Department of Surgery, Cancer Center Amsterdam, Amsterdam, The Netherlands; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
J Am Coll Surg. 2018 Aug;227(2):238-246.e2. doi: 10.1016/j.jamcollsurg.2018.03.041. Epub 2018 Apr 6.
Many patients with resectable perihilar cholangiocarcinoma (PHC) on imaging are diagnosed intraoperatively with occult metastatic or locally advanced disease, precluding a curative-intent resection. This study aimed to develop and validate a preoperative risk score.
Patients with resectable PHC on imaging who underwent operations in 2 high-volume centers (US and Europe) between 2000 and 2015 were included. Multivariable logistic regression analysis was used to develop the risk score. Cross-validation was used to validate the score, alternating the 2 centers as "training" and "testing" datasets.
Of 566 patients who underwent operations, 309 (55%) patients had a resection, and in 257 (45%) patients, a curative-intent resection was precluded due to distant metastasis (n = 151 [27%]) or locally advanced disease (n = 106 [19%]). Preoperative predictors included bilirubin >2 mg/dL, bile duct involvement on imaging, portal vein involvement on imaging (≥180 degrees), hepatic artery involvement on imaging (≥180 degrees), and suspicious lymph nodes on imaging. The new risk score (c-index 0.75 after cross-validation) provided significantly more accurate predictions than the Bismuth classification (c-index 0.62), Blumgart T-staging (c-index 0.67), and cTNM staging (c-index 0.68). The new risk score identified 4 risk groups for occult metastatic or locally advanced disease: low (14.7%), intermediate (29.5%), high (47.3%), and very high risk (81.3%). The preoperative score groups also predicted survival after operation, irrespective of intraoperative findings (p < 0.001).
The validated risk score can predict occult distant metastatic or locally advanced PHC based on 5 preoperatively available factors. The score can be useful in preoperative shared decision making and selection of patients in neoadjuvant clinical trials.
许多影像学上可切除的肝门部胆管癌（PHC）患者在术中被诊断为隐匿性转移性或局部晚期疾病，从而无法进行根治性切除。本研究旨在开发和验证一种术前风险评分。
纳入了 2000 年至 2015 年间在 2 家高容量中心（美国和欧洲）接受手术的影像学上可切除的 PHC 患者。采用多变量逻辑回归分析来开发风险评分。采用交叉验证来验证评分，将这 2 个中心交替作为“训练”和“测试”数据集。
在 566 例接受手术的患者中，309 例（55%）患者进行了切除术，257 例（45%）患者由于远处转移（n=151[27%]）或局部晚期疾病（n=106[19%]）而无法进行根治性切除。术前预测因素包括胆红素>2mg/dL、影像学上胆管受累、影像学上门静脉受累（≥180 度）、影像学上肝动脉受累（≥180 度）和影像学上可疑淋巴结。新的风险评分（交叉验证后的 C 指数为 0.75）比 Bismuth 分类（C 指数为 0.62）、Blumgart T 分期（C 指数为 0.67）和 cTNM 分期（C 指数为 0.68）提供了更准确的预测。新的风险评分确定了 4 个隐匿性转移性或局部晚期疾病的风险组：低危（14.7%）、中危（29.5%）、高危（47.3%）和极高危（81.3%）。术前评分组也预测了手术后的生存，无论术中发现如何（p<0.001）。
验证后的风险评分可根据术前 5 个可获得的因素预测隐匿性远处转移性或局部晚期 PHC。该评分可在术前的共同决策和新辅助临床试验中患者选择中发挥作用。
