美国《临床肿瘤杂志》2017年10月6日在线先发

http://ascopubs.org/doi/full/10.1200/JCO.2017.75.1586

“肿瘤人文”栏目ART OF ONCOLOGY

肝门胆管癌的幸存者

一天下午，天灰蒙蒙、淅沥沥下着雨，随着一阵电话铃声响起，故事开始了，电话是我的一位同事打来的，这位同事是社区医院的一名外科主治医师，这家医院位于我们城镇密集区周边，属于社会资源极度匮乏的区域。他在电话中说，“嗨，我这儿有一位63岁无痛性梗阻性黄疸患者，做了CT检查，显示是一个小的肝门部胆管癌Klatskin瘤，你治疗这样的病人吗？还是我把他转诊给肝脏移植的外科大夫？”我跟他说我愿意接手这个病人，并安排到我们病区进行治疗。经皮放置胆道外引流管后，他的黄疸消失了。我们的肿瘤专家组仔细审阅了入院时的CT、磁共振血管造影和经胆道引流管造影检查结果等其它信息，结论是患者的Klatskin瘤累及右前、后肝管汇合区，可以手术。

我跟患者交待病情，向他解释到，虽然我有丰富的肝脏手术经验，患者预后也不错，但做的Klatskin瘤切除手术并不多，而且几乎没有医生报道过手术切除的大宗病例，因为大多数病人是不可切除的Klatskin瘤。我主动提出把他转诊到肝移植中心，他说对于他和他的家人来说，在我们医院呆了这么久的时间后，并不觉得去第三家医院是个好建议，他让我继续安排下一步的治疗。

我为他做了扩大右肝切除术（现在称为右肝三分区切除术），并切除了肝尾状叶和肝外胆道分支，并通过Roux环进行重建。术后恢复顺利，我写信给病人的家庭医生，说他的治疗很顺利，但组织学结果不是很好，是pT2、pN0、M0肝门胆管癌，手术切缘净（R0），有神经和血管周围浸润。

2001年，肝门胆管癌切除术后并没有辅助化疗的要求，因此我继续做病人诊疗的主诊医生。3、6、9个月的CT复查无复发迹象。手术后大约12个月的时候，一切都好，我承认当时我对他的随访失去了兴趣，因为即使癌症复发，我也做不了什么了。因此，这个阶段，定期复查是由专科护士和高年资住院医师安排来做的。

接下来几年，我不常遇到他，直到第5年随访时我才关注到他这个病例。因为胆管癌手术切除后复发虽然常见，但并不是非常普遍，并且偶尔有的病人会出乎意料地好于预期，尽管如此，Klatskin瘤肝切除术后5年无复发并不常见，因此我对这个病例安排了一个全面检查，包括对原始标本独立的组织病理学检查、胸腹部和骨盆CT扫描、PET-CT。肿瘤专家组及时收到报告，原先的组织病理学报告正确，而且扫描结果显示没有任何复发迹象。

虽然很难说出具体时间，但就是这段时间里，我意识到有些东西不寻常，有点特别。就像我对待其他病人一样，我开始期待着和他每年一次的见面，里面夹杂着复杂的情绪、忐忑不安，既担心他可能复发，又满怀期待地要看到他、了解他的生活。与以往不同的是，见过他之后，我就会变得心情愉悦、步履轻盈。我认真思考过为什么我会有这种心态，可以解释为，如果我能够帮助这个人让他的生活变得有一点点不一样的话，那么我可以同样帮助我诊所里的其他癌症病人，当我接诊其他癌症患者时，我回想起这个病例，这样我就会采用同样的方法，事实就是、务实且乐观。

时光流逝，他状态依然很好。手术10周年之际，我说，我们现在应该停止常规随访了，他73岁，状态很好（除了可能有新发前列腺癌，但目前正处于临床监测中），胆管癌不太可能复发。他说，他发现每年的随访能让他极为宽心，因此我同意对他继续随访。

几周前，第16个年头的随访时我见到他，仍然很好。当我第一次遇到他时，我们两个谁也没有想到，手术后这么长时间他依然硬朗。这样的病人并非个案，这要得益于现代多学科治疗，使这样的故事愈发常见，我的病人生动地展现了癌症手术后长期生存的震撼力。对于个人，极为重要的是让被癌症扰乱的生活逐渐归于平静、继续前行，这也是肿瘤外科的终极目的；这个案例还表明，癌症手术后的长期生存并不单单病人获益，还使得不断进取的外科医生及其团队终身受益。老实说，还有一点要承认的是，尽管我们已经掌握了大量的肿瘤生物学知识，但仍不完备（例如，这个病例长期生存的原因是什么？我们能否找到让其他病人也获益的一些因素？），或许最重要的是，我们可以从这样的病例中受到鼓舞，极力将其他癌症患者尽可能多地转变为长期生存者。

《壹篇》孟祥志

Klatskin Tumor

Ajith K. Siriwardena

Ajith K. Siriwardena, Manchester Royal Infirmary and University of Manchester, Manchester, United Kingdom.

