Tsukahara Tetsuo, Ebata Tomoki, Shimoyama Yoshie, Yokoyama Yukihiro, Igami Tsuyoshi, Sugawara Gen, Mizuno Takashi, Nagino Masato
*Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan †Department of Pathology and Clinical Laboratories, Nagoya University Graduate School of Medicine, Nagoya, Japan.
Ann Surg. 2017 Jul;266(1):126-132. doi: 10.1097/SLA.0000000000001944.
The aim of the study was to evaluate whether carcinoma in situ (CIS) residue at the ductal stump affects the survival of patients undergoing resection for extrahepatic cholangiocarcinoma.
Positive ductal margin with CIS has been treated as a tumor-free margin from a prognostic viewpoint because several studies have reported that residual CIS foci at the ductal stump do not affect survival after resection.
Patients who underwent resection for extrahepatic cholangiocarcinoma were retrospectively reviewed. The surgical margin status was histologically divided into negative (R0), positive with CIS (R1cis), and positive with invasive cancer (R1inv). The survival and incidence of local recurrence were compared among the groups.
Of 684 consecutive resected patients, 172 patients with early-stage (pTis-2N0M0) cholangiocarcinoma (perihilar, n = 144; distal, n = 28) were analyzed. The cumulative incidence of local recurrence in R1cis patients was higher than R0 patients (32.8% vs 4.4% at 5 years, P < 0.001) and lower than R1inv patients (50.0% at 2 years, P = 0.012). The disease-specific survival for R1cis patients was worse than for R0 patients (35.1% vs 78.7% at 5 years, P = 0.005) and better than for R1inv patients (40.0% at 2 years, P = 0.002). The uni- and multivariate analyses identified the surgical margin status as an independent prognostic factor (R1cis vs R0, relative risk 2.39, P = 0.026; R1inv vs R0, RR 10.28, P < 0.001).
R1cis increases the incidence of local recurrence and shortens postoperative survival in patients with early-stage cholangiocarcinoma, although this prognostic effect was less severe compared with R1inv. R1cis should be avoided as much as possible in surgery for early-stage cancer, although it may be allowed in advanced tumors.
本研究旨在评估肝外胆管癌切除术后胆管残端原位癌（CIS）残留是否会影响患者的生存。
从预后角度来看，伴有CIS的胆管切缘阳性一直被视为无瘤切缘，因为多项研究报告称胆管残端残留的CIS病灶并不影响切除术后的生存。
对接受肝外胆管癌切除术的患者进行回顾性分析。手术切缘状态在组织学上分为阴性（R0）、伴有CIS阳性（R1cis）和伴有浸润性癌阳性（R1inv）。比较各组的生存率和局部复发率。
在684例连续接受手术切除的患者中，对172例早期（pTis-2N0M0）胆管癌患者（肝门部，n = 144；远端，n = 28）进行了分析。R1cis患者的局部复发累积发生率高于R0患者（5年时分别为32.8%和4.4%，P < 0.001），低于R1inv患者（2年时为50.0%，P = 0.012）。R1cis患者的疾病特异性生存率低于R0患者（5年时分别为35.1%和78.7%，P = 0.005），高于R1inv患者（2年时为40.0%，P = 0.002）。单因素和多因素分析均确定手术切缘状态为独立的预后因素（R1cis与R0相比，相对风险为2.39，P = 0.026；R1inv与R0相比，RR为10.28，P < 0.001）。
R1cis会增加早期胆管癌患者的局部复发率并缩短术后生存期，尽管与R1inv相比这种预后影响较轻。在早期癌症手术中应尽可能避免R1cis，尽管在晚期肿瘤中可能允许存在。
