直肠恶性黑色素瘤术后复发乳腺转移1例报道

恶性黑色素瘤是临床上较为常见的皮肤黏膜和色素膜恶性肿瘤,也是发病率增长最快的恶性肿瘤之一,年增长率为3％ ～5％.多发生于皮肤和眼睛,原发肛管直肠少见,是一种少见且预后极差的恶性肿瘤,约占肛管直肠恶性肿瘤的1％[1].恶性黑色素瘤转移部位多为肺、骨、肝、脑及局部复发,乳腺转移性恶性黑色素瘤极少见[2].本院于2012年10月收治了1例直肠恶性黑色素瘤术后复发乳腺转移患者,现报告如下.     

直肠肛管恶性黑色素瘤诊治体会

目的探讨直肠肛管恶性黑色素瘤的临床特点及生存分析。方法回顾性分析22例直肠肛管恶性黑色素瘤患者的临床资料和生存率。结果本组22例,占同期收治结直肠癌的0.3%（22/7300）,首发症状为便血（77.3%）,误诊率68.2%,首诊转移率63.6%;腹会阴联合切除术16例,局部切除术4例;辅助化疗9例,辅助免疫治疗6例;辅助放疗1例。22例患者1、3、5年生存率分别为54.5%、13.6%、9.1%。中位生存时间12月（95%CI：7.48-16.52）。结论直肠肛管恶性黑色素瘤少见,易误诊,易转移,预后差。外科治疗是目前无转移直肠肛管恶性黑色素瘤的首选治疗方法。     

唾液腺腺样囊性癌颈淋巴结转移规律的临床研究*

目的:本研究旨在回顾性分析头颈部腺样囊性癌的颈部淋巴结的临床转移规律。方法:回顾性分析1995年1 月至2008年12月就诊于上海交通大学医学院附属第九人民医院口腔颌面- 头颈肿瘤科的616 例腺样囊性癌患者的临床资料,对其中62例腺样囊性癌合并颈部淋巴结转移的患者进行临床统计学分析。结果:头颈部腺样囊性癌的颈淋巴结转移的发生率约为10% ,原发于舌根、舌体及口底部的腺样囊性癌较其他部位更易发生颈部淋巴结转移,分别为19.2% 、17.6% 和15.3% ,转移部位多发生在Ⅰb区与Ⅱ区。淋巴结转移的方式以经典的管道性转移为主,直接浸润型转移仅常见于下颌下腺的腺样囊性癌累及颌下淋巴结。原发部位及瘤周淋巴血管浸润与颈部淋巴结转移的发生密切相关。出现颈部淋巴结转移的患者其临床预后明显较差（P < 0.01）。结论:舌- 口底复合体为头颈部腺样囊性癌发生淋巴结转移的常见原发部位,在临床治疗及随访上应得到更多关注。      

16例肛管直肠恶性黑色素瘤临床分析

[目的]探讨肛管直肠恶性黑色素瘤的诊断、治疗及预后。[方法]回顾性分析16例肛管直肠恶性黑色素瘤的临床资料及随访结果。[结果]16例患者首诊确诊率仅25%（4/16）,误诊为直肠肛管癌8例、直肠息肉3例。14例行腹会阴联合切除术,1例局部扩大切除术,1例单纯化疗。随访6个月～17年,11例发生远处转移,12例死亡,至今存活4例。1、3、5年生存率分别为54.5%、20.4%和7.6%,中位生存期18个月。肿瘤浸润越深、临床分期越晚,预后越差（P〈0.05）。而不同肿瘤大小、联合治疗与否的患者间预后差异无统计学意义（P〉0.05）。[结论]肛管直肠恶性黑色素瘤易误诊,预后差。早期诊断并行手术治疗,有助于改善预后。     

原发性肛管直肠恶性黑色素瘤27例报告

背景与目的:肛管直肠恶性黑色素瘤在临床上极为少见,除外科手术外,缺乏有效的治疗手段,而外科治疗方式的选择也一直存在争议。本研究旨在通过对该病临床特征、治疗方式和患者生存情况的分析,探讨肛管直肠恶性黑色素瘤的诊断和治疗。方法:收集过去16年本院收治的所有肛管直肠恶性黑色素瘤患者,分析其临床特点和治疗方式。结果:共收集肛管直肠恶性黑色素瘤27例,平均年龄55.38岁,女性略占多数,73.0%的患者曾被误诊,肿瘤最大径平均为3.76cm,淋巴结转移(72.7%)较脉管/神经侵犯(22.7%)常见,但仅脉管/神经侵犯和远处转移与预后有相关性。接受扩肛广泛切除者术后局部复发率高,而腹会阴联合切除术(abdominoperineal resection,APR)者无局部复发,手术方式与预后无相关性。结论:肛管直肠恶性黑色素瘤以女性略占多数,该病易被误诊,脉管/神经侵犯和远处转移者预后差。APR手术在肛管直肠恶性黑色素瘤的治疗中仍是一个重要选择。     

