"Extended" radical cholecystectomy for gallbladder cancer: long-term outcomes, indications and limitations.
"Extended" radical cholecystectomy for gallbladder cancer: long-term outcomes, indications and limitations.
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DOI：
10.3748/wjg.v18.i34.4736
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发表时间：
2012-09
影响因子：
4.3
通讯作者：
Y. Shirai;J. Sakata;T. Wakai;T. Ohashi;K. Hatakeyama
中科院分区：
文献类型：
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作者：
Y. Shirai;J. Sakata;T. Wakai;T. Ohashi;K. Hatakeyama
目的探讨胆囊癌扩大根治术的适应证和局限性。方法1982年至2006年145例胆囊癌根治性切除患者中，52例（36%）行扩大根治性胆囊切除术，包括胆囊、胆囊窝、肝外胆管和区域淋巴结（第一和第二梯队淋巴结组）的整块切除。对52例患者进行了回顾性分析，包括至少5年的随访。残留肿瘤状态判定为无残留肿瘤（R 0）或显微镜/肉眼可见残留肿瘤（R1-2）。根据美国癌症联合委员会癌症分期手册（第7版）记录病理学结果。结果原发肿瘤病理T1（pT 1）3例，pT 2 36例，pT 3 12例，pT 4 1例。23例患者有淋巴结转移; 11例有单个阳性淋巴结，4例有两个阳性淋巴结，8例有三个或更多个阳性淋巴结。3例pT 1肿瘤患者无淋巴结疾病，而49例pT 2或更晚期肿瘤患者中有23例（47%）有淋巴结疾病。1例患者在住院期间死亡以进行最终切除，院内死亡率为2%。所有52例患者在扩大根治性胆囊切除术后的5年和10年总生存率（OS）分别为65%和53%。OS根据pT分类（P < 0.001）和淋巴结状态（P = 0.010）而不同。3例pT 1肿瘤和29例pT 2肿瘤均存活5年以上。在1 - 2例pT 3肿瘤患者中，8例R1-2切除、远处转移或广泛肝外器官受累患者在切除后不久死亡。在其余4例pT 3患者中，有局限性肝扩散通过胆囊窝并接受了R 0切除术，2例存活超过5年，另1例存活4年2个月。唯一的pT 4肿瘤患者在切除后不久死于疾病。在23例淋巴结阳性患者中，11例存活超过5年，其中10例有中度淋巴结疾病（1个或2个阳性淋巴结）。结论扩大根治性胆囊切除术适用于pT 2肿瘤和部分pT 3肿瘤伴局限性肝侵犯，只要区域淋巴结病变程度不超过2个阳性淋巴结。广泛的pT 3疾病、pT 4疾病或明显的淋巴结疾病似乎超出了这种根治性手术的范围。
AIM To delineate indications and limitations for "extended" radical cholecystectomy for gallbladder cancer: a procedure which was instituted in our department in 1982. METHODS Of 145 patients who underwent a radical resection for gallbladder cancer from 1982 through 2006, 52 (36%) had an extended radical cholecystectomy, which involved en bloc resection of the gallbladder, gallbladder fossa, extrahepatic bile duct, and the regional lymph nodes (first- and second-echelon node groups). A retrospective analysis of the 52 patients was conducted including at least 5 years of follow up. Residual tumor status was judged as no residual tumor (R0) or microscopic/macroscopic residual tumor (R1-2). Pathological findings were documented according to the American Joint Committee on Cancer Cancer Staging Manual (7th edition). RESULTS The primary tumor was classified as pathological T1 (pT1) in 3 patients, pT2 in 36, pT3 in 12, and pT4 in 1. Twenty-three patients had lymph node metastases; 11 had a single positive node, 4 had two positive nodes, and 8 had three or more positive nodes. None of the three patients with pT1 tumors had nodal disease, whereas 23 of 49 (47%) with pT2 or more advanced tumors had nodal disease. One patient died during the hospital stay for definitive resection, giving an in-hospital mortality rate of 2%. Overall survival (OS) after extended radical cholecystectomy was 65% at 5 years and 53% at 10 years in all 52 patients. OS differed according to the pT classification (P < 0.001) and the nodal status (P = 0.010). All of 3 patients with pT1 tumors and most (29 of 36) patients with pT2 tumors survived for more than 5 years. Of 12 patients with pT3 tumors, 8 who had an R1-2 resection, distant metastasis, or extensive extrahepatic organ involvement died soon after resection. Of the remaining four pT3 patients who had localized hepatic spread through the gallbladder fossa and underwent an R0 resection, 2 survived for more than 5 years and another survived for 4 years and 2 mo. The only patient with pT4 tumor died of disease soon after resection. Among 23 node-positive patients, 11 survived for more than 5 years, and of these, 10 had a modest degree of nodal disease (one or two positive nodes). CONCLUSION Extended radical cholecystectomy is indicated for pT2 tumors and some pT3 tumors with localized hepatic invasion, provided that the regional nodal disease is limited to a modest degree (up to two positive nodes). Extensive pT3 disease, pT4 disease, or marked nodal disease appears to be beyond the scope of this radical procedure.