栏目寄语
胆囊癌是胆道系统最常见的恶性肿瘤，具有症状隐匿、发展迅速、早期转移、预后极差的特点，被称为新的“癌中之王”。我国是胆囊癌的高发地区之一，发病率和病死率近年来都呈持续缓慢上升趋势。胆囊慢性炎症、胆囊结石、胆囊息肉等都是胆囊癌的危险因素，但是胆囊癌目前仍缺乏特异性和敏感性都较好的早期诊断手段，临床发现的胆囊癌多为中晚期。尽管医学科技不断发展，根治性手术切除仍是当前唯一可能治愈胆囊癌的手段，行之有效的系统性治疗方法依然还在不断探索寻找中。因此，深入开展胆囊癌的临床和基础研究能够帮助我们更好地应对此类恶性肿瘤。
上海交通大学医学院附属新华医院普外科肝胆胰中心长期以来致力于胆道疾病诊治难点的攻关，形成了普外科、上海市胆道疾病研究重点实验室、上海市胆道疾病研究中心、Ⅰ期临床研究病房等多位一体的转化医学研究体系。尤其在胆囊癌的基础和临床研究方面的科研水平位于国内外领先水准，相关成果发表SCI论文50余篇，其中包括NatureGenetics、GUT、Hepatology等国际顶尖学术期刊，并获得了包括科技部新药创制项目、国家自然科学基金重点项目、上海市启明星、浦江人才、上海市优秀学科带头人、上海市卫健委新优靑等在内的多项科研及人才项目。
本期关于胆囊癌的研究呈现了多个领域的新进展，涵盖了新辅助和辅助治疗、个性化药物筛选、术前诊断方法、新的化疗方案、免疫治疗以及分子水平的分析等方面。研究重点包括改善治疗效果、个性化治疗方案的探索，以及对胆囊癌发病机制的深入了解。因此，我们特别鸣谢西安交通大学第一附属医院肝胆外科耿智敏教授，上海交通大学附属新华医院普外科蔡浩医师、宋晓玲医师，以及上海市胆道疾病研究重点实验室翟杨杨研究员、汤秋义博士、张健硕士和周哲硕士做出的贡献！
欢迎各位同道与我们积极交流探讨，共同推动胆囊癌研究和诊治的进步！
龚伟
1.胆道恶性肿瘤的新辅助治疗和辅助治疗：进展和局限性（IF:11.5）
Wilbur HC, Soares HP, Azad NS. Neoadjuvant and adjuvant therapy for biliary tract cancer: Advances and limitations. Hepatology. Published online January 24, 2024.
新辅助治疗可以提高R0切除率，消灭微转移灶，改善患者预后，但目前BTC新辅助治疗数据有限，尚无标准方案，主要借鉴晚期BTC系统治疗方案。多项回顾性研究初步证明了BTC新辅助治疗的安全性和可行性，但多为小样本研究，且每项研究的纳入标准不同，其研究结果不具备统计学意义以指导临床实践。（1）少数前瞻性临床试验评估了BTC的新辅助治疗。基于GAP试验结果，开展了NEO-GAP试验探索白蛋白紫杉醇联合吉西他滨和顺铂（GAP方案）在具有高复发风险的肝内胆管癌新辅助治疗中的疗效，治疗响应率与无复发生存率与ABC-02研究结果相似，其结果并未体现出增加白蛋白紫杉醇的疗效，因此该项研究结果仅支持GAP方案作为BTC新辅助治疗可选方案，但并不支持作为首选方案。SWOG 1815研究结果也证明在吉西他滨联合顺铂标准方案（GC方案）中加入白蛋白紫杉醇并没有改善患者总生存期，验证了NEO-GAP试验的结果。（2）肝移植（LT）在治疗胆道恶性肿瘤中仍存在争议。少数研究表明经严格筛选的不可切除的肝外胆管癌或肝内胆管癌患者经过新辅助治疗后进行肝移植可以改善患者预后，对肝门部胆管癌是潜在可选的治疗方式，但在iCCA中效果欠佳；各项研究都存在一定的局限性，其研究结果并不能指导临床实践，仅在极少数中心开展并处于探索阶段。（3）当前多数的BTC新辅助化疗和放化疗的临床研究纳入了多种类型BTC的患者，通常是在单中心和单臂进行的。尽管在回顾性分析和早期临床试验中取得了成功，但新辅助治疗的方案需要大样本的III期临床研究来确定。BTC新辅助治疗正在进行中的临床研究包括新辅助化疗的欧洲多中心、随机对照的III期GAIN研究、新辅助化疗联合免疫治疗的DEBATE II研究等，预期结果将阐明新辅助方案的效果。（4）动脉内钇-90放射栓塞与化疗相结合可作为iCCA降期的方法之一。
