直肠神经内分泌癌16例临床分析

目的总结直肠神经内分泌癌（NEC）的临床病例资料与外科治疗策略。方法回顾性分析北京肿瘤医院2003-2007年经外科手术治疗16例直肠NEC患者的临床资料,并与同期经手术治疗的222例直肠腺癌患者的临床资料进行对比分析。结果16例直肠NEC患者占同期直肠恶性肿瘤392例的4．1％,其中非典型类癌10例,小细胞NEC3例,大细胞NEC3例。仅12．5％的患者术前血清癌胚抗原（CEA）升高;25．0％的患者行腹会阴联合切除术（APR）,43．8％行低位前切除术（LAR）,12．5％行联合脏器切除术,18．8％的患者肿瘤经肛门局部切除（LR）;有脉管癌栓者占37．5％,有淋巴结转移者占68．8％,43．9％的患者术中发现远处转移或肿瘤播散。222例直肠腺癌患者中,行根治性APR19．4％,行根治性LAR68．5％,行姑息性LAR5．4％,行结肠造口术2．7％,行剖腹探查术4．1％;有脉管癌栓者占20．7％,有淋巴结转移者占56．3％。直肠NEC患者术后1、2、3年的生存率分别为62．5％、25．0％和0．6％,明显低于直肠腺癌患者的83．1％、61．7％和46．1％（P〈0．01）。结论直肠NEC临床少见,较易发生脉管癌栓、淋巴结转移及远处脏器转移,生存率低于直肠腺癌;其外科手术原则与直肠腺癌相似。     

DukesC期直肠癌Miles术后同步放化疗与单纯化疗的疗效对比分析

为对比分析DukesC期直肠癌患者行腹会阴联合切除术（Miles术）后同步放化疗与单纯化疗的疗效,本研究统计符合条件的临床病例132例,其中54例术后予以单纯化疗,78例术后予以同步放化疗。化疗方案：奥沙利铂130mg／m^2,d1;亚叶酸钙100mg／m^2,d1-5;氟尿嘧啶350mg／m^2,d1-5;每月化疗1次,连续化疗6个月。放射治疗方法：术后放射治疗定位采用CT模拟机,应用15MVX线,1．8Gy／次,4次／周,共7周,总剂量为50．4Gy。随访5年,观察患者局部复发、远处转移和5年生存情况。结果显示,（1）局部复发：单纯化疗组12例（22．22％）,同步放化疗组6例（7．69％）,两组局部复发率差异有统计学意义,P〈0．05。（2）远处转移：单纯化疗组28例（51．85％）,同步放化疗组37例（47．44％）,两组远处转移率差异无统计学意义,P〉0．05。（3）5年生存情况：单纯化疗组16例（29．63％）,同步放化疗组37例（47．44％）,两组5年生存率差异有统计学意义,P〈0．05。结果表明,DukesC期直肠癌患者Miles术后行同步放化疗,与单纯化疗相比,局部复发率降低,5年生存率升高,远处转移率相近。     

颊黏膜鳞状细胞癌的治疗及预后分析

目的总结颊黏膜鳞癌的治疗方法及分析影响预后的因素。方法回顾我科于1987～1999年收治的52例颊黏膜鳞癌患者，分析病理分期、淋巴结情况、上下颌骨受侵与否、治疗失败等对预后的影响。结果52例颊黏膜鳞癌，11例单纯手术，41例术前放疗。5年生存率为56．4％，早期（Ⅰ＋Ⅱ期）和晚期（Ⅲ＋Ⅳ期）5年生存率分别为64．6％、53．0％。影响预后的因素有：（1）鳞癌病理分级，高分化者明显好于低分化者；（2）颈部淋巴结情况，cN0术后淋巴结阳性率为14％，cN1-3术后淋巴结阳性率为44％，病理淋巴结阳性和阴性的5年生存率分别为35．7％和64．8％；多因素分析发现影响预后的因素包括临床和病理分期的早晚。治疗失败以局部复发占多数，共出现11例局部复发，3例颈部淋巴结复发或转移，4例远处转移。结论颊黏膜鳞癌手术中的局部处理很重要，应注意保留足够的安全界，并需提高一期修复的能力。要重视对颈部淋巴结的处理，对cN0病例应行肩胛舌骨肌上清扫。     

