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远端胆管癌行胰十二指肠切除术后早期复发预测因素研究
张晨, 李洁, 王良, 王立学, 孙智鑫, 肖颖, 董鸿鹏, 郑卓肇
中国实用外科杂志 ›› 2025, Vol. 45 ›› Issue (12) : 1456-1460.
PDF(1998 KB)
PDF(1998 KB)
远端胆管癌行胰十二指肠切除术后早期复发预测因素研究
Predictive factors for early recurrence after pancreaticoduodenectomy for distal cholangiocarcinoma
目的 探讨远端胆管癌（DCC）行胰十二指肠切除术（PD）后早期复发（ER）相关的危险因素。方法 回顾性分析清华大学北京清华长庚医院2015年1月至2023年7月经PD术病理确诊为DCC的60例病人资料。收集术前临床资料及上腹部增强多层螺旋CT（MSCT）图像，比较ER组（n =18）与无ER组（n=42）在胰腺侵犯、淋巴结转移、胰腺周围淋巴结转移及肠系膜上动脉周围出现软组织等指标上的差异；采用卡方检验或Mann-Whitney U检验初筛，随后以二元Logistic回归分析确定独立危险因素，并通过受试者工作特征曲线（ROC）评估其预测效能。结果 60例DCC病人中，18例（30.0%）术后12个月内发生ER。ER组胰腺侵犯比例为72.2%、淋巴结转移为61.1%、胰腺周围淋巴结转移为55.6%、肠系膜上动脉周围出现软组织影为55.6%，均显著高于无ER组（40.5%、28.6%、23.8%、16.7%；均P<0.05）。多因素Logistic回归显示，只有肠系膜上动脉周围出现软组织影为独立危险因素（P=0.010，OR=5.878，95%CI：1.525~22.647），其ROC曲线下面积（AUC）为0.694，特异度为83.8%。结论 肠系膜上动脉周围出现软组织影可作为预测DCC术后早期复发的影像学标志，为术前风险分层与治疗策略制定提供参考。
Objective To investigate the risk factors associated with early recurrence (ER) after pancreaticoduodenectomy (PD) for distal cholangiocarcinoma (DCC). Methods A retrospective study was conducted based on the data of 60 patients pathologically confirmed with DCC following PD at Beijing Tsinghua Changgung Hospital between January 2015 and July 2023. Preoperative clinical data and contrast-enhanced upper abdominal multislice computed tomography (MSCT) images were collected. Differences in pancreatic invasion, lymph node metastasis, peripancreatic lymph node metastasis, and the presence of soft tissue around the superior mesenteric artery (SMA) were compared between the ER group (n=18) and the non-ER group (n=42). Chi-square test or Mann-Whitney U test was used for univariate analysis, followed by binary logistic regression to identify independent risk factors. Predictive performance was evaluated using the receiver operating characteristic (ROC) curve. Results Among the 60 patients with DCC, 18 (30.0%) cases experienced ER within 12 months postoperatively. The ER group showed significantly higher rates of pancreatic invasion (72.2%), lymph node metastasis (61.1%), peripancreatic lymph node metastasis (55.6%), and the presence of soft tissue around the SMA (55.6%) compared to the non-ER group (40.5%, 28.6%, 23.8%, and 16.7%, respectively; all P<0.05). Multivariate logistic regression identified the presence of soft tissue around the SMA as the only independent risk factor for ER (P=0.010, OR=5.878, 95%CI: 1.525-22.647). The area under the ROC curve (AUC) was 0.694, with a specificity of 83.8%. Conclusion The presence of soft tissue around the superior mesenteric artery is an independent imaging marker for predicting early recurrence after PD for DCC, providing a useful reference for preoperative risk stratification and treatment planning.
