第一部分 123例肝内胆管癌手术切除后的生存分析

【目的】研究影响手术切除后的肝内胆管癌患者预后的相关因素。

【方法】收集整理本院1999年1月至2015年6月行外科手术切除且获得随访的123例肝内胆管癌病例的临床及病理资料。用Kaplan-Meier法计算生存率，Log-rank法进行生存曲线比较，卡方检验或Fisher精确检验进行各临床病理因素间相关性比较，Cox回归模型进行多因素分析。

【结果】123例患者的中位随访时间为22个月，中位无复发生存时间9.0个月。1年、2年、3年的复发率分别为58.6%、68.9%、76.5%。单因素分析显示：对于无复发生存时间，术前化验指标（GGT、ALP、CEA）、手术切缘状态、病灶个数、肿瘤最大直径、淋巴结转移、侵犯肝外组织、神经侵犯、坏死、 黏液等因素差异具有显著性（P<0.05）。Cox回归多因素分析显示术前CEA升高，淋巴结转移，多个病灶，肿瘤侵犯肝外组织，肿瘤合并坏死是影响肝内胆管癌患者术后无复发生存时间的显著性不良预后因素（P＜0.05）。123例患者的中位总生存时为21.2个月，1年、3年、5年总生存率分别为76.6%、33.2%、26.1%。单因素分析显示：对于总生存时间，术前化验指标（GGT、ALP、CEA）、手术切缘状态、病灶个数、肿瘤最大直径、淋巴结转移、侵犯肝外组织、神经侵犯、 黏液等因素差异具有显著性（P<0.05）。Cox回归多因素分析显示术前CEA升高，淋巴结转移，多个病灶，肿瘤侵犯肝外组织是影响肝内胆管癌患者术后总生存时间的显著性不良预后因素（P＜0.05）。进一步将全部病例拆分为CEA正常组和CEA升高组进行生存分析，结果显示对于CEA正常组，ALP升高亦是术后无复发生存时间及总生存时间的显著性不良预后因素。对于CEA升高组多个病灶可能为无复发生存时间的显著性不良预后因素，肿瘤累及肝被膜可能是术后总生存时间的显著性不良预后因素。

【结论】术前CEA升高、淋巴结转移、肿瘤多灶及肿瘤侵犯肝外组织是手术切除后肝内胆管癌的无复发生存时间及总生存时间的显著性不良预后因素。对于CEA正常的亚组患者，ALP升高亦是影响无复发生存时间及总生存时间的不良预后因素。

【关键词】肝内胆管癌；手术切除；生存分析；CEA；

第二部分 肝内胆管癌中Beclin 1、ARID1A、IDH1和CA9的表达情况及临床意义

【目的】研究Beclin 1、ARID1A、IDH1和CA9在肝内胆管癌中表达情况及临床意义

【方法】以“临床研究”部分涉及的123例肝内胆管癌病例为基础，挑选出其中石蜡标本保存完好的113例，通过免疫组化染色的方法研究Beclin 1、ARID1A、IDH1和CA9的表达情况，并进一步分析其与各临床病理因素及预后的关系。

【结果】Beclin 1低表达48例，高表达65例。ARID1A阴性36例，阳性77例。IDH1阴性8例，阳性105例。CA9阴性17例，阳性96例。染色结果与各临床病理因素相关性分析显示Beclin 1与肿瘤最大径相关，ARID1A与肿瘤累及肝外组织相关，IDH1与术前CA19-9相关，CA9与淋巴结转移及神经受侵相关。113例患者的中位无复发生存时间9.0个月。1年、2年、3年的复发率分别为59.4%、69.8%和77.2%。单因素分析显示：Beclin 1及ARID1A表达水平、术前化验指标（GGT、ALP、CEA）、切缘状态、病灶个数、肿瘤最大直径、淋巴结转移、侵犯肝外组织、坏死和 黏液因素与无复发生存时间具有显著相关性（P<0.05）。中位总生存时间为20.3个月。1年、3年、5年总生存率分别为75.4%、30.8%和23.3%。单因素分析显示，Beclin 1表达水平、术前化验指标（GGT、ALP、CEA）、切缘状态、病灶个数、肿瘤最大直径、淋巴结转移、侵犯肝外组织、神经侵犯、肿瘤大体分型、 黏液因素与总生存时间具有显著相关性（P<0.05）。此外，Beclin 1和ARID1A表达程度呈正相关。Cox回归多因素分析显示Beclin 1高表达和ARID1A阳性表达是影响肝内胆管癌患者术后无复发生存时间及总生存时间的显著性不良预后因素。IDH1和CA9的表达情况与无复发生存时间及总生存时间均不相关。

【结论】Beclin 1高表达及ARID1A阳性是影响肝内胆管癌患者术后无复发生存时间及总生存时间的显著性不良预后因素。

【关键词】肝内胆管癌；Beclin 1；ARID1A；IDH1；CA9；

PartⅠ Survival analysis of 123 intrahepatic cholangiocarcinoma patients following surgical resection

【Objective】To investigate the prognostic factors of intrahepatic cholangiocarcinoma following surgical resection.

