CPG มะเร็งตับและท่อน้ำดี

·π«∑“ß°“√√—°…“
·≈–µ√«®µ¥‘ µ“¡¡–‡√Áß∑àÕπÈ”¥’

¡– ‡√Áß∑àÕπ”È ¥’ §◊Õ¡–‡√Áß∑’ˇ°‘¥®“°‡´≈≈凬Ë◊Õ∫ÿºπ—ߢÕß∑àÕ∑“߇¥‘ππÈ”¥’´Ë÷ß√«¡∂÷ß∑àÕ

πÈ”¥’¿“¬„π·≈–¿“¬πÕ°µ∫— ·µà‰¡à√«¡∂÷߇¬ËÕ◊ ∫ÿ¢Õß∂ÿßπ”È ¥’·≈– Papilla of Vater ·∫ßà ‡ªìπ 2 ª√–‡¿∑
§◊Õ ¡–‡√Áß∑àÕπ”È ¥’¿“¬„πµ—∫ (Intrahepatic or peripheral type cholangiocarcinoma) ·≈–¡–‡√Áß
∑àÕπÈ”¥’¿“¬πÕ°µ—∫ (Extrahepatic type cholangiocarcinoma)(1-6) æ∫‚√§¡–‡√Áßπ’È„π‡æ»™“¬
¡“°°«à“‡æ»À≠ß‘ §Õ◊ 135.4 µàÕ 100,000 „𙓬·≈– 43.0 µÕà 100,000 „πÀ≠ß‘ (7) ´Ë÷ß
‡ªìπÕÿ∫—µ‘°“√≥å∑’Ë Ÿß‡ªìπÕ—π¥—∫Àπ÷Ëß„π‚≈° ¡–‡√Áß∑àÕπ”È ¥’¬—ߧ߇ªìπªí≠À“∑“ß “∏“√≥ ÿ¢∑Ë’
 ”§—≠¢Õß¿“§µ–«—πÕÕ°‡©’¬ß‡Àπ◊Õ¢Õߪ√–‡∑»‰∑¬  “‡Àµÿ ”§—≠¢Õß¡–‡√Áß™π‘¥π’Èæ∫«à“
‡°’ˬ«¢âÕß°—∫°“√√—∫ª√–∑“πª≈“π”È ®◊¥∑’Ë¡’‡°≈Á¥·∫∫¥‘∫Ê ´Ë÷ß®–∑”„À≥â√—∫µ—«ÕàÕπ¢Õß欓∏‘
„∫‰¡âµ—∫ (Metacercaria of Opisthorchis viverrini) ·≈–®–‡®√‘≠‡µ‘∫‚µÕ¬Ÿà„π∑àÕ∑“߇¥‘ππÈ”¥’

πÕ°®“°π’Ȭ—ßæ∫«à“°“√√—∫ª√–∑“πÕ“À“√À¡—°¥ÕߢÕß™“«Õ’ “𠇙àπ ª≈“√â“ ª≈“‡®à“
ª≈“®àÕ¡ √«¡∑—Èߪ≈“ â¡ ®–¡’ “√ N-Nitrosocompound ·≈– Nitrosamines ´Ë÷ß®–‡√àß„À⇰‘¥¡–‡√Áß
‰¥‡â √Á«¢π÷È ‰¥â (8-12)

Õ“°“√·≈–Õ“°“√· ¥ß

ºâŸªÉ«¬¡—°¡’Õ“°“√∑’Ë·∫àßÕÕ°‰¥â‡ªìπ 2 °≈àÿ¡„À≠à§◊Õ°≈àÿ¡∑Ë’¡’Õ“°“√µ—«‡À≈◊Õß µ“‡À≈◊Õß
(Malignant obstructive jaundice) ·≈–°≈ÿà¡∑Ë’‰¡à¡’Õ“°“√µ—«‡À≈◊Õßµ“‡À≈◊Õß (Non-jaundice)
‚¥¬æ∫‰¥â√âÕ¬≈– 70 ·≈– 30 µ“¡≈”¥—∫ ·µàÕ¬à“߉√°Áµ“¡ºâŸªÉ«¬∑’ˉ¡à¡’Õ“°“√µ—«‡À≈◊Õßµ“‡À≈◊Õß¡’
·π«‚π⡇æË‘¡¢È÷π ®“° ∂‘µ‘„πªï æ.». 2547 æ∫Õ—µ√“ à«π¥—ß°≈à“«ª√–¡“≥§√Ë÷ßµàÕ§√Ë÷ß πÕ°®“°π’È
ºŸªâ É«¬Õ“®¡“æ∫·æ∑¬¥å «â ¬ªí≠À“°âÕπ„πµ—∫ (Liver mass) √âÕ¬≈– 14 §≈”∂ÿßπ”È ¥‰’ ¥â (Hydrops of
gallbladder) √Õâ ¬≈– 6.7 ∂ßÿ π”È ¥Õ’ °— ‡ ∫‡©¬’ ∫æ≈π— ·∫∫‰¡¡à π’ «‘Ë „π∂ßÿ πÈ”¥’ (Acute acalculous cholecystitis)
√Õâ ¬≈– 7 ‡ªπì ‰¢‰â ¡à∑√“∫ “‡Àµÿ·≈–æ∫‚¥¬∫ß— ‡Õ≠‘ „π¢≥–∑˺’ à“µ¥— ™àÕß∑âÕߥ⫬ “‡ÀµÿÕπË◊

°“√µ√«®∑“ßÀÕâ ߪØ∫‘ µ— °‘ “√∑™’Ë «à ¬„π°“√«π‘ ®‘ ©¬— §Õ◊ °“√µ√«®«¥— √–¥∫— Alkaline phosphatase
„π‡≈◊Õ¥ ßŸ ∑ßÈ— „πºâªŸ «É ¬∑µ’Ë “‡À≈◊Õß·≈–µ“‰¡à‡À≈Õ◊ ß·≈–¬—ßæ∫«“à √–¥∫— CEA  ßŸ ∂ß÷ √âÕ¬≈– 90 ‚¥¬∑√Ë’ –¥—∫
Alphafetoprotein (AFP) ª°µ‘

46

欓∏‘«∑‘ ¬“ Cholangiocarcinoma

欓∏‘ ¿“æ à«π„À≠à∑’Ëæ∫¢≥–ºà“µ—¥¡—°®–‡ªìπ√–¬–∑’Ë‚√§≈ÿ°≈“¡·≈â« ·µàÕ¬à“߉√°Áµ“¡
欓∏‘ ¿“æ¢Õß¡–‡√Áß∑àÕπÈ”¥’∑’ˇ°‘¥¿“¬„πµ—∫ (Intrahepatic cholangiocarcinoma : ICC) ‡¡◊ËÕµ—¥
°âÕπ‡π◊ÈÕßÕ°®–æ∫«à“Àπ⓵—¥¡’ ’¢“«·°¡‡∑“·≈–§àÕπ¢â“ß®– –∑âÕπ· ß·«««“«‡π◊ËÕß®“°°“√À≈Ë—ßπ”È
‡¡Õ◊ °®“°°Õâ π¡–‡√ßÁ Õ“®æ∫‡ªπì °Õâ π‡¥¬Ë’ «Ê À√Õ◊ À≈“¬°Õâ π ·≈–Õ“®æ∫¢“â ߇¥¬’ «À√Õ◊ ®“°µ∫— ∑ßÈ—  Õߢ“â ß
°Á‰¥â ´÷Ëß欓∏‘ ¿“æÕ¬à“ßπ’ÈÕ“®∑”„À⇢Ⓞ®º‘¥«à“‡ªìπ°âÕπ¡–‡√Áß∑Ë’°√–®“¬ (Metastasis) ¡“®“°
∑Ë’ÕË◊π‰¥â  à«π¡–‡√Áß∑àÕπ”È ¥’∑’ˇ°‘¥¿“¬πÕ°µ—∫ (Extrahepatic cholangiocarcinoma : ECC) ®–æ∫«à“
‡°‘¥Õ¬à„Ÿ π∑Õà ∑“߇¥π‘ πÈ”¥’ 3 √–¥∫— §Õ◊

1. √–¥—∫∑àÕπÈ”¥’ Ÿß„°≈â°—∫µ—«µ—∫ ‚¥¬‡°‘¥Õ¬àŸ„π∑àÕπ”È ¥’µ—∫®π∂÷ß∑àÕπ”È ¥’µ—∫√à«¡ (Upper
third from hepatic duct to common hepatic duct) À√◊Õ Hilar cholangiocarcinoma
æ∫‰¥â√âÕ¬≈– 60 欓∏‘ ¿“æ∑Ë’æ∫®–¡’≈—°…≥–·¢Áß¡“°∑”„Àâ∑àÕπÈ”¥’µ’∫·§∫
(Scirrhous and stenotic type) ·µà∫“ߧ√—Èß°ÕÁ “®æ∫«“à ‡ªìπ·∫∫ÕË◊π‰¥â ‡™πà papillary
À√Õ◊ nodular type ‡ªìπµπâ

2. √–¥—∫∑àÕ∑“߇¥‘ππ”È ¥’ à«π°≈“ß (Middle third from distal common duct, cystic
duct and its confluence to proximal common bile duct) æ∫‰¥â√âÕ¬≈– 20

3. √–¥—∫∑àÕ∑“߇¥‘ππÈ”¥’ à«π≈à“ß (Lower third from distal common bile duct to
periampullary region) æ∫‰¥â√âÕ¬≈– 20 欓∏‘ ¿“æ à«π∑Ë’æ∫„π∑àÕπÈ”¥’ à«π°≈“ß
·≈– «à π≈à“ß ¡°— ®–‡ªπì nodular ·≈– papillary type µ“¡≈”¥∫—

欓∏‘ ¿“æ∑’Ëæ∫∑—Èß™π‘¥∑’ˇ°‘¥„π∑àÕ∑“߇¥‘ππÈ”¥’¿“¬„πµ—∫·≈–¿“¬πÕ°µ—∫π—ÈπÕ“®®–
æ∫À≈“¬Ê ∑Ë’ (multifocal) „π¡–‡√ßÁ ∑àÕπ”È ¥¿’ “¬πÕ°µ∫— Õ“®®–æ∫«“à ‡ªìπÕ¬àÀŸ ≈“¬√–¥∫— (skip lesions)
æ∫√âÕ¬≈– 10 πÕ°®“°π’Ȭ—ßæ∫«à“¡’µ—∫¢â“ß„¥¢â“ßÀπË÷ß¡’¢π“¥‡≈Á°≈ß°«à“ª°µ‘ À√◊Õ¡’°“√ΩÉÕ¢Õßµ—∫
¢â“ß∑Ë’¡’欓∏‘ ¿“æ ∑—ÈßπÈ’Õ“®®–‡°‘¥®“°°“√Õÿ¥µ—π∑àÕ∑“߇¥‘ππÈ”¥’‡ªìπ‡«≈“π“πÀ√◊Õ¡’°“√≈ÿ°≈“¡¢Õß
¡–‡√ßÁ ‡¢“â ‰ª„π‡ πâ ‡≈Õ◊ ¥∑¡’Ë “‡≈¬È’ ßµ∫—  «à πππÈ— ·≈«â ∑”„À‡â  πâ ‡≈Õ◊ ¥Õ¥ÿ µπ— ·≈–∑”„Àµâ ∫— ¢“â ßππÈ— ΩÕÉ (atrophy)
„π∑’Ë ÿ¥ πÕ°®“°π’Ȭ—ß¡’欓∏‘ ¿“æ∑’Ë ”§—≠∑’Ëæ∫‰¥âª√–¡“≥√âÕ¬≈– 5 °Á§◊Õ¡–‡√Áß∑àÕπÈ”¥’∑Ë’‡°‘¥µ≈Õ¥
∑—ßÈ ∑“߇¥π‘ π”È ¥¿’ “¬πÕ°µ—∫·≈–¿“¬„πµ∫— ≈°— …≥–‡™àππ’È∑”„Àâ°“√µ—¥ π‘ „®√—°…“‡°‘¥§«“¡¬“°≈”∫“°
·≈– à«π„À≠à®– “¡“√∂∑”‰¥â‡æ’¬ß°“√√—°…“·∫∫ª√–§—∫ª√–§Õ߇∑à“πÈ—π ¡’πâÕ¬¡“°∑’Ë “¡“√∂∑”°“√
º“à µ¥— ‡Õ“‡πÕ◊È ßÕ°ÕÕ°‰¥∑â —ßÈ À¡¥ (Curative intent)

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®≈ÿ 欓∏«‘ ∑‘ ¬“

‡πÈ◊Õ¡–‡√Áߪ√–°Õ∫¥â«¬‚§√ß √â“ߢÕßµàÕ¡·≈–≈âÕ¡√Õ∫¥â«¬ à«πæ¬ÿß (Stroma) ∑Ë’‡ªìπ
æ—ߺ◊¥·¢Áß®”π«π¡“° ·≈–¡’°“√‡√’¬ßµ—«‡ªìπ∑àÕπ”È ¥’∑’Ë¡’æ—≤π“°“√¢Õ߇´≈≈å√–¥—∫¥’À√◊Õª“π°≈“ß
(Simple ductular arrangement of well or moderatelly differentiated collumnar or cuboidal
epithelium) ‡´≈≈å¡–‡√ßÁ À≈—Ë߇¡Õ◊ ° (Mucin) ·µà®–‰¡à √“â ßπÈ”¥’ ®÷ß„™§â ≥ÿ  ¡∫µ— π‘ „È’ π°“√«‘π®‘ ©—¬·¬°‚√§
®“°¡–‡√Áßµ—∫™π‘¥ hepatocellular carcinoma  à«π°“√«‘π‘®©—¬·¬°‚√§®“° metastatic
adenocarcinoma ‚¥¬‡©æ“–Õ¬à“߬‘Ëß®“°¡–‡√Áß≈”‰ â„À≠à∑Ë’¡’°“√ √â“߇¡◊Õ°µâÕßÕ“»—¬æ‘®“√≥“¢âÕ¡Ÿ≈
∑“ߧ≈‘π°‘ ·≈–∑“ß欓∏«‘ ‘∑¬“√«à ¡°π—

°“√°√–®“¬¢Õß¡–‡√Áß∑àÕπ”È ¥’

æ∫°“√°√–®“¬≈ÿ°≈“¡‰ªµ“¡∑“߇¥π‘ π”È ‡À≈◊Õß (Lymphatic invasion) ·≈–‡ πâ ª√– “∑
(Perineural invasion) ‰¥∫â Õà ¬ ‰¡§à Õà ¬æ∫°“√°√–®“¬‰ª∑“ß°√–· ‡≈Õ◊ ¥ (Hematogenous spreading)
Õ¬“à ߉√°Áµ“¡Õ“®æ∫¡’°“√°√–®“¬‰ª∑Õ’Ë ◊ËπÊ ‡™àπ °√–¥°Ÿ  ¡Õß º«‘ Àπß— ·≈–‡π◊ÈÕ‡¬Õ◊Ë „µºâ ‘«Àπß— ‡ªπì µπâ
 à«π„À≠à¢Õß¡–‡√Áß∑àÕπ”È ¥’‡ªìπ¡–‡√Áß∑’Ë¡’°“√‡®√‘≠‡µ‘∫‚µ™â“ ·µà “¡“√∂æ∫¡’°“√≈ÿ°≈“¡‰ª ŸàÕ«—¬«–
Õ◊Ëπ‰¥â‚¥¬‡©æ“–Õ«—¬«–¢â“߇§’¬ß·≈–µàÕ¡π”È ‡À≈◊Õß∑Ë’Õ¬Ÿà„°≈âÊ (Regional lymph nodes) ª√–¡“≥
√Õâ ¬≈– 15 ππÈ— ¡’°“√·æ√°à √–®“¬Õ¬“à ß√«¥‡√«Á µ“¡°√–· ‡≈Õ◊ ¥

¡–‡√ßÁ ∑àÕπ”È ¥¿’ “¬„πµ—∫ (Intrahepatic or peripheral cholangiocarcinoma)

