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        不同治療方法對肝門部膽管癌預(yù)后的影響

        2021-04-12 00:00:00孫嵩曹廣華仲灝辰馮玉杰孫兆偉張炳遠(yuǎn)

        [摘要]"目的"探討不同的治療方法對肝門部膽管癌(HCCA)病人預(yù)后的影響。方法"回顧性分析我院2006—2015年收治的366例HCCA病人的臨床資料,并根據(jù)治療方法將病人分為根治性切除組、非根治性切除組和單純減黃組。使用Kaplan-Meier生存曲線進行生存分析,并使用Cox比例風(fēng)險模型評估HCCA的獨立預(yù)后因素。結(jié)果"根治性切除組(115例)、非根治性切除組(97例)以及單純減黃組(154例)病人的1年生存率分別為71.7%、52.5%和35.3%,2年生存率分別為52.2%、25.8%和7.8%,3年生存率分別為36.7%、8.9%和0;中位生存期分別為23.6、14.7和9.7個月。3組病人的1、2、3年生存率及中位生存期比較差異均有統(tǒng)計學(xué)意義(χ2=34.31~64.55,Plt;0.001)。多因素分析顯示,治療方法、清蛋白、總膽紅素、術(shù)后病理T分期和遠(yuǎn)處轉(zhuǎn)移等為HCCA的獨立預(yù)后指標(biāo)。結(jié)論"根治性切除可顯著提高HCCA病人的生存率,提高清蛋白水平和降低總膽紅素水平可以改善HCCA病人的預(yù)后。

        [關(guān)鍵詞]"Klatskin腫瘤;外科手術(shù);預(yù)后;影響因素分析

        [中圖分類號]"R735.7;R657.43

        [文獻(xiàn)標(biāo)志碼]"A

        [文章編號]"2096-5532(2021)04-0481-06

        肝門部膽管癌(HCCA),也稱為Klatskin瘤,是一種累及肝總管、左右肝管以及肝管匯合部分的腫瘤[1-3]。由于其特殊的生長位置、較低的切除率和較低的5年生存率,HCCA對于臨床醫(yī)生來說是一個頗具挑戰(zhàn)性的難題[4-6]。根治性切除可以延長HCCA病人生存期,從而使5年生存率達(dá)到20%~40%[7-10],但是大多數(shù)病人由于腫瘤位置較高或者已侵犯周圍血管神經(jīng),因此在診斷明確后不宜行根治性切除,故這些病人需行非根治性切除、內(nèi)鏡逆行膽管置管引流(ERBD)或者經(jīng)皮經(jīng)肝膽管置管引流(PTCD)[8,11-12]。上述方法對HCCA病人生存的影響仍存在爭議[13]。此外,影響HCCA病人生存的預(yù)后因素也存在爭議。因此,本研究回顧性分析了2006年1月1日—2015年12月31日在我院接受治療的366例HCCA病人的臨床資料,探討不同治療方法對HCCA病人預(yù)后的影響。

        1"資料和方法

        1.1"一般資料

        回顧性收集我院2006年1月1日—2015年12月31日收治的366例HCCA病人的臨床資料。本文366例病人,男233例,女133例;中位年齡60歲;平均住院時間16 d。所有病人均接受了上腹部增強CT、胰膽管造影磁共振成像(MRCP)和肝功能等術(shù)前檢查。伴有糖尿病、高血壓、冠狀動脈粥樣硬化性心臟病等內(nèi)科基礎(chǔ)疾病的病人44例。根據(jù)有關(guān)文獻(xiàn)重度飲酒和吸煙的診斷標(biāo)準(zhǔn)[14],有重度飲酒史者41例,有重度吸煙史者70例。本研究經(jīng)青島大學(xué)附屬醫(yī)院倫理委員會審查批準(zhǔn),所有研究對象均同意在科學(xué)研究中使用其醫(yī)學(xué)信息。

        1.2"納入標(biāo)準(zhǔn)

