Kondo Satoshi, Nimura Yuji, Kamiya Junichi, Nagino Masato, Kanai Michio, Uesaka Katsuhiko, Hayakawa Naokazu
First Department of Surgery, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
Langenbecks Arch Surg. 2002 Oct;387(5-6):222-8. doi: 10.1007/s00423-002-0318-6. Epub 2002 Oct 2.
The mode and degree of tumor spread in gallbladder carcinoma is poorly documented. The present study classifies the patterns of dissemination of this tumor with a focus on surgical strategy.
Surgical specimens from 112 patients who underwent curative resection were reviewed. There were stage I, II, III, and IV in 9, 11, 14, and 78 patients, respectively.
Six types of spread were identified. In the hepatic bed type ( n=20) a large mass in the fundus and body penetrated into the liver through the gallbladder bed with or without contiguous spread to the gastrointestinal tract. The extent of hepatectomy was individualized from wedge resection to extended right hepatectomy based on the clinical findings. In the hepatic hilum type ( n=26) a relatively small tumor in the neck infiltrated the hepatic hilum causing obstructive jaundice. Extended right hepatectomy plus bile duct resection with or without portal vein resection was necessary for curative resection because the tumor had extended into the right portal pedicle, and postoperative hepatic failure was common. In the bed and hilum type ( n=18) a huge mass occupying the entire gallbladder involved both the gallbladder bed and the hepatic hilum. Extended right hepatectomy with combined resection of contiguous spread was necessary for curative resection. In the lymph node type ( n=15) enlarged metastatic lymph nodes were the most prominent feature, and the primary tumor remains limited to the gallbladder in most cases. Extended lymphadenectomy with combined individualized resection was performed. In the cystic duct type ( n=9) a small mass arising from the cystic duct involved the common bile duct. This type presented at an earlier stage than the first four types. In the localized type ( n=24) tumor spread is localized to the gallbladder and presented at the earliest stage of any type. Simple cholecystectomy with or without wedge hepatic resection and regional lymphadenectomy resulted in a satisfactory outcome. Prognosis depends on the stage rather than on the mode of tumor spread. Even in the advanced types favorable results may be obtained in selected patients undergoing radical resection for M0 tumors without portal vein invasion. Success also was achieved in the rare patients with para-aortic lymph node metastases that were not infiltrative.
These six types of gallbladder cancer can be diagnosed preoperatively by clinical and radiological examination. This information should assist the surgeon in the choice of operation and predict outcome.
胆囊癌的肿瘤扩散方式和程度记录不足。本研究对该肿瘤的扩散模式进行分类，重点关注手术策略。
回顾了112例行根治性切除患者的手术标本。其中Ⅰ期、Ⅱ期、Ⅲ期和Ⅳ期患者分别有9例、11例、14例和78例。
确定了六种扩散类型。肝床型（n = 20）：胆囊底部和体部的大肿块通过胆囊床侵入肝脏，伴或不伴有向胃肠道的连续扩散。肝切除范围根据临床情况从楔形切除到扩大右肝切除个体化确定。肝门型（n = 26）：颈部相对较小的肿瘤浸润肝门导致梗阻性黄疸。由于肿瘤已扩展至右门静脉蒂，根治性切除需要扩大右肝切除加胆管切除，伴或不伴门静脉切除，术后肝衰竭很常见。肝床和肝门型（n = 18）：占据整个胆囊的巨大肿块累及胆囊床和肝门。根治性切除需要扩大右肝切除并联合切除连续扩散的组织。淋巴结型（n = 15）：肿大的转移淋巴结是最突出的特征，大多数情况下原发肿瘤局限于胆囊。进行扩大淋巴结清扫并联合个体化切除。胆囊管型（n = 9）：起源于胆囊管的小肿块累及胆总管。此类型比前四种类型出现得更早。局限型（n = 24）：肿瘤扩散局限于胆囊，是所有类型中出现最早的。单纯胆囊切除伴或不伴楔形肝切除及区域淋巴结清扫可取得满意效果。预后取决于分期而非肿瘤扩散方式。即使在晚期类型中，对于无门静脉侵犯的M0肿瘤行根治性切除的部分患者也可能获得良好结果。对于罕见的无浸润性腹主动脉旁淋巴结转移患者也取得了成功。
这六种类型的胆囊癌可通过临床和影像学检查在术前诊断。这些信息应有助于外科医生选择手术方式并预测预后。