肛管直肠恶性黑色素瘤38例临床分析

目的 通过对肛管直肠恶性黑色素瘤患者的临床病理特征、诊断治疗及生存预后进行分析,规范手术方式,探讨综合治疗模式.方法 回顾性分析38例经手术治疗的肛管直肠恶性黑色素瘤患者的临床病理资料,分析其与预后的相关性.结果 本组38例患者中,男10例,女28例,平均年龄58.7岁（28～75岁）,行腹会阴联合切除术28例,局部扩大切除术10例.1、3、5年无病生存率分别为64.9％、18.5％、5.7％,1、3、5年总生存率分别85.8％、24.1％、6.4％.肿瘤厚度≥1.51 mm、肿瘤直径≥3 cm与淋巴结转移相关（x2值分别为13.093、4.449;P值分别为0.011、0.020）,且肿瘤厚度亦与远处转移相关（χ^2=11.965,P=0.018）.单因素分析显示,术后辅助治疗与无病生存相关（χ^2=7.441,P=0.006）;肿瘤厚度、淋巴结转移、临床分期与总生存相关（χ^2值分别为16.741、16.474、16.775;P值分别为0.002、0.000、0.000）.多因素分析显示,术后辅助治疗为无病生存的独立危险因素（95％CI 1.420～17.621,P=0.012）;肿瘤厚度、淋巴结转移为总生存的独立危险因素（95％ CI 0.250～0.949,P=0.035;95％ CI 1.033～2.573,P=0.036）.结论 早期诊断、合理选择手术方式、重视免疫治疗的多学科协作诊疗是提高肛管直肠恶性黑色素瘤患者生存质量、延长生存期的关键.     

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。     

头颈部皮肤与粘膜恶性黑色素瘤的临床探讨

目的 :探讨头颈部皮肤恶性黑色素瘤和粘膜恶性黑色素瘤的转移规律及疗效 ,及头颈部粘膜恶性黑色素瘤套用皮肤恶性黑色素瘤临床分期是否合理。方法 :采用回顾性多因素回归分析 ,将 5 5例头颈部恶性黑色素瘤分成皮肤恶性黑色素瘤组 31例 ,黏膜恶性黑色素瘤 2 4例 ,分析转移规律及预后因素。结果 :皮肤恶性黑色素瘤和粘膜恶性黑色素瘤原发灶复发率、淋巴结转移率、血行转移率分别为 4 8 38%、4 5 16 %、2 1 81%和 37 5 0 %、4 1 6 7%、33 33% ;多因素回归分析两组原发灶复发率、淋巴结转移率、血行转移率有显著性差异 (P <0 0 5 ) ,临床分期、原发灶首次手术方式、起源影响复发率和转移率 (P<0 0 5 )。皮肤恶性黑色素瘤组和粘膜恶性黑色素瘤组 1、3、5年生存率分别为 81 15 %、6 6 2 0 %、4 5 0 7%和 81 95 %、4 9 72 %、39 77% ;多因素回归分析两组间生存率无显著性差异 (P >0 0 5 ) ,临床分期、原发灶首次手术方式、血行转移影响头颈部恶性黑色素瘤生存率 (P <0 0 5 )。分组后行多因素回归分析 ,皮肤恶性黑色素瘤组临床分期与生存率有显著性差异 (P<0 0 1) ,黏膜恶性黑色素瘤组临床分期与生存率无显著性差异 (P >0 0 5 )。结论 :①皮肤恶性黑色素瘤原发灶复发率、淋巴结转移率高 ,粘膜恶性黑色     

