美國《臨床腫瘤雜誌》2017年10月6日在線先發

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

「腫瘤人文」欄目ART OF ONCOLOGY

肝門膽管癌的倖存者

一天下午，天灰濛濛、淅瀝瀝下著雨，隨著一陣電話鈴聲響起，故事開始了，電話是我的一位同事打來的，這位同事是社區醫院的一名外科主治醫師，這家醫院位於我們城鎮密集區周邊，屬於社會資源極度匱乏的區域。他在電話中說，「嗨，我這兒有一位63歲無痛性梗阻性黃疸患者，做了CT檢查，顯示是一個小的肝門部膽管癌Klatskin瘤，你治療這樣的病人嗎？還是我把他轉診給肝臟移植的外科大夫？」我跟他說我願意接手這個病人，並安排到我們病區進行治療。經皮放置膽道外引流管后，他的黃疸消失了。我們的腫瘤專家組仔細審閱了入院時的CT、磁共振血管造影和經膽道引流管造影檢查結果等其它信息，結論是患者的Klatskin瘤累及右前、后肝管匯合區，可以手術。

我跟患者交待病情，向他解釋到，雖然我有豐富的肝臟手術經驗，患者預后也不錯，但做的Klatskin瘤切除手術並不多，而且幾乎沒有醫生報道過手術切除的大宗病例，因為大多數病人是不可切除的Klatskin瘤。我主動提出把他轉診到肝移植中心，他說對於他和他的家人來說，在我們醫院呆了這麼久的時間后，並不覺得去第三家醫院是個好建議，他讓我繼續安排下一步的治療。

我為他做了擴大右肝切除術（現在稱為右肝三分區切除術），並切除了肝尾狀葉和肝外膽道分支，並通過Roux環進行重建。術后恢復順利，我寫信給病人的家庭醫生，說他的治療很順利，但組織學結果不是很好，是pT2、pN0、M0肝門膽管癌，手術切緣凈（R0），有神經和血管周圍浸潤。

2001年，肝門膽管癌切除術后並沒有輔助化療的要求，因此我繼續做病人診療的主診醫生。3、6、9個月的CT複查無複發跡象。手術后大約12個月的時候，一切都好，我承認當時我對他的隨訪失去了興趣，因為即使癌症複發，我也做不了什麼了。因此，這個階段，定期複查是由專科護士和高年資住院醫師安排來做的。

接下來幾年，我不常遇到他，直到第5年隨訪時我才關注到他這個病例。因為膽管癌手術切除后複發雖然常見，但並不是非常普遍，並且偶爾有的病人會出乎意料地好於預期，儘管如此，Klatskin瘤肝切除術后5年無複發並不常見，因此我對這個病例安排了一個全面檢查，包括對原始標本獨立的組織病理學檢查、胸腹部和骨盆CT掃描、PET-CT。腫瘤專家組及時收到報告，原先的組織病理學報告正確，而且掃描結果顯示沒有任何複發跡象。

雖然很難說出具體時間，但就是這段時間裡，我意識到有些東西不尋常，有點特別。就像我對待其他病人一樣，我開始期待著和他每年一次的見面，裡面夾雜著複雜的情緒、忐忑不安，既擔心他可能複發，又滿懷期待地要看到他、了解他的生活。與以往不同的是，見過他之後，我就會變得心情愉悅、步履輕盈。我認真思考過為什麼我會有這種心態，可以解釋為，如果我能夠幫助這個人讓他的生活變得有一點點不一樣的話，那麼我可以同樣幫助我診所里的其他癌症病人，當我接診其他癌症患者時，我回想起這個病例，這樣我就會採用同樣的方法，事實就是、務實且樂觀。

時光流逝，他狀態依然很好。手術10周年之際，我說，我們現在應該停止常規隨訪了，他73歲，狀態很好（除了可能有新發前列腺癌，但目前正處於臨床監測中），膽管癌不太可能複發。他說，他發現每年的隨訪能讓他極為寬心，因此我同意對他繼續隨訪。

幾周前，第16個年頭的隨訪時我見到他，仍然很好。當我第一次遇到他時，我們兩個誰也沒有想到，手術后這麼長時間他依然硬朗。這樣的病人並非個案，這要得益於現代多學科治療，使這樣的故事愈發常見，我的病人生動地展現了癌症手術后長期生存的震撼力。對於個人，極為重要的是讓被癌症擾亂的生活逐漸歸於平靜、繼續前行，這也是腫瘤外科的終極目的；這個案例還表明，癌症手術后的長期生存並不單單病人獲益，還使得不斷進取的外科醫生及其團隊終身受益。老實說，還有一點要承認的是，儘管我們已經掌握了大量的腫瘤生物學知識，但仍不完備（例如，這個病例長期生存的原因是什麼？我們能否找到讓其他病人也獲益的一些因素？），或許最重要的是，我們可以從這樣的病例中受到鼓舞，極力將其他癌症患者儘可能多地轉變為長期生存者。

《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.

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