胃癌腹主动脉旁淋巴结清扫术(附26例临床分析)

目的:分析胃癌腹主动脉旁淋巴结(No 16)转移规律.方法:对本院2004年10月至2005年10月间实施的26例胃癌No 16淋巴结清扫术的临床病理资料作回顾性分析.结果:全组26例均行胃癌No 16(16a2区及16b1区)淋巴清扫术,术后恢复良好,无吻合口漏及手术死亡.乳糜腹1例,术中大出血1例,共切除No 16淋巴结79枚,平均3枚/例,发现肿瘤转移12枚,转移度为15.1%;4例患者发现No 16转移,转移率为15%.结论:No 16淋巴结作为胃癌区域淋巴液引流的终末汇聚地,有较高的转移率.不论是为了手术后正确分期还是提高治疗效果腹主动脉旁淋巴结清扫都是必要的,而且手术也是安全的.     

胃癌腹主动脉旁淋巴结清扫术（附26例临床分析）

目的:分析胃癌腹主动脉旁淋巴结(No.16)转移规律。方法:对本院2004年10月至2005年10月间实施的26例胃癌No.16淋巴结清扫术的临床病理资料作回顾性分析。结果:全组26例均行胃癌No.16(16a2区及16b1区)淋巴清扫术,术后恢复良好,无吻合口漏及手术死亡。乳糜腹1例,术中大出血1例。共切除No.16淋巴结79枚,平均3枚/例,发现肿瘤转移12枚,转移度为15.19%;4例患者发现No.16转移,转移率为15%。结论:No.16淋巴结作为胃癌区域淋巴液引流的终末汇聚地,有较高的转移率。不论是为了手术后正确分期还是提高治疗效果腹主动脉旁淋巴结清扫都是必要的,而且手术也是安全的。     

中晚期宫颈癌腹主动脉旁淋巴结转移治疗的临床研究

目的:研究中晚期（Ⅱb-Ⅲb期）宫颈癌腹主动脉旁淋巴结(PALN)转移采用手术和放疗治疗的疗效。方法:选择中晚期（Ⅱb-Ⅲb期）腹主动脉旁淋巴结转移的宫颈癌患者76例,观察组43例,行腹主动脉旁淋巴结清扫术,术后行同步放化学治疗。对照组33例,行宫颈癌同步放化学治疗。分析与患者3年生存率有关的临床病理因素,探讨影响患者预后的因素。结果:手术分期、病理分级、SCCA水平、局部肿瘤大小、腹主动脉旁淋巴结大小、治疗方法与患者的3年生存率有关。多因素分析表明影响患者生存期的因素是分期、分级、局部肿瘤大小、腹主动脉旁淋巴结大小、治疗方法。结论:中晚期宫颈癌腹主动脉旁淋巴结转移,行腹主动脉旁淋巴结切除并辅以术后延伸放疗联合同期化疗,对于病人治疗有重要意义。     

子宫内膜癌淋巴取样术的临床意义

目的：探讨子宫内膜癌盆腔及腹主动脉旁淋巴取样的临床意义。方法：分析1995年1月～2002年12月本院手术治疗的311例子宫内膜癌患者,其中,197例行淋巴取样或淋巴清扫。手术方式根椐手术切除淋巴结情况分为二组。1）取样组,筋膜外全子宫双附件切除/次广泛子宫切除术＋盆腔/腹主动脉旁淋巴结取样术114例;2）清扫组,次广泛/广泛子宫切除术＋盆腔淋巴结清扫/腹主动脉旁淋巴结切除术83例。结果：取样组切除淋巴结中位组数5组,中位切除淋巴结15枚,淋巴结转移8例。清扫组切除淋巴结中位组数8组,中位切除淋巴结27枚,淋巴结转移6例。5年生存率分别为90.2%和90.9%。结论：子宫内膜癌淋巴取样术可准确了解淋巴结转移情况,适宜手术分期,并不影响生存率,是避免过度治疗的方法。     

