肝门部胆管癌手术切除疗效及预后影响因素分析

doi:10.3877/cma.j.issn.2095-3232.2019.01.008

目的

探讨肝门部胆管癌（HCCA）手术切除的临床疗效及预后影响因素。

方法

回顾性分析2009年1月至2013年12月在解放军福州总医院行手术切除的52例HCCA患者临床资料。其中男31例，女21例；年龄34～80岁，中位年龄63岁。患者均签署知情同意书，符合医学伦理学规定。观察患者生存、肿瘤复发及转移情况。生存分析及预后单因素分析采用Kaplan-Meier法和Log-rank检验，多因素分析采用Cox比例风险回归模型。

结果

随访期间45例患者死于复发、转移，1例死于上消化道出血。52例患者总体中位生存时间为21个月，1、3、5年生存率分别为69.2%、30.8%、11.5%。单因素分析结果显示肿瘤直径、肿瘤根治程度、淋巴结转移、TNM分期、肿瘤分化程度是HCCA手术切除患者预后的影响因素（χ²=3.902，8.820，8.926，4.245，6.071；P<0.05）。多因素分析结果显示肿瘤R0切除、淋巴结阴性、TNM分期Ⅰ～Ⅱ期、肿瘤高分化为HCCA手术切除患者预后的独立保护因素（HR=0.364，0.379，0.546，0.498；95%CI：0.178～0.743，0.190～0.756，0.303～0.984，0.263～0.942；P<0.05）。

结论

HCCA患者预后差，根治性切除、规范淋巴结清扫和肿瘤恶性程度为影响外科手术疗效的关键因素。

关键词: 胆管肿瘤, 肝切除术, 治疗结果, 预后

Objective

To investigate the clinical efficacy of surgical resection for hilar cholangiocarcinoma (HCCA) and the impact factors for the prognosis.

Methods

Clinical data of 52 patients with HCCA who underwent surgical resection in Fuzhou General Hospital of PLA from January 2009 to December 2013 were retrospectively analyzed. Among them, 31 patients were male and 21 were female, aged from 34 to 80 years, with a median age of 63 years. The informed consents of all patients were obtained and the local ethical committee approval was received. The survival, tumor recurrence and metastasis of the patients were observed. Survival ananlysis and univariate analysis of the prognosis was conducted with Kaplan-Meier method and Log-rank test. The multivariate analysis was conducted with Cox's proportional hazard model.

Results

During the follow-up period, 45 patients died of tumor recurrence and metastasis, and 1 died of the upper gastrointestinal bleeding. The overall median survival time of 52 patients was 21 months, and the 1-, 3-, and 5-year survival rates were 69.2%, 30.8% and 11.5%, respectively. Univariate analysis indicated that tumor diameter, degree of radical resection of tumor, lymph node metastasis, TNM stage and tumor differentiation degree were the impact factors for the prognosis of HCCA patients after surgical resection (χ²=3.902, 8.820, 8.926, 4.245, 6.071; P<0.05). Multivariate analysis revealed that R0 resection, negative lymph node, TNM stage Ⅰ-Ⅱ and high differentiation of tumor were the independent protective factors for the prognosis of HCCA patients after surgical resection (HR=0.364, 0.379, 0.546, 0.498; 95%CI: 0.178-0.743, 0.190-0.756, 0.303-0.984, 0.263-0.942; P<0.05).

Conclusions

The prognosis of HCCA patients is poor. Radical resection, standardized lymph node dissection and tumor malignancy are the key factors affecting the surgical efficacy.