两种放化疗联合方法治疗局部晚期直肠癌的疗效比较

为比较序贯放化疗及同步放化疗治疗局部晚期直肠癌的临床疗效和毒副反应,回顾分析大连大学附属新华医院采用序贯放化疗（22例,序贯放化组）及同步放化疗（24例,同步放化组）的46例局部晚期直肠癌患者资料,并对其疗效及毒副反应进行对比分析。序贯放化组采用化疗一放疗化疗交替治疗,共放化疗6周期;同步放化组放疗的第1、4周同时接受化疗2个周期,同步放化疗结束后,再接受4个周期化疗。结果显示,两组近期疗效差异无统计学意义（P〉0．05）。同步放化组（25．3个月）较序贯放化组（18．7个月）延长了中位无进展生存时间（PFS）,且差异有统计学意义（P〈O．05）;两组中位总生存时间（OS,28．5个月和22．5个月）,差异无统计学意义（P〉0．05）。序贯放化组和同步放化组1年无进展生存率分别为77．3％和95．8％,2年无进展生存率分别为31．8％和54．2％,1年总生存率分别为90．9％和100％,2年总生存率分别为40．9％和75．0％。疾病进展主要为远处转移。两组毒副反应主要为恶心、呕吐、WBC下降、腹泻及神经毒性,均较轻,未见Ⅳ级毒副反应,经对症治疗后均能耐受,从而顺利完成治疗。两组毒副反应发生率除腹泻差异有统计学意义（P〈O．05）外,其余均无统计学意义（P〉O．05）。结果表明,同步放化疗缩短了治疗周期,延长了PFS,提高了生存率,虽部分加重了毒副反应但均可耐受,具备临床应用价值。     

胃癌同时性肝转移患者不同治疗方法的疗效比较

目的评价不同治疗方案对胃癌同时性肝转移的疗效。方法回顾性分析解放军总医院1998年1月至2012年11月收治的271例胃癌同时性肝转移患者的临床病理资料,其中单纯接受手术治疗者34例（手术组）,单纯接受化疗者103例（化疗组）,接受综合治疗者134例（综合治疗组）。通过随访比较3组接受不同治疗方案患者的预后情况。结果手术组中位生存期为8（3—41）个月,1、3、5年生存率分别为32．4％、2．9％和0;化疗组中位生存期为7（3-50）个月,1、3、5年生存率分别为21．1％、1．1％和0;综合治疗组中位生存期为11（3—84）个月,1、3、5年生存率分别为50．0％、5．0％和O．8％;3组比较,差异有统计学意义（P〈0．05）;手术组与化疗组比较、手术组与综合治疗组比较以及化疗组与综合治疗组比较,差异均有统计学意义（均P〈0．05）。淋巴结转移程度、治疗方式和肝转移灶是否局部处理是影响胃癌同时性肝转移患者生存期的独立预后因素。结论以手术为基础的多学科综合治疗可以改善胃癌同时性肝转移患者的预后。     

低位直肠癌保肛手术中扩大根治术的临床意义

低位直肠癌中选择部分病例实施保肛手术是可行的。报道了选择６２例低位直肠癌在扩大根治术基础上，保留肛门括约肌，术式为经肛门环扎式结肠－直肠（肛管）吻合术。术后上方淋巴结转移率５３．４％，侧方淋巴结转移率１７．２％，下方淋巴结转移率０％，转移率９．１％。随访１￣３年，未见盆腔软组织、淋巴结、吻合口复发。因肝转移死亡５例。影响低位直肠癌保肛术后生存率主要原因是血行转移，不是局部复发。低位直肠癌中合理选择     