远端胆管癌 / 胰十二指肠切除术 / 早期复发 / 多层螺旋CT / 胰腺侵犯 / 淋巴结转移
distal cholangiocarcinoma / pancreatoduodenectomy / early recurrence / multislice computed tomography / pancreatic invasion / lymph node metastasis
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Cholangiocarcinoma (CCA) carries a poor prognosis, is increasing in incidence and its causes are poorly understood. Although some risk factors are known, they vary globally and collectively account for a minority of cases. The aim of this study was to perform a comprehensive meta-analysis of risk factors for intrahepatic (iCCA) and extrahepatic cholangiocarcinoma (eCCA), from Eastern and Western world studies.A literature search of case-control studies was performed to identify potential risk factors for iCCA and eCCA. Pooled odds ratios (ORs) with 95% CIs and heterogeneity were calculated. Funnel plots were used to assess publication bias, and meta-regression was used to select risk factors for comparison between Eastern and Western studies.A total of 13 risk factors were selected from 25 case-control studies in 7 geographically diverse countries. The strongest risk factors for both iCCA and eCCA were biliary cysts and stones, cirrhosis, hepatitis B and hepatitis C. Choledochal cysts conferred the greatest risk of both iCCA and eCCA with pooled ORs of 26.71 (95% CI 15.80-45.16) and 34.94 (24.36-50.12), respectively. No significant associations were found between hypertension and obesity for either iCCA or eCCA. Comparing Eastern and Western populations, there was a difference for the association of hepatitis B with iCCA (coefficient = -0.15195; 95% CI -0.278 to -0.025; p = 0.022).This is the most comprehensive meta-analysis of CCA risk factors to date. Some risk factors, such as diabetes, although less strong, are increasing globally and may be contributing to rising rates of this cancer.Cholangiocarcinoma (CCA) is a cancer arising in the bile ducts inside (intrahepatic CCA) and connected to the liver (extrahepatic CCA). It is a very aggressive cancer: 95% of patients die within 5 years. CCA rates are increasing globally, but the causes of CCA are poorly understood. The few risk factors that are known account for only a minority of cases. In this study, we found that the strongest risk factors for both intrahepatic and extrahepatic CCA are cysts and stones in the bile ducts, cirrhosis, and hepatitis B and C viruses. Some risk factors for CCA, such as diabetes, although less strong, are increasing globally and may be contributing to rising rates of CCA.Copyright © 2019 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
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赵令, 任翱, 李伟, 等. 远端胆管癌术后预后影响因素分析及列线图预测模型构建[J]. 重庆医学, 2023, 52(17):2615-2620.DOI:10.3969/j.issn.1671-8348.2023.17.011.
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Although multidisciplinary treatments including the use of adjuvant therapy (AT) have been adopted for biliary tract cancers, patients with distal cholangiocarcinoma (DCC) can still experience recurrence. We sought to characterize the incidence and predictors of early recurrence (ER) that occurred within 12 months following surgery for DCC.Patients who underwent resection for DCC between 2000 and 2015 were identified from the US multi-institutional database. Cox regression analysis was used to identify clinicopathological factors to develop an ER risk score, and the predictive model was validated in an external dataset.Among 245 patients included in the analysis, 67 patients (27.3%) developed ER. No difference was noted in ER rates between patients who did and did not receive AT (28.7% vs. 25.0%, p = 0.55). Multivariable analysis revealed that neutrophil-to-lymphocyte ratio (NLR), peak total bilirubin (T-Bil), major vascular resection (MVR), lymphovascular invasion, and R1 surgical margin status were associated with a higher ER risk. A DIstal Cholangiocarcinoma Early Recurrence Score was developed according to each factor available prior to surgery [NLR > 9.0 (2 points); peak T-bil > 1.5 mg/dL (1 points); MVR (2 points)]. Cumulative ER rates incrementally increased among patients who were low (0 points; 10.6%), intermediate (1-2 points; 26.8%), or high (3-5 points; 57.6%) risk (p < 0.001) in the training dataset, as well as in the validation dataset [low (0 points); 3.4%, intermediate (1-2 points); 32.7%, or high risk (3-5 points); 55.6% (p < 0.001)].Among patients undergoing resection for DCC, 1 in 4 patients experienced an ER. Alternative treatment strategies such as neoadjuvant chemotherapy may be considered especially among individuals deemed to be at high risk for ER.
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This study aimed to determine the prognostic factors and generate an atlas of a distribution of locoregional recurrence (LRR) in patients with distal cholangiocarcinoma (DCCA), after pancreatoduodenectomy (PD) without adjuvant radiotherapy.124 DCCA cases registered in our institutional database from 2006 to 2018 were analyzed retrospectively. The Cox proportional hazards model was used for multivariable analysis. All recurrence sites were centrally reviewed, and LRRs were plotted on one CT scan of a template that represents the relapse pattern of the patients.The median follow-up time was 35.3 months (95% CI 22.1-48.5 months). Independent prognostic factor for locoregional recurrence-free survival was lymph node metastasis (p = 0.014). Older age, pancreas invasion, and lymph node metastasis were associated with poor survival (both p < 0.05). During the follow-up period, 69 patients (55.6%) developed disease progression. Among them, 45 patients (65.2%) had recurrence in the locoregional components. 21 patients (30.4%) were diagnosed with liver metastasis. Of the patients with LRR, most recurrences occurred in the nodes along the superior mesenteric artery (36.2%), nodes around the abdominal aorta (26.1%), nodes in the hepatoduodenal ligament (13.0%), nodes around the celiac artery (10.1%), and anastomotic stoma (10.1%).The high-risk sites of LRR after PD for primary DCCA are the nodes along the superior mesenteric artery, abdominal aorta, nodes in the hepatoduodenal ligament, nodes around the celiac artery, and anastomotic stoma. Adjuvant radiation should cover these areas to improve locoregional control for these patients.Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.
