Department of Surgery, Medstar Washington Hospital Center, Washington, DC2Department of Surgery, Alfa Institute of Biomedical Sciences, Marousi, Athens, Greece3Society of Junior Doctors, Athens, Greece.
Society of Junior Doctors, Athens, Greece4Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
JAMA Surg. 2014 Jun;149(6):565-74. doi: 10.1001/jamasurg.2013.5137.
Data on outcomes following surgical management of intrahepatic cholangiocarcinoma (ICC) are limited. The incidence of ICC is increasing and it has a poor prognosis. No consensus has been reached regarding the optimal treatment modalities.
To systematically review and synthesize the available evidence regarding treatment and prognosis in patients with ICC.
The PubMed database was searched for relevant articles published between January 1, 2000, and April 1, 2013.
Only studies assessing predictors of survival or recurrence in patients undergoing curative-intent surgical treatment of ICC were included. Small series, studies reporting on mixed types of cholangiocarcinoma, or exclusively on hepatolithiasis-associated cholangiocarcinoma, and those published in a language other than English, French, German, Italian, or Greek, were excluded. Fifty-seven of 960 articles were therefore analyzed.
Data on preoperative, intraoperative, and postoperative variables were extracted by 3 independent reviewers. Multiple studies reporting on the same population were excluded. Data were pooled using a random-effects model.
We hypothesized that preoperative variables and tumor characteristics affect patient survival. The outcomes of the study were overall survival and recurrence-free survival. The hypothesis was formulated before data collection.
Fifty-seven studies (4756 patients) were included in the review. Median patient age ranged from 49 to 67 years, and 57% were male. Most patients had a solitary (69%), large (median size, 4.5-8.0 cm) tumor of the mass-forming type (86%). Approximately one-third of the patients had lymph node metastasis (34%) or vascular (38%), perineural (29%), or biliary invasion (29%). Most underwent a major hepatectomy (82%), often accompanied by lymphadenectomy (67%) and sometimes by extrahepatic bile duct resection (23%). Median and 5-year overall survival (OS) generally were approximately 28 months (range, 9-53 months) and 30% (range, 5%-56%), respectively; factors predicting shorter OS included large tumor size, multiple tumors, lymph node metastasis, and vascular invasion. Adjuvant chemotherapy or radiotherapy did not appear to be beneficial. Seven studies (2132 patients) provided data for the meta-analysis. Factors associated with shorter OS included older age (pooled hazard ratio, 1.10; 95% CI, 1.03-1.17), larger tumor size (1.09; 1.02-1.16), presence of multiple tumors (1.70; 1.43-2.02), lymph node metastasis (2.09; 1.80-2.43), vascular invasion (1.87; 1.44-2.42), and poor tumor differentiation (1.41; 1.17-1.71).
The prognosis of ICC is dictated mainly by tumor factors. Future research could focus on the usefulness of adjuvant treatment as well as other multidisciplinary treatment modalities.
关于肝内胆管细胞癌（ICC）手术治疗后结果的数据有限。ICC 的发病率正在增加，且预后不良。对于最佳治疗方式，尚未达成共识。
系统地回顾和综合现有的关于 ICC 患者治疗和预后的证据。
从 2000 年 1 月 1 日至 2013 年 4 月 1 日，在 PubMed 数据库中搜索相关文章。
仅包括评估接受 ICC 根治性手术治疗患者生存或复发预测因素的研究。排除小系列研究、报告混合类型胆管癌的研究、仅报告与肝胆管结石相关的胆管癌的研究以及以英语、法语、德语、意大利语或希腊语以外的语言发表的研究。因此，分析了 960 篇文章中的 57 篇。
3 名独立评审员提取术前、术中、术后变量的数据。排除了多项研究报告的同一人群。使用随机效应模型汇总数据。
我们假设术前变量和肿瘤特征会影响患者的生存。研究结果为总生存和无复发生存。在数据收集之前提出了假设。
综述纳入了 57 项研究（4756 名患者）。中位患者年龄为 49-67 岁，57%为男性。大多数患者为单发（69%）、大（中位数大小 4.5-8.0 cm）肿块型肿瘤（86%）。约三分之一的患者有淋巴结转移（34%）或血管（38%）、神经周围（29%）或胆管侵犯（29%）。大多数患者接受了主要肝切除术（82%），常伴有淋巴结清扫术（67%）和偶尔伴有肝外胆管切除术（23%）。中位和 5 年总生存率（OS）通常约为 28 个月（范围 9-53 个月）和 30%（范围 5%-56%）；预测 OS 较短的因素包括肿瘤体积大、多发病灶、淋巴结转移和血管侵犯。辅助化疗或放疗似乎没有益处。7 项研究（2132 名患者）提供了荟萃分析的数据。与 OS 较短相关的因素包括年龄较大（合并危险比 1.10；95%CI 1.03-1.17）、肿瘤较大（1.09；1.02-1.16）、多发病灶（1.70；1.43-2.02）、淋巴结转移（2.09；1.80-2.43）、血管侵犯（1.87；1.44-2.42）和肿瘤分化不良（1.41；1.17-1.71）。
ICC 的预后主要由肿瘤因素决定。未来的研究可以集中在辅助治疗的有效性以及其他多学科治疗方式上。