        ①病人首次診斷為HCCA,且之前未行其他治療;②病人后續(xù)隨訪信息可獲得;③組織病理學(xué)結(jié)果、實驗室檢查結(jié)果、影像學(xué)檢查結(jié)果等資料可獲得;④排除伴有重度心腦血管、腎臟、肺部基礎(chǔ)疾病及重度自身免疫性疾病的病人;⑤排除僅接受剖腹探查及腹腔鏡下探查并取活檢的病人。

        1.3"病人分組

        將病人分為3組:根治性切除組115例,非根治性切除組97例,單純減黃組154例。根治性切除定義為手術(shù)切緣的肉眼觀察及病理學(xué)結(jié)果皆為陰性(R0切除)。本文根治性切除組中,有110例病人術(shù)中根據(jù)Bismuth-Corlette分型進行了肝切除術(shù)。非根治性切除定義為術(shù)后病理結(jié)果提示切緣陽性(R1切除,54例)和肉眼觀察及病理結(jié)果皆提示切緣陽性(R2切除,43例)。單純減黃組病人的治療方式有兩種,包括ERBD(膽管支架通常是塑料的,術(shù)中平均置入的支架數(shù)量為每人2枚)和PTCD(放置引流管的平均數(shù)量為每人1根)[15]。

        1.4"隨訪情況

        隨訪主要包括電話聯(lián)系和門診復(fù)查隨訪,在必要時可進行信函和戶籍查詢。在最初的2年中,每3個月對病人進行一次隨訪,之后的隨訪周期為6個月。門診復(fù)查常規(guī)行血癌胚抗原(CEA)和糖類抗原19-9(CA19-9)、消化系統(tǒng)超聲、上腹部CT平掃等檢查,若考慮腫瘤復(fù)發(fā)時,再行增強CT、MRI等檢查,以明確復(fù)發(fā)與否。最后一次隨訪時間為2018年12月31日。生存期定義為初次治療至死亡或最后一次隨訪的時間。失訪者生存期不計入統(tǒng)計數(shù)據(jù)。

        1.5"數(shù)據(jù)統(tǒng)計分析

        所有數(shù)據(jù)均使用Microsoft Excel軟件(美國Microsoft公司)進行管理,并使用IBM SPSS Statistics軟件(版本20.0,美國IBM公司)進行統(tǒng)計分析。使用Kaplan-Meier生存曲線分析不同治療方法對生存的影響,構(gòu)建Cox比例風(fēng)險回歸模型進行HCCA預(yù)后影響因素的多因素分析。檢驗水準(zhǔn)為α=0.05(雙向檢驗)。

        2"結(jié)"果

        2.1"各組生存情況比較

        本研究共納入366例HCCA病人,其中42例失訪,隨訪率為88.5%。根治性切除組的中位生存期為23.6個月(1.0~71.0個月),1、2、3年生存率分別為71.7%、52.2%和36.7%;非根治性切除組的中位生存期為14.7個月(2.0~45.4個月),1、2、3年生存率分別為52.5%、25.8%和8.9%;單純減黃組的中位生存期為9.7個月(4.0~28.0個月),1、2、3年生存率分別為35.3%、7.8%和0。3組病人的1、2、3年生存率及中位生存期比較差異均有顯著性(χ2=34.31~64.55,Plt;0.001)。見圖1。行R1切除和R2切除病人的生存期(14.0個月vs 13.0個月)比較,以及接受ERBD治療和PTCD治療病人的生存期(9.0個月vs 8.7個月)比較,差異均無統(tǒng)計學(xué)意義(Pgt;0.05)。見圖2。

        2.2"預(yù)后影響因素分析

        單因素分析顯示,治療方法、清蛋白、前清蛋白、總膽紅素、C反應(yīng)蛋白、腫瘤直徑、術(shù)后病理T分期、淋巴結(jié)轉(zhuǎn)移、遠(yuǎn)處轉(zhuǎn)移和Bismuth-Corlette分型等與生存時間顯著相關(guān)。見表1。將這些差異具有統(tǒng)計學(xué)意義因素納入Cox比例風(fēng)險回歸模型進行分析,結(jié)果顯示,治療方法(HR=1.88,95%CI=1.21~2.91)、清蛋白(HR=0.65,95%CI=0.45~0.94)、總膽紅素(HR=1.63,95%CI=1.02~2.59)、術(shù)后病理T分期(HR=1.43,95%CI=1.18~1.72)和遠(yuǎn)處轉(zhuǎn)移(HR=2.29,95%CI=1.15~4.53)等為HCCA獨立預(yù)后影響因素。見表2。