青年女性肺腺癌预后影响因素分析

目的 探讨青年女性肺腺癌的临床病理学特征对预后的影响。方法 回顾性分析手术治疗的青年女性肺腺癌282例，用Kaplan-Meier法计算生存率，分析临床病理学特征与预后的关系，并且进行Cox回归比例风险模型多因素分析。结果 吸烟与非吸烟组5年生存率分别为20．0％与36．4％（P=0．021）；p-TNM各分期5年生存率分别为Ⅰ期65．7％（Ⅰa期66．1％、Ⅰ期60．5％）、Ⅱ期30．9％（Ⅱa期36．3％、Ⅱb期27．5％）、Ⅲ期11．4％（Ⅲa期12．3％、Ⅲb期6．8％）、Ⅳ期3．6％，各期间生存率差异有统计学意义（P〈0．001）；淋巴结转移个数〉3个与≤3个的5年生存率分别为19．1％与38．3％（P=0．006）；高、中、低分化的5年生存率为65．2％、29．5％、19．8％（P〈0．001）。吸烟、p-TNM分期、转移淋巴结个数及分化程度与预后密切相关。多因素分析中吸烟、p-TNM分期和分化程度是独立的预后因素，相对危险比（RR）分别为3．315、2．809、1．195。结论吸烟、p-TNM分期、转移淋巴结个数及分化程度与青年女性肺腺癌的预后关系密切，吸烟、p-TNM分期和分化程度是青年女性肺腺癌的独立预后因素。因此，应当积极控制青年人群的吸烟，彻底清扫淋巴结，这对于青年女性肺腺癌预后具有重要意义。     

新辅助放化疗对直肠/肛管癌患者行经内外括约肌间切除术后近远期疗效的影响

目的 探讨新辅助放化疗对直肠/肛管癌患者行经内外括约肌间切除术（ISR）后近远期疗效的影响.方法 直肠/肛管癌患者115例,根据患者术前是否行长周期（8周）新辅助放化疗分组,术前行长周期（8周）新辅助放化疗的患者定义为A组,术前未行长周期（8周）新辅助放化疗的患者定义为B组.两组均行经内外括约肌间切除术（ISR）.结果 从术后并发症发生率来看,A组肛周感染率明显高于B组（7.5％vs 0％）（P＜0.05）.从患者术后肛门功能恢复情况来看,两组术后2、3年肛门功能均较术后1年明显改善（P＜0.05）.两组间比较,A组术后1、2、3年肛门功能均较B组差（P＜0.05）.从远期效果来看,两组局部复发率及生存率差异无统计学意义（P＞0.05）.结论 新辅助化疗联合ISR治疗超低位直肠/肛管癌较单纯ISR,没有延缓患者术后近期恢复,且能够获得相似的生存率及局部复发率,但是,新辅助化疗增加了ISR手术患者术后肛周感染发生率,同时,对患者术后肛门功能造成一定的影响,但仍在患者可接受范围之内.     

肛管直肠恶性黑色素瘤33例

作者报告了１９６６年～１９９４年本院收治的经病理检查证实的肛管直肠恶性黑色素瘤（ＡＲ－ＭＭ）３３例，并对ＡＲＭＭ的病因、临床诊断及治疗进行了讨论。对３３例ＡＲＭＭ患者分别行根治性切除术（Ｍｉｌｅ′ｓ术）和局部切除术，并辅以化疗、生物治疗、放疗，或单纯化疗。２５例患者获随访，随访时间为６个月～６年。随访结果，Ｍｉｌｅ′ｓ术组中位生存时间为２３．５个月，局部切除组中位生存时间为１７．５个月，单纯化疗组中位生存时间仅为５．５个月。作者认为，提高ＡＲＭＭ患者生存率的关键是早期诊断和早期治疗。对于经病理证实的患者，主张行Ｍｉｌｅ′ｓ术，对伴有腹股沟淋巴结转移或可疑者行腹股沟淋巴结清扫。     