¡–‡√Áß∑àÕπ”È ¥’¿“¬„πµ—∫ (Intrahepatic cholangiocarcinoma : ICC) ‡ªìπ‚√§∑’Ë¡—°∂Ÿ°
«‘π‘®©—¬º¥‘ «à“‡ªπì ¡–‡√Áßµ∫— (Hepatocellular carcinoma : HCC) ‡æ√“–µ∫— ‚µ·≈–¡’°Õâ π∑µË’ —∫ ·µà¡–‡√Áß
∑àÕπÈ”¥’π’È ‡°‘¥®“°‡´≈≈å¢Õ߇¬Ë◊Õ∫ÿ∑àÕπ”È ¥’„πµ—∫ æ∫„πºâŸªÉ«¬™“¬¡“°°«à“ºâŸÀ≠‘ß ‚¥¬¡’Õÿ∫—µ‘°“√≥å
 Ÿß∑’Ë ÿ¥„π‚≈°∑’Ë¿“§µ–«—πÕÕ°‡©’¬ß‡Àπ◊Õ¢Õߪ√–‡∑»‰∑¬ ®“°°“√»÷°…“√à«¡°—π¢ÕßÀπ૬¡–‡√Áß
§≥–·æ∑¬»“ µ√¡å À“«∑‘ ¬“≈¬— ¢Õπ·°πà ,‡™¬’ ß„À¡,à  ß¢≈“·≈– ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘(„π°√ßÿ ‡∑æ¡À“π§√)
√–À«à“ß æ.». 2531-2534  ∂‘µ‘¢Õß¡–‡√Áßµ—∫‡¡Ë◊Õª√—∫„À⇢⓰—∫°≈àÿ¡ª√–™“°√¡“µ√∞“π‚≈°·≈â«
æ∫«“à Õ∫ÿ µ— °‘ “√≥å¢Õß¡–‡√Áßµ∫— ®—ßÀ«¥— ¢Õπ·°πà „πº™âŸ “¬·≈–ºâÀŸ ≠ß‘ ‡ªìπ 94.8 ·≈– 39.4 µÕà ª√–™“°√
100,000 §π µ“¡≈”¥∫— ·≈–§“¥«à“®–¡’ºŸªâ «É ¬„À¡à√“« 8,000 √“¬µÕà ªï „π¢Õπ·°πà æ∫√âÕ¬≈– 89
‡ªìπ¡–‡√Áß∑àÕπ”È ¥’ ‡ª√’¬∫‡∑’¬∫°—∫√âÕ¬≈– 2 „π ß¢≈“´Ë÷ßæ∫ HCC ∂÷ß√âÕ¬≈– 96 ·≈–„π°√ÿ߇∑æ
æ∫ HCC √Õâ ¬≈– 71(13)

 “‡Àµÿ¢Õß ICC „π∑“߬ÿ‚√ª‰¡à∑√“∫·πà«à“ “√°àÕ¡–‡√Á߇ªìπÕ–‰√‡æ’¬ß·µà —ππ‘…∞“π«à“
Õ“®®–‡°¬’Ë «¢Õâ ß°∫— ‚√§¢Õß√–∫∫∑“߇¥π‘ πÈ”¥’, πË‘«„πµ∫— (hepatholithiasis), Caloriûs disease, primary
sclerosing cholangitis À√◊Õ biliary dysplasia ·µà “‡Àµÿ¢Õß ICC „πª√–‡∑»‰∑¬¡’°“√»÷°…“∑’˙Ȓ™—¥
«à“欓∏‘„∫‰¡µâ —∫√«à ¡°∫— N-Nitrosocompound ¡’ «à π‡°¬Ë’ «¢Õâ ß°∫— °“√‡°‘¥‚√§πÈ’

48

欓∏«‘ ‘∑¬“ »“ µ√“®“√¬å𓬷æ∑¬å∑ÕßÕ«∫ Õµÿ √«‘‡™¬’ √ ‰¥â·∫ßà ICC ‡ªìπ 4 ·∫∫(14) Cholangiocarcinoma
·∫∫∑Ë’ 1 : A peripheral mass without intrahepatic duct dilatation and without

jaundice
·∫∫∑’Ë 2 : An intermediate mass with intrahepatic duct segmental dilatation and

still no jaundice
·∫∫∑Ë’ 3 : A central mass with intrahepatic duct lobar dilatation and with or without

jaundice admittedly to have jaundice both right and left lobar intrahepatic
duct will be involved
·∫∫∑’Ë 4 : Diffuse tumor masses of various sizes are found on both lobes and may
be the combination of either one, two or all of the above three types
(I, II, and III). This diffuse type therefore can have either one with or
without intrahepatic duct dilatation, and also with or without jaundice.

Õ“°“√·≈–Õ“°“√· ¥ß
 à«π„À≠à®–¡“¥â«¬Õ“°“√‰¡à ∫“¬„π∑âÕß (abdominal discomfort À√◊Õ dyspepsia)

ª«¥„µ™â “¬‚§√ߢ«“ ª«¥À≈ß— ·≈–‰À≈à À√Õ◊ ¡‰’ ¢â ‡Àπ◊ËÕ¬ÕÕà π‡æ≈’¬ (fatigue), ‡∫◊ËÕÕ“À“√, π”È Àπ—°≈¥
À√Õ◊ §≈π◊Ë ‰ â Õ“°“√· ¥ß‰¥·â °à µ—∫‚µ, ºÕ¡

°“√«‘π‘®©—¬

°“√«‘π‘®©—¬Õ“»—¬°“√´—°ª√–«—µ‘·≈–µ√«®√à“ß°“¬æ∫Õ“°“√·≈–Õ“°“√· ¥ß¥—ß°≈à“«
‡π◊ËÕß®“°‚√§π’ȉ¡à§Õà ¬¡Õ’ “°“√·≈–Õ“°“√· ¥ß„À‡â ÀÁπ¡“°π°— ®π°«“à ‚√§®–≈ÿ°≈“¡‡ªπì √–¬–∑“â ¬Ê ·≈«â
´÷Ëßµà“ß®“°¡–‡√Áß∑àÕπ”È ¥’¿“¬πÕ°µ—∫∑’Ë¡—°¡’Õ“°“√µ—«‡À≈◊Õßµ“‡À≈◊ÕßÀ√◊Õ¡’‰¢âπ”¡“°àÕπ ºâŸªÉ«¬®–¡’
Õ“°“√Õ÷¥Õ—¥ ·πàπ∑âÕß·≈–‡∫Ë◊ÕÕ“À“√√à«¡°—∫π”È Àπ—°≈¥ Õ“®µâÕßæ‘®“√≥“µ√«®Õ—≈µ√â“´“«¥åµ—∫·≈–
™Õà ß∑Õâ ß «à π∫π´ß÷Ë ®– “¡“√∂µ√«®æ∫‰¥§â Õà π¢“â ß·¡πà ¬”°“√µ√«®°“√∑”ß“π¢Õßµ∫— ‚¥¬‡©æ“–Õ¬“à ߬ߑË
Alkaline phosphatase ¡§’ à“ ßŸ À“°§“à ¢Õß Alkaline phosphatase  ŸßÀ≈“¬Ê §√È—ßµ¥‘ µàÕ°π— „À â ß ¬—
«à“Õ“®®–¡æ’ ¬“∏‘ ¿“æ¢Õß CC ·ΩßÕ¬àŸ §à“ AFP ¡°— ®–ª°µ‘ ·µà√–¥—∫¢Õß CA 19-9 ·≈– CEA ®– ßŸ
°“√∑” spiral CT À√◊Õ MRI ®–™à«¬„π°“√«‘π®‘ ©¬— ·≈–™«à ¬„π°“√∑”·ºπ√—°…“

°“√√—°…“

°“√√—°…“‡æ◊ÕË „ÀÀâ “¬¢“¥∑”‰¥¥â «â ¬°“√ºà“µ¥— ‡∑“à π—Èπ °“√º“à µ¥— ‡π◊ÈÕßÕ°ÕÕ°·≈–æ∫«“à
µ¥— ‰¥âÀ¡¥ (negative margin) ‡ªìπ‚Õ°“ ‡¥¬’ «∑®’Ë –√—°…“„ÀÀâ “¬¢“¥‰¥â (™π¥‘ ¢Õߧ”·π–π” 1)
„πª®í ®∫ÿ π— ¬ß— ‰¡¡à ’ definitive adjuvant regimen ∑®’Ë –∑”„ÀÕâ µ— √“°“√Õ¬√àŸ Õ¥¢ÕߺªâŸ «É ¬‡æ¡Ë‘ ¢πÈ÷

49

ºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√º“à µ¥— ·≈«â ·µµà ¥— ÕÕ°‰¡Àà ¡¥ §«√‰¥√â ∫— °“√¥·Ÿ ≈·∫∫ À “¢“‡ªπì √“¬Ê ‰ª
‡™àπ °“√µ¥— ‡πÕÈ◊ ßÕ°ÕÕ° (additional resection), ablative therapy À√Õ◊ °“√„™â‡§¡∫’ ”∫¥— √«à ¡°∫— √ß—  ’
√°— …“Õ¬à“߉√°Áµ“¡‰¡à¡’°“√»÷°…“·∫∫ randomized clinical trial ∑¡Ë’ ’¢âÕ¡≈Ÿ æÕ∑’Ë®–¬◊π¬π— º≈°“√√—°…“
„π·µ≈à –·∫∫∑’Ë°≈à“«¡“·≈«â ‰¥â

„π°√≥’∑’˺⟪ɫ¬‰¡à “¡“√∂µ—¥‡π◊ÈÕßÕ°ÕÕ°‰¥â∑È—ßÀ¡¥ Õ“®¡’·π«∑“ß°“√√—°…“¥—ßπ’È ‡™àπ
°“√ºà“µ—¥‡π◊ÈÕßÕ°ÕÕ°∫“ß à«π  à«π∑’ˇÀ≈◊ÕÕ“®©’¥¥â«¬·Õ≈°ÕŒÕ√å 95 ‡ªÕ√凴Áπµå À√◊Õ°“√∑”≈“¬
°âÕπ∑’ˇÀ≈◊ե⫬«‘∏’Õ◊ËπÊ ‡™àπ ablative therapy with cryotherapy, radiofrequency, or microwave
„π√–À«“à ߺ“à µ—¥ (™π¥‘ ¢Õߧ”·π–π” 3) °“√√°— …“·∫∫ª√–§∫— ª√–§Õß (supportive care)  à«π°“√
„Àâ°“√√—°…“¥â«¬√—ß ’√—°…“√à«¡°—∫„À⇧¡’∫”∫—¥ À√◊Õ°“√„À⇧¡’∫”∫—¥(15) ¬—ߧ߇ªìπ‡æ’¬ß
clinical trial

 à«πºŸâªÉ«¬∑’Ë¡–‡√Áß·æ√à°√–®“¬ (metastatic disease) °“√√—°…“‚¥¬«‘∏’ª√–§—∫ª√–§Õß
¬—ߧ߇ªìπ«‘∏’∑Ë’ª≈Õ¥¿—¬·≈–‡À¡“– ¡‚¥¬Õ“®„Àâ√—°…“‰¥â¥â«¬°“√ºà“µ—¥‡π◊ÈÕßÕ°ª∞¡¿Ÿ¡‘ÕÕ°
(™π‘¥¢Õߧ”·π–π” 2B) ‡æ◊ËÕ„À⺟âªÉ«¬¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥’¢È÷π·≈–ªÑÕß°—π¿“«–·∑√°´âÕπ®“°‡π◊ÈÕßÕ°
ª∞¡¿Ÿ¡‘ À√◊ÕÕ“®®–„À⇧¡’∫”∫—¥‰¥â ·µà¬—߉¡à¡’ regimen ∑Ë’‡À¡“– ¡ °“√∑” clinical trial
¬—ß¡’§«“¡®”‡ªìπ

°“√µ¥‘ µ“¡º≈°“√√—°…“¡–‡√Áß∑Õà πÈ”¥’¿“¬„πµ∫—

°“√µ‘¥µ“¡ºâŸªÉ«¬¿“¬À≈—ß°“√ºà“µ—¥§«√®–µ‘¥µ“¡º≈°“√√—°…“‚¥¬«‘∏’ —߇°µÕ“°“√
·≈–∑”Õ—≈µ√â“´“«¥å À√◊Õ CT ∑ÿ° 3 ‡¥◊Õπ ®π§√∫ 2 ªï ·≈–À√◊Õ¡’°“√√—°…“√à«¡Õ◊ËπÊ „Àâæ‘®“√≥“
µ“¡Õ“°“√

°“√欓°√≥å‚√§

‚¥¬∑Ë—«‰ª·≈â«°“√√—°…“¡–‡√Áß·∑∫®–∑ÿ°™π‘¥πÈ—π°“√ºà“µ—¥‡Õ“°âÕπ¡–‡√ÁßÕÕ°®–‡ªìπ«‘∏’∑’Ë
‰¥âº≈¥’∑Ë’ ÿ¥ ®“°°“√»÷°…“¢Õß»“ µ√“®“√¬å𓬷æ∑¬å∑ÕßÕ«∫ Õÿµ√«‘‡™’¬√ æ∫«à“ºŸâªÉ«¬ Stage III
À≈ß— °“√ºà“µ—¥ªï∑Ë’ 1 ·≈–ªï∑’Ë 3 ¡’Õµ— √“Õ¬àŸ√Õâ ¬≈– 100 ·≈– 33 µ“¡≈”¥—∫ ·≈–¡’ºâªŸ É«¬ 3 √“¬ ∑ËÕ’ ¬Ÿà
√Õ¥‰¥â‡°π‘ 5 ªï  «à π Stage IV-A (‡ªìπ°“√ staging ¢Õß AJCC ·∫∫‡°à“) ®–¡Õ’ µ— √“Õ¬√Ÿà Õ¥ 1, 3 ·≈–
5 ªï À≈—ßºà“µ—¥√âÕ¬≈– 80, 30 ·≈– 0 µ“¡≈”¥—∫ √–¬– IV-B ®–¡’Õ—µ√“Õ¬àŸ√Õ¥ 1, 3 ·≈– 5 ªï
À≈—ߺ“à µ¥— √Õâ ¬≈– 26, 12 ·≈– 0 „π°“√»÷°…“¥—ß°≈“à «‰¡æà ∫ºâŸªÉ«¬√–¬–∑’Ë 1 ·≈– 2

®–‡ÀÁπ‰¥â«à“‚√§ ICC πÈ’º≈°“√√—°…“‰¡à§àÕ¬¥’∑—Èßπ’ÈÕ“®®–‡ªìπ‡æ√“–ºŸâªÉ«¬¡—°®–æ∫„π
√–¬–∑“â ¬ Ê ¥ß— ππ—È °“√„À°â “√«π‘ ®‘ ©¬— „À‰â ¥ºâ ªŸâ «É ¬„π√–¬–·√°¢Õß‚√§®ß÷ ¡§’ «“¡®”‡ªπì Õπß÷Ë °“√ªÕÑ ß°π—
‰¡„à À⇰¥‘ ‚√§‚¥¬°“√„À°â “√»°÷ …“·≈– ¢ÿ »°÷ …“°—∫ª√–™“°√°πÁ —∫«à“¡’§«“¡ ”§—≠Õ¬à“߬Ëß‘

50

¡–‡√Áß∑àÕπ”È ¥’¿“¬πÕ°µ∫— (Extrahepatic cholangiocarcinoma) Cholangiocarcinoma
¡–‡√Áß∑àÕπÈ”¥’™π‘¥πÈ’¡—°®–¡“æ∫·æ∑¬å‡¡Ë◊Õ¡’Õ“°“√µ—«‡À≈◊Õßµ“‡À≈◊Õß·≈⫇ªìπ à«π„À≠à

·µà„π√–¬–·√°¢Õß‚√§®–‰¡à¡’Õ“°“√¡“°‡πË◊Õß®“°°âÕπ¡’¢π“¥‡≈Á° ·µà‡¡◊ËÕ¡’¢π“¥‚µ¢÷Èπ®π∑”„À⇰‘¥
°“√Õÿ¥µ—π¢Õß∑àÕ∑“߇¥‘ππÈ”¥’°Á®–∑”„À⇰‘¥Õ“°“√µ“‡À≈◊Õß ·≈–¢≥–‡¥’¬«°—ππÈ—π¡–‡√Á߉¥â≈ÿ°≈“¡‰ª
¬—ßÕ«¬— «–¢â“߇§¬’ ß·≈–µàÕ¡πÈ”‡À≈◊Õß√Õ∫Ê ∑àÕπÈ”¥·’ ≈â« ¥ß— πÈπ— ºŸâª«É ¬ «à π„À≠à∑Ëæ’ ∫®÷߇ªπì √–¬–∑Ë’ III-IV
´Ë÷ß∑”„Àâº≈°“√√—°…“‰¡à¥’‡∑à“°—∫°“√√—°…“¡–‡√Áß™π‘¥Õ◊ËπÊ ·µàÕ¬à“߉√°Áµ“¡°“√√—°…“ºâŸªÉ«¬‰¡à«à“
®–‡ªπì √–¬–„¥¢Õß‚√§°Á¬—ߥ’°«à“°“√∑’‰Ë ¡∑à ”Õ–‰√‡≈¬

