3D打印微创导向模板在术后复发性宫颈癌近距离治疗中的临床应用

  目的  探讨3D打印微创导向模板在术后复发性宫颈癌三维插植后装治疗中的临床应用。  方法  收集2017年7月至2018年4月10例就诊于河北省沧州中西医结合医院,术后复发的宫颈癌患者行个体化3D打印微创导向模板辅助下三维插植后装治疗的临床资料。根据患者具体情况选用不同阴道定位模板,行CT模拟定位,勾画靶区,设计主要导向针道空间分布,打印出3D微创导向模板。根据预设针道植入插植针,制定治疗计划,高危临床靶区（high risk-clinical target volume,HR-CTV）处方剂量为6 Gy/次,共4~6次。  结果  10例患者共行插植治疗52次,每次插植治疗平均扫描CT次数为（1.58±0.70）次,每次插植治疗从插植针植入至插植针到达满意位置的平均消耗时间为（10.88±2.94）min,每次治疗插植针的使用针数为（5.69±1.91）根。剂量参数HR-CTV包绕90%靶区体积的剂量（D90）为（6.41±0.29）Gy,包绕膀胱、直肠、乙状结肠的2 cm3体积的剂量（D_2cm3）分别为（4.75±0.37）、（3.93± 0.26）、（4.33±0.24）Gy。10例患者治疗结束3个月后进行疗效评价,8例达完全缓解（complete response,CR）、2例达部分缓解（par tial response,PR）。  结论  3D打印微创导向模板应用于术后中心型复发性宫颈癌三维插植后装治疗,定位准确,可重复治疗,插植操作时间短,插植针数少,患者痛苦小,并发症少而轻,肿瘤缩小明显,具有良好的应用前景。      

3D打印模板辅助标准化施源器在ⅢB期宫颈癌影像引导自适应近距离治疗中的应用

目的 探讨3D打印模板辅助标准化施源器在宫颈癌影像引导自适应近距离治疗(BT)中的应用。方法 对 23例外照射(45Gy分25次)后宫旁受侵袭范围较大的 ⅢB期宫颈癌患者行MRI引导自适应BT,处方剂量为7 Gy/次,共4次。根据外照射前后MRI中肿瘤消退情况确定BT范围,预估应用标准化腔内联合组织间插植(IC+IS)施源器剂量欠量区域。对欠量区域虚拟经会阴组织间插植针道,并优化植入角度、间距、深度等。应用图形设计软件设计辅助插植模板,并使用3D打印技术打印辅助模板,并与标准化施源器结合紧密。在全麻条件下超声引导完成IC+IS,术后对患者行MRI定位扫描。将定位MRI传入治疗计划系统进行靶区和危及器官勾画,并给予IC+IS治疗计划设计优化,最终完成计划评估及治疗。结果 3D打印个体化插植模板平均打印时间为(3.5±1.0) h,辅助模板共引导植入插植针382根,单分次(4.2±1.5)根,剂量权重比为(16.49±9.50)%。靶区EQD2Gy,α/β=10剂量高危靶 区D90%为(90.45±3.03) Gy,中危靶 区D90%为(66.46±3.68) Gy。膀胱、直肠、小肠、乙状结肠的 D2cm³EQD2Gy,α/β=3分别为(82.69±2.60)、(73.20±2.52)、(69.35±3.32)、(69.39±3.27) Gy,均满足临床剂量要求。1年和 2年局部控制率、无远处转移生存率、总生存率分别为96%和87%、87%和70%、96%和78%。结论 利用3D打印技术制作的辅助插植施源器可以有效弥补现有标准化施源器在 ⅢB期宫颈癌临床BT时大体积靶区剂量的不足,为晚期宫颈癌BT提供了较为有效的方法。     