直肠癌根治术肠系膜下动脉根部淋巴结的清扫与预后

目的探讨术中进行肠系膜下动脉根部淋巴结清扫对直肠癌预后的影响。方法对临床病理资料完整的260例直肠癌根治术患者的资料进行分析，将是否清扫肠系膜下动脉根部淋巴结（第3站淋巴结）的患者分为非清扫组（D2组，188例）和清扫组（D3组，72例），随访并比较两组患者的预后情况。结果D2组1、3、5年总生存率分别为97．3％、87．2％和77．1％，无瘤生存率分别为93．1％、83．0％和76．8％；D3组1、3、5年总生存率分别为94．4％、79．2％和73．6％，无瘤生存率分别为86．1％、76．4％和71．0％。Kaplan—Meier分析显示，两组总生存率及无瘤生存率差异无统计学意义（P〉0．05）。多元相关分析显示，肠系膜下动脉根部淋巴结清扫与术后复发、转移及总生存时问均无统计学相关性。结论直肠癌根治术中对患者肠系膜下动脉根部进行常规淋巴结清扫并非必要，对预后无显著影响。     

胰头癌外科根治相关问题的探讨

目的探讨胰腺癌外科根治切除术中淋巴清扫D2合并神经鞘、神经束切除的价值。方法对天津医科大学肿瘤医院5年间58例胰头癌行根治切除R0，D2手术同时行神经鞘、神经束切除的病例与同期76例未行神经鞘、神经束切除的R0，D2手术进行对照观察。结果58例行神经鞘切除的病人中有36例（62．1％）经病理证实有神经浸润，22例（37．9％）无浸润。其1、3年生存率分别为61．1％，36．1％和86．4％，59．1％。而神经鞘切除组58例与76例未行神经鞘切除组相比，1、3年生存率分别为70．7％，44．8％和60．5％，25．0％。结论胰腺癌易早期转移。除淋巴结、血行转移和种植转移外，神经浸润转移沿神经鞘、嗜神经转移是其独特的生物学行为，在根治术中应注重这一特征，行神经鞘、神经束切除对提高生存率有一定的临床价值。     

Prognostic Factors of Primary Small Bowel Adenocarcinoma: Univariate and Multivariate Analysis

Background Adenocarcinoma of the small bowel is relatively less common than malignancies of the esophagus, stomach, and colorectum. In small bowel adenocarcinoma, various prognostic factors influence the disease-free status and overall survival rates. Materials and Methods Eighty patients who were diagnosed with small bowel adenocarcinoma and treated at our institute between 1983 and 2003 were retrospectively reviewed. Results The patients included 40 men and 40 women with an age range of 15 to 93 years (median: 62 years). Only 51.3% of patients were accurately proved preoperatively to have a malignancy by endoscopic biopsy. Sixty patients underwent surgical treatment, and 45 of those patients had curative resection. The follow-up period ranged from 2.5 to 229.7 months, with a median of 9.1 months. The cumulative 1-, 3-, and 5-year survival rates for all patients (excluding 3 patients who died in the immediate postoperative period) were 43.6%, 22.8%, and 17.5%, respectively. The cumulative 1-, 3-, and 5-year disease-free survival rate for all 43 patients with curative resection (excluding 2 patients who died in the immediate postoperative period) was 54.9%, 30.5%, and 27.4%, respectively. Meanwhile, multivariate analysis with Cox proportional hazards analysis demonstrated that earlier tumor stages (stages I and II) and curative resection were two independent factors influencing favorable overall survival. Lymph node metastasis was the only independent factor predicting poor disease-free survival in patients undergoing curative resection. Conclusions Poor prognosis of small bowel adenocarcinoma may be related to a delay in the diagnosis and treatment of the disease. Curative resection is the aim of surgical treatment for small bowel adenocarcinoma. Lymph node metastasis at presentation of the disease predicts tumor recurrence and distant metastasis after curative surgical treatment.     