22例肛管直肠恶性黑色素瘤的临床分析并文献复习

背景与目的：肛管直肠恶性黑色素瘤恶性度高,其治疗方法尚存在争议．本研究旨在总结肛管直肠恶性黑色素瘤的诊断及治疗经验。方法：回顾性分析1977年至2003年江苏省肿瘤医院收治的22例肛管直肠恶性黑色素瘤患者的临床及病理资料．包括临床表现、诊断、手术方式和预后,并复习相关文献。结果：本组22例．占同期收治的大肠恶性肿瘤的0．4％（22／5205）,男性6例,女性16例．中位年龄61岁。主要临床表现为：便血86％（19／22）、肛门疼痛或不适59％（13／22）、肛门口肿物27％（6／22）等。首次就诊误诊率86％（19／22）,术前病理诊断确诊率48％（10／21）。无远处转移16例,伴远处转移6例。行腹会阴联合切除术11例．局部广泛切除术5例（2例复发后补充腹会阴联合切除术）,Park’s术2例．Hartmann’s术1例,乙状结肠双腔造瘘术3例。术后1、3、5年生存率分别为45．4％、18．1％、9．1％,中位生存时间12个月（95％CI：6～18个月）。结论：肛管直肠恶性黑色素瘤少见,易误诊,预后差。腹会阴联合切除术可作为无远处转移的肛管直肠恶性黑色素瘤患者的首选术式。     

以急性肾功能衰竭为主要表现的胃癌弥漫型膀胱转移１例

膀胱癌是泌尿系统中最常见的恶性肿瘤,其中绝大部分为膀胱原发肿瘤,转移性膀胱恶性肿瘤仅占1％左右,其原发灶主要是与膀胱毗邻的泌尿生殖系统及结直肠恶性肿瘤,远处原发灶较少见,其中最常见的是黑色素瘤,其次是乳腺癌及胃癌。     

Site‐specific cancer deaths in cancer of unknown primary diagnosed with lymph node metastasis may reveal hidden primaries

Cancer of unknown primary site (CUP) is a fatal cancer ranking among the five most common cancer deaths. CUP is diagnosed through metastases, which are limited to lymph nodes in some patients. Cause‐specific survival data could guide the search for hidden primary tumors and help with therapeutic choices. The CUP patients were identified from the Swedish Cancer Registry between 1987 and 2008; 1,444 patients had only lymph node metastasis of defined histology (adenocarcinoma, squamous cell or undifferentiated). Site‐specific cancer deaths were analyzed by lymph node location and histology. Kaplan‐Meier survival curves were compared with metastatic primary cancer at related sites. Among the patients with metastasis to head and neck lymph nodes, 117 (59.1% of the specific cancer deaths) died of lung tumors. Patients with axillary lymph node metastasis died of lung and breast tumors in equal proportions (40.2% each). Also, squamous cell CUP in head and neck lymph nodes was mainly associated with lung tumor deaths (53.1%). With a few exceptions, survival of CUP patients with lymph node metastasis was indistinguishable from survival of patients with metastatic primary cancer originating from the organs drained by those nodes. The association between lymph node CUP metastases with cancer deaths in the drained organ and the superimposable survival kinetics suggests that drained organs host hidden primaries. Importantly, half of all site‐specific cancer deaths (266/530) were due to lung tumors. Thus, an intense search should be mounted to find lung cancer in CUP patients with lymph node metastases.     

Unknown primary head and neck squamous cell carcinoma: molecular identification of the site of origin

BACKGROUND: Unknown primary head and neck squamous cell carcinoma (HNSCC) presents as a cervical lymph node metastasis without identification of the primary tumor, despite thorough diagnostic work-up that includes physical examination, computed tomography, esophagoscopy, laryngoscopy, bronchoscopy, and multiple surveillance biopsies. We investigated whether the site of origin of the primary tumor could be localized in the upper aerodigestive tract mucosa by detection of genetic alterations identical to those found in metastatic lesions. METHODS: Microsatellite analysis was performed on metastatic tumors obtained from 18 patients with unknown primary HNSCC. Histologically benign surveillance biopsy specimens were also analyzed. Patients were followed up to 13 years with continuing surveillance for primary mucosal tumors. Most patients were treated with neck dissection followed by radiation therapy to the affected neck and ipsilateral Waldeyer's ring. RESULTS: In 10 (55%) of the 18 patients, at least one histopathologically benign mucosal biopsy specimen from defined anatomic sites (i.e., most likely sites for an occult primary tumor) demonstrated a pattern of genetic alterations identical to that present in cervical lymph node metastases. One patient harboring genetic alterations in the base of the tongue and two patients harboring genetic alterations in a tonsillar fossa subsequently developed HNSCC in the identical or adjacent mucosal region; all three of the primary head and neck mucosal tumors that eventually appeared between 1 and 13 years later in these patients had genetic changes identical to those in the benign mucosal biopsy specimens and in the metastatic lymph nodes. CONCLUSIONS: These data support the hypothesis that histopathologically benign mucosa of the upper aerodigestive tract may harbor foci of clonal, preneoplastic cells that are genetically related to metastatic HNSCC and that such mucosal sites are the sites of origin of unknown primary HNSCC. Microsatellite analysis may represent a clinically useful tool for determining such sites.     