辅助治疗具有降低和延迟术后复发，消灭残余微转移灶的潜力，是改善BTC术后生存的重要手段。各项荟萃分析及回顾性研究因其入组标准不同，导致了各种结果的出现，其研究结果尚不支持临床实践。（1）BILCAP研究是一项随机、对照的多中心III期临床研究，明确了BTC的术后辅助治疗首选方案，即卡培他滨单药方案，已获得多项指南的认可。（2）BTC辅助治疗临床研究数量有限，治疗方案仍然需要进一步深入开展大样本及多种心临床研究。（3）当前已开展多项辅助治疗临床研究，在BILCAP研究基础上，在肝外胆管癌根治术后，辅助卡培他滨VS吉西他滨+顺铂（GC）的随机、多中心、II期临床研究显示，两组患者的中位OS均为35.7个月并无显著性差异，对于不能耐受卡培他滨或卡培他滨禁忌症的患者，可选择GC方案。（4）S-1辅助治疗已在日本进行了多中心研究，可以作为亚洲患者的辅助治疗方案。（5）辅助放化疗方面，SWOG S0809多中心II期临床研究评估了辅助卡培他滨联合吉西他滨以及后序放疗联合卡培他滨的作用，初步结果证实了辅助CRT治疗的可行性，有待进一步开展III期临床研究。（6）BTC辅助治疗正在进行中的临床研究包括多中心、前瞻性、随机对照的ACTICCA-1III期研究，评估GC辅助治疗方案效果，预计将于2024年4月完成。
目前BTC新辅助治疗及辅助治疗的局限：（1）BTC是一种发病率相对较低的癌症，发病率每年仅为0.3-6/10万，早期诊断困难且异质性高是开展临床研究的局限之一。大型随机临床研究在罕见癌症中具有挑战性，同时在异质性疾病的患者群体中，小型研究常导致后续研究对照困难。（2）大多数研究包括所有类型BTC，iCCA、eCCA和GBC之间存在明显差异，包括发病率、分子改变和发病机制，肿瘤类型的异质性对指南推荐研究方案造成了一定限制。
BTC新辅助治疗及辅助治疗的未来方向：（1）NGS测序是探索分子靶向治疗的重要检测方法，尤其在iCCA中FGFR2及IDH-1的检测。（2）分子靶向药物作为单一治疗或联合治疗方案需要深入探索。（3）免疫治疗或免疫联合治疗方案作为新辅助和辅助治疗的作用需要进一步深入研究。（4）循环肿瘤DNA（ctDNA）检测可在辅助治疗中监测复发，具有重要意义。
本篇综述详细阐述并分析了BTC新辅助及辅助治疗的现状、研究进展、挑战与不足及未来发展方向。关于新辅助首选治疗方案需要进一步探索，包括分子靶向治疗、免疫治疗及联合治疗方案。另外，NGS测序、MSI/dMMR及ctDNA检测具有重要意义，可对BTC肿瘤生物学特性进行深入探索。在未来，全球医疗机构应通力合作，基于BTC的解剖及分子异质性，设计、实施多中心Ⅲ期临床试验，以探索BTC最佳围手术期治疗策略。
2.胆道恶性肿瘤患者源性类器官的个性化药物筛选及其临床应用（IF:14.3）
Ren X, Huang M, Weng W, Xie Y, Wu Y, Zhu S, Zhang Y, Li D, Lai J, Shen S, Lin J, Kuang M, Li X, Yu J, Xu L. Personalized drug screening in patient-derived organoids of biliary tract cancer and its clinical application. Cell Rep Med. 2023 Nov 21;4(11):101277
为了探讨BTC患者对化疗药物5-氟尿嘧啶和顺铂反应相关基因的转录组特征，作者对19个BTC PDOs进行了全基因组的转录组测序。结果显示，与5-FU中等反应组相比，“肿瘤凋亡”和“化疗敏感性”的基因在5-FU敏感的BTC PDOs中表达上调。值得注意的是，在这些基因中，TP73被报道是作为多种肿瘤的促化疗敏感因子。有趣的是，基因富集分析（GSEA）也表明Fanconi anemia 和ataxia-telangiectasia突变以及Rad3相关（ATR）通路是对5-FU敏感的潜在调节因子。此外，参与程序性细胞死亡和TP53调控的信号通路在顺铂敏感组中富集，而与耐药相关的基因，如DDL4和DNAJC12，在耐药组中表达上调。
最后，作者提出了由13个基因预测对5-FU的反应和17个基因来预测对顺铂的反应。利用SVM和NB模型，作者证实了这些基因面板在有效区分对化疗有效患者和化疗无效患者方面的特殊区分能力。本研究的发现强调通过从BTC PDOs中获得的生物标志物可以预测患者对5-氟尿嘧啶和顺铂的反应的内在潜力。
Ren等人的这项研究提供了一个有价值的BTC PDOs平台，它精确地重建了原发肿瘤的关键特征，并为预测患者的化疗反应提供了潜在的生物标志物。然而，尚存在以下几个问题有待进一步完善。首先，在BTC PDOs中，面临持续增殖的挑战，仅有23% PDOs能够维持短期增长。研究者们需要从临床标本培养、PDOs基因组和转录特征等方面做更深入的探索。其次，需要在更大规模的患者队列中验证化疗敏感的生物标志物的特异性和敏感性。这一步骤对于建立预测化疗反应的生物标志物在BTC精确医学中的临床意义和适用性至关重要。最后，越来越多的证据表明，肿瘤微环境（TME）如癌症相关成纤维细胞（CAFs）和免疫细胞，在决定药物反应中发挥了关键作用。因为目前不可切除BTC的治疗标准需要联合化疗（即顺铂-吉西他滨）和免疫检查点抑制剂（PDL1单抗），主要重点是确定长期治疗有效的生物标志物。然而，目前的BTC PDOs模型中缺乏TME成分，阻碍了TME靶向治疗的药物筛选和生物标志物的发现，需要在这个领域做更进一步的研究。