进展期胃癌腹主动脉旁淋巴结清扫术研究

目的 探讨进展期胃癌患者施行腹主动脉旁淋巴结（N16）清扫手术的必要性及手术适应证。方法 通过对36例进展期胃癌患者行腹主动脉旁淋巴结（N16）清扫术，分析影响腹主动脉旁淋巴结转移的临床病理因素，并与同期进行的D2手术50例进行手术创伤程度、并发症及术后生活质量比较。结果 腹主动脉旁淋巴结出现转移与肿瘤浸润深度、组织学类型及其他各组淋巴在T3，T4及低分化腺癌的进展期胃癌患者，腹主动脉旁淋巴结应纳入清扫范围之内。     

腹腔镜下腹主动脉旁淋巴结清扫术治疗子宫内膜癌的可行性分析

目的：探讨腹腔镜下行腹主动脉旁淋巴结清扫术应用于子宫内膜癌治疗的临床疗效,并分析其安全性。方法选取子宫内膜癌患者90例为研究对象,应用随机数字表法分为观察组与对照组,各45例,其中观察组患者行腹腔镜下腹主动脉旁淋巴结清扫术,对照组患者行传统开腹腹主动脉旁淋巴结清扫术,对比两组患者手术情况、术后恢复情况、术中或术后并发症发生情况,并进行随访。结果与对照组比较,观察组的腹主动脉旁淋巴结切除淋巴结数增多,出血量降低及术后并发症发生率降低,术后肛门排气时间及术后住院时间均缩短,腹主动脉旁淋巴结切除时间延长,差异有统计学意义（P﹤0.05）;与对照组比较,观察组患者术后淋巴囊肿、尿潴留、切口裂开、肺动脉栓塞、深静脉血栓及腔静脉损伤的发生率降低,差异有统计学意义（P﹤0.05）。结论腹腔镜下行腹主动脉旁淋巴结清扫术应用于子宫内膜癌的治疗疗效显著,值得临床推广应用。     

系统的淋巴结清扫术在子宫内膜癌治疗决策中的价值及可行性分析

背景与目的：淋巴结清扫术在子宫内膜癌治疗中的价值一直有争议,国内多数医院仅对部分高危型子宫内膜癌患者行淋巴结活检或选择性盆腔淋巴结切除术,罕有妇科医生对子宫内膜癌行系统的盆腔淋巴结清扫＋腹主动脉旁淋巴结清扫。本文探讨系统的淋巴结清扫术在子宫内膜痛治疗决策中的价值以及手术的可行性。方法：回顾2005年1月-2008年7月在我院行系统的腹膜后淋巴结清扫术的128例子宫内膜癌,对其临床病理特点、淋巴结转移情况、术后治疗决策改变情况以及手术并发症进行分析。结果：128例患者中19例（14．8％）出现淋巴结转移,其中盆腔淋巴结转移15例（11．7％）,腹主动脉旁淋巴结转移11例（8．6％）,7例患者同时出现盆腔及腹主动脉旁淋巴结转移,4例患者仅有腹主动脉旁淋巴结转移。病理类型、组织学分化程度、肌层浸润深度以及淋巴血管间隙浸润与淋巴结转移相关（P〈0．05）。15例患者因淋巴结转移分期升级,术后需要辅以化疗和／或放疗;另50例中危、中高危早期患者因手术排除了子宫外转移免去术后辅助治疗。8例（6．3％）患者术后出现并发症,其中盆腔感染3例,阴道残端出血2例,不全性低位肠梗阻、深静脉血栓伴淋巴囊肿和腔隙性脑梗塞各1例。中位手术时间为150min．中位出血量为300mL,其中27例（21．1％）患者接受输血治疗。结论：在子宫内膜癌患者中行系统的淋巴结清扫足安全可行的,通过全面的手术分期可以明确淋巴结转移情况,准确提供预后相关信息,指导术后辅助治疗。     