经阴道3D打印个体化模板在宫颈癌后装治疗中的应用价值研究

目的 介绍一种经阴道3D打印后装腔内联合插植治疗个体化模板设计方法,比较该方法和徒手插植方法的剂量学和操作安全性差异。方法 研究选取40例行¹⁹²Ir高剂量率腔内联合插植后装治疗计划。实验组为20例使用经阴道3D后装个体化模板设计方法,用基于CT影像的预计划方法设计插植针路径,用3D打印技术创建个体化模板实体和插植针路径,最后在CT引导下置入模板。对照组选取20例腔内联合徒手插植治疗计划,徒手插植方法不做预计划并且插植针方向由操作医生经验决定。结果 两组计划HR-CTV的分次D90相近,实验组正常组织D2cm³的剂量有较显著改善,且肿瘤靶区内高剂量区体积和剂量适形性指数均有改善。实验组共使用273次插植针,脱靶次数为1次,未出现插植针刺穿正常组织事件。对照组共使用203次插植针,脱靶次数4次,且观察到3次刺穿正常组织事件。结论 3D打印后装腔内联合插植治疗个体化模板方法对比徒手插植方法有剂量学优势,并且操作更安全,实际治疗可达到预计划剂量设计要求。     

鼻咽旁区插植配合体外放射治疗鼻咽癌

目的探讨鼻咽旁区插植近距离放射治疗技术在鼻咽癌治疗中的作用。方法初治鼻咽癌患者体外照射56～70Gy（T2期56～60Gy,T3期66～70Gy）后复查CT或MRI发现鼻咽旁区残留病例67例,以腔内+鼻咽旁区插植放射治疗增量,咽旁区在模拟机引导下插入1～4根施源管,采用荷兰核通公司生产的192Ir高剂量率近距离治疗机,放射剂量2.5～4.0Gy/次,2次/d,间隔>6h,总剂量12～20Gy,3～4?d完成。插植组与同期的类似病例（67例）配对进行研究。结果鼻咽旁区插植组和对照组的3年生存率分别为92.4%,84.5%（P>0.05);3年无局部复发生存率分别为97.0%、76.4%（P<0.05);3年无远地转移生存率分别为76.6%、69.1%（P>0.05)。鼻咽旁区插植组的晚期放射反应如口干、张口困难发生率均低于对照组。结论鼻咽旁区插植放射治疗可以显著提高鼻咽癌咽旁区残留的局部控制率,拓宽了鼻咽癌近距离放射治疗的适应证,是一种有效的补充治疗手段。     

宫颈癌引导腔内联合组织间插植近距离放疗阴道模板的临床设计

摘 要：［目的］ 分析研究宫颈癌局部转移的精准影像解剖部位,设计制作普遍适用于宫颈癌宫旁远端转移患者的经阴道插植模板,引导腔内联合组织间插植近距离放疗。［方法］ 基于498例ⅡB～ⅣA期宫颈癌患者局部转移部位的影像解剖分析,以及盆腔外照射后肿瘤回缩变化,设计制作经阴道插植模板,应用于20例盆腔外照射后宫旁残留癌肿≥3cm的宫颈癌患者,引导腔内联合组织间插植近距离放疗。［结果］ 498例局部晚期宫颈癌中,98.5%宫旁转移发生在盆隔之上、腹膜之下,在阴道上1/3处贴近阴道侧壁,在宫颈阴道两侧2～4点和8～10点之间,向上：依次沿阴道直肠韧带、骶韧带向侧后方蔓延,沿主韧带向侧前方蔓延,呈扇形逐步远离宫颈阴道侧壁达侧盆壁,发生宫旁远端转移。盆腔外照射后,97.5%宫旁残留癌肿距宫腔管的距离一侧≤3.5cm、另一侧≤2.5cm,上缘在宫颈内口水平,3%为前后极不对称癌肿。基于此解剖,设计一组经阴道圆柱体插植模板,周边8～10个直针孔,6～12点连线上3个宫腔管孔,在两侧壁2点～4点之间和8点～10点之间有1～2排斜孔。该阴道模板引导腔内联合组织间插植近距离放疗,初步应用于20例盆腔外照射后一侧宫旁残留癌肿>3cm或前后极不对称的宫颈癌患者：平均高危临床靶区体积(HR-CTV) （60.4±20.8）cm3;平均剂量 HR-CTV D90 86.7Gy (EQD2 α/β10),膀胱2cc 76.1Gy (EQD2 α/β 3),直肠2cc 68.7Gy (EQD2 α/β 3),乙状结肠2cc 65.9Gy (EQD2 α/β 3)。放疗后3月完全缓解（CR）18例、部分缓解（PR）2例,无3～4级急性期放疗并发症发生。［结论］该阴道插植模板设计合理,引导宫颈癌腔内联合组织间插植近距离放疗,操作简单,损伤小,可重复性好。对于盆腔外照射后宫旁残留癌肿≥3cm者,获得了更好处方剂量的HR-CTV靶区覆盖,较好保护危及器官。     