¡–‡√Áß∑àÕπ”È ¥’™π‘¥∑Ë’Õ¬àŸ¿“¬πÕ°µ—∫πÈ’ à«π„À≠à®–Õ¬àŸ∑Ë’∑àÕ∑“߇¥‘ππ”È ¥’∑’Ë„°≈âÊ°—∫µ—∫
(Porta hepatic) ´Ëß÷ ¡—°®–‡°‘¥„π∑Õà πÈ”¥’µ∫— ¢“â ß„¥¢“â ßÀπËß÷ À√Õ◊ ∑àÕπ”È ¥’µ∫— √«à ¡ (Right or left hepatic or
common hepatic bile duct) ‡π◊ËÕß®“°≈—°…≥–∑“ß°“¬«‘¿“§¢Õß∫√‘‡«≥π’ȇªìπ∫√‘‡«≥∑’Ë∑àÕπ”È ¥’
‡ πâ ‡≈Õ◊ ¥¥”·≈–‡ âπ‡≈◊Õ¥·¥ß∑Ë’¡“‡≈È’¬ßµ—∫¡“Õ¬àŸ„°≈♑¥°—π ®÷߇√’¬°∫√‘‡«≥πÈ’«à“‡ªìπ¢È—«µ—∫ (Hilar À√Õ◊
Hilus) ´ß÷Ë ‡ªπì ∑¡Ë’ “¢Õß™ÕË◊ HilarcholangiocarcinomaµÕà ‰ªπ®’È –‡√¬’ °¡–‡√ßÁ ∑Õà π”È ¥∑’ ‡Ë’ °¥‘ ¢πÈ÷ „π∫√‡‘ «≥π«È’ “à
Hilar cholangiocarcinoma

欓∏‘«‘∑¬“

‡π◊ÈÕßÕ°™π‘¥π¡È’ ’≈°— …≥–∑’‡Ë ÀÁπ‰¥¥â «â ¬µ“‡ª≈à“ ·∫ßà ‰¥‡â ªπì 4 ™π¥‘ (16) §◊Õ
1. Papillary type
2. Nodular type
3. Nodular-infiltrating type
4. Diffusely infiltrating type
·µà≈–™π‘¥®–¡’°“√°√–®“¬·µ°µà“ß°—π§◊Õ papillary ·≈– nodular type °√–®“¬‰ªµ“¡
mucosa  à«π nodular-infiltrating ·≈– diffusely infiltrating type ®–°√–®“¬‰ªµ“¡ submucosa
´÷Ëß∑”„Àâ “¡“√∂°√–®“¬‰ª ŸàÕ«—¬«–¢â“߇§’¬ß·≈–‰ªµàÕ¡π”È ‡À≈◊Õ߉¥â√«¥‡√Á«°«à“ Õß·∫∫·√°
°“√欓°√≥å‚√§®ß÷ ‰¡¥à π’ —° ‡πÕ◊È ßÕ°∑Ë¡’ ’°“√欓°√≥å‚√§∑Ë’¥∑’  Ë’ ÿ¥„π∑πË’ §È’ Õ◊ papillary type
¬—ß¡’°“√·∫àß≈—°…≥–¢Õ߇πÈ◊ÕßÕ°Õ’°·∫∫ÀπË÷ß §◊Õ°“√·∫àßµ“¡ Bismuth-Corlette
classification(17) (¿“æ· ¥ß∑’ËÀπâ“ 52) ´÷Ë߇ªìπ°“√Õ∏‘∫“¬∂÷ß°“√≈ÿ°≈“¡¢Õ߇πÈ◊ÕßÕ°‰ªµ“¡∑àÕ
∑“߇¥‘ππ”È ¥’‡æË◊Õª√–‚¬™πå„π°“√æ‘®“√≥“„Àâ°“√√—°…“·≈–µ‘¥µ“¡º≈°“√√—°…“ ´Ë÷߉¥â¡’°“√°≈à“«∂÷ß
·≈–„™°â —πÕ¬“à ß¡“°

51

Bismuth-Corlette classification

Type I : lesion of the main hepatic duct not involving the main confluence
Type II : lesion involving the confluence but clear of the right and left
hepatic ducts
Type IIIa : lesion involving the right hepatic duct
Type IIIb : lesion involving the left hepatic duct
Type IV : lesion involving the right and left hepatic ducts

°“√·∫ßà ™π¥‘ ¢Õ߇πÕÈ◊ ßÕ°µ“¡∑‡’Ë ÀπÁ ¥«â ¬°≈Õâ ß®≈ÿ ∑√√»πå (Histologic Grade) µ“¡∑Ë’ AJCC
·∫ßà ¡’ 5 ·∫∫§◊Õ

1. Grade cannot be assessed
2. Well differentiated
3. Moderately differentiated
4. Poorly differentiated
5. Undifferentiated

°“√√—°…“

„π°√≥∑’ Ë’‡πÈ◊ÕßÕ°Õ¬Ÿà proximal third ¢Õß∑àÕπÈ”¥’ °“√ºà“µ—¥µâÕß∑” hilar resection ·≈–
lymphadenectomy ´ß÷Ë  «à π„À≠µà Õâ ß∑” liver resection ¥«â ¬ ‡æ√“–°“√∑” hilar resection ¡°— ®–‰¡‡à 欒 ßæÕ
·µ∂à â“∑” frozen section ·≈«â ‰¥â free margin °Á‰¡àµÕâ ß∑” liver resection πÕ°®“°π°’È “√∑” caudate
lobe resection ·π–π”„À∑â ”‡ªπì Õ¬“à ߬ßË‘ ‡æ√“–®–∑”„Àâº≈°“√√—°…“¥’°«à“

„π∫“ß°√≥’∑Ë’µâÕßµ—¥µ—∫ºâŸªÉ«¬∑’Ë¡’Õ“°“√‡À≈◊Õß¡“°·≈–‡ªìπ¡“π“πÕ“®æ‘®“√≥“∑”°“√
√–∫“¬π”È ¥’ºà“π∑“ߺ«‘ Àπ—ß (PTBD) °Õà π°“√ºà“µ—¥

„π°√≥’∑Ë’§“¥«“à ®–¡‡’ πÕ◊È µ—∫‡À≈◊ÕÕ¬àŸπâÕ¬À≈—ß®“°°“√ºà“µ¥— µ—∫ „Àæâ ®‘ “√≥“∑” Portal vein
embolization ‡æÕ◊Ë ‡æ‘¡Ë ¢π“¥‡πÕÈ◊ µ—∫∑‡’Ë À≈Õ◊ Õ¬Ÿà (Future liver remnant ; FLR) „Àâ‡æ¬’ ßæÕ

52

‡πÕÈ◊ ßÕ°∑’ËÕ¬àŸ middle third „À∑â ” major duct resection ·≈– frozen section  «à π‡πÈ◊ÕßÕ° Cholangiocarcinoma
∑ËÕ’ ¬Ÿàª≈“¬ ¥ÿ (distal third) „Àâ∑” Pancreaticoduodenectomy ·≈– Lymphadenectomy

°“√√°— …“ºŸªâ É«¬∑’Ë¡’ positive margin À√Õ◊ ¡’ positive lymph node À√Õ◊ carcinoma in situ
∑’Ë margin Õ“®„Àâ°“√√—°…“·∫∫ À “¢“ ‡™àπ °“√„À√â ß—  √’ —°…“√à«¡°∫— ‡§¡∫’ ”∫¥— À√◊Õ°“√„À⇧¡’∫”∫—¥
·µà‡æ’¬ßÕ¬à“߇¥’¬« Õ¬à“߉√°Á·≈â«·µà¬—߉¡à¡’°“√»÷°…“·∫∫ clinical trial „¥Ê ∑’Ë®–¬◊π¬—π«‘∏’°“√√—°…“
µà“ßÊ∑’Ë°≈à“« ©–π—Èπ®÷ßµâÕßæ‘®“√≥“„Àâ°“√√—°…“‡ªìπ√“¬Ê ‰ª ‚¥¬‡©æ“–·π–π”„Àâ∑”„πß“π«‘®—¬
(Clinical trial)

ºŸâªÉ«¬∑’Ë negative margin Õ“®„Àâ°“√¥Ÿ·≈‚¥¬°“√ —߇°µÕ“°“√·≈–µ‘¥µ“¡‡ΩÑ“√–«—ß
‡ªìπ√–¬– °“√æ‘®“√≥“„À⇧¡’∫”∫—¥√à«¡°—∫√—ß ’√—°…“ µâÕßæ‘®“√≥“‡ªìπ√“¬Ê ‡™àπ°—π ‚¥¬‡©æ“–
·π–π”„Àâ∑”„πß“π«‘®—¬ (Clinical trial)

ºâŸªÉ«¬∑Ë’‰¡à “¡“√∂µ—¥‡πÈ◊ÕßÕ°‰¥â„π¢≥–∑Ë’ºà“µ—¥ §«√∑” surgical bypass À√◊Õ
stent (20-21) À≈ß— ®“°ππ—È Õ“®æ®‘ “√≥“„À°â “√√°— …“‚¥¬ ‡§¡∫’ ”∫¥— À√Õ◊ Õπ◊Ë Ê µ“¡∑°’Ë ≈“à «¡“·≈«â ·µÕà ¬“à ߉√
°Áµ“¡ ¬—ßµâÕß¡’°“√»÷°…“·∫∫ clinical trial Õ¬àŸ °“√„Àâ°“√¥Ÿ·≈·∫∫ª√–§—∫ª√–§ÕßÀ√◊Õ√—°…“µ“¡
Õ“°“√¬ß— π—∫«à“¡’ª√–‚¬™πå ·≈–Õ“®®–¥°’ «“à „Àâ°“√√—°…“Õ¬à“ßÕ◊ËπÊ ¥«â ¬

„πºâŸª«É ¬∑‚’Ë √§Õ¬Ÿà„π¢πÈ— ≈°ÿ ≈“¡ (metastatic disease) §«√‰¥√â ∫— °“√√–∫“¬π”È ¥‚’ ¥¬°“√„ à
stent °“√„À°â “√√—°…“ÕË◊π Ê ¬ß— µâÕß∑” clinical trial ·≈–√—°…“·∫∫ª√–§—∫ª√–§ÕßÕ¬à“ߥ’∑ ’Ë ¥ÿ  à«π°“√
„À⇧¡∫’ ”∫—¥π—πÈ ¬—߉¡à¡’ µŸ √°“√√°— …“∑’‡Ë ªπì ¡“µ√∞“π ∂ß÷ ·¡®â –¡«’ ‘∏°’ “√∑’°Ë ”≈ß— ‰¥√â —∫°“√¬Õ¡√—∫Õ¬à∫Ÿ â“ß
°µÁ “¡(15,22-23)

°“√µ¥‘ µ“¡º≈°“√√—°…“¡–‡√ßÁ ∑àÕπ”È ¥’¿“¬πÕ°µ∫—

µ‘¥µ“¡º≈‚¥¬°“√∑”Õ—≈µ√â“´“«¥å À√◊Õ CT ∑ÿ° 3 ‡¥◊Õ𠇪ìπ‡«≈“ 2 ªï ∂â“æ∫«à“‚√§
°”‡√‘∫°Á„À∑â ”°“√ ∫◊ §âπÕ¬“à ß≈–‡Õ¬’ ¥‡À¡Õ◊ π°—∫µÕπ∑Ë’æ∫‚√§„À¡à ·≈–„Àâ°“√√—°…“µ“¡∑Ë°’ ≈“à «¡“·≈â«

53

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17. Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis carcinoma of the hilus
of the liver. Surg Gynecol Obstet.1975;140:170-178.

18. Sudan D, Deroover A, Chinnakotla S, et al. Radiochemotherapy and transplantation allow
long-term survival for non resectable hilar cholangiocarcinoma. AM J Transplnt. 2002;
2:774-779.

19. Heimbach JK, Haddock MG,Alberts SR, et al. Transplantation for hilar cholangiocarcinoma.
Liver Transpl.2004;10:s65-68.

20. Davids PH, Groen AK, Rauws EA, et al.Randomized trial of self-expanding metal
stents versus polyethyllene stents for distal malignant biliary obstruction. Lancet.1992;
340:1488-1492.

21. Prat F, Chapat O, Ducot B, et al. A randomized trial of endoscopic drainage methods
for inoperable malignant strictures of the common bile. Gasteointest Endosc. 1998;47:1-7.

22. Kim TW, Chang HM, Kang HJ, et al. Phase II study of capecitabine plus cisplatin as
first-line chemotherapy in advanced biliary cancer. Ann Oncol. 2003;14:1115-1120.

23. Weidman M, Berr F, Schiefke I, et al. Photodynamic therapy in patients with non-resectable
hilar cholangiocarcinoma: 5-year follow-up of a prospective phase II study. Gastrointest
Endosc. 2004;60:68-75.

55

·π«∑“ß°“√√°— …“¡–‡√Áß∑àÕπÈ”¥’
º“à π°≈Õâ ß Õà ßµ√«®∑àÕπÈ”¥’

·≈–µ∫— ÕàÕπ

 ¡“§¡·æ∑¬å√–∫∫∑“߇¥π‘ Õ“À“√·Àßà ª√–‡∑»‰∑¬

§≥–ºŸ®â —¥∑”

1. √Õß»“ µ√“®“√¬å𓬷æ∑¬æå ‘»“≈ ‰¡‡â √’¬ß
2. »“ µ√“®“√¬å·æ∑¬åÀ≠ß‘ °√√≥°‘ “√å æ√æ≤— π°å ÿ≈
3. »“ µ√“®“√¬·å æ∑¬Àå ≠ß‘ ™µÿ ‘¡“ ª√–¡Ÿ≈ π‘ ∑√—æ¬å
4. æ—π‡Õ°π“¬·æ∑¬Õå π™ÿ µ‘ ®±Ÿ –æÿ∑∏‘
5. ºâŸ™«à ¬»“ µ√“®“√¬å𓬷æ∑¬å∑«»’ —°¥Ï‘ ·∑π«π— ¥’
6. √Õß»“ µ√“®“√¬πå “¬·æ∑¬∏å ’√– æ√‘ ™— « ‘ ÿ∑∏‘Ï

56

·π«∑“ß°“√√°— …“¡–‡√Áß∑Õà πÈ”¥º’ “à π°≈âÕß Cholangiocarcinoma
 Õà ßµ√«®∑Õà πÈ”¥’·≈–µ—∫ÕàÕπ

∫∑π”
°“√√°— …“¡“µ√∞“π¢Õß¡–‡√ßÁ ∑Õà π”È ¥™’ π‘¥ perihilar tumor ·≈– extrahepatic distal tumor

§Õ◊ °“√ºà“µ—¥‡Õ“‡πÕÈ◊ ßÕ°ÕÕ° „π°√≥’∑’‰Ë ¡ à “¡“√∂º“à µ—¥‰¥â ∑“߇≈◊Õ°ÀπßË÷ ¢Õß°“√√°— …“§Õ◊ °“√√—°…“
∫√√‡∑“Õ“°“√ºà“π°“√ àÕß°≈âÕßµ√«®∑àÕπÈ”¥’·≈–µ—∫ÕàÕπ (ERCP) ´÷Ëß¡’«‘∏’°“√√—°…“¥—ßπÈ’ °“√„ à∑àÕ
√–∫“¬πÈ”¥’ (biliary stent), photodynamic therapy, high intensity ultrasound „π∑π’Ë ®’È –°≈“à «∂ß÷ ·π«∑“ß
°“√√°— …“¡–‡√ßÁ ∑àÕπ”È ¥’º“à π°≈âÕß Õà ßµ√«®∑Õà π”È ¥·’ ≈–µ∫— ÕàÕπ

°“√√—°…“¡–‡√Áß∑Õà πÈ”¥º’ à“π°≈Õâ ß àÕßµ√«®∑Õà πÈ”¥·’ ≈–µ—∫ÕÕà π

‚¥¬∑«Ë— ‰ªºªŸâ «É ¬¡–‡√ßÁ ∑Õà πÈ”¥®’ –¡Õ’ “°“√∑“ߧ≈π‘ °‘ ·≈–º≈µ√«®∑“ßÀÕâ ߪØ∫‘ µ— °‘ “√∫ßà ∫Õ°
«à“¡’∑àÕπ”È ¥’Õÿ¥µ—π®–‰¥â√—∫°“√µ√«®Õ—≈µ√“´“«¥å∂â“æ∫¡’∑àÕπ”È ¥’„πµ—∫¢¬“¬„À≠à¢È÷π‚¥¬Õ“®®–æ∫
°Õâ π‡πÈÕ◊ ßÕ°∑ÕË’ ÿ¥µ—πÀ√Õ◊ ‰¡à°Á‰¥§â «√‰¥â√∫— °“√µ√«®√°— …“µ“¡·π«∑“ßµÕà ‰ªπÈ’
°“√µ√«®∑“ß√ß—  ‡’ æË◊Õ∫Õ°√–¬–¢Õß‚√§·≈–«“ß·ºπ°“√√°— …“