胰头癌扩大切除在胰头癌根治术中的作用

目的 探讨后腹膜软组织和淋巴结扩大清扫在胰头癌根治术中的作用.同时合并肠系膜上-门静脉切除的安全性和对生存率的影响.方法 2001年6月至2004年12月共施行56例胰头癌扩大切除术,根据术后病理检查有无淋巴结转移分为两组,A组:存在淋巴结转移,B组:未发现淋巴结转移;根据有无合并门静脉-肠系膜上静脉切除分为两组,Ⅰ组:未合并门静脉切除,Ⅱ组:合并门静脉切除.比较各组术后生存率.结果 56例胰头癌扩大切除术并发症发生率为30%,死亡率2%,术后1年,3年、5年生存率分别为63%,29%和16%.术后病理检查发现淋巴结阳性(A组)40例(71%),其中腹主动脉旁淋巴结阳性(A1组)11例;淋巴结阴性(B组)16例(29%),A、B两组术后生存率无明显差别,但腹主动脉旁淋巴结阳性组生存率较A、B组降低.合并门静脉切除17例,Ⅰ、Ⅱ组术后生存率无明显差别.切缘阳性5例,中位生存时间9个月,切缘阴性51例,中位生存时间23个月.结论 胰头癌扩大切除以及合并门静脉切除可以安全施行,对部分淋巴结阳性的胰头癌有一定意义,但未能提高腹主动脉旁淋巴结阳性病人的长期生存率,门静脉侵犯并非预后不良的组织学指标.     

Results of surgical treatment of residual and recurrent anal tumors

Radio- or chemotherapy is a modern standard of anal cancer treatment. Recurrence or partial remission rate after radiochemotherapy achieves 20-40%. The study is aimed to evaluate the role of abdominoperineal resection in the treatment of residual and recurrent anal cancer. 120 patients (aged from 30 to 81 (59+/-11) years, men:women ratio--1:9) were prospectively studied in the period of 1995 to 2007. The TNM distribution was as follows: T1-2N0M0--66(55.0%), T3-4N0M0--18(15.0%), T1-2N1-3M0--15(12.5%) and T3-4N1-3M0--21(17.5%) patients. The radiotherapy delivered in a dose range of 55-65 Gy was used alone or in combination with chemotherapy with 5-fluoruracil, mitomycin C or Xeloda. The complete tumor regression after radiotherapy/radiochemotherapy was achieved in 74(61.1%) of 120 patients with cancer-specific survival rate of 81.7%. Partial tumor regression was registered in 46 of 120 patients. The abdominoperineal resection was performed in 39(84.8%) of patients with the residual tumor. Thus, surgical treatment allowed secondary local tumor control in 76.9% of patients with the 5-year survival rates of 69.0%. The median survival time for the non-operated patients, including those, received an extra course of radiotherapy, was 19 months. The locoregional tumor relapse was diagnosed in 10(13.74%) of 74 patients with the complete tumor regression. The use of abdominoperineal resection allowed the secondary local tumor control and 5 year survival. Thus, abdominoperineal resection remains the method of choice in the treatment of residual and recurrent anal tumors.     

Diagnostik und Therapie des Analkarzinoms

Of all carcinomas in the anal canal, 75–80% are squamous cell carcinomas—the remaining 25% being adenocarcinomas. Carcinomas of the anal margin are to be differentiated from basal cell carcinomas and Paget’s and Bowen’s diseases. More than 80% of anal carcinomas show high-risk HP viruses. Every suspicious lesion in the anal canal and margins must be examined histologically. Primary radiochemotherapy is the first treatment option for epidermoid carcinomas of the anal canal and anal margin. Overall 5-year survival is reported at up to 90%. Surgery is reserved for the primary biopsy or excision of small tumors and for salvage abdominoperineal resection in patients with tumor persistence or local recurrence after radiochemotherapy. Systematic inguinal lymphadenectomy is not indicated. The first follow-up examination should be done 6 weeks after the end of radiochemotherapy. A biopsy is necessary after 3 months.     

