Altman Ariella M, Kizy Scott, Marmor Schelomo, Huang Jing Li, Denbo Jason W, Jensen Eric H
Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
J Gastrointest Oncol. 2018 Oct;9(5):942-952. doi: 10.21037/jgo.2017.11.06.
Intrahepatic cholangiocarcinoma (ICC) is a rare and aggressive disease with an increasing incidence in the United States, and there is no level 1 evidence to help guide treatment decisions. We sought to determine national trends in surgical and medical management of patients with resected ICC, and more specifically, the role of lymphadenectomy (LAD) and utilization of chemotherapy.
An augmented version of the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) cancer database registry was used to identify all surgically resected ICC patients from 2000 to 2014. We evaluated the incidence and adequacy of LAD, and receipt of chemotherapy over time. Next, multivariable logistic regressions were performed to determine the predictors of LAD and receipt of chemotherapy. Overall survival (OS) was evaluated using Kaplan-Meier and Cox proportional hazard models.
We identified 1,263 patients who underwent resection for ICC. Lymph nodes (LNs) were removed in 49% of patients, however, only 10% of patients received adequate LAD by the American Joint Committee on Cancer (AJCC) criteria (≥6 nodes). LN metastases were found in 29% of patients who underwent nodal evaluation. Chemotherapy was administered to 40% of patients, was utilized more frequently over time (P<0.05), and was associated with improved survival in node positive patients (P<0.05). Patients who did not have LNs evaluated were significantly less likely to receive chemotherapy than those who did. Lastly, OS for the entire cohort improved over time (P<0.05).
After analyzing the treatment and outcomes of resectable ICC, we concluded: (I) LN evaluation at the time of surgical resection remains inadequate; (II) utilization of chemotherapy has increased over time; (III) the lack of LAD likely results in under-staging and underutilization of chemotherapy; and (IV) despite less than ideal surgical and medical therapy median OS continues to improve.
肝内胆管癌（ICC）是一种罕见且侵袭性强的疾病，在美国其发病率呈上升趋势，目前尚无一级证据来指导治疗决策。我们试图确定接受手术切除的ICC患者的手术和药物治疗的全国趋势，更具体地说，是淋巴结清扫术（LAD）的作用和化疗的使用情况。
使用美国国立癌症研究所监测、流行病学和最终结果（SEER）癌症数据库登记处的增强版，来识别2000年至2014年所有接受手术切除的ICC患者。我们评估了LAD的发生率和充分性，以及随时间推移化疗的接受情况。接下来，进行多变量逻辑回归以确定LAD和化疗接受情况的预测因素。使用Kaplan-Meier和Cox比例风险模型评估总生存期（OS）。
我们确定了1263例接受ICC切除术的患者。49%的患者进行了淋巴结（LN）切除，然而，根据美国癌症联合委员会（AJCC）标准（≥6个淋巴结），只有10%的患者接受了充分的LAD。在接受淋巴结评估的患者中，29%发现有LN转移。40%的患者接受了化疗，随着时间的推移使用频率更高（P<0.05），并且与淋巴结阳性患者的生存期改善相关（P<0.05）。未进行LN评估的患者接受化疗的可能性明显低于进行了评估的患者。最后，整个队列的OS随时间推移有所改善（P<0.05）。
在分析了可切除ICC的治疗和结果后，我们得出以下结论：（I）手术切除时的LN评估仍然不足；（II）化疗的使用随时间增加；（III）缺乏LAD可能导致分期不足和化疗使用不足；（IV）尽管手术和药物治疗并不理想，但中位OS仍在持续改善。