盆腔插植调强近距离放疗治疗5例局部晚期宫颈癌

[目的]探讨盆腔插植调强近距离放疗在局部晚期宫颈癌中的价值。[方法]5例局部晚期原发宫颈癌患者在MRI图像及CT模拟机引导下行插植后装调强近距离放疗,肿瘤区周边剂量40Gy,2次/d,共4d完成。后装结束后1周开始外照射,盆腔淋巴结区剂量50Gy。观察近期疗效及合并症。[结果]所有患者均完成治疗计划。放疗结束后3个月复查MRI等发现CR4例,PR1例。出现1例2级肠炎。[结论]盆腔插植调强近距离放疗治疗局部晚期宫颈癌近期疗效满意,合并症可耐受。     

经鼻咽旁插植组织间后装治疗在鼻咽癌放疗后程加量中的应用

背景与目的:后装近距离治疗常常用于早期鼻咽癌放射治疗后程加量,但常规施源器置入方法定位不准、重复性差,无法向咽旁追量.本研究采用存鼻窦内窥镜引导下进行咽旁插植后装放疗的新方法,旨在解决常规后装治疗的上述缺陷.方法:选择2005年9月至2006年8月初治和复发鼻咽癌外照射后仍有鼻咽粘膜下肿瘤残留超过1 cm或/和咽旁浸润但侵犯范围较局限的患者23例,在鼻窦内窥镜引导下经鼻腔进行鼻咽及咽旁施源器插植术,术后经CT扫描定位并确认插植位置合格后,利用三维近距离治疗系统进行鼻咽、咽旁肿瘤靶区勾画、剂量优化和组织问近距离治疗,测量治疗前后施源器植入的深度,并观察近距离治疗的疗效及并发症.结果:施源器均准确插入肿瘤区,插植位置100%合格.插人和拔出施源器时粘膜下植入深度分别为(9.59±2.72)mm和(9.43±2.30)mm,两者差异无统计学意义(t=0.23,P＞0.05);漂移长度为(0.75±0.75)mm.治疗后3个月内肿瘤完全消失,无肿瘤局部复发,无远处转移.随访3～15个月(中位随访时间6个月),随访率100%,无大出血、感染等手术并发症,无腭穿孔、鼻咽坏死等严重后装放疗并发症;3例鼻甲粘连,经分解后完全缓解.结论:经鼻窦内窥镜鼻咽、咽旁插植定位准确,固定良好,安全可行;对鼻咽癌放疗后鼻咽、咽旁残留病灶进行组织问近距离治疗近期疗效良好,无严重近期并发症.     

