Salloum C, Castaing D
Centre hépatobiliaire, hôpital Paul-Brousse, Villejuif, France.
Bull Cancer. 2008 Dec;95(12):1183-91. doi: 10.1684/bdc.2008.0758.
It is admitted that only complete tumor clearance with negative surgical margins provides benefit for patients undergoing surgery for hepatobiliary malignancies. For hepatocellular carcinoma, since micrometastases disseminate via portal venous branches, anatomic resection is preferred over non-anatomic resection in liver resection carried out with curative intent. Thus, an anatomic liver resection with a wider resection margin theoretically gives a higher potential for cure. However, preserving non-tumorous liver parenchyma is an important consideration, especially in cirrhotic liver resection to decrease the incidence of postoperative liver failure. The optimal liver resection margin is still controversial. It seems that a resection margin of 2 cm is associated with a decreased postoperative recurrence rate and improved survival outcomes especially for hepatocellular carcinoma <or= 2 cm. Due to the unsatisfying alternatives in the medical and interventional treatment of intrahepatic cholangiocarcinoma, hepatic resection, whenever technically possible, should be enforced. Expected narrow hepatic resection margins should not exclude patients from potentially curative surgery, and should not be used as a reason to establish palliative treatment instead since R1 resection is compatible with long-term survival. Aggressive hepatic surgery could and should therefore be performed if the peri-operative mortality is low. For hilar cholangiocarcinoma, surgical radicality has been shown in multivariate analyses of multiples studies to be the only parameter with a significant impact on survival. Extended right-side hepatectomies seems to give the best oncologic results. A predicted margin of < 1 cm after resection of hepatic colorectal metastases should not be used as an exclusion criterion for resection and will not impair patients' prognosis. Resection should be performed whatever the width of the surgical margin, rather than not performing the resection at all.
公认的是，只有实现肿瘤完全清除且手术切缘阴性，才会让接受肝胆恶性肿瘤手术的患者获益。对于肝细胞癌，由于微转移灶通过门静脉分支扩散，因此在以治愈为目的的肝切除术中，解剖性切除优于非解剖性切除。所以，理论上切缘更宽的解剖性肝切除具有更高的治愈潜力。然而，保留无肿瘤的肝实质是一个重要考量因素，尤其是在肝硬化肝切除术中，以降低术后肝衰竭的发生率。最佳肝切除切缘仍存在争议。似乎2 cm的切缘与术后复发率降低及生存结果改善相关，特别是对于直径≤2 cm的肝细胞癌。由于肝内胆管癌的药物治疗和介入治疗效果不尽人意，只要技术上可行，就应实施肝切除术。预期肝切除切缘较窄不应将患者排除在可能治愈的手术之外，也不应作为确立姑息治疗的理由，因为R1切除与长期生存是相容的。因此，如果围手术期死亡率较低，就可以并且应该积极进行肝脏手术。对于肝门部胆管癌，多项研究的多因素分析表明手术根治性是对生存有显著影响的唯一参数。扩大右侧肝切除术似乎能带来最佳的肿瘤学效果。肝结直肠癌转移灶切除术后预计切缘<1 cm不应作为切除的排除标准，也不会损害患者的预后。无论手术切缘宽度如何，都应进行切除，而不是根本不进行切除。