总之，利用病人来源的BTC PDOs研究为精确医学提供更为精准和有效的策略。这些模型为揭示肿瘤特征和个性化化疗药物筛选提供有效工具，为改善BTC患者的预后带来新的希望。
3.术前区分黄色肉芽肿性胆囊炎和胆囊癌的深度学习列线图：一种手术决策的新方法（IF: 7.7）
Zhang W, Wang Q, Liang K, Lin H, Wu D, Han Y, Yu H, Du K, Zhang H, Hong J, Zhong X, Zhou L, Shi Y, Wu J, Pang T, Yu J, Cao L. Deep learning nomogram for preoperative distinction between Xanthogranulomatous cholecystitis and gallbladder carcinoma: A novel approach for surgical decision. Comput Biol Med. 2023 Dec 1;168:107786.
摘要：The distinction between Xanthogranulomatous Cholecystitis (XGC) and Gallbladder Carcinoma (GBC) is challenging due to their similar imaging features. This study aimed to differentiate between XGC and GBC using a deep learning nomogram model built from contrast enhanced computed tomography (CT) scans. 297 patients were included with confirmed XGC (94) and GBC (203) as the training and internal validation cohort from 2017 to 2021. The deep learning model Resnet-18 with Fourier transformation named FCovResnet18, shows most impressive potential in distinguishing XGC from GBC using 3-phase merged images. The accuracy, precision and area under the curve (AUC) of the model were then calculated. An additional cohort of 74 patients consisting of 22 XGC and 52 GBC patients was enrolled from two subsidiary hospitals as the external validation cohort. The accuracy, precision and AUC achieve 0.98, 0.99, 1.00 in the internal validation cohort and 0.89, 0.92, 0.92 in external validation cohort. A nomogram model combining clinical characteristics and deep learning prediction score showed improved predicting value. Altogether, FCovResnet18 nomogram has demonstrated its ability to effectively differentiate XGC from GBC preoperatively, which significantly aid surgeons in making informed and accurate surgical decisions for XGC and GBC patients.