3D打印非共面模板辅助CT引导125 I放射粒子植入治疗脊柱转移瘤的临床应用

目的 探讨3D打印非共面模板辅助CT引导¹²⁵ I放射粒子植入治疗脊柱转移瘤的临床疗效。方法 回顾性分析2017年3月至2019年3月于辽宁省人民医院接受3D打印非共面模板辅助CT引导¹²⁵ I放射粒子植入治疗的脊柱转移瘤患者,评估90％靶区所接受的剂量（D90）、100％处方剂量的体积百分比（V100）、150％处方剂量体积百分比（V150）等参数,评价粒子植入质量,并观察术后并发症及生存情况。结果 15例患者均成功进行了3D打印非共面模板辅助CT引导行125 I放射粒子植入,平均放射粒子活度为（0.68±0.10）mCi,平均D90为（12 195.60±1 654.78） cGy,平均V100为（91.69±2.25）%,平均V150为（61.75±11.67）%。术后6个月,疾病控制率为100.00%,客观缓解率为73.33%。中位局部无进展生存时间为17.00个月（95%CI：13.42~20.58个月）,中位总生存时间为17.00个月（95%CI：13.42~20.58个月）。术后6个月NRS评分低于术前［（2.27±1.28） 分 vs （5.00±1.51） 分）,P<0.001］,而KPS评分高于术前［（86.00±12.42） 分和（72.67±11.00） 分,P＜0.001］。术前至术后6个月,ASIA分级C级变为D级,C级变为E级,D级变为E级各1例。结论 3D打印非共面模板辅助CT引导¹²⁵ I放射粒子植入治疗脊柱转移瘤能有效控制局部病灶,明显缓解疼痛及部分神经损伤,且并发症少见,是一种安全、有效的微创姑息性治疗手段。     

CT 引导的插植近距离治疗联合容积调强弧形治疗在宫颈癌患者中疗效及安全性分析

目的:探讨插植近距离治疗与常规球管联合近距离治疗在宫颈癌中的疗效与毒副作用。方法:100例初治Ⅱa-Ⅳ期宫颈鳞状细胞癌患者经容积调强弧形放射治疗联合CT引导的近距离治疗,根据后装治疗时施源器分为组织间插植组52例,常规球管联合组48例。两组均开始于全部盆腔外照射(剂量为50.4 Gy)结束后。结果:放疗结束后,插植组与常规球管联合组的局部有效率,3个月为94.23%(49/52) vs 95.83%（46/48）,6个月为88.46%（46/52） vs 77.08%（37/48）,1年为71.15%(37/52) vs 54.17%（26/48）;无进展生存时间分别为21.94个月和 14.33个月;截止至患者死亡或者随访时间终点总生存时间分别为37.8个月和20.16个月。依据肿瘤分期分层比较,插植组总生存均高于常规球管联合组（P＜0.05）,其余年龄、肿瘤大小及分化程度分层比较可见插植组总生存时间也高于常规球管联合组,但差异无统计学意义。按美国肿瘤放疗协作组（Radiation-therapy Oncology Group,RTOG）急性期及晚期放射反应评分标准,常见的不良反应为放射性直肠炎、放射性膀胱炎及骨髓抑制,插植组发生率明显低于常规球管联合组（P＜0.05）。结论:CT引导的组织间插植近距离治疗联合容积调强弧形治疗在宫颈癌患者中,可以在减轻宫颈癌放疗副作用的同时提高宫颈癌的治疗效果,值得临床推广应用。     

~(125)I组织间插植放射治疗腹腔内恶性肿瘤的探讨

背景与目的：^125I组乡只间植入术主要应用于前列腺癌治疗，近来研究表明该治疗方法在其他实体肿瘤中的治疗中亦具有一定疗效。本研究拟探讨腹腔内恶性肿瘤^125I组织间插植放射治疗技术及近期疗效。方法：2006年2月--2009年1月本院治疗的腹腔内恶性肿瘤20例，其中肝转移灶7例，腹膜后淋巴结转移病灶8例，胰腺癌3例，直肠痛盆腔复发2例。结果：治疗结束后2个月采用CT复查评价，局部完全缓解（CR）7例，部分缓解（PR）7例，稳定（SD）3例、进展（PD）3例，总有效率（CR＋PR）70％。结论：^125I组织间插植放射治疗是腹腔内恶性肿瘤的有效治疗方法，近期有效率高，不良反应可以接受，远期疗效仍需进一步观察。     

