Liang Jian-Wei, Zhao Ping, Zhou Zhi-Xiang, Tian Yan-Tao, Zhao Dong-Bing, Wang Cheng-Feng
Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing 100021, China.
Zhonghua Wai Ke Za Zhi. 2009 May 1;47(9):677-80.
To discuss the significance of a positive ductal margin and evaluate the prognostic factors related to surgical resection for middle and distal bile duct carcinoma.
A retrospective clinicopathological analysis of 79 patients who had undergone surgical resection for middle or distal bile ductal cancer between January 1990 and December 2006 was conducted. The surgical procedures consisted of pancreatoduodenectomy in 46 patients, bile duct resection in 25 patients, bile duct resection plus hepatectomy in 6 patients, and bile duct resection with partial resection of portal vein in 2 patients. In 74 patients, 5 patients were excluded because they died after surgery without being discharged from the hospital, 15 clinicopathologic factors were evaluated using univariate and multivariate analysis.
The overall 5-year survival rate and the median survival time was 30.7% and 36 months, respectively. Sixteen of 74 patients (20.3%) were determined to have positive ductal margins on the final pathological examination. As a result, hepatic-side ductal margin, duodenal-side ductal margin and both was found to be positive in 6, 3 and 2 patients, respectively. Five patients had positive radial margins. The 5-year survival rate was 34.4% in 58 patients without microscopic residual disease (R0), and 15.5% in 16 patients with microscopic residual tumor (R1). The ductal recurrence rate of 16 patients with R1 resection was higher than 58 patients with R0 resection (62.5% vs. 17.2%, chi(2) = 13.024, P < 0.01). The 1-, 3-, and 5-year survival rates were better in the patients with R0 (92.5%, 56.7%, and 34.4%, respectively) than those in the patients with R1 resection (75.0%, 23.2%, and 15.5%, respectively) (P < 0.05). Twelve patients received postoperative adjuvant therapy. The 5-year survival rate was not significantly different between patients with postoperative adjuvant therapy and those without (18.2% vs. 31.8%, P = 0.221). The preoperative serum level of hemoglobin, pathological differentiation grade, the depth of neoplastic invasion, lymph node metastasis, R1 resection, and TNM stage were significant prognostic factors on the univariate analysis. Multivariate analysis revealed that lymph node metastasis and R1 resection were the independent prognostic factors.
In the treatment of middle and distal bile duct cancer, radical resection should be made to obtain a tumor-free margin. An aggressive surgical approach may improve the survival for middle bile duct cancer. Adjuvant therapy needs to be further developed.
探讨胆管切缘阳性的意义，并评估中、远端胆管癌手术切除的预后因素。
对1990年1月至2006年12月间接受中、远端胆管癌手术切除的79例患者进行回顾性临床病理分析。手术方式包括46例行胰十二指肠切除术，25例行胆管切除术，6例行胆管切除加肝切除术，2例行胆管切除加门静脉部分切除术。74例患者纳入研究，5例因术后未出院死亡被排除在外，对15项临床病理因素进行单因素和多因素分析。
总体5年生存率和中位生存时间分别为30.7% 和36个月。74例患者中有16例（20.3%）最终病理检查确定胆管切缘阳性。其中肝侧胆管切缘阳性6例，十二指肠侧胆管切缘阳性3例, 两侧均阳性2例。5例患者有阳性径向切缘。58例无镜下残留病灶（R0）患者5年生存率为34.4%，16例有镜下残留肿瘤（R1）患者5年生存率为15.5%。R1切除组的16例患者胆管复发率高于R0切除组的58例患者（62.5%比17.2%，χ2=13.024，P<0.01）。R0组患者的1年、3年和5年生存率分别为92.5%、56.7%和34.4%，优于R1切除组患者（分别为75.0%、23.2%和15.5%）（P<0.05）；12例患者接受了术后辅助治疗，接受术后辅助治疗和未接受术后辅助治疗患者的5年生存率无显著差异（分别为18.2%和31.8%；P=0.221）。单因素分析显示术前血清血红蛋白水平、病理分化程度、肿瘤浸润深度及有无淋巴结转移、R1切除及TNM分期均为预后的显著影响因素；多因素分析显示淋巴结转移和R1切除是独立的预后因素。
中、远端胆管癌治疗应行根治性切除以获得切缘阴性，积极手术方式可能提高中段胆管癌患者生存率，辅助治疗有待进一步研究。