        3"討"論

        本次研究的366例HCCA病人中,有212例病人接受了切除手術(shù),根治性切除率為54.2%(115/212),比GUGLIELMI等[16]報道的76.7%要低,但GUGLIELMI等[16]僅研究了62例病人。本文手術(shù)切除病人的中位生存期明顯長于單純減黃處理病人,就中位生存期和1、2、3年生存率而言,根治性切除優(yōu)于其他治療方法[17-19]。多因素分析結(jié)果也顯示,治療方法為HCCA的獨立預(yù)后影響因素。

        對于僅接受單純減黃處理的HCCA病人,使用ERBD和PTCD治療對生存率無顯著影響。

        本文研究結(jié)果顯示,清蛋白、總膽紅素水平為HCCA的獨立預(yù)后影響因素。清蛋白水平反映了在我院接受治療之前病人的空腹血清清蛋白水平,也可以反映病人的營養(yǎng)狀況[20-21]。當(dāng)清蛋白水平低且營養(yǎng)狀況較差時,病人將無法接受外科手術(shù)等治療[22-23]。

        本文研究結(jié)果顯示,清蛋白≥35 g/L的病人比清蛋白lt;35 g/L的病人具有更高的生存率。臨床上可通過靜脈輸注人血清蛋白改善HCCA病人的預(yù)后[24-25]。將病人按照術(shù)前總膽紅素水平(以40 mg/L為界)進行分組對照研究,結(jié)果顯示,兩組病人的生存率存在顯著差異,這反映了總膽紅素對HCCA病人預(yù)后的影響;多因素分析也顯示,總膽紅素是HCCA的一個獨立預(yù)后因素。血清膽紅素水平升高可對全身多個器官造成損害,因此術(shù)前降低膽紅素水平可改善預(yù)后[2,26-28]。但術(shù)前膽紅素水平為多少適合先行減黃處理和膽紅素降至多少可行手術(shù)治療等問題仍存在爭議[29-31]。

        本文結(jié)果顯示,術(shù)后病理T分期和遠(yuǎn)處轉(zhuǎn)移為HCCA的獨立預(yù)后影響因素。我院對HCCA病人的治療主要集中在肝膽外科,有些在其他科室接受治療的HCCA病人具有較早的Bismuth-Corlette分期,CT或MRI等檢查顯示無遠(yuǎn)處轉(zhuǎn)移,因此接受了非手術(shù)治療,從而使這部分病人錯失了根治性切除的機會。目前,HCCA的治療仍有多種方法可供選擇[32-33]。因此,多學(xué)科聯(lián)合診治對改善HCCA病人的預(yù)后具有重要的價值[34-36]。

        總之,早期診斷和根治性手術(shù)切除對于延長HCCA的生存期很重要,術(shù)前提高清蛋白水平和降低總膽紅素水平有助于改善HCCA病人的預(yù)后。

        [參考文獻(xiàn)]

        [1]MANSOUR J C,"ALOIA T A,"CRANE C H,"et al. Hilar cholangiocarcinoma: expert consensus statement[J]."HPB,"2015,17(8):691-699.

        [2]MIZUNO T,"EBATA T,"NAGINO M. Advanced hilar cholangiocarcinoma: an aggressive surgical approach for the treatment of advanced hilar cholangiocarcinoma: perioperative management,"extended procedures,"and multidisciplinary approaches[J]."Surgical Oncology,"2020,33:201-206.

        [3]PORUK K E,"PAWLIK T M,"WEISS M J. Perioperative management of hilar cholangiocarcinoma[J]."Journal of Gastrointestinal Surgery,"2015,19(10):1889-1899.

