Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
Department of Surgery, Pancreas Institute, University of Verona, Verona, Italy.
Ann Surg Oncol. 2017 Dec;24(13):3926-3933. doi: 10.1245/s10434-017-6095-9. Epub 2017 Sep 26.
Resectability rates for extrahepatic cholangiocarcinoma have increased over time, but long-term survival after resection alone with curative intent remains poor. Recent series suggest improved survival with adjuvant therapy. Patient subsets benefiting most from adjuvant therapy have not been clearly defined.
Patients with extrahepatic cholangiocarcinoma who underwent resection with curative intent and received adjuvant therapy (chemotherapy ± radiotherapy) or surgery alone (SA) were identified in the U.S. National Cancer Data Base (2004-2014). Cox regression identified covariates associated with overall survival (OS). Adjuvant therapy and SA cohorts were matched (1:1) by propensity scores based on the survival hazard in Cox modeling. Overall survival was compared by Kaplan-Meier estimates.
Of 4872 patients, adjuvant chemotherapy was used frequently for 2416 (49.6%), often in conjunction with radiotherapy (RT) (n = 1555, 64.4%). Adjuvant chemotherapy with or without RT was used increasingly for cases with higher T classification [reference: T1-2; T3: 1.36; 95% confidence interval (CI), 1.19-1.55; T4: 1.77; 95% CI 1.38-2.26], nodal positivity [odds ratio (OR), 1.26; 95% CI 1.01-1.56], lymphovascular invasion (OR 1.21; 95% CI 1.01-1.46), or margin-positive resection (OR 1.85; 95% CI 1.61-2.12), and was associated with significant improvements in OS for each high-risk subset in the propensity score-matched cohort. Adjuvant therapy was associated with improved median OS for hilar tumors (40.0 vs 30.6 months; p = 0.025) but not distal tumors (33.0 vs 30.3 months; p = 0.123). Chemoradiotherapy was associated with superior outcomes compared with chemotherapy alone in the subset of margin-positive resection [hazard ratio (HR), 0.63; 95% CI 0.42-0.94].
Adjuvant multimodality therapy is associated with improved survival for patients with resected extrahepatic cholangiocarcinoma and high-risk features.
随着时间的推移，肝外胆管癌的可切除率有所提高，但单独手术切除（根治性切除）的长期生存仍然较差。最近的研究表明，辅助治疗可改善生存。尚未明确明确受益于辅助治疗的患者亚组。
在美国国家癌症数据库（2004-2014 年）中，确定了接受根治性切除术并接受辅助治疗（化疗±放疗）或单独手术（SA）的肝外胆管癌患者。Cox 回归确定了与总生存期（OS）相关的协变量。根据 Cox 建模中的生存风险，通过倾向评分对辅助治疗组和 SA 组进行了 1:1 匹配。通过 Kaplan-Meier 估计比较总生存期。
在 4872 名患者中，有 2416 名（49.6%）患者经常使用辅助化疗，通常与放疗（RT）联合使用（n=1555，64.4%）。对于 T 分类较高的病例（参考 T1-2；T3：1.36；95%置信区间[CI]，1.19-1.55；T4：1.77；95%CI 1.38-2.26）、淋巴结阳性（比值比[OR]，1.26；95%CI 1.01-1.56）、脉管侵犯（OR 1.21；95%CI 1.01-1.46）或边缘阳性切除（OR 1.85；95%CI 1.61-2.12），辅助化疗与 OS 的显著改善相关，在倾向评分匹配队列中，每种高危亚组均有改善。辅助治疗与肝门部肿瘤的中位 OS 延长相关（40.0 与 30.6 个月；p=0.025），但与远端肿瘤无关（33.0 与 30.3 个月；p=0.123）。在边缘阳性切除的亚组中，放化疗与单独化疗相比，结果更优[风险比（HR），0.63；95%CI 0.42-0.94]。
对于具有高危特征的肝外胆管癌患者，辅助多模态治疗与生存改善相关。