目前仅有两篇文献报道了CT影像组学在鉴别XGC和GBC中的应用，其中一项研究采用的基于随机森林的机器学习算法，但相较于深度学习诊断效能较低；另一项研究采用了基于CT的深度学习模型，但其样本量太少（仅40例）。
本研究的纳入标准为1、接受单纯胆囊切除或扩大胆囊切除的患者；2、病理证实为XGC或GBC。排除标准为1、术前接受胆囊减压，如ENBD、内镜胆道支架置入或经皮胆囊穿刺；2、术前未行增强CT检查；3、尽管病理报告了XGC或GBC，但胆囊壁增厚难以辨认。根据上述标准，共回顾性纳入浙大一附院的94例XGC患者和203例GBC患者作为训练集和内部验证集，按照8：2随机分配；纳入另外两家二级医院的22例XGC患者和52例GBC患者作为外部验证集。从样本量来看，该研究较既往研究有明显提升。
本研究采用深度学习的算法，将傅里叶变换和残差网络（ResNet）相结合，构建了一种全新的深度学习模型（FCovResnet18）。具体方法学上，采用ITK-SNAP软件进行图像分割。然后，将不同时相的CT图像融合成包含三通道的超级图像（采用OpenCV-Python软件库，通过行间插值算法调整成统一的大小）。在图像特征提取过程中，通过傅里叶变换，将图像分解成正弦和余弦分量，使得输入信号在空间域，而输出信号在频率域中，进而过滤掉不需要的噪声，提取有用的信息。将基于傅里叶变换的卷积（FConv）整合进ResNet框架，进而创新性地构建了本研究中的深度学习模型FCovResnet18。为解决XGC发病率低、样本量较小的问题，该研究在训练集中进行了数据增强操作：采用random rotation（角度从-10到10）、random resized crop（比例从0.95到1.05）以及random horizontal flip（50%翻转概率）在训练集中进行数据增强；采用加权随机采样器，平衡XGC和GBC数量不均衡的情况。最后，采用Adam优化器和交叉熵损失函数进行深度学习模型的训练。
FCovResnet18模型在内部验证集及外部验证集中均获得较好的诊断效能（在外部验证集中，准确度89%、精确度92%、曲线下面积92%）。以此模型为基础，结合临床信息，构建列线图，用于XGC和GBC的术前判断，使得预测价值得到进一步改善（XGC：86.4% vs. 81.8%；GBC：96.2% vs 92.3）。
该研究进一步体现了人工智能在疑难少见病例中的诊断优势，有望为XGC和GBC的术前鉴别，提供强有力的武器，可以更好地为外科手术决策提供依据。然而，尽管本研究采用了数据增强的算法来解决样本量较小的问题，但未来仍需尽可能纳入更多中心更多数目的XGC病例，从而增强模型的稳定性。此外，本研究在纳排过程中存在一定的选择偏倚，在排除标准中，XGC的患者更容易合并胆管炎，因此胆道减压的情形较多见，导致XGC的患者被剔除较多，未来需要进一步采用前瞻性研究方法，增强模型的可靠性
4.FOLFIRI方案联合贝伐珠单抗作为基于吉西他滨的化疗后晚期胆道癌的二线治疗（IF：4.7）
Roussot N, Vincent J, Palmier R, et al. FOLFIRI-bevacizumab as a second-line treatment for advanced biliary tract cancer after gemcitabine-based chemotherapy. Front Oncol. 2023;13:1293670. Published 2023 Nov 30.
