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胆管导管内乳头状肿瘤的临床病理特征与治疗策略

吴昕, 李秉璐, 郑朝纪, 刘卫, 洪涛, 谢勇, 肖剑春, 曲强, 何小东

吴昕, 李秉璐, 郑朝纪, 等. 胆管导管内乳头状肿瘤的临床病理特征与治疗策略[J]. 中华消化外科杂志, 2021, 20(8): 876-882. DOI: 10.3760/cma.j.cn115610-20210817-00399
引用本文: 吴昕, 李秉璐, 郑朝纪, 等. 胆管导管内乳头状肿瘤的临床病理特征与治疗策略[J]. 中华消化外科杂志, 2021, 20(8): 876-882. DOI: 10.3760/cma.j.cn115610-20210817-00399
Wu Xin, Li Binglu, Zheng Chaoji, et al. Clinicopathological features and treatment strategies of intraductal papillary neoplasm of the bile duct[J]. Chinese Journal of Digestive Surgery, 2021, 20(8): 876-882. DOI: 10.3760/cma.j.cn115610-20210817-00399
Citation: Wu Xin, Li Binglu, Zheng Chaoji, et al. Clinicopathological features and treatment strategies of intraductal papillary neoplasm of the bile duct[J]. Chinese Journal of Digestive Surgery, 2021, 20(8): 876-882. DOI: 10.3760/cma.j.cn115610-20210817-00399

胆管导管内乳头状肿瘤的临床病理特征与治疗策略

基金项目: 

中国医学科学院中央级公益性科研院所基本科研业务费专项资金 2019XK320012

详细信息
    通讯作者:

    李秉璐,Email:libinglu@pumch.cn

Clinicopathological features and treatment strategies of intraductal papillary neoplasm of the bile duct

Funds: 

Non‑profit Central Research Institute Fund of Chinese Academy of Medical Sciences 2019XK320012

More Information
  • 摘要:
    目的 

    探讨胆管导管内乳头状肿瘤(IPNB)的临床病理特征与治疗策略。

    方法 

    采用回顾性描述性研究方法。收集2000年8月至2020年4月中国医学科学院北京协和医院收治的40例IPNB病人的临床病理资料;男19例,女21例;年龄为(60±14)岁。病人术前均行影像学检查和血液检验,判断肿瘤位置和范围,评估其可切除性。根据病人实际情况和意愿选择治疗方式。观察指标:(1)术前检查和检验结果。(2)治疗情况。(3)病理学检查情况。(4)随访情况。采用门诊、电话和网络问诊等方式进行随访。了解肿瘤复发和病人生存情况。随访时间截至2021年4月。计数资料以绝对数和百分比表示。正态分布的计量资料以x±s表示,偏态分布的计量资料以M(范围)表示。采用Kaplan‑Meier方法计算累积生存率和绘制生存曲线。

    结果 

    (1)术前检查和检验结果:40例病人术前均行影像学检查和血液检验。40例病人中,33例行腹部超声检查,31例行腹部CT检查,21例行磁共振检查,15例行内镜逆行胰胆管造影(ERCP)检查,8例行PET‑CT检查,6例行内镜超声检查,部分病人行多种检查。IPNB在影像学检查中主要表现为胆管扩张及管腔内肿瘤,CT增强扫描检查结果显示肿瘤强化。术前血液检验结果显示:40例病人中,21例肝功能异常,17例胆红素升高;9例癌胚抗原升高,24例CA19‑9升高。(2)治疗情况:40例病人中,35例施行手术治疗;5例行ERCP检查及活组织病理学检查,基于病人意愿未行根治性手术切除。35例行手术治疗病人中,20例行半肝或肝叶切除术,8例行胰十二指肠切除术,7例行胆管肿瘤切除术;手术时间为(262±91)min,术中出血量为300 mL(50~2 000 mL)。35例手术病人中,6例发生术后并发症,根据Clavien‑Dindo并发症分级标准,Ⅰ级3例、Ⅱ级3例。(3)病理学检查情况:40例病人行病理学检查,均诊断为IPNB,其中肝外病灶19例、肝内病灶21例;良性病变20例(低‑中级别上皮内瘤变15例、高级别上皮内瘤变5例),恶性病变(浸润性癌)20例;18例肿瘤分泌黏液,22例肿瘤无黏液分泌或相关资料不详。35例手术病人中,5例切缘阳性,30例切缘阴性。21例病人行淋巴结清扫,清扫淋巴结数目为154枚,其中阳性淋巴结3枚。(4)随访情况:40例病人中,35例获得随访,随访时间为(53±35)个月。35例病人中,17例无瘤生存;3例带瘤生存,肿瘤复发时间分别为治疗后12、17、37个月;15例死亡,死亡时间为治疗后(30±19)个月。35例病人的1、3、5年累积生存率分别为88.6%、73.6%、50.7%。

    结论 

    IPNB临床少见,影像学检查结果主要表现为胆管扩张及管腔内肿瘤,肿瘤增强后强化,手术是主要治疗方式,淋巴结转移率低。

    Abstract:
    Objective 

    To investigate the clinicopathological features and treatment strategies of intraductal papillary neoplasm of the bile duct (IPNB).