1. Magnetic resonance imaging (MRI) ·≈– Magnetic resonance cholangio-
pancreatography (MRCP)

ºªâŸ «É ¬§«√‰¥√â ∫— °“√µ√«® MRI ·≈– MRCP ‡æÕË◊ ª√–‡¡π‘ ¢Õ∫‡¢µ¢Õ߇πÕ◊È ßÕ° ≈°— …≥–
¢Õ߇πÈ◊Õµ—∫·≈–∑àÕπÈ”¥(’ 1-5) ‡æË◊Õª√–‡¡‘π«à“ “¡“√∂ºà“µ—¥‡π◊ÈÕßÕ°ÕÕ°‰¥âÀ√◊Õ‰¡à „π°√≥’∑’ˉ¡à “¡“√∂
ºà“µ—¥‡πÈ◊ÕßÕ°‰¥â®–¡’ª√–‚¬™πå„π°“√‡≈◊Õ°¢â“ß∑Ë’®–«“ß∑àÕ√–∫“¬π”È ¥’ (biliary stent) ‚¥¬®–‡≈◊Õ°«“ß
∑àÕ√–∫“¬‡¢“â ‰ª„π¢“â ß∑∑Ë’ Õà πÈ”¥¡’ ¢’ 𓥄À≠à·≈–¡°’ “√‡™Õ◊Ë ¡µÕà °π— ¡“°∑’ Ë ÿ¥(6)

2. Computed tomography (CT)
„π°√≥∑’ ‰Ë’ ¡¡à ’ MRCP ºâªŸ É«¬§«√‰¥√â —∫°“√µ√«® CT ´Ëß÷ ‡ªìπ°“√µ√«®∑¥Ë’ ’∑Ë’™à«¬„π°“√

«‘π‘®©—¬¡–‡√Áß∑àÕπ”È ¥’ ·µà∫Õ°¢Õ∫‡¢µ¢Õ߇π◊ÈÕßÕ°‰¥â‰¡à¥’‡∑à“ MRCP(7,8) „π°√≥’∑Ë’∑” CT ·≈â«
ª√–‡¡‘π«à“ºŸâªÉ«¬‰¡à “¡“√∂ºà“µ—¥‡π◊ÈÕßÕ°ÕÕ°‰¥â CT ¬—ß¡’ª√–‚¬™πå„π°“√™à«¬µ—¥ ‘π„®‡≈◊Õ°¢â“ß∑Ë’®–
«“ß∑Õà √–∫“¬πÈ”¥’‰¥¥â «â ¬(6)

57

°“√√—°…“¡–‡√ßÁ ∑Õà π”È ¥’

1. °“√ºà“µ—¥
1.1 ºà“µ—¥‡πÕÈ◊ ßÕ° (tumor resection) À≈ß— ®“°°“√µ√«® MRI ·≈– MRCP À√◊Õ CT

ºŸâªÉ«¬∑’˧“¥«à“ “¡“√∂ºà“µ—¥°âÕπ‡πÈ◊ÕßÕ°ÕÕ°‰¥â„Àâ√—°…“‚¥¬°“√ºà“µ—¥‡Õ“°âÕπ‡πÈ◊ÕßÕ°ÕÕ°
‡æ√“–‡ªπì «∏‘ ¡’ “µ√∞“π∑ Ë’ “¡“√∂‡æË‘¡Õ—µ√“√Õ¥™’«µ‘ ¢ÕߺŸâª«É ¬‰¥â (9,10)

1.2 ºà“µ—¥√–∫“¬∑àÕπÈ”¥’ (surgical bypass) „πºâŸªÉ«¬∑Ë’§“¥«à“ºà“µ—¥‡π◊ÈÕßÕ°‰¥â
·µà„π¢≥–∑Ë’ºà“µ—¥æ∫«à“√–¬–¢Õß‚√§‰¡à “¡“√∂ºà“µ—¥ÕÕ°‰¥â§«√‰¥â√—∫°“√ºà“µ—¥√–∫“¬∑àÕπ”È ¥’
‡æ√“– “¡“√∂√—°…“Õ“°“√§—π·≈–‡À≈◊ÕߢÕߺŸâªÉ«¬‰¥â·µà‰¡à∑”„Àâ¡’™’«‘µ¬◊𬓫¢÷Èπ·≈–¡’Õ“°“√°≈—∫
‡ªìπ´”È πâÕ¬°«à“ºŸâª«É ¬∑Ë„’  ∑à Õà √–∫“¬π”È ¥’·µà¡’¿“«–·∑√°´âÕπ·≈–µÕâ ßπÕπ‚√ß欓∫“≈π“π°«“à (11-13)

2. °“√√—°…“¡–‡√ßÁ ∑àÕπÈ”¥’º“à π°≈âÕß àÕßµ√«®∑àÕπÈ”¥·’ ≈–µ—∫ÕàÕπ
„π°√≥’∑Ë’‰¡à “¡“√∂ºà“µ—¥‡πÈ◊ÕßÕ°ÕÕ°‰¥âÀ√◊պ⟪ɫ¬‰¡à “¡“√∂√—∫°“√ºà“µ—¥‰¥âÀ√◊Õ

ºŸâª«É ¬ªØ‡‘  ∏°“√ºà“µ¥— ¡’«‘∏’°“√√—°…“ºâŸªÉ«¬¥—ßπ’È
2.1 „ à∑àÕ√–∫“¬πÈ”¥’ (biliary stent)
2.1.1 °“√„ à∑àÕ√–∫“¬πÈ”¥’„πºŸâªÉ«¬∑àÕπ”È ¥’Õÿ¥µ—π®“°¡–‡√Áß “¡“√∂∫√√‡∑“
Õ“°“√§—π ‡À≈◊ÕߢÕߺ⟪ɫ¬·µà‰¡à∑”„Àâ¡’™’«‘µ¬◊𬓫¢È÷π(11-13) ºŸâªÉ«¬¡’
§ÿ≥¿“晫’ µ‘ ¥’¢÷πÈ (14)
2.1.2 °“√„ ∑à Õà æ≈“ µ°‘ √–∫“¬πÈ”¥¡’ ª’ √– ∑‘ ∏¿‘ “æ‡∑¬’ ∫‡∑“à °∫— °“√º“à µ¥— ·°‰â ¢
°“√Õ¥ÿ µπ— (surgical bypass) „π°“√√°— …“Õ“°“√§π— ·≈–‡À≈Õ◊ ß °“√„ ∑à Õà
√–∫“¬π”È ¥’ ‚¥¬°“√ àÕß°≈âÕß¡’¢âÕ¥’§◊Õ¡’¿“«–·∑√°´âÕππâÕ¬°«à“
°“√ºà“µ—¥·µà¡’Õ“°“√‡À≈◊Õß°≈—∫‡ªìπ´È”∫àÕ¬°«à“∑”„ÀâµâÕ߇ª≈Ë’¬π∑àÕ
√–∫“¬À≈“¬§√ß—È (11-13)·µ¬à ß— ‰¡¡à °’ “√»°÷ …“‡ª√¬’ ∫‡∑¬’ ∫√–À«“à ß°“√º“à µ¥—
°∫— °“√„ ∑à Õà ‚≈À–√–∫“¬π”È ¥’ (metallic stent) ‚¥¬°“√ àÕß°≈Õâ ß
2.1.3 °“√„ à∑àÕæ≈“ µ‘°√–∫“¬πÈ”¥’„πºŸâªÉ«¬ hilar cholangiocarcinoma
‡æÕ◊Ë ·°‰â ¢°“√Õ¥ÿ µ—π 1 ¢â“ß·≈– 2 ¢â“ß¡’ª√– ‘∑∏‘¿“æ‡∑à“‡∑¬’ ¡°π— „π°“√
√–∫“¬πÈ”¥’ ·µà°“√„ ∑à àÕ√–∫“¬π”È ¥’ 2 ¢â“ß®–¡∑’ àÕπ”È ¥Õ’ —°‡ ∫‡ªìπ¿“«–
·∑√°´âÕπ¡“°°«à“°“√„ à∑Õà √–∫“¬‡æ’¬ß¢â“߇¥’¬«(15)
2.1.4 ¢Õâ ‡ ¬’ ¢Õß∑Õà æ≈“ µ°‘ √–∫“¬π”È ¥§’ Õ◊ Õ¥ÿ µπ— ‡√«Á ª√–¡“≥ 3-4 ‡¥Õ◊ π(16,17)
 à«π∑àÕ‚≈À–√–∫“¬®–Õÿ¥µ—πÀ≈—ß„ àª√–¡“≥ 6-9 ‡¥◊Õπ(18-20) ·≈–
‡π◊ËÕß®“°ºâŸªÉ«¬¡–‡√Áß∑àÕπ”È ¥’∑’ˉ¡à “¡“√∂ºà“µ—¥√—°…“‰¥â¡’√–¬–‡«≈“
Õ¬Ÿà√Õ¥‡©≈’ˬª√–¡“≥ 140-147 «—π(18,19) °“√„ à∑àÕ‚≈À–®–¡’§«“¡
§ÿâ¡§à“¡“°°«à“°“√„ à∑àÕæ≈“ µ‘°‡π◊ËÕß®“°Õÿ¥µ—π™â“°«à“∑”„À≡àµâÕß¡“
 àÕß°≈âÕ߇æË◊Õ‡ª≈’ˬπ∑àÕ√–∫“¬∫àÕ¬(20,21) „πºŸâªÉ«¬∑’˧“¥«à“®–¡’™’«‘µÕ¬àŸ
 π—È °«à“ 4 ‡¥Õ◊ π °“√„ à∑Õà √–∫“¬æ≈“ µ°‘ ®–‡À¡“– ¡°«à“(19)

58

2.1.5 ºªŸâ «É ¬§«√‰¥√â ∫— °“√µ√«®¥«â ¬ MRCP À√Õ◊ CT ‡æÕË◊ ª√–‡¡π‘ °“¬«¿‘ “§¢Õß Cholangiocarcinoma
∑àÕπ”È ¥’∑Ë’Õÿ¥µ—π·≈–«“ß·ºπ àÕß°≈âÕ߇¢â“‰ª√–∫“¬∑àÕπ”È ¥’¡’¢π“¥„À≠à
·≈–¡’°“√‡™◊ËÕ¡µàÕ°—π¡“°∑Ë’ ÿ¥‡æË◊ÕÀ≈’°‡≈’ˬ߰“√©’¥ “√∑÷∫· ß‡¢â“‰ª
„π∑àÕπ”È ¥’¢â“ß∑Ë’‰¡àµâÕß°“√√–∫“¬‡æ√“–®–¡’‚Õ°“ ‡°‘¥∑àÕπ”È ¥’Õ—°‡ ∫ Ÿß
∂â“ “√∑÷∫· ß∂Ÿ°©’¥‡¢â“‰ª„π∑àÕπ”È ¥’¢â“ß∑’ËÕÿ¥µ—π·µà‰¡à “¡“√∂√–∫“¬
ÕÕ°¡“‰¥â (5,6,22)

2.1.6 ∑àÕ‚≈À–√–∫“¬π”È ¥’∑Ë’„™âÕ“®„™â™π‘¥ covered metal stent ‡æ◊ËÕªÑÕß°—π
‡πÈ◊ÕßÕ°‡®√‘≠‡µ‘∫‚µ‡¢â“¡“∑àÕ√–∫“¬ ∑”„Àâ∑àÕ√–∫“¬Õÿ¥µ—π™â“°«à“
‡¡◊ËÕ‡∑’¬∫°—∫ noncovered metal stent(23,24) „πºâŸªÉ«¬∑’Ë¡’√Õ¬‚√§„π
common bile duct

2.2 Photodynamic therapy
‡ªìπ«‘∏’°“√„À¡à„π°“√√—°…“¡–‡√Áß∑àÕπ”È ¥’∑Ë’ “¡“√∂‡æ‘Ë¡Õ—µ√“√Õ¥™’«‘µ„πºâŸªÉ«¬

¡–‡√Áß∑àÕπ”È ¥’∑’ˉ¡à “¡“√∂ºà“µ—¥‰¥â‚¥¬°“√©’¥Õπÿæ—π∏å¢Õß hematoporphyrin ‡¢â“„π‡ âπ‡≈◊Õ¥
À≈—ß®“°πÈ—π®÷ß∑” intraluminal photoactivation ºà“π∑“ß°≈âÕß ERCP(25) ¡’°“√»÷°…“ prospective
randomized study ‡ª√’¬∫‡∑’¬∫√–À«à“ß°“√√—°…“‚¥¬ photodynamic therapy (PDT) √à«¡°—∫°“√
„ ∑à Õà √–∫“¬πÈ”¥‡’ ª√¬’ ∫‡∑¬’ ∫°∫— °≈¡ÿà ∑„’Ë  ∑à Õà √–∫“¬π”È ¥Õ’ ¬“à ߇¥¬’ «æ∫«“à °≈¡ÿà ∑‰’Ë ¥√â ∫— °“√√°— …“¥«â ¬PDT
¡™’ «’ µ‘ ¬π◊ ¬“«°«“à °≈¡àÿ §«∫§¡ÿ πÕ°®“°π¬’È ß— √–∫“¬°“√Õ¥ÿ µπ— ·≈–¡§’ ≥ÿ ¿“晫’ µ‘ ∑¥’Ë °’ «“à °≈¡àÿ §«∫§¡ÿ (26)

2.3 Intraductal high intensity ultrasound
¡’ pilot study »°÷ …“‡°Ë’¬«°—∫º≈¢Õß high intensity ultrasound µÕà ¡–‡√Áß∑àÕπÈ”¥’

6 √“¬‚¥¬„™â ultrasound probe ¢π“¥ 8x2.8 ¡‘≈≈‘‡¡µ√  ¡— º— ·≈–ª≈àÕ¬§≈Ëπ◊ ultrasound ‡¢“â ‰ª„π
√Õ¬‚√§„π∑àÕπÈ”¥’‚¥¬µ√ß ‚¥¬„™â guidewire π”ºà“πµ√ß°≈“ß√Õ¬‚√§ºà“π∑“ß°≈âÕß ERCP æ∫«à“
 “¡“√∂∑”≈“¬‡πÈ◊ÕßÕ°„Àⵓ¬‰¥â(27) ·µàµâÕß√Õ°“√»÷°…“‡æË‘¡‡µ‘¡µàÕ‰ª«à“®–¡’º≈„π°“√√—°…“‚√§¡–
‡√Áß∑àÕπ”È ¥À’ √Õ◊ ‰¡à

59

·ºπ¿Ÿ¡‘∑’Ë 1 ·π«∑“ß°“√√°— …“ºâŸª«É ¬¡–‡√Áß∑Õà πÈ”¥º’ “à π°“√ àÕß°≈âÕßµ√«®∑Õà πÈ”¥’·≈–µ∫— ÕàÕπ

Õ“°“√∑“ߧ≈‘π°‘ º≈µ√«®∑“ßÀâÕߪØ∫‘ —µ°‘ “√
º≈Õ—≈µ√“´“«¥å ß ¬— ∑àÕπ”È ¥’Õÿ¥µ—π®“°¡–‡√Áß∑Õà π”È ¥’

™π¥‘ extrahepatic distal tumor À√◊Õ perihilar

CT upper abdomen +/- MRCP

§“¥«“à º“à µ¥— ‡πÈÕ◊ ßÕ°ÕÕ°‰¥â §“¥«“à º“à µ¥— ‡πÕ◊È ßÕ°ÕÕ°‰¡‰à ¥â
ºà“µ—¥

ºà“µ—¥·°‰â ¢∑Õà π”È ¥Õ’ ÿ¥µπ— ·°‰â ¢∑Õà π”È ¥’Õÿ¥µπ— ‚¥¬«∏‘ °’ “√ Õà ß°≈âÕß √—°…“‚¥¬«‘∏Õ’ ◊πË 1

æ‘®“√≥“„ ∑à àÕ√–∫“¬π”È ¥’ Photodynamic
therapy

¡–‡√ßÁ ∑àÕπ”È ¥™’ 𥑠extrahepatic distal ¡–‡√ßÁ ∑Õà π”È ¥’
tumor ·≈– perihilar tumor type I perihilar tumor type II, III, IV

„ à∑àÕ√–∫“¬π”È ¥’ 1 ∑Õà ºà“π√Õ¬ „ à∑àÕ√–∫“¬π”È ¥’ 1 ∑àÕ‡¢â“¢“â ß∑’∑Ë àÕ
µ∫’ ¢Õß∑Õà π”È ¥2’ π”È ¥’„πµ—∫‡™Ë◊Õ¡µÕà °—π¡“°∑’Ë ÿ¥2,3

1 «∏‘ ’√°— …“ÕπË◊ Ê ‡™πà brachytherapy
2 „ ∑à Õà æ≈“ µ‘°‡¡ÕË◊ §“¥«“à ®–¡™’ ’«‘µ√Õ¥πÕâ ¬°«“à 4 ‡¥Õ◊ π·≈–„ à∑àÕ‚≈À–‡¡◊ËÕ§“¥«“à ¡’™«’ µ‘ √Õ¥π“π°«à“ 4 ‡¥◊Õπ
3 æ‘®“√≥“®“° CT À√◊Õ MRCP

60

References Cholangiocarcinoma

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2. Zidi SH, Prat F, Le Guen O, Rondeau Y, Pelletier G. Performance characteristics of magnetic
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3. Liessi G, Cesari S, DellûAntonio C, Avventi P, Spaliviero B, Butini R, Pavanello M. Cholangio-
pancreatography with magnetic resonance. Clinical use of a new çinversion-recoveryé
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4. Fulcher, A.S. and Turner, M.A. HASTE MR cholangiography in the evaluation of hilar
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5. Lopera JE, Soto JA, Munera F. Malignant Hilar and Perihilar Biliary Obstruction:Use of
MR Cholangiography to Define the Extent of Biliary Ductal Involvement and Plan Percutaneous
Interventions Radiology 2001;220:90-6.

