区域淋巴结清扫对肝内胆管癌根治术后复发模式的影响

doi:10.3877/cma.j.issn.1674-0793.2022.02.002

目的

目前肝内胆管癌（ICC）是否常规进行区域淋巴结清扫（LND）仍存争议。本研究旨在探究LND对ICC根治术后复发模式的影响。

方法

回顾性研究中山大学附属第一医院2010年1月至2021年5月165例ICC并行LND的患者，收集患者的一般资料、血液学检查指标、术前影像学检查资料（CT、MRI或PET-CT）和手术记录，分析术前影像学诊断淋巴结转移的价值以及LND对ICC术后不同复发模式的影响。

结果

术前影像学诊断ICC淋巴结转移的敏感度为61.0%，特异度为58.9%，准确性为59.4%。124例cN0并行LND患者中，清扫个数≥6组阳性淋巴结比例占60.8%（31/51），显著高于清扫个数<6组的27.4%（20/73），差异有统计学意义（χ²=13.82，P<0.001）；随访期间，中位无复发生存时间为9.3个月（1~49.5个月），清扫个数≥6组和清扫个数<6组分别复发26、40例，清扫个数≥6组患者的局部淋巴结复发率更低，两组复发模式差异有统计学意义（P=0.037）。

结论

术前影像学诊断ICC淋巴结转移价值有限，应常规进行区域LND，清扫数量6个以上有助于改善淋巴结分期和减少cN0患者根治术后局部淋巴结复发。

关键词: 肝内胆管癌, 淋巴结清扫, 淋巴结转移, 复发模式

Objective

Routine regional lymph node dissection (LND) in the resection of intrahepatic cholangiocarcinoma (ICC) is still controversial. This study aims to investigate the impact of LND on the recurrence pattern of ICC after radical resection.

Methods

A total of 165 ICC patients from January 2010 to May 2021 in the First Affiliated Hospital of Sun Yat-sen University were retrospectively selected as the research subjects. The general information, hematological examination indexes, preoperative imaging data (CT, MRI or PET-CT) and operation records of patients were collected to analyze the impact of LND on the recurrence pattern of ICC after radical resection.

Results

The sensitivity, specificity and accuracy of preoperative imaging in diagnosing lymph node metastasis were 61.0%, 58.9% and 59.4%, respectively. Among the 124 patients with cN0 complicated with LND, the proportion of positive lymph nodes in the group with dissection ≥6 accounted for 60.8% (31/51), which was significantly higher than 27.4% (20/73) in the group with dissection <6 (χ²=13.82, P<0.001). During the follow-up period, the median recurrence free survival time was 9.3 (1-49.5) months. 26 cases recurred in the group with dissection ≥6 and 40 cases in the group dissection <6, respectively. There was significant difference in the recurrence pattern between the two groups, and the recurrence rate of regional lymph nodes in the group with dissection ≥6 was lower (P=0.037).

Conclusions

The value of preoperative imaging in diagnosing lymph node metastasis in ICC is limited, and regional LND should be performed routinely. Dissection of more than 6 lymph nodes can help to improve lymph node staging and reduce local lymph node recurrence in patients with cN0 after radical resection.

Key words: Intrahepatic cholangiocarcinoma, Lymph node dissection, Lymph node metastasis, Recurrence pattern

表1 不同清扫个数的cN0复发肝内胆管癌患者临床病理特征(例)

临床参数		清扫个数<6	清扫个数≥6	χ²值	P值
例数		40	26
年龄(岁)				1.410	0.859
	<65	30	20
	≥65	10	6
性别				0.001	0.830
	男	22	15
	女	18	11
癌胚抗原(μg/L)				2.607	0.337
	<5	23	18
	≥5	17	8
CA19-9 (U/ml)				0.002	0.399
	<40	10	9
	≥40	30	17
乙肝表面抗原				0.443	0.630
	阴性	27	19
	阳性	13	7
血红蛋白(g/L)				<0.001	1.000
	≤130	20	13
	>130	20	13
白蛋白(g/L)				0.389	0.739
	<35	5	4
	≥35	35	22
总胆红素(μmol/L)				1.879	0.027
	≤17.1	33	15
	>17.1	7	11
谷丙转氨酶(U/L)				0.033	0.453
	<40	31	18
	≥40	9	8
谷草转氨酶(U/L)				1.605	0.453
	<40	31	18
	≥40	9	8
凝血酶原时间(s)				0.432	0.826
	<14	38	25
	≥14	2	1
肿瘤大小(cm)				0.408	0.350
	<5	11	10
	≥5	29	16
肿瘤个数				1.375	0.812
	1	25	17
	>1	15	9
出血量(ml)				0.001	0.130
	≤300	26	12
	>300	14	14
输血				0.010	0.399
	无	30	17
	有	10	9

表1 不同清扫个数的cN0复发肝内胆管癌患者临床病理特征(例)

临床参数		清扫个数<6	清扫个数≥6	χ²值	P值
例数		40	26
年龄(岁)				1.410	0.859
	<65	30	20
	≥65	10	6
性别				0.001	0.830
	男	22	15
	女	18	11
癌胚抗原(μg/L)				2.607	0.337
	<5	23	18
	≥5	17	8
CA19-9 (U/ml)				0.002	0.399
	<40	10	9
	≥40	30	17
乙肝表面抗原				0.443	0.630
	阴性	27	19
	阳性	13	7
血红蛋白(g/L)				<0.001	1.000
	≤130	20	13
	>130	20	13
白蛋白(g/L)				0.389	0.739
	<35	5	4
	≥35	35	22
总胆红素(μmol/L)				1.879	0.027
	≤17.1	33	15
	>17.1	7	11
谷丙转氨酶(U/L)				0.033	0.453
	<40	31	18
	≥40	9	8
谷草转氨酶(U/L)				1.605	0.453
	<40	31	18
	≥40	9	8
凝血酶原时间(s)				0.432	0.826
	<14	38	25
	≥14	2	1
肿瘤大小(cm)				0.408	0.350
	<5	11	10
	≥5	29	16
肿瘤个数				1.375	0.812
	1	25	17
	>1	15	9
出血量(ml)				0.001	0.130
	≤300	26	12
	>300	14	14
输血				0.010	0.399
	无	30	17
	有	10	9

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Impact of regional lymph node dissection on the recurrence pattern of intrahepatic cholangiocarcinoma after radical resection

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Impact of regional lymph node dissection on the recurrence pattern of intrahepatic cholangiocarcinoma after radical resection