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关宇, 刘军广, 史继荣, 等. 远端胆管癌根治性胰十二指肠切除术的预后影响因素分析[J]. 解放军医学杂志, 2022, 47(3):237-242.DOI:10.11835/j.issn.0253-2670.2022.03.008.
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Distal cholangiocarcinoma (DCC) is a malignancy associated with a short survival time. In this study, we aimed to create an online nomogram calculator to predict early recurrence and long‐term survival in patients with DCC after pancreaticoduodenectomy.
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The effect of adjuvant treatment on those undergoing pancreaticoduodenectomy (PD) for periampullary carcinomas (PAC) is not well studied. Most studies employed chemoradiation as the adjuvant modality. We aimed to analyse clinicopathological differences between types of PACs, the prognostic factors and the role of adjuvant therapy (chemotherapy in the majority).Patients with PAC who underwent PD from Jan 2011 to Dec 2015 were retrospectively analysed.Ninety-five patients with PAC underwent PD in the study period. Ampullary carcinoma (AC) was the most common. Pancreatic carcinomas (PC) were larger. AC had lower T stage, perineural invasion (PNI) and R1 resections. Median overall survival (OS) was 32.7 months. On multivariate analysis, lymph node ratio (LNR) ≥ 0.2 and advanced T stage adversely affected the OS. Fifty-seven (66.3%) patients received adjuvant treatment, of which 50 had chemotherapy alone. Adjuvant treatment resulted in better OS in patients with T stage ≥ 3, lymph node involvement, LNR ≥ 0.2, lymphovascular invasion, PNI, tumour size > 2 cm, higher grade and distal cholangiocarcinoma.In patients of PAC undergoing PD, AC had favourable clinicopathological profile. LNR ≥ 0.2 and advanced T stage adversely affected OS. Adjuvant treatment resulted in significantly better OS in patients with high-risk features.
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To elucidate the multi-detector row computed tomography (MDCT) findings of extrapancreatic nerve plexus (PLX) invasion by pancreas head carcinoma (PhC) by "point-by-point" correlation with en bloc pathological specimens and to assess their diagnostic accuracy.Each pathological section of PhC and adjusted double oblique multiplanar reconstruction MDCT images were correlated in 554 sections from 37 patients. The diagnostic accuracy of the MDCT patterns derived was assessed by blind reading.PLX invasion with fibrosis showed mass or strand shape (85.6%) or coarse reticula (13.3%). The CT findings were divided into fine reticular and linear, coarse reticular, mass and strand, and nodular patterns. PLX invasion was revealed pathologically in 92% of the regions of investigation showing the mass and strand pattern and 63% of the coarse reticular pattern (all continuous with PhC), and they were highly suggestive of PLX invasion by PhC on MDCT images (p < 0.001). Sensitivity, specificity, accuracy, and positive and negative predictive values of these MDCT findings in the diagnosis of PLX invasion were 100% (25/25), 83.3% (10/12), 94.6% (35/37), 92.6% (25/27) and 100% (10/10), respectively.The mass and strand pattern and the coarse reticular pattern continuous with PhC on MDCT images were highly suggestive of PLX invasion by PhC.
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Purpose To test the hypothesis that patients with pancreatic adenocarcinoma who otherwise are viewed to have resectable disease but have preoperative findings of extrapancreatic perineural invasion (EPNI) and/or duodenal invasion at multidetector computed tomography (CT) have reduced postoperative survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC). Materials and Methods This study was approved by the institutional review board and complied with HIPAA. The authors retrospectively evaluated 76 consecutive patients with PDAC who underwent preoperative multidetector CT and subsequent pancreaticoduodenectomy. Two radiologists blinded to surgical pathology results and clinical outcome evaluated multidetector CT images for evidence of EPNI and duodenal invasion; discrepancies were resolved by consensus. Also determined for each patient were resected lymph node status, tumor size, surgical margin status, time to progression, and time to death. Data were assessed with the Goodman-Kruskal gamma for correlations among indicators and the log-rank test, Kaplan-Meier estimates, and multivariate Cox proportional hazards regression for survival analysis. Results In univariate analysis, duodenal invasion and/or EPNI on preoperativemultidetector CT images was associated with significantly decreased progression-free survival (P <.0001) and overall survival (P =.0013), and the clinical indicators (lymph node status, tumor size, and surgical margin status) as well as duodenal invasion and/or EPNI showed correlation with each other. In multivariate regression that included multidetector CT findings as well as the three traditional clinical indicators, only duodenal invasion and/or EPNI showed significant independent association with reduction in both modes of survival (P <.0001 and P =.014, respectively). Interobserver agreement was substantial with respect to EPNI and duodenal invasion (κ = 0.691 and 0.682, respectively). Conclusion Patients with evidence of EPNI and/or duodenal invasion on preoperative multidetector CT images have significantly reduced survival after pancreaticoduodenectomy for PDAC. RSNA, 2016.