    Methods 

    The retrospective and descriptive study was conducted. The clinicopathological data of 40 patients with IPNB who were admitted to Peking Union Medical College Hospital from August 2000 to April 2020 were collected. There were 19 males and 21 females,aged (60±14) years. Patients underwent preoperative imaging examination and blood test for evaluation of tumor location, range and resectability. The treatment strategies of patients depended on preoperative examination and their own willingness. Observation indicators: (1) preoperative examinations and tests; (2) treatment; (3) pathological examination; (4) follow‑up. Follow‑up using outpatient examination, telephone interview and online diagnosis was performed to detect tumor recurrence and survival of patients up to April 2021. Count data were represented as absolute numbers and percentages. Measurement data with normal distribution were represented as Mean±SD, and measurement data with skewed distribution were represented as M(range). The Kaplan‑Meier method was used to calculate the cumulative survival rate and draw survivla curve.

    Results 

    (1) Preoperative examinations and tests: 40 patients received preoperative imaging examination and blood test. Of 40 patients, 33 cases underwent abdominal ultrasonography, 31 cases underwent abdominal computed tomography (CT) examina-tion, 21 cases underwent magnetic resonance imaging (MRI), 15 cases underwent endoscopic retrograde cholangiopancreatography (ERCP), 8 cases underwent position emission tomography CT examination, 6 cases underwent endoscopic ultrasonography; some patients underwent multiple examinations. The main imaging features of IPNB were bile duct dilatation, and intraluminal tumor. Enhanced CT scan showed tumor reinforcement. Preoperative blood tests showed of the 40 patients, 21 cases with abnormal liver function, 17 cases with increased bilirubin, 9 cases with increased carcinoembryonic antigen, and 24 cases with increased CA19-9. (2) Treatment: 35 of 40 patients underwent surgery, 5 patients underwent ERCP and biopsy and didn′t undergo surgery based on their willings. Of 35 patients with surgeries,20 cases underwent hemihepatectomy or lobectomy, 8 cases underwent pancreatico-duodenectomy, 7 cases underwent bile duct tumor resection. The operation time was (262±91)minutes, and volume of intraoperative blood loss was 300 mL(range, 50‒2 000 mL). Postopera-tive complications occurred in 6 of 35 patients, including 3 cases with Grade Ⅰ complications and 3 cases with Grade Ⅱ complication according to Clavien‑Dindo classi-fication system. (3) Pathological examination: 40 patients were diagnosed as IPNB by pathological examinations. There were 19 and 21 patients with extrahepatic and intrahepatic lesions, respectively. There were 20 benign lesions (15 cases of low or intermediate‑grade intraepithelial neoplasia and 5 cases of high‑grade intraepithelial neoplasia) and 20 malignant lesions of invasive carcinoma. There were 18 cases with mucus secretion and 22 cases without mucus secretion or information. Five of 35 patients with surgeries had positive margin and the rest of 30 patients had negative margin. A total of 154 lymph nodes were dissected in 21 patients, including 3 positive lymph nodes. (4) Follow‑up: 35 of 40 patients were followed up for (53±35)months. Seventeen of 35 patients survived without tumor, and 3 patients survived with tumor of which the time to tumor recurrence were 12, 17, 37 months. Fifteen patients died, with the time interval to death of (30±19)months. The 1‑, 3‑, and 5‑year cumulative survival rates of 35 patients were 88.6%, 73.6%, and 50.7%, respectively.

    Conclusions 

    IPNB is rare, with the main imaging features as bile duct dilatation, and intraluminal tumor. The tumor is reinforce-ment after enhanced scan. Surgery is the main treatment for IPNB and lymph node metastasis is rare.

  • 所有作者均声明不存在利益冲突
    吴昕, 李秉璐, 郑朝纪, 等. 胆管导管内乳头状肿瘤的临床病理特征与治疗策略[J]. 中华消化外科杂志, 2021, 20(8): 876-882. DOI: 10.3760/cma.j.cn115610-20210817-00399.

    http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20210817-00399

  • 图  1   胆管导管内乳头状肿瘤的影像学检查结果 1A:CT检查结果显示肝外胆管管壁增厚,增强后可见异常强化(↓);1B:MRI检查结果显示肝外胆管局部充盈缺损(←),伴肝内外胆管多发狭窄和扩张

    Figure  1.   Imaging examination of intraductal papillary neoplasm of the bile duct 1A: Computed tomography examination showed wall thickening of extrahepatic bile duct, with abnormal reinforcement after enhancement scan (↓); 1B: Magnetic resonance imaging showed local filling defect of extrahepatic bile duct (←), with multiple extrahepatic and intrahepatic biliary strictures and dilatation

    图  2   35例胆管导管内乳头状肿瘤病人累积生存曲线

    Figure  2.   Cumulative survival curve of 35 patients with intraductal papillary neoplasm of the bile duct

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  • 收稿日期:  2021-08-16
  • 网络出版日期:  2024-07-18
  • 刊出日期:  2021-08-19

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