碘-125粒子植入治疗碘难治性分化型甲状腺癌淋巴结转移灶的临床研究

背景与目的：随着甲状腺癌发病率不断攀升,碘难治性分化型甲状腺癌（radioactive iodine-refractory differentiated thyroid cancer,RAIR-DTC）成为目前临床诊疗的难点。探索碘-125（ ¹²⁵ I）粒子植入治疗RAIR-DTC的疗效及安全性。方法：对中南大学湘雅医学院附属肿瘤医院自2013年—2017年收治的39例RAIR-DTC患者颈部淋巴结转移灶行 125 I粒子植入治疗,每3个月监测血清甲状腺球蛋白（thyroglobulin,Tg）水平及病灶变化情况。采用实体瘤疗效评价标准1.1（response evaluation criteria in solid tumors,RECIST 1.1）评估疗效,采用常见不良事件评价标准5.0（common terminology criteria for adverse events,CTCAE 5.0）评估安全性。结果：治疗后39例患者的客观缓解率为43.6%,疾病控制率为92.3%。治疗3个月血清Tg水平较治疗前有显著降低（t=2.2,P<0.05）;治疗后6个月较治疗后3个月、治疗后9个月较治疗后6个月、治疗后12个月较治疗后9个月差异无统计学意义（P均>0.05）。治疗后3、6、9和12个月的淋巴结最大截面短径分别为（15.1±1.1）、（13.8±1.0）、（12.9±1.0）和（12.9±1.0）mm,与治疗前的（18.3±1.2）mm相比,差异均有统计学意义（P<0.001）。粒子植入数量与可测量病灶短径缩小量弱相关（P<0.05）,与Tg水平减少量不相关（P>0.05）。未观察到与该治疗相关的严重不良事件。结论： ¹²⁵ I粒子植入治疗RAIR-DTC颈部淋巴结转移灶疗效及安全性良好。     

A case of advanced gastric cancer successfully treated with chemoradiotherapy targeting for recurrent lymph node metastasis

The patient was a 75-year-old male, who was diagnosed with type 3 advanced gastric cancer and bulky lymph node metastasis. Two courses of neoadjuvant chemotherapy (S-1, CDDP) which showed a partial remission and distal gastrectomy were performed. Although he received S-1 medication as adjuvant chemotherapy, lymph node recurrence appeared 6 months after the operation. Radiation therapy at a total dose of 65 Gy (10MV X ray, 2.5 Gy/day × 26 Fr) selectively targeting for recurrent lymph node metastasis with S-1 medication were applied. There were no adverse effects during chemoradiation therapy and the metastatic node showed regression (30 mm to 15 mm). Sixteen months passed from chemoradiation, and the patient remains alive with no signs of relapse without any treatment after the chemoradiation. Therefore, our case suggests that chemoradiation therapy could be an effective treatment for recurrent lymph nodes metastasis in gastric cancer.     

A complete response persisting for twelve months with the use of TS-1 in a patient with paraaortic lymph node metastasis of gastric cancer]

A 74-year-old female patient underwent total gastrectomy, splenectomy and D2 lymph node dissection for gastric cancer with non-dissectible paraaortic lymph node metastasis. Pathological examination revealed a high level of metastasis of dissected lymph nodes. The patient received daily oral administration of 100 mg TS-1, a novel oral anticancer agent. Each treatment course consisted of a four-week administration followed by two drug-free weeks. A partial response was obtained after the second course and a complete response was observed in the middle of the fourth and after the sixth course. The treatment was stopped because of grade 2 anemia in the middle of the seventh course, but no other adverse effect was observed. Complete response of the treatment persisted for twelve months and the patient has now been in good health without a recurrence for twenty months after surgery. Although the prognosis of gastric cancer with a high level of lymph node metastasis is poor, TS-1 therapy may have a potent efficacy in gastric cancer patients with a high level of lymph node metastasis such as the current case.     