Key words: Bile duct neoplasms, Hepatectomy, Treatment outcome, Prognosis

图1 52例行手术切除肝门部胆管癌患者术后Kaplan-Meier生存曲线

表1 影响HCCA手术切除患者预后的单因素分析结果

临床病理参数		例数	5年累积生存率（%）	χ²值	P值
性别		?	?	1.692	>0.05
?	男	31	12.9	?	?
?	女	21	9.5	?	?
年龄（岁）		?	?	1.214	>0.05
?	≥60	28	7.1	?	?
?	< 60	24	16.7	?	?
术前最高TB（μmol/L）		?	?	0.060	>0.05
?	≥342	9	11.1	?	?
?	< 342	43	14.0	?	?
术前CA19-9（kU/L）		?	?	2.118	>0.05
?	≥39	13	10.3	?	?
?	< 39	39	16.9	?	?
肿瘤直径(cm)		?	?	3.902	<0.05
?	≥3.3	23	8.7	?	?
?	< 3.3	29	13.8	?	?
肿瘤根治程度		?	?	8.820	<0.05
?	R1切除	11	0	?	?
?	R0切除	41	14.6	?	?
淋巴结转移		?	?	8.926	<0.05
?	阳性	12	0	?	?
?	阴性	40	15.7	?	?
TNM分期		?	?	4.245	<0.05
?	Ⅲ～Ⅳ期	29	3.4	?	?
?	Ⅰ～Ⅱ期	23	13.0	?	?
肿瘤分化程度		?	?	6.071	<0.05
?	高分化	12	25.0	?	?
?	中分化	25	12.0	?	?
?	低分化	15	0	?	?

表1 影响HCCA手术切除患者预后的单因素分析结果

临床病理参数		例数	5年累积生存率（%）	χ²值	P值
性别		?	?	1.692	>0.05
?	男	31	12.9	?	?
?	女	21	9.5	?	?
年龄（岁）		?	?	1.214	>0.05
?	≥60	28	7.1	?	?
?	< 60	24	16.7	?	?
术前最高TB（μmol/L）		?	?	0.060	>0.05
?	≥342	9	11.1	?	?
?	< 342	43	14.0	?	?
术前CA19-9（kU/L）		?	?	2.118	>0.05
?	≥39	13	10.3	?	?
?	< 39	39	16.9	?	?
肿瘤直径(cm)		?	?	3.902	<0.05
?	≥3.3	23	8.7	?	?
?	< 3.3	29	13.8	?	?
肿瘤根治程度		?	?	8.820	<0.05
?	R1切除	11	0	?	?
?	R0切除	41	14.6	?	?
淋巴结转移		?	?	8.926	<0.05
?	阳性	12	0	?	?
?	阴性	40	15.7	?	?
TNM分期		?	?	4.245	<0.05
?	Ⅲ～Ⅳ期	29	3.4	?	?
?	Ⅰ～Ⅱ期	23	13.0	?	?
肿瘤分化程度		?	?	6.071	<0.05
?	高分化	12	25.0	?	?
?	中分化	25	12.0	?	?
?	低分化	15	0	?	?

表2 影响肝门部胆管癌手术切除患者预后的多因素分析结果

临床病理参数	b	SE(b)	Wald χ²	HR	95%CI	P值
R0切除	-1.011	0.364	7.708	0.364	0.178～0.743	<0.05
淋巴结阴性	-0.971	0.353	7.569	0.379	0.190～0.756	<0.05
TNM分期Ⅰ～Ⅱ期	-0.606	0.301	4.053	0.546	0.303～0.984	<0.05
高分化	-0.697	0.325	4.592	0.498	0.263～0.942	<0.05
肿瘤直径<3.3 cm	-0.579	0.302	3.670	0.560	0.310～1.013	>0.05

表2 影响肝门部胆管癌手术切除患者预后的多因素分析结果

临床病理参数	b	SE(b)	Wald χ²	HR	95%CI	P值
R0切除	-1.011	0.364	7.708	0.364	0.178～0.743	<0.05
淋巴结阴性	-0.971	0.353	7.569	0.379	0.190～0.756	<0.05
TNM分期Ⅰ～Ⅱ期	-0.606	0.301	4.053	0.546	0.303～0.984	<0.05
高分化	-0.697	0.325	4.592	0.498	0.263～0.942	<0.05
肿瘤直径<3.3 cm	-0.579	0.302	3.670	0.560	0.310～1.013	>0.05

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Efficacy of surgical resection for hilar cholangiocarcinoma and prognostic impact factors analysis

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Efficacy of surgical resection for hilar cholangiocarcinoma and prognostic impact factors analysis