        [4]LIU C H,"HUANG Q,"JIN Z Y,"et al. Circulating microRNA-21 as a prognostic,"biological marker in cholangiocarcinoma[J]."Journal of Cancer Research and Therapeutics,"2018,14(1):220-225.

        [5]LO E C,"RUCKER A N,"FEDERLE M P. Hepatocellular carcinoma and intrahepatic cholangiocarcinoma: imaging for diagnosis,"tumor response to treatment and liver response to radiation[J]."Seminars in Radiation Oncology,"2018,28(4):267-276.

        [6]XIAO J,"ZHU J S,"LIU Z Y,"et al. Role of surgical treatment for hepatolithiasis-associated intrahepatic cholangiocarcinoma: a retrospective study in a single institution[J]."Journal of Cancer Research and Therapeutics,"2017,13(5):756-760.

        [7]DINANT S,"GERHARDS M F,"RAUWS E A,"et al. Improved outcome of resection of hilar cholangiocarcinoma (Klatskin tumor)[J]."Annals of Surgical Oncology,"2006,13(6):872-880.

        [8]ITO F,"CHO C S,"RIKKERS L F,"et al. Hilar cholangiocarcinoma: current management[J]."Annals of Surgery,"2009,250(2):210-218.

        [9]ANDERSON B,"DOYLE M B M. Surgical considerations of hilar cholangiocarcinoma[J]."Surgical Oncology Clinics of North America,"2019,28(4):601-617.

        [10]ZHANG X F,"BAGANTE F,"CHEN Q Y,"et al. Perioperative and long-term outcome of intrahepatic cholangiocarcinoma involving the hepatic hilus after curative-intent resection: comparison with peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma[J]."Surgery,"2018,163(5):1114-1120.

        [11]CELOTTI A,"SOLAINI L,"MONTORI G,"et al. Preoperative biliary drainage in hilar cholangiocarcinoma: Systematic review and meta-analysis[J]."European Journal of Surgical Oncology,"2017,43(9):1628-1635.

        [12]HU H J,"WU Z R,"JIN Y W,"et al. Minimally invasive surgery for hilar cholangiocarcinoma: state of art and future perspectives[J]."ANZ Journal of Surgery,"2019,89(5):476-480.

        [13]BLECHACZ B. Cholangiocarcinoma: current knowledge and new developments[J]."Gut and Liver,"2017,11(1):13-26.

        [14]ANDERSON M A,"ZOLOTAREVSKY E,"COOPER K L,"et al. Alcohol and tobacco lower the age of presentation in sporadic pancreatic cancer in a dose-dependent manner: a multicenter study[J]."The American Journal of Gastroenterology,nbsp;2012,107(11):1730-1739.

        [15]LIU J G,"WU J,"WANG J,"et al. Endoscopic biliary drainage versus percutaneous transhepatic biliary drainage in patients with resectable hilar cholangiocarcinoma: a systematic review and meta-analysis[J]."Journal of Laparoendoscopic amp; Advanced Surgical Techniques Part A,"2018,28(9):1053-1060.

        [16]GUGLIELMI A,"RUZZENENTE A,"CAMPAGNARO T,"et al. Prognostic significance of lymph node ratio after resection of peri-hilar cholangiocarcinoma[J]."HPB,"2011,13(4):240-245.

        [17]DOHERTY B,"NAMBUDIRI V E,"PALMER W C. Update on the diagnosis and treatment of cholangiocarcinoma[J]."Current Gastroenterology Reports,"2017,19(1):2.

        [18]RIZVI S,"KHAN S A,"HALLEMEIER C L,"et al. Cholangiocarcinoma-evolving concepts and therapeutic strategies[J]."Nature Reviews Clinical Oncology,"2018,15(2):95-111.

        [19]ESNAOLA N F,"MEYER J E,"KARACHRISTOS A,"et al."Evaluation and management of intrahepatic and extrahepatic cholangiocarcinoma[J]."Cancer,"2016,122(9):1349-1369.

        [20]BIRGIN E,"RASBACH E,"REISSFELDER C,"et al. A systematic review and meta-analysis of caudate lobectomy for treatment of hilar cholangiocarcinoma[J]."European Journal of Surgical Oncology,"2020,46(5):747-753.

