Kai Masahiro, Chijiiwa Kazuo, Ohuchida Jiro, Nagano Motoaki, Hiyoshi Masahide, Kondo Kazuhiro
Department of Surgical Oncology and Regulation of Organ Function, Miyazaki University School of Medicine, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan.
J Gastrointest Surg. 2007 Aug;11(8):1025-32. doi: 10.1007/s11605-007-0181-4.
The aim of this study was to evaluate the results of our series of 90 operations for gallbladder carcinoma according to the Japanese Society of Biliary Surgery (JSBS) classification system and to clarify the appropriate surgical strategy for advanced gallbladder carcinoma based on the depth of primary tumor invasion and lymph node metastasis. Generally, only a surgical resection can achieve a prognostic improvement of the advanced gallbladder carcinoma. The survival of patients with this neoplasm depends strictly on the depth of histological primary tumor invasion and lymph node metastasis. A retrospective analysis was conducted on 90 patients from 1990 to 2004 who underwent a surgical resection of gallbladder carcinoma. The factors influencing survival were examined. Thirty-nine patients with palliative treatment (not resected cases), which was diagnosed as T3 or T4 by preoperative imagings, were also included in this study. The significance of the variables for survival was examined by the Kaplan-Meier method and the log-rank test followed by multivariate analyses using Cox's proportional hazard model. Portal invasion, lymph node metastasis, the surgical margin (+ vs. -) and the final curability (fCurA, B vs. C) were all found to be independent prognostic factors in the multivariate analysis. In pT2 gallbladder carcinoma, a better survival was achieved in an aggressive surgical approach, in order of a S4a+S5 hepatic resection, an extended cholecystectomy and a cholecystectomy. In pT3 and pT4, although radical extended surgery did not provide the opportunity for good survival even after lobectomy of the liver, the survival of patients with curative surgery was statistically better than in those without curative surgery. In addition, the nodal involvement of pN1 to pN2 was better than that with pN3. A S4a+S5 hepatectomy, therefore, appears to be adequate for the treatment of pT2 gallbladder carcinoma. Even in patients with pT3 and pT4 gallbladder carcinoma, long-term survival can be expected by an operation with a tumor-free surgical margin. The role of radical surgery, however, is considered to be limited in patients with pN3 lymph node metastasis.
本研究的目的是根据日本胆道外科学会（JSBS）分类系统评估我们所做的90例胆囊癌手术的结果，并根据原发肿瘤浸润深度和淋巴结转移情况阐明晚期胆囊癌的合适手术策略。一般来说，只有手术切除才能改善晚期胆囊癌的预后。该肿瘤患者的生存情况严格取决于组织学上原发肿瘤的浸润深度和淋巴结转移情况。对1990年至2004年间接受胆囊癌手术切除的90例患者进行了回顾性分析。研究了影响生存的因素。本研究还纳入了39例接受姑息治疗（未切除病例）的患者，这些患者术前影像学检查诊断为T3或T4。采用Kaplan-Meier法和对数秩检验来检验生存变量的意义，随后使用Cox比例风险模型进行多变量分析。在多变量分析中，门静脉侵犯、淋巴结转移、手术切缘（阳性与阴性）以及最终治愈情况（fCurA、B与C）均被发现是独立的预后因素。在pT2期胆囊癌中，积极的手术方式能取得更好的生存效果，按顺序依次为S4a+S5肝切除术、扩大胆囊切除术和胆囊切除术。在pT3和pT4期，尽管根治性扩大手术即使在肝叶切除术后也未提供良好生存的机会，但接受根治性手术患者的生存情况在统计学上优于未接受根治性手术的患者。此外，pN1至pN2的淋巴结受累情况优于pN3。因此，S4a+S5肝切除术似乎足以治疗pT2期胆囊癌。即使是pT3和pT4期胆囊癌患者，通过手术获得无瘤手术切缘也有望实现长期生存。然而，对于有pN3淋巴结转移的患者，根治性手术的作用被认为是有限的。