胃癌术后复发和转移部位及规律对预防性放疗靶区设计的临床探讨

目的 总结胃癌术后复发和转移部位及规律,为术后预防性放疗靶区设计寻找依据.方法 回顾分析近8年来130例胃癌根治术后复发和转移患者,所有患者均经B超、CT或MRI影像学临床诊断.其腹水28例中10例有细胞病理学诊断,所有浅表淋巴结及腹壁转移均经穿刺组织病理学证实,27例残胃和吻合口复发均由活检手术组织病理学证实.结果 130例中多部位复发和转移53例,残胃和(或)吻合口复发27例,腹膜转移28例,肝脏转移22例,胰腺转移9例,腹腔淋巴结转移60例,腹壁切口和引流口转移8例,盆腔种植5例,肺转移6例,脑转移5例,骨(主要为椎体)转移5例,颈部淋巴结转移8例,纵隔淋巴结转移9例,其他少见转移8例.60例腹腔淋巴结转移患者中胃周淋巴结转移35例,胰周淋巴结转移16例,腹主动脉旁淋巴结转移9例.77例原发胃底或贲门胃癌患者腹腔淋巴结转移33例,40例原发胃体部胃癌患者腹腔淋巴结转移20例,13例原发胃窦部胃癌患者腹腔淋巴结转移7例.结论 胃癌患者根治术后局部复发和转移的部位主要发生在残胃或吻合口、腹膜、肝脏及腹腔淋巴结,淋巴结以胃周、胰周和腹主动脉旁淋巴结转移多见.因此胃癌术后预防性放疗应包括贲门胃底、胃体和胃窦部,放射野应包括残胃、吻合口及胃周、胰周和腹主动脉旁淋巴结区域,并且须辅以化疗.     

胃癌术后复发转移部位分析及其对术后治疗的意义

 目的　总结胃癌术后复发转移类型和部位,探讨胃癌术后预防性治疗的方法。方法　回顾性分析2001年1月至2009年8月162例胃癌根治术后出现复发转移的患者,复发转移均经超声、CT或MRI检查进行诊断,34例腹腔积液中有15例经病理学诊断,所有浅表淋巴结及腹壁转移均经穿刺细胞病理学证实,31例残胃和吻合口复发均由病理组织学证实。结果　162例中63例为多部位复发转移,其中腹腔淋巴结转移76例（46.9 %）,腹膜转移34例（21.0 %）,残胃和（或）吻合口复发31例（19.1 %）,肝脏转移31例（19.1 %）,其他部位发生率均＜10 %。在76例腹腔淋巴结转移患者中,胃周淋巴结转移37例（48.7 %）,胰周淋巴结转移24例（31.6 %）,腹主动脉旁淋巴结转移15例（19.7 %）;其中97例原发于胃底贲门癌患者腹腔淋巴结转移56例（57.7 %）,48例原发于胃体部的胃癌患者腹腔淋巴结转移29例（60.4 %）,胃窦部的胃癌患者腹腔淋巴结转移11例（64.7 %）。结论　胃癌根治术后局部复发主要发生在残胃和（或）吻合口、腹腔淋巴结及腹腔、盆腔的种植转移, 腹腔淋巴结以胃周、胰周和腹主动脉旁淋巴结转移多见;远处转移的部位主要为肝、肺、脑、椎骨、颈部及纵隔淋巴结等。胃癌术后的治疗应以预防局部复发和远处转移为主,进行全身化疗、腹腔灌注化疗及联合局部区域的放疗。预防性放疗的范围应包括残胃、吻合口及胃周、胰周和腹主动脉旁淋巴结区域。     

根治性全胃切除术(D3淋巴结清扫术)

进展期胃癌D2或D2+根治术是可治愈性胃癌的标准治疗方案.对于T2、T3或T4期胃癌,在D2淋巴结清扫术基础上增加腹主动脉旁淋巴结清扫术(para-aortic lymph node dissection,PAND)能否改善患者生存一直存在争议.研究表明当胃癌侵犯到浆膜下层、浆膜层或突破浆膜侵犯到临近脏器,其淋巴结转移可达腹主动脉旁区域.     