6. Freeman ML, Overby C. Selective MRCP and CT-targted drainage of malignant hilar biliary
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61

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25. Wiedmann M, Berr F, Schiefke I, Witzigmann H, Kohlha K, Mossner J, Caca K. Photodynamic
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27. Prat F, Lafon C, De Lima DM, Theilliere Y, Fritsch J, Pelletier G, Buffet C, Cathignol D.
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56:909-15.

62

·π«∑“ß°“√√—°…“¥«â ¬ Cholangiocarcinoma
‡§¡’∫”∫—¥„π¡–‡√Áß∑Õà π”È ¥’

¡–‡√Áß«∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬

§≥–ºŸâ®—¥∑”

1. »“ µ√“®“√¬·å æ∑¬åÀ≠‘ß ¡ÿ ‘µ√“ ∑Õߪ√–‡ √‘∞
2. 𓬷æ∑¬Õå “§¡ ‡™’¬√»≈‘ ªá
3. º™âŸ «à ¬»“ µ√“®“√¬·å æ∑¬Àå ≠ß‘ ‡ÕÕ◊È ¡·¢  ¢ÿ ª√–‡ √∞‘
4. ·æ∑¬Àå ≠ß‘ °π°æ√ „® ∂“æ√

63

·π«∑“ß°“√√—°…“¥«â ¬‡§¡’∫”∫¥—
„π¡–‡√ßÁ ∑Õà π”È ¥’

„πºâŸªÉ«¬¡–‡√Áß∑àÕπÈ”¥’π—Èπ °“√∫”∫—¥√—°…“¥â«¬‡§¡’∫”∫—¥‡ªìπ‡√Ë◊Õß∑’Ë¡’§«“¡ ”§—≠
‡æ√“–ºŸâªÉ«¬¡–‡√ßÁ ∑Õà π”È ¥ ’ à«π¡“°®–‡°‘¥°“√‡ªπì ´È” (local recurrence) ·≈–/À√Õ◊ ¡–‡√Áß·æ√°à √–®“¬
„π√–À«à“ß°“√¥”‡π‘π‚√§ ‚¥¬¡“°°«à“ 2 „π 3 ¢Õߺ⟪ɫ¬®–‡ªìπ¡–‡√Áß√–¬–∑’ˉ¡à “¡“√∂ºà“µ—¥‰¥â
(unresectable disease) ‡¡ËÕ◊ ‰¥√â —∫°“√«π‘ ‘®©¬— (1) ·≈–∂÷ß®–ºà“µ—¥‰ª·≈â«°Á¡Õ’ —µ√“°“√°≈∫— ¡“‡ªπì ´È” ßŸ
(high rate of recurrence) ¡’Õ—µ√“°“√Õ¬Ÿà√Õ¥ 5 ªï (five-year median survival rate) 9-18%
„π¡–‡√Áß∑àÕπÈ”¥’ à«πµâπ (proximal biliary lesions) ·≈– 20-30% „π¡–‡√Áß∑àÕπ”È ¥’ à«πª≈“¬
(distal)(2)

°“√„™â‡§¡’∫”∫—¥„πºŸâªÉ«¬¡–‡√Áß∑àÕπÈ”¥’∑Ë’‰¡à “¡“√∂√—°…“„ÀâÀ“¬¢“¥‰¥âπÈ—π‡æË◊Õ∑Ë’®–
§«∫§¡ÿ ‚√§‡æ¡‘Ë Õµ— √“Õ¬√Ÿà Õ¥·≈–‡æ¡Ë‘ §≥ÿ ¿“晫’ µ‘ „πºªŸâ «É ¬‡À≈“à π’È¡°’ “√»°÷ …“°“√„™¬â “‡§¡∫’ ”∫¥— ∑ß—È ∑‡’Ë ªπì
Single agent ·≈– Combination „πºªâŸ «É ¬¡–‡√ßÁ ∑Õà πÈ”¥∑’ ß—È „π·≈–πÕ°µ∫— ¡–‡√ßÁ ∂ßÿ π”È ¥·’ ≈–¡–‡√ßÁ µ∫— ÕÕà π
∂÷ß·¡â«à“®–¡’√“¬ß“π∂÷ߺ≈¢Õ߇§¡’∫”∫—¥®–‡æË‘¡§ÿ≥¿“æ™’«‘µ ‡¡◊ËÕ‡∑’¬∫°—∫°“√¥Ÿ·≈ª√–§—∫ª√–§Õß
(best supportive care) ·µà√–¬–‡«≈“°“√Õ¬√Ÿà Õ¥ (median survival time) °Á¬ß— §ßµË” (6 ‡¥◊Õπ‡∑’¬∫°∫—
2.5 ‡¥◊Õπ) (3)

¡’°“√»÷°…“°“√„™â 5-Fluorouracil (5-FU) ∑—Èß∑Ë’‡ªìπ°“√„À⬓µ—«‡¥’¬«À√◊Õ√à«¡°—∫
¬“‡§¡µ’ «— Õπ◊Ë ´ß÷Ë  «à π¡“°®–‡ªπì °“√»°÷ …“„π¢π“¥µ«— Õ¬“à ß®”π«ππÕâ ¬ ·≈–‰¡¡à °’ “√§«∫§¡ÿ (small and
uncontrolled trial) ·≈– à«π¡“°®–¡’¡–‡√Áß∂ÿßπÈ”¥’ ¡–‡√Áß∑àÕπÈ”¥’®“°∑ÿ°µ”·Àπàß ·≈–¡–‡√Áßµ—∫ÕàÕπ
∑”„À≡ à “¡“√∂À“¢âÕ √ªÿ „π‡√ÕË◊ ߢÕߪ√– ∑‘ ∏‘¿“æ (Table 1)(4-12) Õ—µ√“µÕ∫ πÕß (response rate)
0-40% ·≈–√–¬–‡«≈“°“√Õ¬àŸ√Õ¥ 2-12 ‡¥◊Õπ ¡’°“√»÷°…“°“√„™â 5-FU √à«¡°—∫ Leucovorin
™à«¬‡æË‘¡°“√µÕ∫ πÕ߇ªìπ 32%(12) ·µà°Á¡’°“√»÷°…“Õ◊ËπÊ ¬—ßµÕ∫ πÕß‡æ’¬ß 7%(13) °“√„™â
Doxorubicin ·≈– Mitomycin-C, methyl CCNU À√◊Õ Streptozotocin √à«¡°∫— 5-FU ‰¡à‰¥â‡æË‘¡Õµ— √“
µÕ∫ πÕßÀ√◊Õ√–¬–‡«≈“°“√Õ¬àŸ√Õ¥„πºâªŸ «É ¬°≈ÿ¡à ‡À≈“à π’È

¡√’ “¬ß“π°“√„™â 5-FU √à«¡°∫— Cisplatin ´Ëß÷ ¡Õ’ —µ√“µÕ∫ πÕß 24%(11) °“√„™â Cisplatin,
Epirubicin ·≈– 5-FU ‡æË¡‘ Õ—µ√“µÕ∫ πÕ߇ªπì 40% ¡’√–¬–‡«≈“°“√Õ¬Ÿ√à Õ¥ 11 ‡¥◊Õπ(9)

¡’√“¬ß“π°“√»÷°…“°“√„™â Interferon-α (IFN-α) √à«¡°—∫ 5-FU „πÀ≈“¬√“¬ß“π
´ßË÷ ¡’ Partial response rate 34%(8)  à«π°“√„™â¬“‡§¡µ’ «— ÕπË◊ (Cisplatin, Doxorubicin) √«à ¡°—∫ 5-FU
°—∫ IFN-α ®“°√“¬ß“π®–‰¥âº≈¢â“߇§’¬ß®“°æ‘…¬“‡æ¡Ë‘ ¡“°¢È÷π·µ‰à ¡à‰¥â‡æ¡‘Ë º≈Õ—µ√“µÕ∫ πÕß (14)

64

¡’°“√»÷°…“°“√„™â¬“°≈àÿ¡ 5-FU ™π‘¥√—∫ª√–∑“π (oral 5-FU prodrug) ‡™àπ UFT, Cholangiocarcinoma
capecitabine and S-1 „π¡–‡√Áß∑àÕπÈ”¥’√–¬–≈ÿ°≈“¡ °“√„™â UFT √à«¡°—∫ Leucovorin „πºâŸªÉ«¬
14 √“¬ ‰¥ºâ ≈ stable diseases 2 √“¬ ¡’√–¬–‡«≈“°“√Õ¬Ÿ√à Õ¥ 5 ‡¥◊Õπ(15) °“√„™â Capecitabine ºŸªâ É«¬
18 √“¬ ‰¥âº≈ Partial response rate 6% ·≈– Stable response 28% ¡’√–¬–‡«≈“°“√Õ¬àŸ√Õ¥
8.1 ‡¥◊Õπ(16)  à«π°“√„™â Capecitabine √à«¡°—∫ Cisplatin ®–‰¥âÕ—µ√“°“√µÕ∫ πÕß 21.4% ·≈–
√–¬–‡«≈“°“√Õ¬Ÿà√Õ¥ 9.1 ‡¥◊Õπ(17) °“√„™â S1 „πºâªŸ É«¬®”π«π 19 √“¬ ‰¥Õâ —µ√“µÕ∫ πÕß 21.1%
·≈–√–¬–‡«≈“°“√Õ¬àŸ√Õ¥ 8.3 ‡¥Õ◊ π (18)

¢Õâ ¡≈Ÿ ‰¥‡â  πÕ·π–«“à Paclitaxel ‰¡‰à ¥¡â ª’ √–‚¬™π„å π¡–‡√ßÁ ∑Õà π”È ¥·’ ≈–∂ßÿ πÈ”¥(’ 19) „π¢≥–∑Ë’
Docetaxel ∑Ë„’ À⇪ìπ Single agent „πºªŸâ É«¬®”π«π 21 √“¬ ®–¡’ Complete response 1 √“¬ Partial
response 3 √“¬(20) ·µà°“√»÷°…“Õ◊ËπÊ ‰¡àæ∫«à“¡’°“√µÕ∫ πÕß (Objective response) „πºŸâªÉ«¬
17 √“¬(21) °“√»÷°…“ Inrinotecan „πºŸâªÉ«¬ 36 √“¬ ¡’ƒ∑∏Ï‘µàÕ¡–‡√Áß∑àÕπÈ”¥’‡≈Á°πâÕ¬¡’Õ—µ√“
°“√Õ¬Ÿ√à Õ¥ 8% (22)

°“√„™â Gemcitabine ·∫∫ Single agent πÈ—π¡’ƒ∑∏‘ϵàÕ¡–‡√Áß∑àÕπ”È ¥’ (Table 2)(23-29)
¡’°“√»÷°…“À≈“¬¢π“¥¬“ ‚¥¬¡’Õ—µ√“°“√µÕ∫ πÕß 8-60% √–¬–‡«≈“Õ¬àŸ√Õ¥ 6.3-16.0 ‡¥◊Õπ
 «à π°“√„™â Gemcitabine √«à ¡°∫— ¬“‡§¡’µ«— ÕËπ◊ ¡Õ’ —µ√“µÕ∫ πÕß 9-50% ·≈– “¡“√∂∑πµàÕæ…‘ ¬“‰¥â
(Table 3)(30-37) √–¬–‡«≈“Õ¬Ÿà√Õ¥ 5-15.4 ‡¥◊Õπ °“√„™â Gemcitabine °∫— Cisplatin ®–¡’Õ—µ√“µÕ∫
 πÕß 27.5-50% ·≈–√–¬–‡«≈“Õ¬√Ÿà Õ¥ 5-11.3 ‡¥Õ◊ π(31-33) °“√„™â Oxaliplatin √«à ¡°∫— Gemcitabine
¡’Õ—µ√“µÕ∫ πÕß 35.5% „πºŸâªÉ«¬®”π«π 31 √“¬ ∑’Ë¡’ ¿“æ√à“ß°“¬ ¡∫Ÿ√≥å·¢Áß·√ß ·≈–„πºŸâªÉ«¬
23 √“¬ ∑Ë’¡’ ¿“æ√à“ß°“¬∑Ë’‰¡à ¡∫Ÿ√≥å®–¡’Õ—µ√“µÕ∫ πÕß 22%(34) °“√„™â Gemcitabine √à«¡°—∫
¬“‡§¡’µ—«ÕπË◊ ‡™àπ Capecitabine, Irinotecan ·≈– Docetaxel ¡’ª√–‚¬™ππå Õâ ¬(35-37)

‡§¡’∫”∫—¥∑’Ë¥’∑Ë’ ÿ¥ ”À√—∫¡–‡√Áß∑àÕπÈ”¥’µâÕßÀ“µàÕ‰ª ·µà®“°¢âÕ¡Ÿ≈°“√»÷°…“æ∫«à“°“√„™â
Gemcitabine ‡ªìπ “√‡§¡’∫”∫—¥µ—«‡¥’¬«À√◊Õ√à«¡°—∫ Cisplatin À√◊Õ Oxaliplatin º≈ —¡ƒ∑∏‘Ϻ⟪ɫ¬
∑πµàÕ¬“‰¥¥â ’ „π°“√πÈ’ 5-FU °∫— Leucovorin √«à ¡°—∫ Cisplatin ¬—ßµâÕß»÷°…“µÕà ‰ª µÕâ ß∑”°“√»÷°…“
‡ª√’¬∫‡∑’¬∫ °“√„™¬â “‡§¡’∫”∫—¥µ—«‡¥’¬« Gemcitabine °∫— Gemcitabine √«à ¡°—∫ Cisplatin, Oxaliplatin
À√◊Õ 5-FU ·≈– Leucovorin µÕà ‰ª °“√§πâ À“¬“‡§¡∫’ ”∫¥— µ«— „À¡à ·≈– Novel targeted therapy

65

Table 1. Selected chemotherapy for advanced biliary tract cancer

Drug No. of Pts. Overall response% Median survival References

5-FU/leucovorin+etoposide 37 11 6.5 mo. Glimelius et al [3]
5-FU 30 10 26 wk Falkson et al [4]
5-FU+streptozotocin 26 8 12 wk
5-FU+MeCCNU 31 10 8 wk Takada et al [5]
5-FU 18 0 NR
5-FU, mitomycin-C, 18 0 NR Gebbia et al [6]
doxorubicin
5-FU/leucovorin/ 30 30 8 mo. Choi et al [7]
hydroxyurea Patt et al [8]
5-FU/leucovorin 28 32 6 mo. Ellis et al [9]
5FU, interferon-α 32 34 12 mo.
5FU, epirubicin, 20 40 11 mo. Sanz-Altamira et al [10]
cisplatin
5-FU/leucovorin/ 14 21.4 5 mo. Ducreux et al [11]
carboplatin Taieb et al [12]
5FU+Cisplatin 25 24 10 mo. Raderer et al [13]
5-FU/leucovorin/Cisplatin 29 34 9.5 mo.
5-FU/leucovorin/ 20 25 9.5 mo.
Mitomycin-C

66

Table 2. Activity of single agent gemcitabine in advanced biliary tract cancer

Gemcitabine Dose No. of Response Overall References
Regimen Ass. Pts. (%) survival (mo)

1200 mg/m2/wkx.3 every 2 wks 19 16 6.5 Raderer et al [13]

1,000 mg/m2 every 4 wks 18 22 8.0 Gebbia et al [23]

2,200 mg/m2 day1. every 2 wks 32 22 11.5 Penz et al [24]

1,000 mg/m2/wk x 7 18 60 6.3 Dobrila-Dintinjana et al [25]

then 1,000 mg/m2/wk x 3 every 4 wks

1,000 mg/m2/wk x 7 23 30 NR Kubicka et al [26] Cholangiocarcinoma

then 1,000 mg/m2/wk x 3 every 4 wks

1,200 mg/m2/wk x 3 every 5 wks 24 17 6.8 Valencak et al [27]

2,200 mg/m2/wk every 2 wks 14 29 10.5

1,000 mg/m2/wk x 3 every 4 wks 39 36 6.5 Arroyo et al [28]

1,000 mg/m2/wk x 7 13 8 16.0 Mezger et al [29]

then 1,000 mg/m2/wk x 3 every 4 wks

67

Table 3. Combination chemotherapy with gemcitabine in biliary tract carcinomas

Chemotherapy No. of Pts. RR Median OS References
(%) (mo.)

