【作者】 肖建；

【导师】 肖卫东；

【作者基本信息】 南昌大学 ， 外科学（专业学位）， 2018， 硕士

【摘要】 目的:探讨肝内胆管结石合并肝内胆管癌的临床病理特征及预后。方法:回顾性分析我院2005年1月至2017年12月间经外科手术治疗的肝内胆管癌病例资料,按纳入及排除标准筛选符合的研究对象。根据是否合并肝内胆管结石分为肝内胆管癌合并肝内胆管结石组(A组)、肝内胆管癌不合并肝内胆管结石组(B组),比较分析两组的临床病理特征和预后差异。结果:(1)本研究共纳入81例研究对象,A组53例,B组28例。主要临床症状依次是腹痛(84.0%,68/81)、畏寒发热(18.5%,15/81)、恶心呕吐(18.5%,15/81)、黄疸(14.8%,12/81),其中A组病例腹痛、畏寒发热、恶心呕吐症状出现率较B组高(P<0.05)。两组的肝功能及血清肿瘤学指标(CEA、CA19-9、CA125)等实验室检查结果差异无统计学意义(P>0.05)。B组术前彩超、CT诊断符合率分别为87.0%、92.0%,显著高于A组的62.2%、70.8%(P<0.05),但两组MRI诊断符合率无统计学差异(94.4%vs 86.8%,P>0.05)。(2)大范围肝切除(≥3个肝段)38例(A组25例,B组13例),小范围肝切除(<3个肝段)43例(A组28例,B组15例)。合并淋巴结清扫术57例(A组38例,B组19例),获R0切除63例(A组42例,B组21例)。A组手术并发症发生率和死亡率分别为20.8%(11/53)、1.9%(1/53),B组分别为10.7%(3/28)、0。两组的手术时间、肝切除范围、淋巴结清扫术比例、R0切除率、并发症发生率及死亡率差异均无统计学意义(均P>0.05)。(3)A组淋巴结阳性率为34.2%(13/38),B组为21.1%(4/19),差异无统计学意义(P>0.05)。A组的镜下脉管癌栓阳性率明显高于B组(37.7%vs 14.3%,P=0.028),周围神经浸润阳性率也明显高于B组(32.1%vs 10.7%,P=0.034)。两组的肿瘤大小、大体组织类型、分化程度和TNM分期差异均无统计学意义(均P>0.05)。(4)全组72例获得随访资料,1、3、5年累积生存率分别为86.8%、44.9%、17.1%,中位生存期为35个月。A组的1、3、5年累积生存率和中位生存期分别为84.3%、35.7%、11.9%和29个月,明显低于B组(91.4%、62.1%、24.8%和41个月,P=0.017);所有获得随访的病例中,行淋巴结清扫术者的1、3、5年累积生存率高于未行淋巴结清扫术者(P=0.042)。A组获得随访的病例中,行淋巴结清扫术者的1、3、5年累积生存率高于未行淋巴结清扫术者(P=0.047),pN0期的1、3、5年累积生存率高于pN1期和pNx期(pN0 vs pN1,P=0.006;pN0 vs pNx,P=0.044)。结论:合并肝内胆管结石的肝内胆管癌更易出现腹痛、畏寒发热、恶心呕吐等临床症状。彩超、CT检查对不合并肝内胆管结石的肝内胆管癌诊断符合率高于合并肝内胆管结石者。肝内胆管结石合并肝内胆管癌易发生脉管癌栓和周围神经浸润,预后比不合并肝内胆管结石的肝内胆管癌差。根治性切除是肝内胆管癌最有效的治疗手段,淋巴结清扫有助于肿瘤分期和改善预后。更多还原

【Abstract】 Objective: To investigate clinicopathological characteristics and prognosis of hepatolithiasis-associated intrahepatic cholangiocarcinoma(HL-iCCA).Methods: The clinical data of patients with intrahepatic cholangiocarcinoma(i CCA)underwent surgery in our hospital from January 2005 to December 2017 were retrospectively analyzed.The eligible subjects were enrolled according the inclusion and exclusion criteria and divided into two groups: HL-iCCA group(group A)and non-HL-iCCA group(group B).Then,the clinicopathological and prognostic differences between these two groups were compared.Results:(1)81 patients enrolled this study including 53 of the group A and 28 of the group B.The most common symptoms were abdominal pain(84.0%,68/81),chills and fever(18.5%,15/81),nausea and vomiting(18.5%,15/81),and jaundice(14.8%,12/81).The present of the first three symptoms were more common in group A than group B(P<0.05).There was no significant difference in the laboratory data between the two groups(P>0.05).The diagnostic accuracy of imaging examination(BUS,CT)in group B was significantly higher than those in group A(87.0%,92.0%vs 62.2%,70.8%,P<0.05).(2)Among these cases,38 patients underwent major hepatectomy(25 in group A and 13 in group B),and 43 patients underwent minor hepatectomy(28 in group A and 15 in group B).Fifty-seven patients underwent lymphadenectomy(38 in group A and 19 in group B).Sixty-three patients achieved R0 resection(42 in group A and 21 in group B).The morbidity and mortality were20.8% and 1.9% in group A,10.7% and 0 in group B.There was no statistically significant difference in the operative time,extent of hepatectomy,lymphadenectomy,R0 resection,morbidity and mortality between the two groups(all P>0.05).(3)The frequency of lymph node metastases was 34.2%(13/38)in group A and 21.1%(4/19)in group B(P>0.05).The incidence of lymph vessel tumor emboli in group A was significantly higher than that in group B(37.7% vs 14.3%,P=0.028),as well as the incidence of perineural invasion(32.1% vs 10.7%,P=0.034).There wasno statistically significant difference in the tumor size,morphological type,histologic differentiation,and TNM stage between the two groups(all P>0.05).(4)72 patients achieved survival data,and the 1-,3-,5-year cumulative survival rates were 86.8%,44.9%,and 17.1%,respectively.The median survival time was 35 months.The 1-,3-,5-year survival rates of patients in group B were significantly superior than those of group A(91.4%,62.1%,24.8% vs 84.3%,35.7%,11.9%,P=0.017).The median survival time of patients in group A and B was 29 and 41 months,respectively.Among these patients achieved survival data,the 1-,3-,5-year survival rates of patients with lymphadenectomy were significantly superior than those without lymphadenectomy(P=0.042).In group A,the 1-,3-,5-year survival rates of patients with lymphadenectomy were also significantly superior than those without lymphadenectomy(P=0.047).Meanwhile,the 1-,3-,5-year survival rates of pN0 subgroup were significantly superior than those of pN1 and pNx subgroup(pN0 vs pN1,P=0.006;pN0 vs pNx,P=0.044).Conclusion: Patients of HL-iCCA are more likely to present with clinical symptoms,while have a lower diagnostic accuracy of imaging examinations of BUS and CT.HL-iCCA is prone to lymph vessel tumor emboli and perineural invasion,and its prognosis is worse than non-HL-iCCA.Radical resection is the most effective therapy for iCCA,and regional lymphadenectomy is helpful in tumor staging and improving the prognosis.更多还原