Objective: To discuss the rationality of stage pT3 in the AJCC 8(th) TNM criteria of gallbladder carcinoma. Methods: A retrospective study was performed to analyze the clinical and pathological data of 88 patients with pT3 gallbladder carcinoma admitted to Department of Second Biliary Surgery of Eastern Hepatobiliary Surgery Hospital, affiliated to Naval Medical University from May 2013 to September 2018.pT3 stage tumors were divided into two groups: (1) pT3a stage: tumors had penetrated serosa but not directly invaded liver and/or an adjacent organ or structure; (2) pT3b stage: tumor penetrating serosa and directly invaded liver and/or an adjacent organ or structure. There were 45 patients with pT3a stage, including 15 males and 30 females, aged 36 to 80 years, with a median age of 59 years; 43 patients with pT3b, including 24 males and 19 females, aged 41 to 78 years old, median aged 63 years old.Patients with pT3a and pT3b were further divided into two groups respectively: radical resection group and extended radical resection group according to surgical radicalization. Independent sample t-test was used for comparison between two groups with normal distribution measurement data. Wilcoxon rank sum test was used between groups of non-normally distributed measurement data.The comparison of the count data was performed by χ(2) test or Fisher exact probability method. Survival analysis was performed using Kaplan-Meier method, and survival rate was compared using Log-rank test. Results: (1)Serum total bilirubin(15.6(90.3)mmol/L), albumin(40.2(4.8)mmol/L), and CA19-9(132.90(455.78)U/ml) levels in pT3b patients were higher than that in pT3a patients(10.2(6.8)mmol/L, 41.8(4.9)mmol/L, 14.35(36.27)U/ml), respectively(Z=-3.816, -1.966, -3.739, all P<0.05),postoperative complication rate in pT3b patients(24.4%) was higher than that in pT3a patients(8.9%)(P<0.05),postoperative hospital stay(12(7)days) and overall hospital stay((26±17)days) of pT3b patients were longer than that of pT3a patients((10±5) days and (19±7)days) (P<0.05). (2) The 1-, 3-, 5-year survival rates of pT3b and pT3a patients were 53%,22%,22% and 69%, 46%,38%,and the median survival time was 13 months and 26 months, respectively. The difference in survival rates between the two groups was statistically significant(χ(2)=5.117, P=0.024). (3)The 1-, 3-year survival rates of extended radical resection group(n=19) and radical resection group(n=24) in the pT3b stage were 73%, 36% and 28%, 7%, respectively.The survival time was 20 months and 9 months,respectively,and the difference in survival rates between the two groups was statistically significant(χ(2)=4.976, P=0.026). Conclusions: pT3 gallbladder carcinoma could be further subdivided into pT3a stage and pT3b stage based on the TNM criteria of AJCC 8(th) gallbladder carcinoma. Extended radical resection for pT3b gallbladder carcinoma should be further considered after comprehensive assessment of the patient's basic condition and surgical tolerance.
目的： 探讨AJCC第8版胆囊癌TNM分期中pT3期分期的合理性。 方法： 回顾性收集2013年5月至2018年9月海军军医大学东方肝胆外科医院胆道二科收治的88例pT3期胆囊癌患者的临床和病理学资料。将pT3期进一步分为：（1）pT3a期：肿瘤穿透浆膜，但未直接侵入肝脏和（或）一个邻近器官或结构；（2）pT3b期：肿瘤穿透浆膜且直接侵入肝脏和（或）一个邻近器官或结构。pT3a期患者45例，其中男性15例，女性30例，年龄36~80岁，中位年龄59岁；pT3b期患者43例，其中男性24例，女性19例，年龄41~78岁，中位年龄63岁。根据手术根治情况将pT3a期和pT3b期患者进一步分为胆囊癌根治术组和胆囊癌扩大根治术组。符合正态分布计量资料的组间比较采用独立样本t检验；不符合正态分布计量资料的组间比较采用Wilcoxon秩和检验。计数资料的比较采用χ(2)检验或Fisher确切概率法。生存分析采用Kaplan-Meier法，生存率的比较采用Log-rank检验。 结果： （1）pT3b期患者的血清总胆红素[15.6（90.3）mmol/L]、白蛋白[40.2（4.8）mmol/L]、CA19-9[132.90（455.78）U/ml]水平高于pT3a期患者[10.2（6.8）mmol/L、41.8（4.9）mmol/L、14.35（36.27）U/ml]（Z=-3.816、-1.966、-3.739，P值均<0.05），pT3b期患者术后并发症发生率（24.4%）高于pT3a期患者（8.9%）（P<0.05），术后住院时间[12（7）d]和总体住院时间[（26±17）d]长于pT3a期患者[（10±5）d和（19±7）d]（P值均<0.05）。（2）pT3b和pT3a期患者的1、3、5年累积生存率分别为53%、22%、22%和69%、46%、38%，中位生存时间分别为13个月和26个月，两组生存率的差异有统计学意义（χ(2)=5.117，P=0.024）。（3）pT3b期患者中行胆囊癌扩大根治术患者（n=19）和胆囊癌根治术患者（n=24）的1、3年累积生存率分别为73%、28%和36%、7%，中位生存时间分别为20个月和9个月，两组生存率的差异有统计学意义（χ(2)=4.976，P=0.026）。 结论： pT3期胆囊癌在AJCC第8版胆囊癌TNM分期的基础上可进一步细分为pT3a期和pT3b期。将pT3b期胆囊癌患者的基础状况、手术耐受情况等综合评估后可选择合适的患者行胆囊癌扩大根治术。.
Keywords: Extended radical resection of gallbladder carcinoma; Gallbladder neoplasms; Neoplasm staging; Radical resection of gallbladder carcinoma; TNM staging.