Gemcitabine (1,000 mg/m2, Days 1.8)/5-FU (100 mg/m2 ) 22 36 (PR) 11 Gebbia et al [30]

2 h, then 400 mg/m2 IV bolus, and then 5-FU 600

mg/m2 22 h, every 21 d

Gemcitabine (1,000 mg/m2)/cisplatin (30 mg/m2) 11 50 (PR) 11.3 Carraro et al [31]

Days 1, 8, 15 every 28 d

Gemcitabine (1,000 mg/m2, days 1.8)/cisplatin 30 36.6 (CR+PR) 20 wks Doval et al [32]

(70 mg/m2, day 1), every 21 d

Gemcitabine (1,250 mg/m2/days) days 1.8/ 40 27.5 (PR) 9 Thongprasert et al [33]

cisplatin (75 mg/m2/day) day 1 every 21 d

Gemcitabine (1,000 mg/m2/days) days 1 33 36 15.4 Andre et al [34]

oxaliplatin (100 mg/m2) days 2

Gemcitabine (1,000 mg/m2)/docetaxel (35 mg/m2), 43 9 (PR) 11 Kuhn et al [35]

days 1, 8, 15 every 28 d

Gemcitabine (1,000 mg/m2)/irinotecan (100 mg/m2) 14 14 (PR vs) NR Bhargava et al [36]

days 1, 8, every 21 d

Gemcitabine (2,200 mg/m2, day 1)+capecitabine 83 14 (PR) 8.2 vs Scheithauer et al [37]
17 (PR) 9.5
(2,500 mg/m2d, days 1-7) every 14 d

68

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69

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15. Chen JS, Yang TS, Lin YC, Jan YY. A phase II trial of Tegafur-Uracil plus leucovorin
(LV) in the treatment of advanced biliary tract carcinomas. Japanese Journal of Clinical
Oncology 2003;33:353-356.

16. Patt YZ, Hassan MM, Alvaro Aguayo A, et al. Oral capecitabine for the treatment of
hepatocellular carcinoma, cholangiocarcinoma, and gallbladder carcinoma. Cancer 2004;
101:578-86.

17. Kim TW, Chang HM, Kang HJ, et al. Phase II study of capecitabine plus cisplatin as first-line
chemotherapy in advanced biliary cancer. Ann Oncol 2003;14:1115-1120.

18. Ueno H, Okusaka T, et al. Phase II study of S-1 in patients with advanced biliary tract
cancer British Journal of Cancer 2004;91:1769-1774.

19. Jones DV, Lozano R, Hoque A, et al. Phase II study of paclitaxel therapy for unresectable
biliary tree carcinomas. J Clin Oncol 1996;14:2306-2310.

20. Papakostas P, Kouroussis C, Androulakis N, et al. First-line chemotherapy with docetaxel
for unresectable or metastatic carcinoma of the biliary tract. A multicentre phase II study.
Eur J Cancer 2001;37:1833-1838.

21. Pazdur R, Royce ME, Rodrigues GI, et al. Phase II trial of docetaxel for cholangiocarcinoma.
Am J Clin Oncol 1999;22:78-81.

22. Fishkin PA. Alberts SR, Burgart LJ, et al. CPT-11 for bile duct and gall bladder carcinoma.
A Phase II North Central Cancer Treatment Group Study International Journal of
Gastrointestinal Cancer 2002;32:110-114.

23. Gebbia V, Giuliani F, Maiello E, et al. Treatment of inoperable and/or metastatic biliary
tree carcinoma with single agent gemcitabine or in combination with levofolinic acid
and infusional fluorouracil: results of a multicenter phase II study. J Clin Oncol 2001;
19:4089-4091.

24. Penz M, Kornek GV, et al. Phase II trial of two-weekly gemcitabine in patients with
advanced biliary tract cancer. Ann Oncol 2001;12:183-186.

25. Dobrila-Dintinjana R, Kovac D, Depolo A, et al. Gemcitabine in patients with nonresectable
cancer of the biliary system or advanced gallbladder cancer. Am J Gastroent 2000;95:2476.

26. Kubicka S, Rudolf KL, et al. Phase II study of systemic gemcitabine chemotherapy for
advanced unresectable hepatobiliary carcinomas. Hepatogastroenterology 2001;48:783-789.

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27. Valencak J, Kornek GV, Raderer M, et al. Gemcitabine for the treatment of advanced biliary Cholangiocarcinoma
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28. Arroyo G, Gallardo J, Rubio B. Gemcitabine (GEM) in advenced biliary tract cancer (ABTC).
Experience from Chile and Argentina in phase II trials. Proc Am Soc Clin Oncol 2001;157a:
(Abstr 626).

29. Mezger J, Sauerbruch T, Ko Y, et al. A phase II trial of gemcitabine in gallbladder and biliary
tract carcinomas. Oncologie 1998;21:232-234.

30. Gebbia V, Giuliani F, Maiello E, et al. Treatment of inoperable and/or metastatic biliary tree
carcinomas with single-agent gemcitabine or in combination with levofolinic acid and infusional
fluorouracil: Results of a multicenter phase II study. J Clin Oncol 2001;19:4089-4091.

31. Carraro S. Servienti PJ, Bruno MF. Gemcitabine and cisplatin in locally advanced or
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32. Doval DC, Sekhon JS, Gupta SK, et al. A phase II study of gemcitabine and cisplatin in
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33. Thongprasert S. Napapan S. Charoentum C, Moonprakan S. Phase II study of gemcitabine
and cisplatin as first line chemotherapy in inoperable biliary tract carcinoma. Ann Oncol
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34. Andre T. Tournigand C, Rosmorduc O, et al. Gemcitabine combined with oxaliplatin (GEMOX)
in advanced biliary tract adenocarcinoma : a GERCOR study. Ann Oncol 2004;15(9):
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35. Kuhn R, Hribaschek A, Eichelmann K, Rudolph S, Fahlke J, Ridwelski K. Outpatient therapy
with gemcitabine and docetaxel for gallbladder, biliary, and cholangio-carcinomas. Invest
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36. Bhargava P. Jani CR, Savarese DM, et al. Gemcitabine and irinotecan in locally advanced
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23-26.

37. Scheithauer W. Schull B, Ulrich-Pur H, et al. Biweekly high-dose gemcitabine alone or
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71

·π«∑“ß°“√„™â√ß—  √’ °— …“
„π¡–‡√ßÁ ∑Õà π”È ¥’

 ¡“§¡√—ß √’ —°…“·≈–¡–‡√ßÁ «∑‘ ¬“·Ààߪ√–‡∑»‰∑¬

§≥–ºŸâ®¥— ∑”

1. º™âŸ «à ¬»“ µ√“®“√¬πå “¬·æ∑¬™å ≈‡°¬’ √µ‘ ÀÕª√–‡ √∞‘
2. 𓬷æ∑¬»å °— ¥‘Ïæ ‘ ∑‘ Æå π« ‘√‘
3. 𓬷æ∑¬å¬ß¬ÿ∑∏ §ß∏π“√—µπå

72

·π«∑“ß°“√„™â√ß—  ’√°— …“„π¡–‡√Áß∑àÕπÈ”¥’

 ”À√—∫ Unresectable Cholangiocarcinoma πÈ—π °“√„Àâ√—ß ’√—°…“√à«¡°—∫¬“‡§¡’∫”∫—¥
‡ªìπ°“√√—°…“∑’Ë¡’·π«‚πâ¡„Àâº≈¥’°«à“ °“√„™√â —ß ’√—°…“ À√◊Õ ¬“‡§¡’∫”∫—¥‡æ¬’ ßÕ¬à“߇¥¬’ « µ“√“ß∑Ë’ 1
‡ªπì  √ªÿ °“√«‘®—¬¢Õß°“√„™â√—ß √’ °— …“√à«¡°∫— ¬“‡§¡∫’ ”∫¥— „π Cholangiocarcinoma

µ“√“ß∑’Ë 1Chemoradiation for hilar cholangiocarcinoma

Author Chemoradiotherapy

McMasters Experimental Survival Remarks
et al.(11)
Control

31 adjuvant No survival advantage Extrahepatic bile duct Ca.
chemoradiation (18)
9 neoadjuvant 5 FU Margin negative resection in all 9 Cholangiocarcinoma
infusion+EBRT patients with neoadjuvant therapy

Foo et al.(12) 15 22% 5 years survival (2 of 9) Extrahepatic bile duct Ca.
EBRT+Brachytherapy
9 5 FU infusion+EBR Trend towards improved survival by
+Brachytherapy addition of chemotherapy

Morganti 20 Median survival 21 months. Brachytherapy in 12 patients. 11
et al.(13) - 2 of 16 unresectable patients patients with HCCa. 4 patients had

survived more than 5 years residual disease after resection

Ca-carcinoma, EBRT-external beam radiotherapy.

·µàÕ¬à“߉√°Áµ“¡ °“√«‘®—¬‡°◊Õ∫∑—ÈßÀ¡¥¬—ß¡’°≈ÿࡵ—«Õ¬à“߉¡à¡“°π—° ·≈–‡ªìπ°“√»÷°…“
∑‰Ë’ ¡„à ™à °“√«®‘ ¬— §«∫§¡ÿ ·∫∫ ¡ÿà (randomized controlled study) ´ßË÷ §«√®–¡°’ “√»°÷ …“«®‘ ¬— ‡æ¡‘Ë ‡µ¡‘ ‡æÕ◊Ë À“
¢Õâ  √ÿªµÕà ‰ª

73

Intrahepatic Cholangiocarcinoma

Residual disease after resection 㪉 Radiotherapy

+ 5FU based Chemotherapy À√Õ◊ Gemcitabine
-

Õ“®æ‘®“√≥“„Àâ
√ß—  √’ —°…“„π°√≥’

Unresectable, Inoperable Cases 㪉 Radiotherapy
+- 5FU based Chemotherapy À√◊Õ Gemcitabine

À¡“¬‡Àµÿ : °“√„™â√—ß ’√—°…“„π Intrahepatic Cholangiocarcinoma ¬—ß¡¢’ âÕ¡Ÿ≈°“√«‘®—¬πâÕ¬
§«√√—°…“ºªâŸ «É ¬·∫∫„π‚§√ß°“√»°÷ …“«®‘ —¬

Extrahepatic Cholangiocarcinoma

Residual disease after resection 㪉 Radiotherapy

+ 5FU based Chemotherapy À√◊Õ Gemcitabine
-

Õ“®æ®‘ “√≥“„Àâ
√—ß √’ —°…“„π°√≥’

Unresectable, Inoperable Cases 㪉 Radiotherapy

+ 5FU based Chemotherapy À√◊Õ Gemcitabine
-

À¡“¬‡Àµÿ : °“√„™√â ß—  ’√°— …“„π Extrahepatic Cholangiocarcinoma ¬—ß¡’¢âÕ¡Ÿ≈°“√«‘®¬— πÕâ ¬
§«√√°— …“ºâªŸ É«¬·∫∫„π‚§√ß°“√»÷°…“«‘®¬—

References

1. K.M. McMasters, T.M. Tuttle and S.D. Leach et al., Neoadjuvant chemoradiation for extrahepatic
cholangiocarcinoma, American Journal of Surgery 174 (1997) (6), pp. 605-608.

2. M.L. Foo, L.L. Gunderson and C.E. Bender et al., External radiation therapy and transcatheter
iridium in the treatment of extrahepatic bile duct carcinoma, International Journal of Radiation
Oncology Biology Physics 39 (1997) (4), pp. 929-935.

3. A.G. Morganti, L. Trodella and V. Valentini et al., Combined modality treatment in unresectable
extrahepatic biliary carcinoma, International Journal of Radiation Oncology Biology Physics 46
(2000) (4), pp. 913-919.

74

·π«∑“ß°“√®¥— √–¬– Cholangiocarcinoma
‚√§¡–‡√Áß∑Õà π”È ¥’

75

·π«∑“ß°“√®—¥√–¬–‚√§¡–‡√ßÁ ∑Õà πÈ”¥’

√–¬–¢Õß‚√§ (Staging) Intrahepatic cholangiocarcinoma
(American Joint Committee on Cancer 2002)

Stage I T1 N0 M0
Stage II T2 N0 M0
Stage IIIA T3 N0 M0
T4 N0 M0
IIIB AnyT N1 M0
IIIC AnyT Any N M1
Stage IV

Primary Tumor (T)
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Solitary tumor without vascular invasion
T2 Solitary tumor with vascular invasion or multiple tumors none more
than 5 cm
T3 Multiple tumors more than 5 cm or tumor involving a major branch
of the portal or hepatic vein (s)
T4 Tumor (s) with direct invasion of adjacent organs other than the
gallbladder or with perforation of the visceral peritoneum

Regional lymph Nodes (N)
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph nodes metastasis
N1 Regional lymph nodes metastasis

Distant Metastasis (M)
Mx Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis

Histological Grade(G)
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated

76

Staging TNM classification (Hilar cholangiocarcinoma)
(American Joint Committee on Cancer 2002)

Stage 0 TiS N0 M0 Cholangiocarcinoma
Stage IA T1 N0 M0
Stage IB T2 N0 M0
Stage IIA T3 N0 M0
Stage IIB T1 N1 M0
T2 N1 M0
Stage III T3 N1 M0
Stage IV T4 Any N M0
Any T Any N M1

Primary Tumor (T)
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor confined to the bile duct histologically
T2 Tumor invades beyond the wall of bile duct
T3 Tumor invades the liver, gallbladder, pancreas, and/or unilateral
branches of the portal vein (right or left) or hepatic artery (right or left)
T4 Tumor invades any of the following: main portal vein or its branches
bilaterally, common hepatic artery, or other adjacent structures,
such as the colon, stomach, duodenum, or abdominal wall

Regional Lymph Nodes (N)
Nx Regional lymph nodes cannot be assessed
No No regional lymph nodes metastasis
N1 Regional lymph nodes metastasis

77

Distant Metastasis (M) Distant metastasis cannot be assessed
Mx No distant metastasis
M0 Distant metastasis
M1

Histological Grade (G) Grade cannot be assessed
Gx Well differentiated
G1 Moderately differentiated
G2 Poorly differentiated
G3 Undifferentiated
G4

78

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● 欓∏«‘ ∑‘ ¬“¢Õ߇´≈≈·å ≈–™È‘π‡πÕÈ◊ ¡–‡√ßÁ µ∫— ·≈–¡–‡√Áß∑Õà π”È ¥’

✦ ·ºπ¿¡Ÿ ‘·π«∑“ß°“√‡µ√¬’ ¡·≈–°“√«‘π‘®©¬— ∑“߇´≈≈å欓∏«‘ ‘∑¬“
✦ ·π«∑“ß°“√«π‘ ‘®©¬— ¡–‡√ßÁ µ∫— ·≈–¡–‡√ßÁ ∑Õà π”È ¥®’ “° Ë‘߇®“–¥¥Ÿ
✦ ·ºπ¿Ÿ¡‘·π«∑“ß°“√‡µ√¬’ ¡·≈–°“√«‘π®‘ ©—¬∑“߇π◊ÕÈ ‡¬◊ËÕ欓∏‘«∑‘ ¬“
✦ ·π«∑“ß°“√µ√«®™‘Èπ‡πÕÈ◊ º“à µ—¥®“°µ∫—
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79

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∑“߇´≈≈å欓∏‘«∑‘ ¬“

√“™«‘∑¬“≈¬— 欓∏·‘ æ∑¬å

·π«∑“ß„π°“√√—°…“¡–‡√ßÁ µ∫—
·≈–°“√µ√«®µ‘¥µ“¡

80

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ª√–‡¿∑·≈–≈°— …≥– °“√‡µ√¬’ ¡ÀâÕßµ√«®/ÀÕâ ߺ“à µ¥— °“√‡µ√¬’ ¡∑’ÀË Õâ ߪØ∫‘ µ— ‘°“√/ °“√µ√«®¥â«¬°≈âÕß®ÿ≈∑√√»π/å
¢Õßµ—«Õ¬“à ߇´≈≈«å ‘∑¬“ ÀÕâ ßµ√«®™πÈ‘ ‡πÕ◊È °“√«‘π‘®©—¬
‡µ√¬’ ¡ ‡¡’¬√‰å ¥â 2 ·∫∫
 ß‘Ë ‡®“–¥¥Ÿ ®“°°Õâ π‡πÕ◊È ● ®¡àÿ  ‰≈¥„å π 95% ethanol ∑π— ∑’ (Wet- fixed) ● ¬Õâ ¡ ’ Papanicolaou  ”À√∫— °“√‡µ√’¬¡ ¥‡Ÿ Õ° “√·π«∑“ß°“√«‘π®‘ ©—¬¡–‡√ßÁ µ∫—
 ‡¡¬’ √·å ∫∫ Wet-fixed ®“° ß‘Ë ‡®“–¥¥Ÿ
·≈–/À√◊Õ
● ‡µ√¬’ ¡‡ªπì  ‡¡¬’ √å·Àßâ (Air-dried) ● ¬Õâ ¡ ’ Diff-Quik À√Õ◊  ¬’ âÕ¡Õπ◊Ë „π°≈¡àÿ
Romanovski*  ”À√—∫°“√‡µ√¬’ ¡ ‡¡’¬√å
·∫∫ Air-dried