https://doi.org/10.1200/JCO.2017.75.1586

It started one rainy afternoon with a telephone call from a colleague, an attending surgeon at a community hospital on the periphery of our conurbation in an area of substantial social deprivation. He said, “Hi, I have a 63-year-old patient here with painless obstructive jaundice. He has a CT [computed tomography] scan that shows a small Klatskin tumor. Do you deal with these or should I send him on to a liver transplant surgeon?” I said I would accept the care of the patient and arranged for him to be transferred to our service. After percutaneous placement of external biliary drains, his jaundice resolved. Our tumor board reviewed the baseline CT and additional information in the form of magnetic resonance angiography and contrast studies through the biliary drains. The conclusion was that the patient had an operable Klatskin tumor involving the confluence of the right anterior and posterior hepatic ducts.

When I spoke to the patient, I explained to him that although I had a reasonable experience of liver surgery with good patient outcomes, I had done relatively little resectional surgery for patients with Klatskin tumors. I qualified this by saying that few surgeons report large numbers of resections, because most patients had unresectable disease. I offered to refer him to a liver transplant center. He said that travel time to our hospital was long enough for him and his family and he did not find the prospect of going to a third hospital an attractive proposition. He asked me to go ahead and schedule the procedure.

He underwent an extended right hepatectomy (now termed right trisectionectomy), together with excision of the caudate lobe of the liver and the extrahepatic biliary tree. Reconstruction was by a Roux loop. The postoperative course was uneventful and I wrote to the patient’s family practitioner that he had experienced a favorable course. The histology was not so favorable. He had a pT2, pN0, M0 perihilar cholangiocarcinoma that, although clear of the surgical resection margins (R0), showed both perineural and perivascular infiltration.

In 2001, there was no policy of adjuvant chemotherapy after resection of perihilar cholangiocarcinoma and so I continued to be the principal clinician in charge of the patient’s care. Surveillance CT scans at 3, 6, and 9 months showed no evidence of recurrence. At approximately 12 months out from surgery, I confess I rather lost interest in his follow-up because all appeared to be well and there would be little I could offer if the cancer recurred. So at this stage, regular surveillance scans were arranged and reviewed by specialist nurse practitioners and senior residents.

I met him infrequently over the next several years and thought nothing more about his case until about the occasion of his 5-year follow-up. Recurrence of cholangiocarcinoma after surgical resection is common but not universal and, occasionally, lead time bias may result in patients apparently doing well or better than expected. Still, an asymptomatic patient 5 years out from Klatskin liver resection was unusual and I arranged a comprehensive case review including independent histopathological review of the original specimen; CT scans of thorax, abdomen, and pelvis; and 18fluorodeoxyglucose positron emission tomography. The tumor board duly received notification that the original histopathology report was correct and that neither scan showed any evidence of recurrence.

Although it is difficult to be precise, it was around this time that I became aware there was something a little out of the ordinary and a bit special going on here. As with my other patients, I looked forward to our annual meetings with the typical mixture of trepidation over the possibility of his having recurrence and a happy anticipation to see him and hear about his life. The difference here was that there was also a subtle but definite spring in my step after meeting him. I reflected on this and it seemed that it was because if I could, in some little way, have been instrumental in making a difference for the better in this man’s life, then surely there were other patients with cancer in my clinic that I could equally help. I remembered his case when I approached other patients with cancer and I tried to use the same combination of honesty and realism infused with a little optimism.

Time went on and he remained uncannily well. At the 10th anniversary of the operation, I said we should now discontinue regular follow-up. He was 73 years old, clinically well (apart from a possible new prostate cancer, which was under a watchful wait policy), and it seemed unlikely that the cholangiocarcinoma would now recur. He said he found the annual follow-up to be tremendously reassuring and so I agreed to keep him on.

I saw him a few weeks ago for his 16th anniversary follow-up. He remained well. Little did either of us suspect back when I first saw him that he would still be going strong so long after his surgery. Although this patient’s story is not unusual and, thanks to modern multimodality treatment, this is the type of tale that is seen more frequently, my patient vividly illustrates the power of long-term survival after cancer surgery. For the individual, the effect of a life seemingly all at sea gradually regaining some order and progression is priceless and is at the heart of good oncologic surgical practice. This case also illustrates the less tangible but equally important impression that the benefits of long-term survival after cancer surgery are not all unidirectional. There is a life-enhancing benefit for the surgeon and his or her team in the ability to have made such a difference for the better. If we are honest with ourselves, there is also an acceptance that our knowledge of cancer biology, although substantial, is still so incomplete (eg, what was it about this case that led to long-term survival, and how can we isolate the factors responsible to benefit others?). Perhaps most importantly, we can take inspiration from this type of case to try to transform as many as possible of our other patients with cancer into long-term survivors.

《壹篇》（与桓兴医讯同步）系主要面向医务人员的公益性头条号，不以营利为目的，不进行任何有偿咨询和服务，不出售任何产品，与ASCO、CSCO等所有专业学会和机构没有任何关系和联系，也不代表任何官方学会发声。

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