladder cancer. The mode of spread of the gallbladder cancer to the kidney appeared to be lymphogenous.     

Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is a surgical procedure of choice for benign gallbladder diseases. In about 1-2% of cases histopathological examination demonstrate incidental gallbladder cancer (GBCA). We report a case of a 61 year old woman who developed port site metastases after laparoscopic cholecystectomy for adenocarcinoma of the gallbladder. Metastases appeared on all four port sites. Review of literature regarding incidental GBCA an port site metastases was also performed. We conclude that the retrieval bag should be routinely used in laparoscopic cholecystectomy; the procedure should be performed with minimal trauma; in cases of incidental GB carcinoma, full thickness excision of the abdominal wall of the port sites demands additional studies; additional liver bed excision and local lymphadenectomy for T1b carcinoma are yet to be considered.     

胆囊癌淋巴结转移的临床病理学分析

目的 探讨胆囊癌区域淋巴结转移情况及影响因素,为手术切除范围提供依据。方法 回顾性分析34例胆囊癌根治术患者的临床病理资料。结果 总体淋巴结转移率为68%（23/34）,其中PT10（0/3）,PT243%（3/7）,PT385%（11/13）,PT482%（9/11）,按淋巴结部位转移率分别为：胆囊管淋巴结29%（10/34）,胆总管旁淋巴结44?5/34）,肝门淋巴结18%（6/34）,肝动脉旁淋巴结24%（8/34）,门静脉旁淋巴结21%（7/34）,胰十二指肠后上淋巴结38%（13/34）,腹主动脉旁淋巴结4/6。结论 肿瘤浸润深度与淋巴结转移密切相关,淋巴结清扫范围应根据术中探查和冰冻病理提供的资料确定。     

True left-sided gallbladder with a portal anomaly: report of a case

A 65-year-old female who presented with back pain was diagnosed to have the presence of biliary sludge in the gallbladder. Computed tomography showed that the round ligament connected to the left portal umbilical portion was in the normal anatomical position. However, the gallbladder was located to the left of the middle hepatic vein and the round ligament, attached to the left lateral segment of the liver. The right posterior portal vein diverged alone from the main portal vein, and there was a long stem from the right anterior and left portal veins. Laparoscopic cholecystectomy confirmed the abnormal location of the gallbladder. Most reported cases of left-sided gallbladder are caused by a right-sided round ligament, which is called a "false" left-sided gallbladder. A case of left-sided gallbladder with a normal left-sided round ligament, which is designated as a case of "true" left-sided gallbladder, is extremely rare.     

Early gallbladder carcinoma does not warrant radical resection

BACKGROUND: This study was designed to address whether gallbladder cancer invading the muscle layer (stage pT(1b)) is a local disease and whether radical resection is necessary. METHODS: A retrospective analysis of 25 patients with pT(1b) gallbladder tumours, 13 of whom underwent simple cholecystectomy and 12 radical resection with regional lymph node dissection, was performed. A total of 147 regional lymph nodes was examined for metastasis. The median follow-up time was 95 months. RESULTS: No patient had blood vessel or perineural invasion on histology. Lymphatic vessel invasion was seen in one patient. Both overt metastasis and micrometastases were absent in all lymph nodes examined. Overall 10-year survival was 87 per cent. The outcome after simple cholecystectomy was comparable to that after radical resection (P = 0.16). Two patients who underwent radical resection died from tumour relapse in distant sites. CONCLUSION: Most pT(1b) gallbladder carcinomas spread only locally. Additional radical resection is not necessary when the depth of invasion of gallbladder carcinoma is limited to the muscle layer after simple cholecystectomy.     

胆囊腺鳞癌和鳞癌与胆囊腺癌的临床对比研究

目的 探讨胆囊腺鳞癌和鳞癌的临床特点.方法 回顾性分析112例胆囊癌患者的临床资料,将其中11例胆囊腺鳞癌和鳞癌的临床特点和预后与同期收治的101例胆囊腺癌进行比较.结果 腺鳞癌/鳞癌组与腺癌组的肿瘤浸润分期为13或T4的比例分别为100%和53%,两组的差异有统计学意义(X2=7.013,P=0.008).腺鳞癌/鳞癌与进展期腺癌(T3或T4期)的远处转移发生率分别为0和35%,差异有统计学意义(X2=3.900,P=0.048),两组的淋巴结转移率为82%和87%(X2=0.000,P=1.000).腺鳞癌/鳞癌组和进展期的腺癌组的胃肠道侵犯发生率分别为45%和15%,差异无统计学意义(X2=3.618,P=0.054).两组的中位生存期分别为5个月和4个月,生存差异无统计学意义(X2=0.359,P=0.549).结论 胆囊腺鳞癌和鳞癌的局部侵袭性强,而远处转移率低.淋巴结转移情况与腺癌相似.     