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To assess the utility of axial and coronal reformatted multidetector computed tomographic (CT) images in the evaluation of the invasion of posterior hepatic plexuses by extrahepatic bile duct cancer.This retrospective study was approved by the institutional review board, and informed consent was waived. Forty-three patients (22 men, 21 women; age range, 40-80 years; mean age, 65 years) with surgically resected cancer involving the extrahepatic bile duct between December 2004 and September 2010 were included. Posterior hepatic plexus 1 runs from the superior and middle bile duct to the right celiac ganglion, and posterior hepatic plexus 2 runs between the lower bile duct and right celiac ganglion behind the portal vein. Invasion of the posterior hepatic plexuses was elucidated by using pathologic and postoperative multidetector CT findings. Three radiologists independently evaluated the preoperative axial and coronal reformatted images with a separate viewing session for the invasion of posterior hepatic plexuses that was detected on the basis of the presence of increased attenuation of fat tissue along the nerve routes. Receiver operating characteristic analysis was performed to compare the diagnostic performance of the two image interpretations.Invasion of posterior hepatic plexus 1 and of posterior hepatic plexus 2 was recognized in 10 (23%) and nine (21%) of 43 patients, respectively. The diagnostic performance of coronal reformatted image interpretation was significantly greater than that for axial image interpretation (mean area under the curve, 0.99 vs 0.89, P =.04; mean accuracy, 95% vs 82%, P =.003). In all reviewers, one false-positive diagnosis of the invasion of posterior hepatic plexus occurred on axial and/or coronal image display types because of fibrosis and inflammatory cell infiltration along these plexus routes.Coronal reformatted images can be useful for accurate diagnosis of the invasion of posterior hepatic plexuses and may facilitate surgical decision making in regard to the resection of celiac ganglion.
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刘颖斌, 贾子衡, 陈炜, 等. 重视胆道恶性肿瘤诊断与治疗新知识的应用[J]. 中国实用外科杂志, 2025, 45(1):52-58.DOI:10.19538/j.cjps.issn1005-2208.2025.01.08.
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Few studies have been conducted on patterns of recurrence after resection for distal cholangiocarcinoma (DCC). The aim of this study was to investigate the incidence and pattern of recurrence after resection of DCC, and to evaluate prognostic factors for time to recurrence and recurrence-free survival (RFS).Patients who underwent pancreatoduodenectomy with curative intent for DCC between 2001 and 2010 at one of 30 hospitals in Japan were reviewed retrospectively, with special attention to recurrence patterns. The Cox proportional hazards model was used for multivariable analysis.In the study interval, 389 patients underwent pancreatoduodenectomy for DCC with R0/M0 status. Recurrence developed in 213 patients (54·8 per cent). The estimated cumulative probability of recurrence was 54·3 per cent at 5 years. An initial locoregional recurrence occurred in 55 patients (14·1 per cent) and initial distant recurrence in 168 (43·2 per cent), most commonly in the liver. Isolated initial locoregional recurrence occurred in 45 patients (11·6 per cent). Independent prognostic factors for time to recurrence and RFS were perineural invasion (P = 0·001 and P = 0·009 respectively), pancreatic invasion (both P < 0·001) and lymph node metastasis (both P < 0·001). RFS worsened as the number of risk factors increased: the 5-year RFS rate was 70·6 per cent for patients without any risk factors, 50·3 per cent for patients with one factor, 31·8 per cent for those with two factors, and 13·4 per cent when three factors were present.More than half of patients with DCC experienced recurrence after R0 resection, usually within 5 years. Perineural invasion, pancreatic invasion and positive nodal involvement are risk factors for recurrence.© 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.
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季鸿翔, 司马辉, 匡悦, 等. 肝内胆管癌根治性切除术中淋巴结清扫价值研究[J]. 中国实用外科杂志, 2020, 40(6):703-709.DOI:10.19538/j.cjps.issn1005-2208.2020.06.18.
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韩智强, 尹毅青, 王凯元, 等. 肝内胆管癌术后生存预后预测列线图模型预后评估效能研究[J]. 中国实用外科杂志, 2025, 45(3):322-328,339.DOI:10.19538/j.cjps.issn1005-2208.2025.03.16.
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