Improved survival in resected biliary malignancies
Improved survival in resected biliary malignancies
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DOI：
10.1067/msy.2002.127555
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发表时间：
2002-10-01
期刊：
影响因子：
3.8
通讯作者：
Pitt, HA
中科院分区：
文献类型：
--
作者：
Nakeeb, A;Tran, KQ;Pitt, HA
背景。多年来，胆道恶性肿瘤患者的预后一直很差。然而，放射学和腹腔镜的最新进展改善了分期，积极的胆道支架治疗可能改善这些患者的预后。在过去，手术的目标是切除所有的肿瘤。现在，手术的目标是达到阴性的镜下边缘，即使需要大的肝脏切除术。同样，化疗或放疗也经常单独进行，但放化疗已成为标准。因此，本分析的目的是确定更好的分期、积极的支架管理、更积极的手术和放化疗是否提高了生存率。从1990年到2001年，140名胆道恶性肿瘤患者在威斯康辛医学院接受了治疗。111例恶性肿瘤为胆管癌（肝内22%，门周65%，远端13%），29例为胆囊癌（GB）。140例患者中有86例（61%）接受了探查（肝内，58%；门周，57%；远端，67%，GB, 72%）。86例患者中有44例（51%）接受了切除（肝内64%，门周41%，远端70%，GB 52%）。自1998年以来，共聚焦放化疗、5-氟尿嘧啶和吉西他滨在切除的患者中应用较多。30天手术死亡率为4%。在切除的患者（n = 44）中，5年精算生存率为31%，中位生存期为27.8个月。1998年至2001年间切除的患者（n = 25）的中位生存期超过44个月，3年精算生存率为70%，而1990年至1997年间切除的患者（n = 19）的中位生存期为13个月，3年精算生存率为21% （P < 0.01）。这些数据表明：(1)大约三分之一的胆道恶性肿瘤患者有可切除的疾病，(2)对精心选择的患者进行辅助放化疗手术可提高切除患者的生存率。我们推测，改善的分期、积极的胆道支架置入术、安全但广泛的手术以获得负切缘以及更新的放化疗技术的结合，已经改善了胆道恶性肿瘤患者的预后。
Background. For many years the prognosis for patients with biliary malignancies has been poor. However, recent advances in radiology and laparoscopy have improved staging, and active biliary stent management may improve outcome in these patients. In the past the goal with surgery was to excise all gross tumor. Now, the surgical goal is to achieve negative mocroscopic margins even if a major hepatic resection is required. Similarly, chemotherapy or radiation was frequently given in isolation, but chemoradiation has become the standard. Therefore, the aim of this analysis was to determine whether survival has improved with better staging, active stent management, more aggressive surgery, and chemoradiation.Methods. From 1990 through 2001, 140 patients with biliary malignancies were treated at the Medical College of Wisconsin. One hundred eleven malignancies were cholangiocarcinomas (intrahepatic, 22%; perihilar, 65%; and distal, 13%), and 29 were gallbladder (GB) cancers. Eighty-six of the 140 patients (61%) underwent exploration (intrahepatic, 58%; perihilar, 57%; distal, 67%, and GB, 72%). Forty-four of these 86 patients (51%) underwent resection (intrahepatic, 64%; perihilar, 41%; distal, 70%; and GB, 52%). Chemoradiation with confocal radiation, 5-fluorouracil, and gemcilabine was used more frequently in the patients resected since 1998.Results. Thirty-day operative mortality was 4%. In the resected petients (n = 44) the 5-year actuarial survival was 31% and the median survival was 27.8 months. Patients resected between 1998 and 2001 (n = 25) had a median survival longer than 44 months with a 3-year actuarial survival of 70% as compared to patients resected between 1990 and 1997 (n = 19), who had a median survival of 13 months and a 3-year actuarial survival of 21% (P < .01).Conclusions. These data suggest that (1) approximately one third of patients with biliary malignancies have resectable disease and (2) surgery in carefully selected patients with adjuvant chemoradiation has improved survival in resected patients. We suspect that a combination of improved staging, active biliary stenting, safe but extensive surgery to obtain negative margins, and newer techniques for chemoradiation have resulted in improved outcomes for patients with biliary malignancies.