 Ë‘߇®“–¥Ÿ¥®“°∂ÿßπ”È ● ¥Ÿ¥πÈ”®π·Àßâ ·≈–‡®“–¥¥Ÿ ´È”∑’√Ë Õ¬‚√§ ªπòí  “√π”È ‡æÕ◊Ë ∑” ‡¡¬’ √å/¬Õâ ¡ ’ Simple cyst/Hydratid cyst/
●  àßπ”È ‡®“–¥Ÿ¥∑—ßÈ À¡¥ Papanicolaou À√◊Õ °≈¡ÿà Romanovski* Neoplastic cyst

 ß‘Ë ‡®“–¥Ÿ¥®“°Ωµï —∫ ● À¬¥ ßË‘ ‡®“–¥¥Ÿ ∫π ‰≈¥·å ≈–‡µ√¬’ ¡ ‡¡¬’ √å ● ¬âÕ¡ ’ Papanicolaou À√Õ◊ Pyogenic abscess/Amebic abscess/
·∫∫ Wet-fixed ·≈–/À√Õ◊ Air-dried °≈¡ÿà Romanovski* Necrotic malignant tumor

● æ‘®“√≥“ ßà µ√«®À“‡™◊ÕÈ ·≈–‡æ“–‡™◊ÕÈ ● ¬Õâ ¡ PAS °√≥¬’ ◊π¬—π ameba
∑“ß®≈ÿ ™«’ «∑‘ ¬“

*  °’ ≈ÿ¡à Romanovski ‰¥·â °à Diff-Quik, Giemsa, May Guenwald Giemsa, Wrightûs stains ‡ªπì µπâ

81

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√“™«‘∑¬“≈—¬æ¬“∏‘·æ∑¬å

§≥–ºŸâ®¥— ∑”

1. 𓬷æ∑¬å摇™∞  ¡— ª∑“π°ÿ ≈ÿ
2. 𓬷æ∑¬æå ß…æå ’√–  ÿ«√√≥°≈Ÿ
3. ·æ∑¬åÀ≠‘ß¿“π‘π’ ∂“«√—ß°Ÿ√
4. 𓬷æ∑¬å™«≈µ‘ ‰æ‚√®πå°≈ÿ
5. 𓬷æ∑¬å‰æ‚√®πå ®√√¬“ߧ¥å °’ ÿ≈
6. ·æ∑¬Àå ≠ß‘ πƒ¡≈ §≈“â ¬·°«â
7. ·æ∑¬åÀ≠ß‘ π√‘ ™— √å ‡≈»‘ ª√–‡ √‘∞ ÿ¢
8. 𓬷æ∑¬§å ≥‘µ Õ∏‘ ¢ÿ

82

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∫∑π”

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§«“¡∂°Ÿ µÕâ ߠߟ ®ß÷ ·π–π”„À·â æ∑¬„å ™„â π°“√«π‘ ®‘ ©¬— ·∑π°“√‡®“–™π‘È ‡πÕ◊È (Core-needle biopsy) Õ¬“à ߉√
°Áµ“¡  ”À√—∫°âÕπ·≈–√Õ¬‚√§∑’Ë ß —¬‡ªìπ¡–‡√Áßµ—∫∑’Ë¡’‚Õ°“ ºà“µ—¥ÕÕ°∑—ÈßÀ¡¥‰¥â ∑Ë’ª√–™ÿ¡¢Õߧ≥–
∑”ß“π·≈–ºâŸ‡™’ˬ«™“≠¡’§«“¡‡ÀÁπ«à“ §«√‡≈Ë’¬ß°“√‡®“– ∑—Èßπ’È ‡æ◊ËÕªÑÕß°—π°“√·æ√à¢Õ߇´≈≈å¡–‡√Áß
ÕÕ°¡“µ“¡√Õ¬¢Õ߇¢¡Á πÕ°®“°π’È °“√‡®“–¥Ÿ¥„À‰â ¥âº≈¥’ ·æ∑¬åº‡Ÿâ ®“–§«√¡’∑°— …–·≈–¡’欓∏·‘ æ∑¬å
∑’®Ë –„À°â “√«‘π®‘ ©¬— ®“°µ«— Õ¬à“߇´≈≈å«∑‘ ¬“π‰È’ ¥â

≈”¥∫— ¢π—È ¢Õß°“√«π‘ ®‘ ©¬—

‡πÕË◊ ß®“°∑—Èß Hepatocellular carcinoma ·≈– Cholangiocarcinoma  “¡“√∂„À√â ªŸ ≈°— …≥å
∑“߇´≈≈å«‘∑¬“∑’ËÀ≈“°À≈“¬ ·≈–µâÕß«‘π‘®©—¬·¬°‚√§®“°‚√§·≈–¿“«–ÕË◊πÊ °“√·ª≈º≈®÷ß¡’§«“¡
®”‡ªπì µÕâ ßæ‘®“√≥“¢Õâ ¡≈Ÿ ∑ßÈ— ∑“ߧ≈‘π‘°·≈–°“√µ√«®æ∫∑“߇´≈≈«å ∑‘ ¬“ „π≈°— …≥–Õߧ√å «¡ (1)
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1. ¢âÕ¡Ÿ≈ ”§≠— ∑“ߧ≈π‘ °‘
2. ≈—°…≥–∑“ß√—ß «’ ‘∑¬“
3. ≈—°…≥–∑“߇´≈≈å«∑‘ ¬“
4. °“√¬Õâ ¡·≈–°“√»°÷ …“¥«â ¬«∏‘ æ’ ‘‡»… (∂â“®”‡ªìπ)
5. °“√·ª≈º≈‡™Ë◊Õ¡‚¬ß∑“ߧ≈π‘ ‘°·≈–欓∏«‘ ∑‘ ¬“

≈°— …≥–∑“߇´≈≈å«∑‘ ¬“∑Ë’∫ßà ∫Õ°‡ªìπ Hepatocellular carcinoma (1)
ª√–°Õ∫¥â«¬ ¡’√Ÿª≈—°…≥–¢Õ߇´≈≈å≈–¡â“¬ hepatocyte √à«¡°—∫¡’°“√®—¥‡√’¬ßµ—«‡ªìπ

trabeculae À√◊Õ ¡’ bare tumor nuclei ‡ªìπ≈—°…≥–‡¥πà
1. √Ÿª≈—°…≥–¢Õ߇´≈≈å≈–¡â“¬ hepatocyte
‡´≈≈å∑’Ë¡’≈—°…≥–¢Õß hepatocyte §◊Õ‡ªìπ‡´≈≈å¢π“¥°≈“ß ¡’√Ÿª√à“ßÀ≈“¬‡À≈’ˬ¡

(polygonal shape) ¡’𑫇§≈¬’  °≈¡Õ¬Ÿ°à ≈“߇´≈≈å ¡°— ‡ÀπÁ π«‘ §≈‚‘ Õ≈—  ·≈–¡°— ¡’ «à π¢Õ߉´‚µª≈“ ´¡÷
„Àâ‡ÀÁπ‚¥¬‡©æ“–Õ¬à“߬‘Ëß ∂ⓇÀÁπ granular cytoplasm ·≈–/À√◊Õbile pigment ¬‘Ëß„Àâπ”È Àπ—°„π°“√
∫Õ°«à“‡ªìπ hepatocyte Àπ—°·πàπ¢÷È𠧫“¡ ”§—≠Õ’°ª√–°“√Àπ÷Ëߧ◊Õ °“√∫Õ°«à“‡ªìπ‡´≈≈å¡–‡√Áß ´Ë÷ß
≈—°…≥–∑’Ë®”‡ªìπ§◊Õ ¡’ —¥ à«π¢Õߢπ“¥π‘«‡§≈’¬ µàÕ‰´‚µª≈“ ´÷¡‡æ‘Ë¡¢÷Èπ (increased nuclear
cytoplasmic ratio)

83

2. °“√®¥— ‡√’¬ßµ—«‡ªπì trabeculae
°“√®¥— ‡√’¬ßµ«— ‡ªìπ ·∂«À√◊Õ·π«¬“« (trabeculae) ‡ªìπ§≥ÿ ≈—°…≥–¢Õß hepatocyte

·µà≈–·∂« ®–¡’ sinusoid §—πË ¥—ßπÈ—π ®ß÷ Õ“»—¬ endothelial cell ∑Ë’§≈¡ÿ Õ¬Ÿà¥â“π¢“â ߇ªπì µ«— ∫àß∫Õ°§«“¡
‡ªìπ·∂« ‡¡Ë◊Õ‡ªìπ¡–‡√Áß °“√‡√’¬ßµ—«®–¡’µ—Èß·µà 3 ‡´≈≈å¢÷Èπ‰ª„π·∂«·∑π∑®Ë’ –‡ªπì ‡´≈≈·å ∂«‡¥¬’ « ®ß÷ „Àâ
≈°— …≥–¢Õß·∂«∑’Ë°«“â ß (broad trabeculae) ´÷Ëß≈—°…≥–∑’˪√“°Ø„π ‘Ë߇®“–¥Ÿ¥®–¡’‰¥â 2 √Ÿª·∫∫ §◊Õ
·∫∫∑‡’Ë ÀÁπ‡´≈≈‡å √’¬ß‡ªìπ·∂«°«â“ß ¡’ endothelial cell ª√“°Ø∑“ߥâ“π¢â“ß ‡√¬’ ° trabecular pattern
(Fig.1) ·≈–·∫∫∑’ˇÀπÁ sinusoid ∑Ë’¡’ endothelial cell æ“¥ºà“π°≈¡ÿà ¢Õ߇´≈≈å¡–‡√Áß ‡√’¬° sinusoidal
pattern (Fig.2) πÕ°®“°π’È ¬—ßÕ“®æ∫√Ÿª·∫∫°“√‡√’¬ßµ—«∑Ë’‡ªìπ pseudoacinar pattern ´÷Ëß„Àâ
≈—°…≥–°“√‡√’¬ßµ—«¢Õ߇´≈≈凪ìπ«ß¡’™àÕß«à“߇°‘¥¢÷Èπµ√ß°≈“ß≈—°…≥–°“√®—¥‡√’¬ßµ—«¢Õ߇´≈≈å¡–‡√Áß
‡À≈“à π‡È’ ªìπÀ≈°— ‡°≥±«å ‘π‘®©¬— ∑ ’Ë ”§—≠¢Õß hepatocellular carcinoma ®“° ß‘Ë ‡®“–¥¥Ÿ

Fig. 1 : Hepatocellular carcinoma with trabecular pattern Fig. 2 : Hepatocellular carcinoma with sinusoidal pattern

3. Bare tumor nuceli
≈—°…≥–πÈ’‡ªìπ≈—°…≥–摇»…∑Ë’æ∫‰¥â‡©æ“–„π hepatocellular carcinoma ®“° Ë‘ß

‡®“–¥Ÿ¥ ‚¥¬∑Ë’ 𑫇§≈’¬  ∑’Ë¡’≈—°…≥–¢Õß hepatocyte ·µà¡’¢π“¥‚µ™—¥‡®π ®–°√–®“¬µ—«Õ¬àŸ‡¥Ë’¬«Ê
‡ªìπ®”π«π¡“° (Fig.3) 𑫇§≈’¬ ‡À≈à“πÈ’ ‰¡à‡ÀÁπ¡’‰´‚µª≈“ ´÷¡§≈ÿ¡ ‡¢â“„®«à“∂Ÿ°≈Õ°À≈ÿ¥‰ª
„π°√–∫«π°“√‡µ√¬’ ¡∑“߇´≈≈å«‘∑¬“

Fig. 3 : Hepatocellular carcinoma manifesting bare tumor nuclei
84

πÕ°®“°πÈ’ hepatocellular carcinoma  “¡“√∂„Àâ≈—°…≥–ÕË◊π‰¥â¥â«¬ ´Ë÷ß°“√«‘π‘®©—¬
®”‡ªìπµÕâ ß¡°’ “√¬Õ⠡懑 »…À√Õ◊ °“√»÷°…“摇»… √«à ¡°∫— °“√·ª≈º≈‡™ÕË◊ ¡‚¬ß°—∫≈—°…≥–∑“ߧ≈π‘ °‘

≈°— …≥–∑“߇´≈≈å«∑‘ ¬“∑’∫Ë ßà ∫Õ°‡ªìπ Cholangiocarcinoma (1)

ª√–°Õ∫¥â«¬‡´≈≈å¡–‡√Áß∑Ë’®—¥‡√’¬ßµ—«°—π‡ªìπ√ŸªµàÕ¡À√◊Õ∑àÕ √à«¡°—∫≈—°…≥–¢ÕßÕߧå
ª√–°Õ∫·«¥≈Õâ ¡·≈–¢âÕ¡≈Ÿ ∑“ߧ≈π‘ ‘°∑’Ë π—∫ ππÿ

1. ‡´≈≈¡å –‡√Áß∑Ë®’ —¥‡√¬’ ßµ«— °—π‡ªπì √ŸªµÕà ¡À√Õ◊ ∑àÕ
≈—°…≥–∑“߇´≈≈å«‘∑¬“§◊Õ≈—°…≥–¢Õß adenocarcinoma ‡´≈≈å¡–‡√Áß¡—°¡’𑫇§≈’¬ 

Õ¬Ÿà§àÕπ‰ª¥â“π¢â“ߢÕ∫‡¢µ‡´≈≈å‰¡à™—¥ ‡πË◊Õß®“°‰´‚µª≈“ ´÷¡‚ª√àß µ‘¥ ’®“ß ·≈–‡´≈≈å¡—°¡’°“√√«¡
µ«— °—π‡ªìπ√ŸªµÕà ¡À√Õ◊ ∑àÕ·∫∫ “¡¡µ‘ ‘ ´ßË÷ ‰¡‡à ÀÁπ√Ÿµ√ß°≈“ß ‡´≈≈å ¡°— ¡’°“√´Õâ π∑—∫°—π (Fig.4)

Fig. 4 : Cholangiocarcinoma with 3-D gland arrangement pattern °“√µ√«®∑“ß欓 ‘∏«‘∑¬“

2. ≈—°…≥–¢ÕßÕߧªå √–°Õ∫·«¥≈Õâ ¡
≈—°…≥–¢ÕßÕߧåª√–°Õ∫·«¥≈âÕ¡‡ªìπµ—«™à«¬„π°“√«‘π‘®©—¬ cholangiocarcinoma

∂“â æ∫≈—°…≥–¢Õß desmoplasia (scant cellularity pattern) À√◊Õæ∫ ductular proliferation(2) (Fig.5)
®–„ÀâπÈ”Àπ—° π—∫ πÿπ ¢≥–∑’Ë ∂â“æ∫≈—°…≥–¢Õß necrosis ¡—°‡ªìπ metastasis from colorectal
adenocarcinoma

Fig. 5 : Cholangiocarcinoma associated with ductular proliferation feature

85

3. ¢âÕ¡Ÿ≈∑“ߧ≈π‘ ‘°∑Ë’ π∫—  πÿπ
°“√«‘π‘®©—¬‡ªìπ cholangiocarcinoma ®”‡ªìπµâÕß¡’¢âÕ¡Ÿ≈∑“ߧ≈‘π‘° π—∫ πÿπ ‰¥â·°à

°“√‰¡àæ∫¡–‡√Áߪ∞¡¿Ÿ¡‘∑Ë’ÕËπ◊ ·≈–°“√æ∫ dilated hepatic bile duct πÕ°®“°π’È ∂â“§π‰¢¡â ’¿¡Ÿ ≈‘ ”‡π“Õ¬àŸ
∑“ßÕ’ “π ®–¡Õ’ ∫ÿ µ— ‘°“√≥å¢Õß‚√§π È’ Ÿß¡“°

°“√√“¬ß“πº≈

§«√√“¬ß“π„Àâ™—¥‡®π«à“‡ªìπ¡–‡√ÁßÀ√◊Õ‰¡à ·≈–∂Ⓡªìπ¡–‡√Áß ‡ªìπ™π‘¥‰Àπ πÕ°®“°π’È
Õ“®„ÀâπÈ”Àπ—°¢Õߧ«“¡‡™Õ◊Ë ¡πË— ¢Õߺ≈ ‚¥¬∑’„Ë ™§â ÿ≥»—æ∑åπ”Àπâ“ µ«— Õ¬à“ߢÕß°“√√“¬ß“πº≈ ‡™àπ

● Malignant; hepatocellular carcinoma
● Malignant; suggestive of hepatocellular carcinoma
● Malignant; adenocarcinoma, probably cholangiocarcinoma
● Malignant; adenocarcinoma, possibly primary or secondary
● Malignant; adenocarcinoma, in favor of metastasis
● Malignant; type not determined
● Benign; cirrhotic feature
● Benign; suggestive of focal nodular hyperplasia etc.

