Yamaguchi K, Chijiiwa K, Saiki S, Shimizu S, Takashima M, Tanaka M
Department of Surgery I, Kyushu University Faculty of Medicine, Japan.
Hepatogastroenterology. 1997 Sep-Oct;44(17):1256-61.
BACKGROUND/AIMS: The postoperative course of patients with bile duct carcinoma after surgical resection remains dismal. The purpose of this study was to examine the mode of spread from the original site of the carcinoma and its prognostic significance.
A total of 46 Japanese patients with extrahepatic bile duct carcinoma who underwent surgical resection from January 1976 to August 1995 were retrospectively reviewed.
Out of 24 patients with upper bile duct carcinoma, 16 (67%) were papillary or well differentiated tubular adenocarcinoma of the polypoid or nodular type on gross configuration, whereas 7 of 11 patients (64%) with lower bile duct carcinoma had moderately differentiated tubular adenocarcinoma or poorly differentiated adenocarcinoma of the annular constrictive or diffusely infiltrating type (p < 0.01). A noteworthy feature was perineural invasion (18/24, 75%) in the former group. Lymphatic permeation and venous invasion were seen in 50% and 38% of the former group and these were present in 73%, and in 73% of the latter (p < 0.01). Lymph node metastasis was most frequent in patients with lower bile duct carcinoma (5/11, 45%). Periductal spread along the bile duct toward the liver was more frequent and extensive in the infiltrating type than in the polypoid, nodular, or annular constrictive type. Carcinoma of the polypoid type often extended along the mucosa and rarely through the periductal layer. The mean distance between the edge of carcinoma invasion estimated by cholangiography and that proved by histology on the resected specimens was 6.1 +/- 6.1 mm in the hepatic and 6.2 +/- 9.1 mm in the duodenal direction. In all 11 patients with lower bile duct carcinoma, surgical margins were free of cancer cells, while they were affected by malignant cells in 17 of 24 patients with upper bile duct carcinoma. Univariate log-rank analysis showed that venous invasion, perineural infiltration, and the presence or absence of cancer cells at the cut edge of the bile duct in the hepatic direction and at the resection margins in the transverse direction were significant prognostic factors. Multivariate Cox regression analysis revealed that cancer cells at the edge of the bile duct in the hepatic direction constitute a significant and independent prognostic variant.
Extrahepatic bile duct carcinoma should be excised to a distance of 1.5 cm from the edge of the carcinoma as estimated on cholangiography to achieve cancer-free margins, especially at the resected margins in the hepatic direction.
背景/目的：胆管癌患者手术切除后的术后病程仍然不容乐观。本研究的目的是研究癌肿原发部位的扩散方式及其预后意义。
对1976年1月至1995年8月期间接受手术切除的46例日本肝外胆管癌患者进行回顾性研究。
在24例肝上胆管癌患者中，16例（67%）大体形态为息肉样或结节样的乳头状或高分化管状腺癌，而11例肝下胆管癌患者中有7例（64%）为中度分化管状腺癌或低分化腺癌，呈环形缩窄或弥漫浸润型（p<0.01）。一个值得注意的特征是前一组中存在神经周围侵犯（18/24，75%）。前一组中50%出现淋巴渗透，38%出现静脉侵犯，后一组中这两个比例分别为73%和73%（p<0.01）。肝下胆管癌患者淋巴结转移最为常见（5/11，45%）。浸润型沿胆管向肝脏的导管周围扩散比息肉样、结节样或环形缩窄型更频繁、更广泛。息肉样癌通常沿黏膜扩展，很少穿过导管周围层。通过胆管造影估计的癌肿侵犯边缘与切除标本组织学证实的边缘之间的平均距离，在肝脏方向为6.1±6.1mm，在十二指肠方向为6.2±9.1mm。在所有11例肝下胆管癌患者中，手术切缘无癌细胞，而24例肝上胆管癌患者中有17例切缘受癌细胞影响。单因素对数秩分析显示，静脉侵犯、神经周围浸润以及胆管肝向切缘和横向切除边缘有无癌细胞是显著的预后因素。多因素Cox回归分析显示，胆管肝向边缘的癌细胞是一个显著且独立的预后变量。
肝外胆管癌应在胆管造影估计的癌肿边缘向外1.5cm处切除，以实现切缘无癌，尤其是在肝脏方向的切除边缘。
