原发性肝癌瘤周肝组织内微转移的回顾性与前瞻性研究

目的探讨原发性肝癌癌周肝组织内微转移的分布情况，以确定肝癌切除所需要的切缘最小值。方法回顾性分析本组114例无肉眼癌栓或子灶的肝癌病人120次手术标本常规病理切片629张，前瞻性研究本组连续76例术前影像学检查未发现癌栓或子灶的肝癌手术标本及石蜡切片645张。肉眼观察肿瘤距切缘的大小、有无子灶或癌栓，镜下观察有无包膜、有无微卫星灶或微癌栓并测量其远端距肿瘤边缘的距离。采用SPSS10．0和SAS6．12统计软件包分析。结果回顾组120例次肝癌病人中：26例次（21．7％）瘤外肝组织内发现微转移灶；在95％、99％和100％的病例中微转移灶分别在距原发瘤边缘或包膜外3．9mm、5．9mm和6．7mm以内。前瞻组76例肝癌病人：无肉眼癌栓或子灶的59例病人中25例（42．1％）发现瘤外肝组织内微转移灶，在95％、99％和100％的病例中微转移灶分别在距原发瘤边缘或包膜外4．5mm、5．5mm和6．0mm以内；而术前影像学检查未发现而术中探查发现有肉眼癌栓或子灶的18例病人中14例（77．8％）发现瘤外肝组织内微转移灶，在95％、99％和100％的病例中微转移灶分别在距原发瘤边缘或包膜外18．5mm、18．5mm和19．0mm以内。结论对无肉眼癌栓或子灶、无肝外转移的肝癌切除99％和100％的微转移灶所需最小切缘分别为5．5mm和6mm；而对有肉眼癌栓或子灶的肝癌切除99％的微转移灶所需最小切缘应〉18．5mm。

Retrospective and prospective study on micrometastasis in liver parenchyma surrounding PLC

Objective To explore the distributing situation of micrometastasis in liver parenchyma surrounding the PLC and define the minimal value of resection margins needed for hepatectomy. Methods In the retrospective study, there were 114 patients with histologically proved PLC without macroscopic tumor thrombi or macrosatellite or extrahepatic metastasis, who underwent 120 curative hepatectomies from November 2001 to March 2003. A total of 629 routine pathological sections from these patients were examined by light microscopy. In the prospective study, there were 76 patients with histologically proved PLC without definite macroscopic tumor thrombi or macrosatellites or extrahepatic metastasis in preoperative imaging findings, who underwent 76 curative hepatectomies from March 2003 to November 2003. A total of 645 pathological sections from these patients were examined by light microscopy. The resected liver specimens were minutely examined to measure the resection margin and find out the presence and the number of daughter tumor nodules. Besides the dominant lesion, the presence of macroscopic tumor thrombi inside the lumens of the major venous system and the level of its infiltrated venous branches were observed microscopically. The paraffin sections were examined to find out the presence and absence of microsatellites, microscopic tumor thrombi, fibrotic tumor capsules as well as the presence and absence of capsule invasion and the distance of histological spread of the micrometastases microscopically. SPSS10.0 for Windows and SAS6.12 System were used to determine the statistical significance. Results Of the 120 cases in the retrospective study, 70 micrometastases were found in the liver parenchyma surrounding the lesions in 26 cases (21.7%). The farthest distance of histological micrometastasis ranged within 3.5 mm, 5.3 mm and 6.0 mm in 95%, 99% and 100% of the cases, respectively. Of the 76 cases in the prospective study, 18 had macroscopic tumor thrombi or macrosatellites. In the 58 cases totally free of macroscopic tumor thrombi or macrosatellites, 25 (43.1%) exhibited 149 micrometastases in the liver parenchyma surrounding the lesions. The farthest distance of histological micrometastasis ranged within 4.5 mm, 5.5 mm and 6.0 mm in 95%, 99% and 100% of all the cases, respectively. In the 18 cases with macroscopic tumor thrombi or macrosatellites, 267 micrometastases were found in the liver parenchyma surrounding the lesions in 14 cases (77.8%). The farthest distance of histological micrometastasis was within 18.5 mm, 18.5 mm and 19.0 mm in 95%, 99% and 100% of all the cases, respectively. Conclusions The required RM was 5.5 mm and 6 mm respectively to achieve 99% and 100% micrometastasis clearance in liver parenchyma surrounding the lesion in PLC cases without macroscopic tumor thrombi or macrosatellites, while in cases with macroscopic tumor thrombi or macrosatellites the required RM should be greater than 18.5 mm to achieve 99% micrometastasis clearance.