References

1. Wee A, Sampatanukul P. In: Fine Needle Aspiration Cytology of The Liver: Diagnostic
algorithms, a Southeast Asian Perspective. Bangkok : Year Book Publisher 2004.

2. Sampatanukul P, Leong ASY, Kosolbhand P, Tangkijvanich P. Proliferating ductules are
a diagnostic discriminator for intrahepatic cholangiocarcinoma in FNA biopsies. Diagnostic
Cytopathol 2000;22:359-63.

86

·ºπ¿Ÿ¡‘ °“√µ√«®∑“ß欓 ‘∏«‘∑¬“

·π«∑“ß°“√‡µ√’¬¡·≈–°“√«π‘ ®‘ ©¬—
∑“߇πÈ◊Õ‡¬◊ÕË æ¬“∏«‘ ‘∑¬“

√“™«∑‘ ¬“≈¬— 欓∏·‘ æ∑¬å

87

88

·ºπ¿Ÿ¡‘·π«∑“ß°“√‡µ√’¬¡·≈–°“√«π‘ ®‘ ©¬— ∑“߇πÈÕ◊ ‡¬ÕË◊ 欓∏‘«∑‘ ¬“

ª√–‡¿∑·≈–≈—°…≥– °“√‡µ√¬’ ¡ÀÕâ ßµ√«®/ÀÕâ ßºà“µ—¥ °“√‡µ√’¬¡∑’ÀË Õâ ߪؑ∫—µ°‘ “√/ °“√µ√«®¥â«¬°≈Õâ ß®ÿ≈∑√√»πå/
¢Õßµ«— Õ¬“à ß™πÈ‘ ‡πÕÈ◊ ÀÕâ ßµ√«®™π‘È ‡πÕ◊È °“√«‘π‘®©—¬

·∑àß™‘Èπ‡πÈ◊Õ‡®“–¥â«¬‡¢Á¡ «“ß·∑àß™Èπ‘ ‡πÕ◊È „À⇪ìπ‡ âπµ√ß∫π°√–¥“…/ ● π∫— ®”π«π·≈–«¥— §«“¡¬“«¢Õß™πÈ‘ / ¥‡Ÿ Õ° “√À«— ¢Õâ ¢Õß°“√√“¬ß“π°“√«π‘ ®‘ ©¬—
(Core-needle biopsy) ·™à„π 10% øÕ√å¡“≈π‘ „ ∑à —ÈßÀ¡¥≈ß„π∫≈ÕÁ ° ¡–‡√ßÁ µ∫— ®“°™π‘È ‡πÕÈ◊

™‘Èπ‡π◊ÈÕºà“µ—¥‡≈Á°Ê®“°µ—∫ ·™à„π 10% øÕ√å¡“≈π‘ µ—¥‡πÈÕ◊ ∑ß—È À¡¥À√◊Õ «à π∑Ë¡’ ‡’ π◊ÈÕßÕ°„ ∫à ≈ÕÁ ° ¥‡Ÿ Õ° “√À—«¢Õâ ¢Õß°“√√“¬ß“π°“√«π‘ ‘®©—¬
¡–‡√ßÁ µ∫— ®“°™πÈ‘ ‡πÕÈ◊
(Wedge or incisional biopsy)

ºà“µ—¥µ∫— (Hepatic lobectomy §«√Ω“πµ—∫‡ªπì ·«àπÊ¢π“¥§«“¡Àπ“ ● ∑”§«“¡‡¢â“„®°∫— ¥â“πµà“ßÊ ¢Õß™πÈ‘ ‡πÕ◊È / ¥Ÿ‡Õ° “√ Practical Pathological Guideline for
or segmental resection/ 1-2 ‡´πµ‘‡¡µ√ («“¥¿“æ· ¥ß°“√«“ßµ—« ¥Ÿ°“√∫√√¬“¬ Gross ·≈–°“√µ¥— ‡πÈ◊Õ„ ∫à ≈ÁÕ° Liver specimens ·≈–À—«¢âÕ¢Õß°“√√“¬ß“π
Hepatectomy ¢Õßµ∫— ·≈–∑‘»∑“ß°“√Ω“π)/ ·™à„π 10% „π‡Õ° “√ Practical Pathological Guideline °“√«π‘ ‘®©¬— ¡–‡√ßÁ µ—∫®“°™‘Èπ‡π◊ÈÕ
øÕ√å¡“≈‘π∑’¡Ë ª’ √¡‘ “µ√¡“°°«“à ‡π◊ÈÕµ∫— for Liver specimens
‰¡πà âÕ¬°«à“ 10 ‡∑“à

·π«∑“ß°“√µ√«®™‘Èπ‡πÕÈ◊ °“√µ√«®∑“ß欓 ‘∏«‘∑¬“
ºà“µ—¥®“°µ∫—

√“™«∑‘ ¬“≈¬— 欓∏·‘ æ∑¬å

§≥–º®Ÿâ —¥∑”

1. 𓬷æ∑¬æå ß…åæ√’ –  ÿ«√√≥°≈ÿ
2. ·æ∑¬Àå ≠ß‘ ¿“π‘π’ ∂“«√—ß°Ÿ√
3. 𓬷æ∑¬™å «≈µ‘ ‰æ‚√®π°å ÿ≈
4. 𓬷æ∑¬å‰æ‚√®πå ®√√¬“ߧ¥å ’°≈ÿ
5. ·æ∑¬åÀ≠‘ßπƒ¡≈ §≈“â ¬·°«â
6. ·æ∑¬Àå ≠‘ßπ√‘ —™√å ‡≈‘»ª√–‡ √∞‘  ÿ¢
7. 𓬷æ∑¬§å ≥µ‘ Õ∏‘ ¢ÿ

89

·π«∑“ß°“√µ√«®™π‘È ‡π◊ÈÕº“à µ—¥®“°µ—∫

(Practical Pathological Guideline for Liver specimens)

Pathological Practical Guideline for the Management of Liver Mass

Pathological Practical Guideline (PPG) is systematically developed recommendations
that assist the practitioner pathologists in making decisions about Gastrointestinal, hepato-biliary
and pancreatic specimens. These guidelines are not intended as standard or absolute
requirements. These guidelines may be adopted, modified, or rejected and are subject to revision
from time to time as warranted by the evolution of knowledge, technology and practice.

The guidelines provide basic recommendations that are supported by analysis of
the current literatures and by a synthesis of gastrointestinal hepato-biliary expert opinion.

The recommendations have been divided into four major areas:
1. Items that provide an informative gross description.
2. Additional diagnostic features that are recommended to be included in every

report if possible.
3. Optional features that may be included in the final report
4. An example of Gross description and Diagnosis form.

Point of interest:
çThe gross description of Hepatocellular carcinoma specimens is critical, as a 1.0 cm

margin has been determined to be an important prognostic factor for recurrence. So!, initially
the friable and irregular resected margin should be painted or inked and following which the
specimen should be serially sectioned perpendicular to the inked surgical margin at approximately
1 cm interval.é

Gross Description:
The following features are recommended to be included in the final report because

they are generally accepted as being of prognostic importance, are required for therapy, or are
traditionally expected as part of the diagnosis.

1. How the specimen was received: fresh, in formalin, opened, unopened etc.
2. How the specimen was identified: labeled with name and number and designation

(e.g. right lobectomy)
3. Types of specimens: wedge resection, partial resection, right or left lobectomy

and total hepatectomy followed by liver transplantation.

90

4. Tumor description: Macroscopic examination: Both hepatic parenchymal lesions °“√µ√«®∑“ß欓 ‘∏«‘∑¬“
and lesions of major bile ducts.
✦ Identify and orient the specimen
✦ Measure and weight of the specimen
✦ Describe the covering surface and attached tissue: describe and locate position
of visible mass or other abnormality
✦ Identify all of the bile duct and vascular surgical margins (portal and hepatic
vessels) and submit them en face.
✦ Palpate the bile ducts for the area of indurations; open longitudinal and take
serially sectioning the bile duce perpendicularly to long axis.
✦ Search for hilar lymph nodes: number, size, and appearance.
✦ Paint or ink the resected margin and other margins related to tumor or lesion
✦ Serially section liver into 1 cm thick slabs in the transverse plane from
superior to inferior, fix in formalin (put paper between slabs to aide fixation)
✦ Locate and record location of lesion: mass, cavity, cyst, abscess
✦ Record size of the lesion. Measure distance of lesion from deep and other
related margins
✦ Describe the lesion: color, consistency, border, hemorrhage and necrosis,
in case of multifocally or multicentricity, described all lesion and also the
distance from the main lesion.
✦ Describe cirrhotic nodules if present, indicating the overall color and nodule
size range. Specifically mention and sample nodules 1 cm in size or greater or
any nodules that differ in color from the overall liver.
✦ Attached gallbladder: describe the size, serosa, wall thickness, mucosa and
stones or sludge or bile content.

5. Sections submitted
✦ Hepatic parenchymal lesions: Representative sections from tumor, at lease
four sections or more depending on size and extent. If nodules are present,
samples of up to five should be taken.
✦ Surgical resected margin and other margins related to lesion: at lease one
perpendicular section of the nearest margin and other margins related to
the lesion
✦ Adjacent non-neoplastic liver tissue
✦ Lymph nodes, if present
✦ Gallbladder, if present

91

Diagnostic Information:
Recommendation:

1. Tumor classification: Based on WHO histological classification of tumors of the
liver and intrahepatic bile ducts.

2. Tumor staging: Based on AJCC/UICC: TNM classification of tumors of the liver
and intrahepatic bile ducts. (http://uicc.org)

For Hepatocellular Carcinoma (HCC):
✦ Histological subtype: Hepatocellular Carcinoma (HCC)
✦ Architectural pattern: Trabecular/Pseudoglandular/Scirrhous
✦ Cytological variant: Hepatic cell type/clear cell type/pleomorphic cell type/

sarcomatous cell type
✦ Histological grading: well differentiated (Edmonson grade II)/moderately

differentiated (Edmonson grade III)/poorly differentiated (Edmonson grade IV)
✦ Status of vascular and or lymphatic invasion
✦ Status of non involved liver tissue
✦ Status of surgical resected margins

Immunohistochemistry of HCC: - Positive (most useful in diagnosis)
Hepatocyte (Dako) - Positive (canalicular pattern)
CEA - positive or negative
Alpha fetoprotein - positive or negative
Fibrinogen - usually positive
Cytokeratin 8 and 18 - usually negative
Cytokeratin 7 and 19 - usually negative
Cytokeratin 20 - negative
Epithelial membrane antigen

For Intrahepatic cholongiocarcinoma (ICC):
■ Histological subtype: Adenocarcinoma
■ Architectural pattern: Tubular/Papillary
■ Cytological variant: Mucinous type/clear cell type/pleomorphic type/sapindle
cell type
■ Histological grading: well differentiated/moderately differentiated/poorly
differentiated
■ Status of vascular and or lymphatic invasion
■ Status of non involved liver tissue
■ Status of surgical resected margins
■ Status of regional lymph node

92

Immunohistochemistry of ICC: - Positive (most useful in diagnosis)
Cytokeratin 7 and 19 - Positive
CEA - positive
Epithelial membrane antigen - negative
Alpha fetoprotein - negaitive
Hepatocyte (Dako)

Features Considered Optional in the Final Report:
1. Stage: the required data should provide sufficient information for application
of most staging system. (If a stage is to be included in the report, the staging
system used should be specified)
2. Specific Lymph Nodes. (AJCC/UICC TNM classification* is used and based on)
3. Nature of the involved liver tissue

* AJCC/UICC TNM : American Joint Cancer Commission/Union Internationale Contre le Cancer
Tumor Node Metastasis

An example of Gross description and Diagnosis form

Gross: Liver SN........................................... °“√µ√«®∑“ß欓 ‘∏«‘∑¬“

The specimen is received in formalin, labeled with the patientûs name and labeled with an accession
number with additional labeling as ç...............................é, and consists of a wedge resection,
partial resection, right or left lobectomy and total hepatectomy followed by liver transplantation
of liver, measuring............X.............X............cm with/without gallbladder. The capsular surface
shows glistening/dull/indurated/smooth/nodular surface, measuring up to............cm
in maximal diameter. The surgical resected margin measures.................X................X...............cm.
Serial cross sections of the liver show single/multiple round irregular mass (es) with tan/gray/
brown/white/yellow color and soft/firm/rubbery consistency and friable/hemorrhagic/necrotic
appearance, measuring from...............cm up to...............cm in size. Well circumscribe
completed, partial fibrous capsule is seen/is not seen. The extension of lesion/tumor invades
into the surgical resected margin/capsular surface//adjacent structure as...............Rupture
of tumor is/is not seen at...................Tumor emboli is/is not found in main hepatic veins. Multiple
satellite nodules measuring up to............cm in diameter are seen/are not seen. The uninvolved
hepatic tissue is unremarkable/show yellow smooth surface/green smooth surface/
micro-nodular cirrhotic surface (<0.5 cm)/macro-nodular cirrhotic surface (>0.5 cm)/mixed
macro-micro nodular cirrhotic surface. Grossly, the surgical resected margins are/are not free
of tumors.

93

The gallbladder measuring..........X.........X..........cm is attached. The cystic duct measures...........cm
long and............cm in maximal diameter. The mucosa shows smooth velvety/fine granular/coarse
granular/reticular surface with/without hemorrhagic necrotic eroded surface. No/........stones/
yellow polyp, measuring.........cm in maximal diameter with yellow/black colour are found.
Regional lymph nodes of portal area and along course of major vascular trunks are identified.
Sections are taken from: #1-5 Lesion or tumor including area of closest resected margin,
#6 Lesion or tumor including area of closest capsular surface #7 surgical resected margin,
#8 area of vascular invasion, #9-10 random sections of non-neoplastic liver tissue, #11
gallbladder, #12 adjacent structure #13 others............................

Diagnosis:

For HCC
Liver tissue, wedge resection, partial resection, right or left lobectomy and total hepatectomy
followed by liver transplantation

■ Histological subtype: Hepatocellular Carcinoma (HCC)
■ Architectural pattern: Trabecular/Pseudoglandular/Scirrhous
■ Cytological variant: Hepatic cell type/clear cell type/pleomorphic cell type/

sarcomatous cell type
■ Histological grading: well differentiated (Edmonson grade II)/moderately

differentiated (Edmonson grade III)/poorly differentiated (Edmonson grade IV)
■ Size.........x.......x.......cm of right/left lobe
■ Invasion: Local invasion of tumor into capsular surface/adjacent structure..........
■ Presence/absence of vascular, tumor emboli, lymphatic, perineural invasion
■ Surgical resected margins: all surgical resected margins are free./The surgical

resected margins are involved by tumor cells.
■ Uninvolved hepatic tissue is unremarkable

/shows cirrhosis of micronodular macronodular mixed macro-micronodular
type with non-active/active
/shows chronic hepatitis of viral B/viral C: degree of activity; degree of
fibrosis; HAI score; degree of liver cell dysplasia
/shows...............................................................eg. steatosis, hepatic fibrosis,
portal inflammation.
■ Lymph nodes: No direct tumor extension into lymph nodes is identified
Presence of metastatic tumor in..........out of..........nodes

94

For Cholangio Carcinoma (CHC) °“√µ√«®∑“ß欓 ‘∏«‘∑¬“
Liver tissue, wedge resection, partial resection, right or left lobectomy and total hepatectomy
followed by liver transplantation

■ Histological subtype: Adenocarcinoma
■ Architectural pattern: Tubular/Papillary
■ Cytological variant: Mucinous type/clear cell type/pleomorphic type/sapindle

cell type
■ Histological grading: well differentiated/moderately differentiated/poorly

differentiated
■ Invasion: Local invasion of tumor into capsular surface/adjacent structure...........
■ Presence/absence of vascular, tumor emboli, lymphatic, perineural invasion
■ Surgical resected margins: all surgical resected margins are free./The surgical

resected margins are involved by tumor cells.
■ Uninvolved hepatic tissue is unremarkable

/shows cirrhosis of micronodular macronodular mixed macro-micronodular
type with non-active/active
/shows chronic active/non-active cholangitis with/without opisthorchiasis
/shows chronic hepatitis of viral B/viral C: degree of activity; degree of
fibrosis; HAI score; degree of liver cell dysplasia
■ shows.............eg. steatosis, hepatic fibrosis, portal inflammation.
■ Status of Lymph nodes: No direct tumor extension into lymph nodes is identified
Presence of metastatic tumor in..out of...nodes

References

1. Bronner M. Guidelines for Handling Anatomic Pathology Specimens. Department of
Pathology-Hospital Pathology, University of Washington Health Sciences Center, Seattles,
1996

2. Hamilton SR and Aaltonen LA. Pathology and Genetics Tumours of the Digestive system.
World Health Organization Classification of Tumours. IARC Press, Lyon, 2000

3. Rosai J. Guidelines for handling of most common and important surgical specimens.
In Rosai & Ackermanûs Surgical Pathology. London; Mosby, 2004

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