摘要：Background: Advanced biliary tract cancer (BTC) has a poor prognosis. Gemcitabine with platinum chemotherapy was the standard first-line chemotherapeutic regimen until the recent addition of anti-PD-1/PD-L1 antibodies. After disease progression, the only second-line chemotherapy that has demonstrated a survival benefit versus supportive care is FOLFOX (folinic acid, fluorouracil, and oxaliplatin), with a modest benefit. This study aimed to assess the efficacy and safety of second-line FOLFIRI (folinic acid, fluorouracil, and irinotecan) combined with bevacizumab for advanced BTC. Methods: This single-center retrospective study enrolled patients with metastatic BTC (intrahepatic cholangiocarcinoma [ICC], extrahepatic cholangiocarcinoma [ECC], or gallbladder carcinoma) that progressed after first-line gemcitabine-based chemotherapy. FOLFIRI-bevacizumab was administered intravenously every 2 weeks [folinic acid 200 mg/m², fluorouracil 400 mg/m² (bolus), fluorouracil 2400 mg/m² (46-h continuous intravenous infusion), irinotecan 180 mg/m², and bevacizumab 5 mg/kg] until unacceptable toxicity, patient refusal, or disease progression. Results: Overall, 28 patients received the FOLFIRI-bevacizumab regimen after gemcitabine-based chemotherapy. The median overall survival (OS) was 9.0 months (95% CI 6.4-16.5). The OS rate was 39.3% (95% CI 24.8-62.3) and 10.7% (95% CI 3.7-32.1) at 12- and 24-months respectively. The median progression-free survival (PFS) was 5.2 months (95% CI 3.1-10.2) with FOLFIRI-bevacizumab. The PFS rates at 12 months and 24 months were 17.9% (95% CI 8.19-39.5] and 10.7% (95% CI 3.7-31.2), respectively. The overall response rate (ORR) to FOLFIRI-bevacizumab was 23.1%, with a disease control rate (DCR) of 69.3%. Grade 3-4 adverse events (sAE) were reported in 20 patients (71.4%) treated with FOLFIRI-bevacizumab. Conclusion: FOLFIRI-bevacizumab as a second-line treatment for advanced BTC after gemcitabine-based chemotherapy showed efficacy and safety with a promising tumor response rate in this retrospective single-center study.
Zhang Y, Zuo C, Li Y, et al. Single-cell characterization of infiltrating T cells identifies novel targets for gallbladder cancer immunotherapy. Cancer Lett. 2024;586:216675.
摘要：Gallbladder cancer (GBC) is among the most common malignancies of biliary tract system due to its limited treatments. The immunotherapeutic targets for T cells are appealing, however, heterogeneity of T cells hinds its further development. We systematically construct T cell atlas by single-cell RNA sequencing; and utilized the identified gene signatures of high_CNV_T cells to predict molecular subtyping towards personalized therapeutic treatments for GBC. We identified 12 T cell subtypes, where exhausted CD8+ T cells, activated/exhausted CD8+ T cells, and regulatory T cells were predominant in tumors. There appeared to be an inverse relationship between Th17 and Treg populations with Th17 levels significantly reduced, whereas Tregs were concomitantly increased. Furthermore, we first established subtyping criterion to identify three subtypes of GBC based on their pro-tumorigenic microenvironments, e.g., the type 1 group shows more M2 macrophages infiltration, while the type 2 group is infiltrated by highly exhausted CD8+ T cells, B cells and Tregs with suppressive activities. Our study provides valuable insights into T cell heterogeneity and suggests that molecular subtyping based on T cells might provide a potential immunotherapeutic strategy to improve GBC treatment.
Astier C, Ngo C, Colmet-Daage L, et al. Molecular profiling of biliary tract cancers reveals distinct genomic landscapes between circulating and tissue tumor DNA. Exp Hematol Oncol. 2024;13(1):2. Published 2024 Jan 8.
摘要：Biliary tract cancers (BTCs) are heterogeneous malignancies with dismal prognosis due to tumor aggressiveness and poor response to limited current therapeutic options. Tumor exome profiling has allowed to successfully establish targeted therapeutic strategies in the clinical management of cholangiocarcinoma (CCA). Still, whether liquid biopsy profiling could inform on BTC biology and patient management is unknown. In order to test this and generate novel insight into BTC biology, we analyzed the molecular landscape of 128 CCA patients, using a 394-gene NGS panel (Foundation Medicine). Among them, 32 patients had matched circulating tumor (ct) DNA and tumor DNA samples, where both samples were profiled. In both tumor and liquid biopsies, we identified an increased frequency of alterations in genes involved in genome integrity or chromatin remodeling, including ARID1A (15%), PBRM1 (9%), and BAP1 (14%), which were validated using an in-house-developed immunohistochemistry panel. ctDNA and tumor DNA showed variable concordance, with a significant correlation in the total number of detected variants, but some heterogeneity in the detection of actionable mutations. FGFR2 mutations were more frequently identified in liquid biopsies, whereas KRAS alterations were mostly found in tumors. All IDH1 mutations detected in tumor DNA were also identified in liquid biopsies. These findings provide novel insights in the concordance between the tumor and liquid biopsies genomic landscape in a large cohort of patients with BTC and highlight the complementarity of both analyses when guiding therapeutic prescription.