Hepatic vein injury during laparoscopic cholecystectomy: The unappreciated proximity of the middle hepatic vein to the gallbladder bed

Uncontrollable hemorrhage during laparoscopic cholecystectomy occurs in 0.1% to 1.9% of all cases, with 88% originating from the gallbladder bed. The anatomical proximity between major branches of the middle hepatic vein and the gallbladder bed, and hence the risk of intraoperative bleeding, is unclear. CT scans of 20 random patients were retrospectively reviewed to identify the closest distance between branches of the middle hepatic vein and the gallbladder bed. The vein diameter was also recorded. Risk factors for intraoperative bleeding during laparoscopic cholecystectomy were also retrospectively reviewed. Large branches (mean diameter=2.1 mm) of the middle hepatic vein are directly adjacent to the gallbladder bed in 10% of patients. An additional 10% of cases also possess branches within 1 mm of the gallbladder bed. Chronically scarred and contracted gallbladder disease may increase the risk of significant bleeding, requiring conversion. Twenty percent of all cases will display a large branch of the middle hepatic vein adherent or immediately adjacent to the gallbladder fossa. These patients are at increased risk for intraoperative bleeding. Furthermore, contracted gallbladders with evidence of chronic disease may be at increased risk for significant hemorrhage.     

Surgical resection of splenic metastasis from the adenosquamous gallbladder carcinoma: A case report

IntroductionSplenic metastasis of gallbladder carcinoma is extremely rare. Specific anatomical, histological, and functional properties of spleen are believed to be responsible for the rarity of solitary splenic metastasis.Presentation of caseWe present the case of a 62-year-old female who developed metachronous splenic metastasis of adenosquamous carcinoma of the gallbladder. We performed central bisegmentectomy of the liver for gallbladder carcinoma. The patient subsequently presented 3 months later with isolated splenic metastasis and liver metastasis. Splenectomy and partial hepatectomy was performed at this time. Histological examination confirmed metastatic adenosquamous carcinoma of the gallbladder. No signs of recurrence were observed at 3 months after the second surgery.DiscussionAlthough splenectomy provides a potential means of radical treatment in patients with isolated splenic metastases, it should be performed with caution as splenic metastatic lesions may represent the initial clinical manifestation of systemic metastases at multiple sites. In this case, radical surgery was performed following the confirmation of no new unresectable metastatic lesions or systemic dissemination.ConclusionThis is the first report on the adenosquamous splenic metastasis from the gallbladder carcinoma. Curative resection may be the treatment of choice for prolonging survival in patients with the splenic metastasis of gallbladder carcinoma.     

Aggressive surgical approach for stage IV gallbladder carcinoma based on Japanese Society of Biliary Surgery classification

BACKGROUND/PURPOSE: The role of aggressive surgery for stage IV gallbladder carcinoma remains controversial. Survival and prognostic factors were analyzed in patients with stage IV disease, based on the Japanese Society of Biliary Surgery (JSBS) classification, to identify the group of patients who could benefit from radical surgery. METHODS: A retrospective analysis was done of 79 patients with JSBS stage IV gallbladder carcinoma who had undergone surgical resection with curative intent at our institution. The standard procedures were anatomical S4a + S5 subsegmentectomy (n = 29) with extrahepatic bile duct resection and extended lymphadectomy, but when right Glisson's sheath and/or the hepatic hilum were involved, right extended hepatectomy (n = 34) or right trisegmentectomy (n = 3) was selected. To achieve a tumor-free margin combined pancreaticoduodenectomy was performed in 12 patients, and major vascular resection in 17 patients. RESULTS: In the patients with stage IV gallbladder carcinoma, the curative resection rate was 65.8% and the hospital mortality rate was 11.4%. The postoperative 5-year survival rate following curative resection was 13.7%. Univariate analysis indicated that curability, hepatoduodenal ligament invasion, nodal involvement, and vascular resection were significant prognostic factors. Neither hepatic invasion nor liver metastasis was a significant factor. CONCLUSIONS: Aggressive surgical resection should be considered even in stage IV patients when hepatoduodenal ligament invasion and nodal involvement are absent or limited. Acceptable survival may be expected among such patients only when curative resection is achieved.