背景在胆囊癌(GBC),如果检测到胆囊管边缘(CDM)的大体直接延伸或显微镜受累,则选择性进行肝外胆管(EHBD)切除术。尽管CDM通常在大多数中心进行术中冷冻活检,没有关于CDM冷冻活检常规使用的研究,无论肿瘤位置如何,也没有关于CDM状态对GBC无复发和总生存期影响的文献.GBC中阻塞性黄疸的存在通常表明EHBD或胆囊管-胆管交界处受累。本研究旨在分析无黄疸可切除GBC患者行常规CDM冷冻活检的必要性,无论肿瘤的位置。还评估了积极的CDM对生存的影响。方法2009年5月至2021年3月进行回顾性观察性病例对照研究,纳入105例可切除GBC患者,无肉眼可见EHBD浸润和黄疸。患者分为CDM阴性(n=91)和CDM阳性(n=14)组。对绩效状态、肿瘤大小,肿瘤淋巴结转移(TNM)分期,和辅助化疗。在倾向得分匹配后,纳入27例患者(CDM阴性=13,CDM阳性=14)。主要结果是分析常规CDM冷冻活检的作用,无论肿瘤位置如何,次要结局是研究CDM阳性状态对生存的影响,并评估CDM阳性的预测因素.进行亚组分析以评估肿瘤解剖位置的临床病理特征和结果。结果105例患者中,91的CDM为阴性,14个有积极的CDM。在14例CDM阳性患者中,只有一名患者的眼底/身体有肿瘤,其余的肿瘤累及颈部.所有CDM阳性患者均接受胆管切除术和肝空肠吻合术。在最终的组织病理学检查中,CDM阳性的患者中有50%存在胆总管(CBD)受累。在匹配的人群中,CDM阳性患者的颈部肿瘤发生率明显较高(p=0.001).无复发生存率(24vs.12个月,p=0.30)和总生存率(24.5vs.20个月,p=0.417)在CDM阴性组和CDM阳性组之间具有可比性,分别。在多变量分析中,术前和术中肿瘤位置是CDM阳性的独立预测因素.关于子群分析,30例肿瘤累及胆囊颈部,剩下的75个在胆囊的底部和身体。颈部肿瘤的无复发生存率较低(17vs.30个月,p=0.012)和总生存率(24vs.36个月,p=0.048)与非颈部肿瘤相比。结论对无黄疸的可切除GBC患者常规使用CDM冰冻分析,不管肿瘤的位置,可以避免。由于发现肿瘤位置是CDM阳性的独立预测因素,因此在涉及颈部的GBC患者中可以选择性地首选。积极的CDM与消极的CDM具有可比的生存结果,提供相似的R0切除率和肿瘤分期。然而,颈部肿瘤比非颈部肿瘤预后差。
Background In gallbladder cancer (GBC), extrahepatic bile duct (EHBD) resection is selectively performed if gross direct extension or microscopic involvement of the cystic duct margin (CDM) is detected. Although CDM is usually sent for frozen biopsy intraoperatively in most centers, there are no studies regarding the routine use of CDM frozen biopsy irrespective of the tumor location and paucity of literature regarding the impact of CDM status on recurrence-free and overall survival in GBC. The presence of obstructive jaundice in GBC usually indicates the involvement of EHBD or cystic duct-bile duct junction. The present study aimed to analyze the necessity of routine CDM frozen biopsy in patients with resectable GBC without jaundice, regardless of the tumor location. The impact of positive CDM on survival was also evaluated. Methods This retrospective observational
case-control study was conducted from May 2009 to March 2021 and included 105 patients with resectable GBC without macroscopic EHBD infiltration and jaundice. Patients were divided into CDM-negative (n=91) and CDM-positive (n=14) groups. Propensity score matching was performed for variables such as performance status, tumor size, tumor-node-metastasis (TNM) stage, and adjuvant chemotherapy. After propensity score matching, 27 patients (CDM-negative=13, CDM-positive=14) were included. The primary outcome was to analyze the role of routine CDM frozen biopsy regardless of tumor location, and secondary outcomes were to study the impact of positive CDM status on survival and evaluate predictive factors for CDM positivity. A subgroup analysis was conducted to assess clinicopathologic characteristics and outcomes of the anatomical location of the tumor. Results Of 105 patients, 91 had negative CDM, and 14 had positive CDM. Among 14 patients with positive CDM, only one patient had a tumor in the fundus/body, and the remaining had a tumor involving the neck. All CDM-positive patients underwent bile duct excision with hepaticojejunostomy. Common bile duct (CBD) involvement was present in 50% of patients with positive CDM in the final histopathological examination. In the matched population, patients with positive CDM had a significantly higher rate of neck tumors (p=0.001). Recurrence-free survival (24 vs. 12 months, p=0.30) and overall survival (24.5 vs. 20 months, p=0.417) were comparable between CDM-negative and CDM-positive groups, respectively. On multivariate analysis, preoperative and intraoperative tumor location were independent predictive factors for CDM positivity. On subgroup analysis, 30 patients had tumor involving the neck of the gallbladder, and the remaining 75 had at the fundus and body of the gallbladder. Neck tumors had inferior recurrence-free survival (17 vs. 30 months, p=0.012) and overall survival (24 vs. 36 months, p=0.048) compared to non-neck tumors. Conclusions Routine use of CDM frozen analysis in patients with resectable GBC without jaundice, regardless of tumor location, can be avoided. It can be selectively preferred in patients with GBC involving the neck since tumor location is found to be an independent predictive factor for CDM positivity. Positive CDM has comparable survival outcomes to negative CDM, providing a similar R0 resection rate and tumor stage. However, neck tumors have a worse prognosis than non-neck tumors.