Vuthaluru S, Sharma P, Chowdhury S, Are C. Global epidemiological trends and variations in the burden of gallbladder cancer. J Surg Oncol. 2023;128(6):980-988.
摘要：Background: Although laparoscopic cholecystectomy is applicable for the treatment of early gallbladder cancer (GBC), minimally invasive surgery is not widely used for advanced GBC. This is because advanced GBCs necessitate complicated surgical techniques, including lymph node dissection and liver resection. Robotic extended cholecystectomy (REC) is thought to overcome the limitations of laparoscopic surgery, but oncological safety studies are lacking. Therefore, in this study, we aimed to evaluate the oncologic outcomes of REC compared with those of open extended cholecystectomy (OEC).Methods: A total of 125 patients, who underwent extended cholecystectomy for GBC with tentative T2 or higher stage between 2018 and 2021, were included and stratified by surgical methods. To minimize the confounding factors, 1:1 propensity-score matching was performed between the patients who underwent REC and those who underwent OEC.Results: Regarding short-term outcomes, the REC group showed significantly lower estimated blood loss (382.7 vs. 717.2mL, P = 0.020) and shorter hospital stay (6.9 vs. 8.5 days, P= 0.042) than the OEC group. In addition, the REC group had significantly lower subjective pain scores than the OEC group from the day of surgery through the 5th postoperative day (P = 0.006). Regarding long-term outcomes, there were no significant differences in the 3-year [5-year] overall survival (OS) and disease-free survival (DFS) rates between the REC group [OS, 92.3% (92.3%); DFS, 84.6% (72.5%)] and the OEC group [OS, 96.8% (96.8%); DFS, 78.2% (78.2%)] (P = 0.807 for OS and 0.991 for DFS).Conclusions: In this study, REC showed superior short-term outcomes to OEC and no difference in long-term survival outcomes. Additionally, REC was superior to OEC in terms of postoperative pain. Therefore, REC may be a feasible option with early recovery compared with OEC for patients with advanced GBC.
本篇文章共纳入125例行胆囊癌扩大切除术的进展期胆囊癌患者，回顾性分析了行机器人辅助胆囊癌扩大切除术（REC）组与行开腹胆囊癌扩大切除术（OEC）组患者的近远期预后，同时采用1:1倾向评分匹配以尽量减少混杂因素的影响，进一步探索REC的肿瘤学安全性。研究结果表明在短期预后方面，REC组的估计失血量( 382.7 ml vs.717.2 ml , P = 0.020)与住院时间( 6.9天vs.8.5天, P = 0.042)均显著少于OEC组，REC组手术当天的平均疼痛评分( 5.6vs.6.6 , P < 0.001) 及术后5天内的主观疼痛评分(P = 0.006)亦均显著低于OEC组；而在3年[5年]总生存期（OS）和无病生存期（DFS）等远期预后方面，REC组[OS, 92.3% (92.3%); DFS, 84.6% (72.5%)]与OEC组[OS, 96.8% (96.8%); DFS, 78.2% (78.2%)]间无显著统计学差异(OS, P = 0.807 ; DFS, P = 0.991)；此外，REC组术中获取的淋巴结数目满足至少6枚淋巴结的临床指南标准，且与OEC组相比无显著统计学差异（7.1 vs 8.2, P = 0.172）。上述研究结果均支持REC的肿瘤学安全性。
作为单中心的回顾性研究，本研究也存在一定的局限性。首先，研究样本量偏少，无法排除选择偏倚对研究结果的干扰；第二，因为该机构腹腔镜手术例数不足，文章并未将腹腔镜胆囊癌扩大切除术患者纳入对比分析；第三，文章中的胆囊癌扩大切除术采取的术式主要包括胆囊切除术、区域淋巴结清扫、切缘2cm阴性的肝楔形切除，肝外器官侵犯的患者并未纳入研究队列。目前机器人辅助手术国内仅在部分较大外科中心开展，其在进展期胆囊癌领域的推广应用仍需大样本、多中心的前瞻性研究进一步证明REC的可行性、安全性以及其相比于其他传统术式的优越性。
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