        [21]SIRICA A E,"GORES G J,"GROOPMAN J D,"et al. Intrahepatic cholangiocarcinoma: continuing challenges and translational advances[J]."Hepatology (Baltimore,"Md),"2019,69(4):1803-1815.

        [22]ZHANG H,"YANG T,"WU M C,"et al. Intrahepatic cholangiocarcinoma: epidemiology,"risk factors,"diagnosis and surgical management[J]."Cancer Letters,"2016,379(2):198-205.

        [23]CHUN Y S,"JAVLE M. Systemic and adjuvant therapies for intrahepatic cholangiocarcinoma[J]."Cancer Control: Journal of the Moffitt Cancer Center,"2017,24(3):1073274817729241.

        [24]QUINN L M,"MANN K,"JONES R P,"et al. Defining enhanced recovery after resection of peri-hilar cholangiocarcinoma[J]."European Journal of Surgical Oncology,"2019,45(8):1439-1445.

        [25]LI Q J,"ZHOU Z G,"LIN X J,"et al. Clinical practice of basin-shaped hepaticojejunostomy following hilar resection of stage Ⅲ/Ⅳ hilar cholangiocarcinoma[J]."BMC Gastroenterology,"2019,19(1):99.

        [26]SEYAMA Y,"KUBOTA K,"SANO K,"et al. Long-term outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate[J]."Annals of Surge-ry,"2003,238(1):73-83.

        [27]SUN Y B,"LI W M,"SUN D L,"et al. Percutaneous transhepatic cholangial drainage combined with percutaneous endoscopic jejunostomy for maintaining nutrition state in patients with advanced ampullary neoplasms[J]."Journal of Cancer Research and Therapeutics,"2018,14(Supplement):S1158-S1162.

        [28]WANG Y D,"FU W K,"TANG Z W,"et al. Effect of preoperative cholangitis on prognosis of patients with hilar cholangiocarcinoma: a systematic review and meta-analysis[J]."Medicine,"2018,97(34):e12025.

        [29]GOUMA D J. Multicentre European study of preoperative bi-liary drainage for hilar cholangiocarcinoma (Br J Surg 2013; 100:274-283)[J]."The British Journal of Surgery,"2013,100(2):283-284.

        [30]PAIK W H,"LOGANATHAN N,"HWANG J H. Preoperative biliary drainage in hilar cholangiocarcinoma: when and how[J]?"World Journal of Gastrointestinal Endoscopy,"2014,6(3):68-73.

        [31]SEWNATH M E,"BIRJMOHUN R S,"RAUWS E A,"et al. The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy[J]."Journal of the American College of Surgeons,"2001,192(6):726-734.

        [32]RASSAM F,"ROOS E,"VAN LIENDEN K P,"et al. Modern work-up and extended resection in perihilar cholangiocarcinoma: the AMC experience[J]."Langenbeck’s Archives of Surgery,"2018,403(3):289-307.

        [33]CHEN K J,"YANG F C,"QIN Y S,"et al. Assessment of clinical outcomes of advanced hilar cholangiocarcinoma[J]."Hepatobiliary amp; Pancreatic Diseases International: HBPD INT,"2018,17(2):155-162.

        [34]BENSON A B 3rd,"ABRAMS T A,"BEN-JOSEF E,"et al. NCCN clinical practice guidelines in oncology: hepatobiliary cancers[J]."Journal of the National Comprehensive Cancer Network: JNCCN,"2009,7(4):350-391.

        [35]SAPISOCHIN G,"IVANICS T,"SUBRAMANIAN V,"et al. Multidisciplinary treatment for hilar and intrahepatic cholangiocarcinoma: a review of the general principles[J]."International Journal of Surgery (London,"England),"2020,82S:77-81.

        [36]BIRD N T E,"MANU N,"QUINN L,"et al. Evaluation of the utility of prognostic models for patients with resected hilar cholangiocarcinoma[J]."HPB,"2019,21(10):1376-1384.

        (本文編輯"馬偉平)

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