Endoanal ultrasonography in the follow-up of anal carcinoma

As the modern treatment for anal carcinoma is either radiotherapy alone or combined radiochemotherapy, an exact histological staging is impossible. Therefore we have to depend on an accurate preoperative staging method. Endoanal ultrasonography enables imaging of the normal anal canal and its pathologies.In a prospective investigation we were able to confirm the histological proven diagnosis of an anal epidermoid carcinoma in 12 patients with a 10-MHz transducer covered with a sonolucent plastic cone. The depth of infiltration can be determined in relation to the normal layers of the anal canal. Six patients treated with radiotherapy alone or combined radiochemotherapy were followed and the success or failure of the treatment was documented. Endosonography of the anal canal allows an exact staging of a primary anal carcinoma and the follow-up in irradiated carcinomas. Besides digital palpation and proctoscopy with biopsy, endosonography complements the preoperative staging of anal carcinomas.     

Surgery and radiotherapy compared with gamma knife radiosurgery in the treatment of solitary cerebral metastases of small diameter.

OBJECT: The aim of this retrospective study was to compare treatment results of surgery plus whole-brain radiation therapy (WBRT) with gamma knife radiosurgery alone as the primary treatment for solitary cerebral metastases suitable for radiosurgical treatment. METHODS: Patients who had a single circumscribed tumor that was 3.5 cm or smaller in diameter were included. Treatment results were compared between microsurgery plus WBRT (52 patients, median tumor dose 50 Gy) and radiosurgery alone (56 patients, median prescribed tumor dose 22 Gy). In case of local/distant tumor recurrence in the radiosurgery group, additional radiosurgical treatment was administered in patients with stable systemic disease. Survival time was analyzed using the Kaplan-Meier method, and prognostic factors were obtained from the Cox model. The patient groups did not differ in terms of age, gender, pretreatment Karnofsky Performance Scale (KPS) score, duration of symptoms, tumor location, histological findings, status of the primary tumor, time to metastasis, and cause of death. Patients who suffered from larger lesions underwent surgery (p < 0.01). The 1-year survival rate (median survival) was 53% (68 weeks) in the surgical group and 43% (35 weeks) in the radiosurgical group (p = 0.19). The 1-year local tumor control rates after surgery and radiosurgery were 75% and 83%, respectively (p = 0.49), and the 1-year neurological death rates in these groups were 37% and 39% (p = 0.8). Shorter overall survival time in the radiosurgery group was related to higher systemic death rates. A pretreatment KPS score of less than 70 was a predictor of unfavorable survival. Perioperative morbidity and mortality rates were 7.7% and 1.6% in the resection group, and 8.9% and 1.2% in the radiosurgery group, respectively. Four patients presented with transient radiogenic complications after radiosurgery. CONCLUSIONS: Radiosurgery alone can result in local tumor control rates as good as those for surgery plus WBRT in selected patients. Radiosurgery should not be routinely combined with radiotherapy.     

大肠间质瘤13例临床分析

目的：探讨大肠间质瘤的诊断及治疗。方法：回顾性分析13例大肠问质瘤的病历资料，男9例，女4例，结肠2例，直肠8例．肛管3例。良性1例，潜在恶性2例，恶性10例。结肠间质瘤表现为腹块、腹痛、肠梗阻等，直肠肛管间质瘤表现为便秘、便血、肛门部疼痛或不适等。免疫组化：CD117、CD34、Vimentin多为弥漫阳性，S-100、HHF35多为阴性。经肛局部切除术3例，经骶尾局部扩大切除术1例，Hartmann术3例，Mises术3例，部分结肠切除3例，活检1例。结果：术后复发5例，3例为经肛局部切除，2例为姑息性Hartmann术。1、3、5年生存率分别为91．7%(11／12)、37．5％(3／8)、28．6％(2／7)。结论：大肠间质瘤术前不易确诊．多发于直肠、肛管，完整的外科手术切除是最有效的治疗方法。     

胆囊癌不同手术方式的疗效分析

目的 探讨胆囊癌不同手术方式的疗效.方法 回顾性分析2000年1月至2009年10月四川大学华西医院收治的81例胆囊癌患者的临床资料,分析胆囊癌患者采用不同治疗方式的疗效,肿瘤不同浸润深度与淋巴结转移的关系.采用Kaplan-Meier法进行生存分析,生存率比较采用Log-rank法.结果 Ⅰ、Ⅱ、Ⅲ、Ⅳ期胆囊癌患者中...