Current status of extended ‘D2 plus’ lymphadenectomy in advanced gastric cancer

The extent of lymph node (LN) dissection has been a topic of interest in gastric cancer (GC) surgery. D2 lymphadenectomy is considered the standard surgical procedure for most resectable advanced GC cases. The value and indications of more extended lymphadenectomy than D2 remain unclear. Currently, the controversial stations beyond the D2 range are mainly focused on no. 14v, no. 16a2/b1 and no. 13 LN stations. The metastatic rate of no. 14v LN is relatively high in advanced distal GC, particularly in patients with suspicious no. 6 LN metastasis. D2 plus no. 14v LN dissection may be attributed to improved survival outcomes for patients with obvious no. 6 LN metastasis. Although GC with para-aortic lymph node (PALN) metastases is considered an M1 disease beyond surgical cure, patients with limited PALN metastases may benefit from the treatment strategy of adjuvant chemotherapy followed by D2 plus no. 16a2-b1 LN dissection. In addition, D2 plus no. 13 LN dissection may be an option in a potentially curative gastrectomy for GC with duodenal invasion. The present review discusses the current status and future perspectives of D2 plus lymphadenectomy.     

Preoperative assessment of para-aortic lymph node metastasis in patients with pancreatic cancer

Background

Para-aortic lymph node (PALN) metastasis is an important prognostic factor in patients with pancreatic cancer, but accurate preoperative diagnosis is difficult. The objective of this study was to assess the accuracy of diagnosis of PALN by computed tomography (CT), magnetic resonance imaging (MRI), and ¹⁸F-fluorodeoxyglucose positron-emission tomography (FDG-PET).

Methods

From August 2005 to July 2008, 119 patients with invasive ductal adenocarcinoma of the pancreas were included in this study. PALNs with a longer diameter >10 mm on CT or MRI were suspected of being involved by metastasis, whereas FDG uptake exceeding that of the adjacent normal tissue was considered to be positive for metastasis on FDG-PET studies. The imaging findings were compared with the pathological diagnosis of PALN metastasis.

Results

PALN dissection was performed in 71 patients (60.0%). Although histopathological examination revealed metastasis in 6 patients (8.5%), none of these patients was positive in any of the preoperative imaging studies. The longer diameter, the shorter diameter, the ratio of the two diameters, and the calculated lymph node volume showed no significant differences between patients with and without PALN metastasis.

Conclusions

Preoperative detection of PALN metastasis in patients with pancreatic cancer is very difficult. Intraoperative histopathological examination of frozen sections is necessary if radical resection is contemplated.     

Efficacy of chemotherapy combined with dissection of para-aortic lymph node metastasis following gastric cancer surgery -- case report

A 64-year-old man visited our hospital complaining of epigastric pain. An upper gastrointestinal endoscopy revealed a type 2 gastric cancer at the lower portion of the lesser curvature of the stomach. We performed a distal gastrectomy with D2 dissection. The histopathological diagnosis was well-differentiated tubular adenocarcinoma, mp, ly2, v0, n2(+), No. 11p(1/ 1), Stage III a.We used postoperative chemotherapy with a combination of S-1(80 mg/body)and low-dose cisplatin(10mg/ body × 10 days). After 1 course, we continued only S-1(80 mg/body)for 3 weeks followed by a 2-week interval. About 1 year after the operation, the CEA value was abnormally high. An abdominal CT scan showed a marked swelling of the paraaortic lymph node. The patient was then treated with the same protocol of S-1 and cisplatin again, but the CEA value did not decrease; therefore, a para-aortic lymph node dissection(No. 16a2b1 latero)was performed. Although the CEA value had decreased to normal, a few months later it was high again, and so we increased the S-1 dosage from 80 mg/body to 100mg/ body. But 6 months after the first para-aortic lymph node dissection, positron emission tomography(PET)revealed a swelling of paraaortic lymph node below the first recurrence site again. We changed the postoperative chemotherapy from S-1 and cisplatin to S-1(100mg/body)and irinotecan(80 mg/m2 day 1, 8). Since the CEA value was not decreased, we performed a second para-aortic lymph node dissection(No. 16b1b2 latero)13 months after the first dissection. The patient is presently alive with no signs of recurrence after over 1. 5 years. Para-aortic lymph node dissection combined with postoperative chemotherapy appeared to be effective for para-aortic lymph node metastasis in this case.     