第7版食管癌锁骨上淋巴结转移分期方式的探讨及152例病例分析

分析食管癌锁骨上淋巴结转移放疗疗效及探讨第7版国际食管癌M分期方式。方法:回顾分析2005年1月至2009年12月经病理证实的锁骨上淋巴结转移的胸段食管癌病例152例,其中食管原发灶放射治疗患者95例,手术治疗57例;食管原发灶治疗后锁骨上淋巴结转移的患者81例,首诊时发现71例;141例患者锁骨上淋巴结行放射治疗,11例未行放射治疗。结果:全组患者中位随访时间为17（2～68）个月。放射治疗后近期疗效评价52.5%的患者达CR（74/141）、41.8%达PR（59/141）、3.6%达NC（5/141）、2.1%达PD（3/141）。至随访截止日期生存者40例,1、2、3年生存率分别为69.1%、37.4%、24.0%。多因素分析显示年龄、锁骨上淋巴结转移时间、单侧或双侧转移、近期疗效及是否合并内脏转移对预后的影响有统计学意义（P<0.05）。根据第7版国际食管癌TNM分期按食管原发灶首诊时有无胸腔内及锁骨上区淋巴结转移分为N分期（39例）和M分期（71例）组,两组患者1、2、3年总生存率分别为82.1%、54.1%、31.0%和56.3%、28.1%、21.7%（P=0.041）。按照第6版国际食管癌TNM分期,根据患者食管原发灶首诊时有锁骨上区淋巴结转移的M分期组71例分为M1a 20例与M1b 51例,两组患者1、2、3年总生存率分别为60.0%、27.3%、27.3%和54.9%、28.7%、19.0%,（P=0.930）。单纯锁骨上淋巴结转移（104例）与合并内脏转移（48例）患者的1、2、3年生存率分别为72.1%、47.0%、32.9%和62.5%、17.5%、5.8%（P<0.001）。结论:胸段食管癌出现锁骨上淋巴结转移与胸腔内淋巴结转移患者生存情况存在显著性差异;单纯锁骨上淋巴结转移与合并内脏器官转移患者的预后有显著性差异,分期时是否应将锁骨上淋巴结转移划分为M分期或N分期,还是分亚组需进一步研究;原发灶的位置对食管癌锁骨上淋巴结转移的预后影响不大;患者的年龄、锁骨上淋巴结转移时间、单侧或双侧转移、近期疗效及是否合并内脏转移对预后有影响。      

Highly advanced gastric cancer that responded to neoadjuvant combination chemotherapy with docetaxel/CDDP/S-1 (DCS)

A 60-year-old male was found to have advanced gastric cancer and multiple lymph node metastases. Since curative surgery was concluded to be unfeasible, we tried neoadjuvant chemotherapy with the aim of controlling the lymph node metastasis. S-1 (80 mg/m2) was administered orally for two weeks then followed by 2-week rest period. CDDP (60 mg/ m2) and docetaxel (40 mg/m2) were simultaneously administered on day 1. Two courses of treatment resulted in marked shrinkage of the primary lesion and a reduction in size of the lymph nodes. The results were evaluated as a clinical PR based on RECIST, and radical resection was considered possible. The patient experienced a grade 3 leukocytopenia and neutropenia as adverse events of the chemotherapy. Total gastrectomy, splenectomy, and D2 lymph node dissection were performed with curative intent, and the postoperative course was uneventful. Histological examination of the surgical specimens revealed almost complete disappearance of cancer cells in the primary lesion in the stomach and complete disappearance in the lymph nodes. Pathological efficacy was Grade 2. The patient experienced a grade 3 appetite loss, and the adjuvant chemotherapy (S-1 regimen) was discontinued. The patient died of peritoneal dissemination eight months after the operation. We concluded that DCS as neoadjuvant chemotherapy was a promising strategy for patients with highly advanced gastric cancer because of its rapid antitumor effect.     

