Wakai Toshifumi, Sakata Jun, Katada Tomohiro, Hirose Yuki, Soma Daiki, Prasoon Pankaj, Miura Kohei, Kobayashi Takashi
Division of Digestive and General Surgery Niigata University Graduate School of Medical and Dental Sciences Niigata Japan.
Ann Gastroenterol Surg. 2018 Jul 26;2(5):359-366. doi: 10.1002/ags3.12196. eCollection 2018 Sep.
Recent advances in dimensional imaging, surgical technique, and perioperative patient care have resulted in increased rates of complete resection with histopathologically negative margins and improved surgical outcomes in patients with extrahepatic cholangiocarcinoma. However, achieving cancer-free resection margins at ductal stumps in surgery for this disease remains challenging because of longitudinal extension, which is one of the hallmarks of extrahepatic cholangiocarcinoma. When the ductal resection margins are shown to be positive on examination of frozen sections, discrimination between carcinoma in situ and invasive carcinoma is clinically important because residual carcinoma in situ may lead to late local recurrence whereas residual invasive carcinoma is associated with early local recurrence. Residual invasive carcinoma at the ductal margins should be avoided whenever technically feasible. Residual "carcinoma in situ" at the ductal margins appears to be allowed in resection for the advanced disease because it has less effect on survival than other adverse prognostic factors (pN1 and/ or pM1). However, in surgery for early-stage (pTis-2N0M0) extrahepatic cholangiocarcinoma, residual carcinoma in situ at the ductal margins may have an adverse effect on long-term survival, so should be avoided whenever possible. In this review, we focus on the histopathological term "carcinoma in situ," the biological behavior of residual carcinoma in situ at ductal resection margins, intraoperative histological examination of the ductal resection margins, outcome of additional resection for positive ductal margins, and adjuvant therapy for patients with positive margins.
在三维成像、手术技术和围手术期患者护理方面的最新进展，已使肝外胆管癌患者实现了更高的组织病理学切缘阴性的完整切除率，并改善了手术效果。然而，由于纵向扩展是肝外胆管癌的特征之一，在该疾病的手术中实现胆管残端无癌切缘仍具有挑战性。当在冰冻切片检查中显示胆管切缘为阳性时，区分原位癌和浸润性癌在临床上很重要，因为残留原位癌可能导致晚期局部复发，而残留浸润性癌则与早期局部复发相关。只要技术可行，应避免胆管切缘残留浸润性癌。对于晚期疾病的切除，似乎允许胆管切缘残留“原位癌”，因为与其他不良预后因素（pN1和/或pM1）相比，其对生存的影响较小。然而，在早期（pTis-2N0M0）肝外胆管癌的手术中，胆管切缘残留原位癌可能对长期生存产生不利影响，因此应尽可能避免。在本综述中，我们重点关注组织病理学术语“原位癌”、胆管切缘残留原位癌的生物学行为、胆管切缘的术中组织学检查、胆管切缘阳性时再次切除的结果以及切缘阳性患者的辅助治疗。