腹腔镜辅助早期胃癌根治术的临床研究（附18例报告）

目的探讨腹腔镜辅助胃癌根治术在早期胃癌中的临床应用。方法回顾性分析2006年5月至2009年12月间接受腹腔镜辅助胃癌根治术的早期胃癌病例的临床资料,包括手术方式、手术时间、术中失血量、排气时间、术后住院时间、术后病理、随访等。结果 18例手术均在腹腔镜辅助下完成,没有中转开腹。其中远端胃切除15例,近端胃切除3例,腹腔镜下D1＋α式淋巴结清扫13例,Dl＋β式淋巴结清扫2例,D2式淋巴结清扫3例。手术时间为（140.5±30.6）分钟,术中失血（120.7±20.2）mL,术后排气时间（3.0±0.5）天,术后住院天数为（9.7±1.2）天;3例（3/18）患者出现并发症,其中腹腔内出血、淋巴漏、切口感染各1例,经手术和非手术治疗后痊愈。标本上、下切缘病理检查均无肿瘤残留,平均清扫淋巴结（13.6±4.0）枚,其中有2例（2/18）发现淋巴结转移。除1例失访外,其余17例随访8-51月,均无肿瘤复发和远处转移。结论腹腔镜辅助胃癌根治术是治疗早期胃癌安全、可行、有效的手术方法。     

Scalene lymph node dissection in locally advanced cervical carcinoma: is it reasonable or unnecessary?

AIMS AND BACKGROUND: The aim of this study was to evaluate the routine use of scalene lymph node dissection to determine the degree of disease spread in women with stage IIB-IVA cervical cancer treated at our hospital. METHODS AND STUDY DESIGN: Patients with locally advanced cervical carcinoma underwent para-aortic lymph node dissection via the extraperitoneal approach. Patients with clinical evidence of scalene or supraclavicular node metastasis were excluded. If their para-aortic nodes were tumor-positive, patients underwent scalene lymph node dissection. RESULTS: Twenty-eight scalene lymph node samplings were performed. Three patients had microscopically positive scalene lymph nodes (10.7%). In one patient the thoracic duct was injured. CONCLUSION: Patients with cervical carcinoma whose only extrapelvic site of metastases is the para-aortic lymph nodes may be eligible for scalene lymph node dissection as part of their pretreatment assessment, especially if extended field radiation is considered.     

进展期远端胃癌行扩大淋巴结清扫术的研究进展

淋巴结清扫范围一直是胃癌外科的热点问题。D2根治术作为进展期胃癌标准手术已达成共识,然而扩大淋巴结清扫的价值依然存在争议。进展期远端胃癌第14v组淋巴结转移率较高,D2+14v组淋巴结清扫有可能改善第6组淋巴结明显转移患者预后;尽管胃癌腹主动脉旁淋巴结转移视为M1,但D2+16a2/b1淋巴结清扫对局限性第16组淋巴结转移患者可能获益;而D2+13组淋巴结清扫有可能提高伴有十二指肠浸润胃癌患者生存率。本文旨在探讨扩大淋巴结清扫在胃癌中的价值,以期为临床提供依据,现就进展期远端胃癌扩大淋巴结清扫的研究进展进行综述。      

胃癌行腹主动脉旁淋巴结清扫的研究进展

手术治疗是治疗胃癌的主要方式之一,标准的术中淋巴结清扫尤为重要。关于胃癌患者是否行腹主动脉旁淋巴结清扫（para-aortic lymph node dissection,PAND）仍存在争议。预防性PAND的意义被否定,但治疗性PAND的效果还有待进一步的研究去证实。术前化疗联合规范的手术治疗可能是未来进展期胃癌伴腹主动脉旁淋巴结转移的标准治疗模式。本文就胃癌行PAND的研究进行综述,以期为临床实践提供指导。