[摘要]  目的 探讨肝门部胆管癌（Hilar Cholangiocarcinoma）的外科治疗策略及预后相关因素。方法 回顾性分析1990年1月～2005年12月间天津医科大学附属肿瘤医院144例行手术切除治疗的肝门部胆管癌患者的临床资料，对其预后影响因素进行统计分析。结果 144例患者中，根治性切除组（R0）86例（59.7%），镜下切缘阳性组（R1）34例（23.6%），肉眼切缘阳性组（R2）24例（16.7%）。120例手术切除患者（R0组+R1组）术后1年、3年及5年总生存率分别为60.2%、36.1%和29.4%，R0组中位生存期46.8个月，R1组中位生存期18.3个月，R2组中位生存期11.2个月。R0组预后好于R1组（p＜0.0001），R1组预后好于R2组（p=0.031）。组织病理学分级：高分化（G1）41例（34.2%），中低分化（G2、G3、G4）79例（65.8%），高分化癌患者预后较好（p=0.003）。淋巴结转移情况：无淋巴结转移（N0）62例（51.7），淋巴结转移（N1、N2）58例（48.3%），淋巴结转移患者预后极差，术后5年生存率仅为2.5%（p＜0.0001）。T分期：T1共42例，T2-3共78例，T1期患者的预后较好（P=0.030）。120例手术切除患者中，实施门静脉局部切除修复41例，共有34例患者术中及术后病理证实门静脉或肝动脉受累，其5年生存率为21.7%，无血管侵犯组（86例）5年生存率为38.2%，血管侵犯组预后较差（P=0.047）（图5），但与R2组相比，预后较好（p＜0.0001）。结论 肝门部胆管癌的病理类型、临床分期和根治性切除与否是影响预后的主要因素。提高肝门部胆管癌疗效的关键在于提高早期诊断率和根治性切除率。联合不同范围的肝切除及淋巴结清扫术对提高肝门部胆管癌的根治率和生存率有重要的意义。
[关键词]  肝门部胆管癌；分期；外科手术；预后

Analysis of the surgical outcome and prognostic factors for Hilar Cholangiocarcinoma
Li Qiang
Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Hospital Tianjin 300060 Tianjin 300060, China

[Abstract] Objective To assess the therapeutic strategies and prognostic factors that could influence clinical outcome of hilar cholangiocarcinoma. Methods A total of 144 of hilar cholangiocarcinoma patients undergoing operation between 1990 and 2005 were included in this study. Univariate analyses were performed to examine factors affecting clinical outcome and recurrence. Results 144 patients underwent resection: 86(59.7%) had an R0 resection (negative histologic margins), 34(23.6%) had an R1 resection (positive histologic margins), 24(16.7%) had an R2 resection. The 1-year, 3-year and 5-year cumulative survival rates (%) of the patients were 60.2%, 36.1% and 29.4%. The median survival time after R0 resection was 46.8 months, 18.3 months after R1 resection, and 11.2 months after R2 resection (p＜0.0001). Survival after resection in patients with negative lymph nodes (n = 62) was significantly longer than in those with positive lymph nodes (n = 58) (p＜0.0001). The T stage system predicted respectability and the likelihood of an R0 resection and correlated with survival (P=0.030). Patients requiring portal vein resection had a worse prognosis than those without vascular resection (P=0.047) but still survived longer than patients who were unresectable (p＜0.0001).Conclusions Negative histologic margins, concomitant partial hepatectomy, and well-differentiated tumor histology were associated with improved outcome after all hilar cholangiocarcinoma resections. In patients who underwent an R0 resection, concomitant partial hepatectomy was the only independent predictor of long-term survival. The T stage system predicted respectability and the likelihood of an R0 resection and correlated with survival. Complete resection remains the only therapy that offers the possibility of long-term survival, and hepatic resection is a critical component of the surgical approach.
[Key words] Hilar Cholangiocarcinoma; Staging; Surgical Procedures; Prognosis