肝门部胆管癌手术切除的远期疗效及预后因素分析

Long-term outcomes and prognostic factors of surgical resection of hilar cholangiocarcinoma

    摘要
  • 摘要: 目的:探讨肝门部胆管癌手术切除的远期疗效及其影响预后的因素。
    方法:采用回顾性病例对照研究方法。收集2007年1月至2014年8月中山大学附属第一医院收治的129例行手术切除肝门部胆管癌患者的临床病理资料。采用门诊及电话方式进行随访，观察患者生存情况，肿瘤复发、转移情况。随访时间截至2015年10月。观察指标：(1)患者远期疗效(1、3、5年生存率，生存时间)。(2)预后因素分析指标：患者性别、年龄、术前CA19-9、肿瘤直径、肿瘤根治程度(R0或R1切除)、血管切除重建、改良T分期、淋巴结转移、TNM分期、肿瘤分化程度。(3)对独立预后因素进行分层分析。采用KaplanMeier法绘制生存曲线，Logrank检验进行生存分析。采用χ2检验进行单因素分析，采用COX回归模型进行多因素分析。
    结果:(1)129例患者中，4例于围术期死亡。 112例患者获得随访，随访时间为1～98个月，中位随访时间为19个月。随访期间，75例患者死亡。129例患者总体中位生存时间为23个月，1、3、5年生存率分别为71.1%、31.4%、14.6%。(2)单因素分析结果显示：肿瘤根治程度、改良T分期、淋巴结转移、TNM分期、肿瘤分化程度是影响行手术切除肝门部胆管癌患者预后的相关因素(χ2=5.566，5.450，4.558，4.033，6.093，P<0.05)。多因素分析结果显示：肿瘤根治程度为R1切除、TNM分期为Ⅲ～Ⅳ期、肿瘤分化程度为低分化是影响行手术切除肝门部胆管癌患者预后不良的独立危险因素(HR=2.328，1.691，1.750，95%可信区间：1.224～4.427，1.035～2.762，1.205～2.542，P<0.05)。(3)110例R0切除患者中位生存时间为24个月，1、3、5年生存率分别为75.5%、36.0%、15.8%；19例R1切除患者中位生存时间为12个月，1、3年生存率分别为47.1%、7.1%，5年生存率未获得，两者生存情况比较，差异有统计学意义(χ2=5.566，P< 0.05)。55例Ⅰ～Ⅱ期患者中位生存时间为30个月，1、3、5年生存率分别为75.0%、42.5%、20.1%；74例Ⅲ～Ⅳ期患者中位生存时间为18个月，1、3、5年生存率分别为68.1%、22.2%、7.0%，两者生存情况比较，差异有统计学意义(χ2=4.033，P<0.05)。19例高分化肿瘤患者中位生存时间为30个月，1、3、5年生存率分别为82.4%、49.5%、49.5%；62例中分化肿瘤患者中位生存时间为24个月，1、3、5年生存率分别为 69.6%、30.4%、11.8%；33例低分化肿瘤患者中位生存时间为18个月，1、3、5年生存率分别为63.5%、 24.2%、0.0，3者生存情况比较，差异有统计学意义(χ2=6.093，P<0.05)。
    结论:肝门部胆管癌手术切除总体远期疗效目前尚不理想。肿瘤根治程度为R1切除、TNM分期为Ⅲ～Ⅳ期、肿瘤分化程度为低分化是影响行手术切除肝门部胆管癌患者预后不良的独立危险因素。

     

    Abstract: Objective:To investigate the longterm outcomes and prognostic factors of surgical resection of hilar cholangiocarcinoma.
    Methods:The retrospective casecontrol study was adopted. The clinicopathological data of 129 patients with hilar cholangiocarcinoma who underwent surgery at the First Affiliated Hospital of Sun Yatsen University between January 2007 and August 2014 were collected. The followup of outpatient examination and telephone interview was performed to observe the survival of patients, tumor recurrence and metastasis up to October 2015. (1) Longterm outcomes (1, 3, 5year survival rates and survival time) were observed. (2) Prognostic factors were collected, including gender, age, preoperative CA19-9, tumor diameter, curative degree oftumor (R0 resection or R1 resection), vascular resection and reconstruction, modified T stage, lymph node metastasis, TNM stage and tumor differentiation. (3) The stratified analyses were used for the independent prognostic factors. The survival curve was drawn by KaplanMeier method, and the survival rate was analyzed using the Logrank test. The univariate analysis and multivariate analysis were respectively done using the chisquare test and COX regression model.
    Results:(1) Of 129 patients, 4 patients were dead in the perioperative period, 112 were followed up for a median time of 19 months (range, 1-98 months). During the followup, 75 patients were dead. The overall median survival time and 1, 3, 5year survival rates of the 129 patients were 23 months, 71.1%, 31.4% and 14.6%, respectively. (2) The results of univariate analysis showed that curative degree of tumor, modified T stage, lymph node metastasis, TNM stage and tumor differentiation were the related factors affecting the prognosis of patients undergoing surgical resection of hilar cholangiocarcinoma (χ2= 5.566, 5.450, 4.558, 4.033, 6.093, P<0.05). The results of multivariate analysis showed that R1 resection, stage Ⅲ-Ⅳ and lowdifferentiated tumor were the independent risk factors affecting the poor prognosis of patients undergoing surgical resection of hilar cholangiocarcinoma (HR=2.328,1.691, 1.750, 95% confidence interval: 1.224-4.427,1.035-2.762, 1.205-2.542, P<0.05). (3) The median survival time and 1, 3, 5year survival rates were 24 months, 75.5%, 36.0% , 15.8% in 110 patients with R0 resection, the median survival time and 1, 3year survival rates were 12 months, 47.1% and 7.1% and the 5year survival rate missed in the 19 patients with R1 resection, with a statistically significant difference (χ2=5.566, P<0.05). The median survival time and 1, 3, 5year survival rates were 30 months, 75.0%, 42.5%, 20.1% in 55 patients with stageⅠ-Ⅱ and 18 months, 68.1%, 22.2%, 7.0% in 74 patients with stage Ⅲ-Ⅳ, respectively, showing a statistically significant difference (χ2=4.033, P<0.05). The median survival time and 1, 3, 5year survival rates were 30 months, 82.4%, 49.5%, 49.5% in 19 patients with highdifferentiated tumor, 24 months, 69.6%, 30.4%, 11.8% in 62 patients with moderatedifferentiated tumor, 18 months, 63.5%, 24.2%, 0.0 in 33 patients with lowdifferentiated tumor, respectively, with a statistically significant difference (χ2=6.093, P< 0.05).
    Conclusions:Longterm outcomes of surgical resection of hilar cholangiocarcinoma are unsatisfactory. Moreover, R1 resection, stage Ⅲ-Ⅳ and lowdifferentiated tumor are the independent risk factors affecting the poor prognosis of patients undergoing surgical resection of hilar cholangiocarcinoma.

     

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