Californium-252 neutron brachytherapy combined with external pelvic radiotherapy plus concurrent chemotherapy for cervicalcancer: a retrospective clinical study

Background: Cervical cancer is the sixth most common cancer in Chinese women. A standard treatment modality for cervical cancer is the combination of surgery, chemotherapy, external-beam radiotherapy and intracavitary brachytherapy. The aim of this study was to retrospectively assess the long-term treatment outcomes of patients with cervical cancer who were treated with californium-252 neutron brachytherapy combined with external-beam radiotherapy plus concurrent chemotherapy.Methods: We retrospectively analyzed the medical records of 150 patients with primary stages IB-IVB cervical cancer who received neutron brachytherapy combined with external-beam radiotherapy concurrently with cisplatin chemotherapy.All patients were followed up. Using an actuarial analysis, patient outcomes and treatment-related adverse effects were evaluated and compared.Results: The median overall survival (OS) was 33.2 months. The 3-year progression-free survival rates for patients with stages Ⅰ—Ⅱ, Ⅲ, and Ⅳ diseases were 81.0% (68/84), 65.0% (39/60), and 0% (0/6), respectively; the 3-year OS rates were 90.5% (76/84), 85.0% (51/60), and 16.7% (1/6), respectively. Vaginal bleeding was controlled within the median time of 4.0 days. One month after treatment, 97.3% of patients achieved short-term local control. The local recurrence rates for patients with stages Ⅰ—Ⅱ, Ⅲ, and Ⅳ disease were 4.8% (4/84), 11.7% (7/60), and 33.3% (2/6), respectively, and the occurrence rates of distant metastasis were 16.7% (14/84), 25.0% (15/60), and 100.0% (6/6), respectively. Cancer stage,tumor size, and lymph node metastasis were identified as prognostic risk factors, but only lymph node metastasis was found to be an independent prognostic factor. The most common adverse effects during treatment were grades 1 and 2 irradiation-related proctitis and radiocystitis.Conclusion: For patients with cervical cancer, neutron brachytherapy combined with external-beam radiotherapy plus concurrent chemotherapy produces a rapid response and greatly improves local control and long-term survival rates with tolerable adverse effects.     

Number and anatomical extent of lymph node metastases in gastric cancer: analysis using intra-lymph node injection of activated carbon particles (CH40)

BACKGROUND: The long-term survival of 200 patients with gastric cancer who underwent radical gastrectomy was analyzed with respect to the number and anatomical extent of lymph node metastasis. All of the patients received intra-lymph node injection of fine activated carbon particle solution (CH40) during surgery. METHODS: The average number of resected lymph nodes increased in line with the anatomical level of lymph node dissection; 32.5 per patient in D1, 42.3 in D2, 3 and 66.3 in D4. The percentage of blackened lymph nodes without metastasis (42.4%) was slightly higher than that of lymph nodes containing metastasis (37.2%), but the difference was not statistically significant. Of the 200 patients, 61 (30.5%) had microscopic evidence of metastatic lymph node involvement. Twenty-two patients had between one and three metastatic lymph nodes, 19 had between four and nine and 20 patients had more than nine. The 5-year survival rate was 93.1% in patients without lymph node metastasis, 71.9% in patients with 1-8 metastatic nodes, 36.1% in patients with 4-9 nodes and 19.2% in patients with > 9 nodes. RESULTS: The 5-year survival rate according to the anatomical extent of metastatic lymph nodes was 93.1% in n0, 63.1% in n1, 37.9% in n2, 27.8% in n3 and 0% in n4. The number of metastatic lymph nodes and also their anatomical extent were identified as independent prognostic factors for survival by multivariate analysis. CONCLUSION: The number and anatomical extent of metastatic lymph nodes have similar impacts on prognosis in gastric cancer.     

The efficiency of micrometastasis by sentinel node navigation surgery using indocyanine green and infrared ray laparoscopy system for gastric cancer

Background

The clinical application of sentinel node navigation surgery (SNNS) for patients with gastric cancer requires accurate intraoperative diagnosis of lymph node metastasis. However, the clinical significance of the diagnosis of lymph node micrometastasis for gastric cancer has not been established. In this study, we evaluated lymph nodes dissected during SNNS by immunohistochemistry with anti-cytokeratin antibody (IHC) staining for gastric cancer to investigate the usefulness of SNNS.