【Methods】Clinical and pathological data of 123 patients who underwent surgical resection for intrahepatic cholangiocarcinoma between January 1999 and June 2015 in our hospital was collected. Survival rate was calculated with Kaplan-Meier method. The Log - rank method was used for comparing survival curves. Correlation between clinicopathological factors was analysed with Chi-square test or Fisher's exact test. Cox regression model was used for multiple factors analysis.

【Results】 Median follow-up time of 123 patients was 22 months and median recurrence-free survival time was 9.0 months .One year, 2 years and 3 years recurrence rate were 58.6%,68.9% and 76.5%. Univariate analysis revealed that factors associated with postoperative recurrence-free survival were preoperative laboratory test results of GGT, ALP and CEA, surgical margin, numbers of lesions, maximum diameter of tumor ,lymph node metastasis, invasion of extrahepatic tissues ,invasion of nerves, necrosis and mucus(P<0.05). Cox multivariate analysis revealed that preoperative rise in CEA , lymph node metastasis , multiple lesions, invasion of extrahepatic tissues and necrosis of the tumor were significant adverse prognostic factors of postoperative recurrence-free survival(P<0.05). Median overall survival time was 21.2 months. One year, 3 years and 5 years overall survival rate were 76.6%,33.2% and 26.1%. Univariate analysis revealed that factors associated with postoperative overall survival were preoperative laboratory test results of GGT, ALP and CEA, surgical margin, numbers of lesions, maximum diameter of tumor ,lymph node metastasis , invasion of extrahepatic tissues ,invasion of nerves,necrosis and mucus(P<0.05). Cox multivariate analysis revealed that preoperative rise in CEA, lymph node metastasis , multiple lesions and invasion of extrahepatic tissues were significant adverse prognostic factors of postoperative overall survival(P<0.05).

All 123 cases were then divided into two groups with normal and high CEA.Futher analysis revealed that preoperative rise in ALP was also a significant adverse prognostic factor of postoperative recurrence-free survival and overall survival for normal CEA group.For high CEA group,multiple lesions may be the significant adverse prognostic factor of postoperative recurrence-free survival ,and invasion of liver capsule may be the  significant adverse prognostic factor of postoperative overall survival.

【Conclusion】Preoperative rise in CEA, lymph node metastasis , multiple lesions and invasion of extrahepatic tissues were significant adverse prognostic factors of postoperative recurrence-free survival and overall survival for intrahepatic cholangiocarcinoma patients who underwent surgical resection. For patients with normal CEA, preoperative rise in ALP was also a significant adverse prognostic factors of postoperative recurrence-free survival and overall survival.

【Key words】:intrahepatic cholangiocarcinoma, surgical resection, survival analysis, CEA

PartⅡ Expression and clinical significances of Beclin 1,ARID1A,IDH1 and CA9 in intrahepatic cholangiocarcinoma

【Objective】To investigate expression and clinical significances of Beclin 1,ARID1A,IDH1 and CA9 in intrahepatic cholangiocarcinoma

【Methods】Based on data of clinical research of 123 cases,we seclected 113 well-preserved paraffin-embedded specimens. Through immunohistochemical staining method, we check expression of Beclin 1,ARID1A,IDH1 and CA9,and then further analyze the correlation between immunohistochemical results,clinicopathological factors and prognosis.

【Results】 For Beclin 1,48 samples presented low expression while 65 samples presented high expression. For ARID1A,36 samples presented negative expression while 77 samples presented positive expression. For IDH1,8 samples presented negative expression while 105 samples presented positive expression. For CA9,17samples presented negative expression while 96 samples presented positive expression. Expression of Beclin 1 was correlated with maximum diameter of tumor. ARID1A was correlated with invasion of extrahepatic tissues..IDH1 was correlated with preoperative CA19-9. CA9 was correlated with lymph node metastasis and invasion of nerves. Median recurrence-free survival time of 113 patients was 9.0 months. One year, 2 years and 3 years recurrence rate were 59.4%,69.8% and 77.2%, respectively. Univariate analysis revealed that factors associated with postoperative recurrence-free survival were the expression levels of Beclin1 and ARID1A, preoperative laboratory test results of GGT, ALP and CEA, surgical margin , numbers of lesions, maximum diameter of tumor ,lymph node metastasis , invasion of extrahepatic tissues , necrosis and mucus(P<0.05). Median overall survival time was 20.3 months , 1 year, 3 years and 5 years overall survival rate were 75.4%,30.8% and 23.3%, respectively.Univariate analysis revealed that factors associated with postoperative overall survival were the expression level of Beclin 1,preoperative laboratory test results of GGT,ALP and CEA,  surgical margin ,numbers of lesions, maximum diameter of tumor ,lymph node metastasis , invasion of extrahepatic tissues ,invasion of nerves,macroscopic type and mucus(P<0.05).The expression levels of Beclin 1 and ARID1A were positive correlated.Cox multivariate analysis revealed that high expression of Beclin 1 and positive expression of ARID1A both were significant adverse prognostic factors of postoperative recurrence-free survival and overall survical(P<0.05).Expression of IDH1 and CA9 were not correlated with postoperative recurrence-free survival and overall survical

【Conclusion】High expression of Beclin 1 and positive expression of ARID1A both were significant adverse prognostic factors of postoperative recurrence-free survival and overall survical in patients with intrahepatic cholangiocarcinoma after surgical resection.

【Key words】intrahepatic cholangiocarcinoma, Beclin 1,ARID1A,IDH1,CA9