Cholangiocarcinoma or IgG4-Associated Cholangitis How Feasible It Is to Avoid Unnecessary Surgical Interventions?
Cholangiocarcinoma or IgG4-Associated Cholangitis How Feasible It Is to Avoid Unnecessary Surgical Interventions?
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DOI：
10.1097/sla.0b013e3182533a0a
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发表时间：
2012-12-01
影响因子：
9
通讯作者：
Malago', Massimo
中科院分区：
文献类型：
--
作者：
Lytras, Dimitrios;Kalaitzakis, Evangelos;Malago', Massimo
目的：评价三级肝胆胰（HPB）中心对疑似胆管癌（CCa）患者的诊断方法和治疗经验，重点是将IgG4相关性胆管炎（IAC）患者排除在不必要的大手术干预之外。 方法：2008年1月至2010年9月期间，通过HPB多学科小组会议，共有152例疑似CCa患者接受了评估。没有组织诊断的患者根据可能存在 IAC 作为潜在病理学进行手术或药物治疗。根据 IAC 的 HISORt（组织学、影像学、血清学、其他器官受累、治疗反应）标准对血清学、免疫染色和影像学进行审查和分析。 结果：104 名患者 (68%) 在诊断检查期间实现了组织诊断，而其余 48 名患者被归类为“高度可疑 CCa”(n = 35) 或“可能 IAC”(n = 13)。在接受手术的 16 名“高度怀疑 CCa”的患者中，病理结果显示 2 名患者分别患有 IAC (n = 1) 和良性慢性炎症性胆管狭窄 (n = 1)。在 13 名主要接受医疗治疗的“可能 IAC”患者中，最终诊断为 CCa（n = 3）和 IAC（n = 9），而 1 名患者没有确诊。血清IgG4诊断IAC的准确率达到60%。活检标本中 IAC 免疫染色的敏感性和特异性分别为 56% 和 89%。影像学特征表明 IAC 的敏感性、特异性和准确性分别为 75%、89% 和 83%。 75% 的 IAC 患者在转诊机构进行了初始影像学修改 (P = 0.009)，而孤立性狭窄 (P = 0.038)、胆道肿块 (P = 0.006) 和计算机断层扫描显示正常胰腺 (P = 0.01) 是区分 CCa 和 IAC 的具有统计学意义的参数。建立 IAC 诊断的平均时间为 12.4 个月（范围：2.5-32 个月）结论：CCa 和 IAC 之间的鉴别诊断要求高怀疑指数和低转诊门槛。需要平衡延迟诊断（尤其是 CCa）和避免 IAC 不必要的手术。成像特征可能对最佳管理最有帮助。
Objective: To evaluate the experience of a tertiary hepatopancreaticobiliary (HPB) center in the diagnostic approach and management of patients with suspicion of cholangiocarcinoma (CCa), focusing on excluding patients with IgG4-associated cholangitis (IAC) from unnecessary major surgical interventions.Methods: Between January 2008 and September 2010, a total number of 152 patients with suspicion of CCa underwent evaluation through a HPB multidisciplinary team meeting. Patients without tissue diagnosis were managed surgically or medically on the basis of probable presence of IAC as underlying pathology. Serology, immunostaining, and imaging were reviewed and analyzed according to the HISORt (Histology, Imaging, Serology, Other organ involvement, Response to therapy) criteria for IAC.Results: Tissue diagnosis during the diagnostic workup was achieved in 104 patients (68%), whereas the remaining 48 were classified as "highly suspicious for CCa" (n = 35) or as "probable IAC" (n = 13). Among 16 "highly suspicious for CCa" patients who underwent surgery, pathology revealed 2 patients harboring IAC (n = 1) and a benign chronic inflammatory biliary stricture (n = 1), respectively. Among the 13 patients with primarily medical management as "probable IAC," final diagnosis was CCa (n = 3) and IAC (n = 9), while 1 patient had no proven diagnosis. The accuracy of serum IgG4 for diagnosis of IAC reached 60%. Sensitivity and specificity of immunostaining for IAC in biopsy specimens were 56% and 89%, respectively. Imaging features suggesting IAC yielded sensitivity, specificity, and accuracy of 75%, 89%, and 83%, respectively. Initial imaging was revised at the referral institute in 75% of IAC patients (P = 0.009), while an isolated stricture (P = 0.038), a biliary mass (P = 0.006), and normal pancreas on computed tomography (P = 0.01) were statistically significant parameters for distinguishing between CCa and IAC. The mean time for establishing a diagnosis of IAC was 12.4 months (range: 2.5-32 months)Conclusions: Differential diagnosis between CCa and IAC mandates high index of suspicion and low threshold for referral in high volume institutes. The delayed establishment of diagnosis particularly for CCa needs to be balanced versus avoiding unnecessary surgery for IAC. Imaging features may be most helpful for optimal management.