Patients and methods

The subjects were 130 patients with gastric cancer (3,381 lymph nodes) who underwent SNNS with infrared ray observation and lymph node dissection of D1+α or more. The dissected lymph nodes were stained with IHC (CAM 5.2), and the results were compared with intra- and postoperative diagnoses by hematoxylin and eosin (H&;E) staining. In addition, the association of metastatic lymph nodes and ICG-positive lymph nodes was examined.

Results

The number of patients (lymph nodes) with lymph node metastasis by HE and IHC staining was 16 (52 nodes) and 31 (91 nodes), respectively. Fifteen patients (27 nodes) diagnosed with pN0 by HE staining were diagnosed to be metastatic by IHC staining. The tumor depth of these patients was pT1 in ten patients (m, 3; sm, 7) and pT2 in five (mp, 4; ss, 1). Regarding the histological type, three patients were classified as well-differentiated type, while six patients each had moderately and poorly differentiated types. The grade of lymphatic invasion was ly0 in 5, ly1 in 6, and ly2 in 4, respectively. Histological assessment of 27 IHC-positive and HE-negative cells indicated 5 single cells, 16 clusters, and 6 micrometastases. These lymph nodes were all included in the sentinel nodes (SN) identified during surgery. All but one patient (0.8%) were recurrence-free at 2–8?years after surgery (median 74.7?months). The one patient developed anastomotic recurrence 4.5?years after the first operation and died.

Conclusion

Since all 27 lymph nodes in 15 patients with metastasis by IHC staining but not by HE staining were micrometastasis or less and included in the SN, ICG-positive lymphatic basin dissection by SNNS with infrared ray observation seems to be an adequate method of lymph node dissection for gastric cancer.     

Prognostic and clinical evaluation of axillary lymph node metastasis in esophageal cancer

Axillary lymph node metastasis (ALNM) from esophageal cancer is rare. Its prognosis and effective treatments remain unknown. Between 1997 and 2005, esophagectomy was performed in 361 patients with esophageal cancer in our hospital. ALNM was identified in four patients (1.1%). All patients had left ALNM with ipsilateral left supraclavicular lymph node metastasis. In two patients ALNM developed after radical esophagectomy with regional lymphadenectomy and in the other two patients after chemoradiotherapy of primary lesions. Axillary lymphadenectomy with chemoradiotherapy was given to all patients. Median survival time and disease-free survival (DFS) after initial treatment for primary esophageal cancer were 30.5 months and 11.5 months, respectively. One patient, who had a small number of regional lymph node metastases (two lymph nodes) at esophagectomy and prolonged DFS (22 months) until axillary node recurrence, is still alive, 67 months after axillary lymphadenectomy. The other three patients, who had larger numbers of regional lymph node metastases (average, 8.3) and shorter DFS (average, 9.7 months), died of recurrence an average of 13.3 months after axillary lymphadenectomy. In conclusion, although ALNM is considered a type of distant organ metastasis, if it is a solitary recurrence, good survival may be obtained after appropriate loco-regional therapy. The number of metastatic regional lymph nodes at initial esophagectomy and the duration of DFS until axillary node recurrence can help to guide the decision whether aggressive treatments are warranted.     

贲门癌前纵隔胸骨旁淋巴结转移—附5例报道

目的:报道5例贲门癌前纵隔胸骨旁淋巴结转移。方法:2009年5月至2013年5月我院就诊的贲门癌根治术后患者5例,4例经CT检查发现有腹腔和纵隔淋巴结转移及胸骨旁淋巴结肿大,1例超声检查发现有胸骨旁淋巴结肿大,全部患者在超声定位引导下行胸骨旁肿大淋巴结穿刺病理活检。结果:穿刺活检组织病理结果全部发现癌组织,提示腺癌。结论:贲门癌发生纵隔淋巴转移时有可能通过隔上淋巴结转移至胸骨旁淋巴结。