Malignant melanoma of the head and neck--a clinical analysis of 46 patients

46 patients with malignant melanoma of the head and neck as treated in our hospital from March 1964 to December 1981 are reported. 29 were male and 17 were female. The sex ratio ws 1.7:1. 56.5% of patients were 40-60 years old. The tumor occurred most frequently in the nasal cavity, next in the oral cavity. Lesions originating from the eye and skin in the head and neck region comprised 15.2% of cases. Melanoma of the nasal cavity and eye rarely metastasized into the cervical lymph nodes but melanoma arising from the skin of head and neck had a metastatic rate of 57.1%. 50% of melanoma of the gingiva metastasized to the neck glands. In this series, 29 patients were treated by operation. The overall 3 and 5 year survival rates of these 46 patients are 38% and 15.7%. The 3 and 5 year survival rates of those without regional lymph node metastasis are 51% and 28%. The 3 and 5 year survivals of those with regional lymph node metastasis are 13% and 0%. Other methods, such as surgery plus chemotherapy, chemotherapy alone and radiotherapy plus surgery or chemotherapy were used only in a few cases which could not be evaluated.     

Malignant melanoma with unknown primary site

From 1955 to 1976, 129 patients were seen with metastatic malignant melanoma from an unknown primary site, comprising 8.1% of all the referred patients with malignant melanoma. Eighty-two percent of the patients presented with a history of mass or lump. Overall median survival and 5-year survival rates after onset of symptoms were 10 months and 13%, respectively. Patients with lesions of the head and neck area had 5-year disease-free survival of 25%, whereas those with lymph node disease had a survival of 18%. Twenty-nine patients with regional disease had wide excision (usually lymphadenectomy) and their 5-year disease-free survival was 58%. Regional disease in patients with malignant melanoma of unknown primary site should be treated with radical surgical excision, since the survival is comparable or better to that of patients with regional disease having known and excised primary site.     

高频超声下不同类型颈部肿大淋巴结分区规律研究

目的 探讨高频超声下转移性淋巴结及其他常见颈部淋巴结疾病在颈淋巴结解剖分区中的分布规律。方法 回顾性分析2016年9月—2017年9月共547例颈部肿大淋巴结资料,根据病理结果分为非特异性淋巴结炎、淋巴结结核、淋巴瘤、转移性淋巴结四类,记录淋巴结常规超声参数及其在颈部淋巴结解剖分区中的分布。结果 不同颈部淋巴结疾病在颈部淋巴结解剖分区中的分布状态不同。头颈部肿瘤的颈部淋巴结转移多分布于Ⅱ(62.00%)、Ⅲ(54.00%)及Ⅳ区(53.00%),锁骨下原发肿瘤的颈部淋巴结转移主要分布于Ⅴ(72.56%)、Ⅳ区(34.15%)。对特定肿瘤而言,还存在淋巴结转移的高危区域。结论 超声检查可显示淋巴结疾病在颈部解剖分区中的分布情况。术前明确淋巴结疾病在解剖分区中的分布规律,可为临床的诊疗、手术术式及清扫范围提供更精确的依据。     

Malignant melanoma of the mucous membranes.

Primary malignant melanoma occurring in mucous membranes is uncommon. Of 410 patients with malignant melanoma, 14 (3.4%) had their primary tumour located in mucosal membranes. Five of the tumours were in the mucosal lining of the head and neck, five in the gastrointestinal tract mucosa and four in the female genitalia. Eight of the tumours were ulcerated, necrotic and deeply invasive. The most common histological subtype was acral lentiginous melanoma. Surgical resection of the primary tumour was performed in 10 patients. In the other four, surgery was not feasible, and they were treated by irradiation and immunotherapy. Six patients underwent regional lymph node dissection. In four of them, regional metastases were found. Chemotherapy was given to seven patients for widespread metastases. Nine patients (64%) died of metastatic melanoma within 2 years. The remaining five patients are alive after 3 to 8 years. It appears that mucosal membrane melanoma is a distinct variant of the disease due to both its aggressive biological behaviour and its relative inaccessibility for surgical removal, and may therefore be classified separately.     

The role of sentinel lymph node biopsy for melanoma

Regional lymph nodes are a common site of melanoma metastases, and the presence or absence of melanoma in regional lymph nodes is the single most important prognostic factor for predicting survival. Furthermore, identification of metastatic melanoma in lymph nodes and excision of these nodes may enhance survival in a subgroup of patients whose melanoma has metastasized only to their regional lymph nodes and not to distant sites. Sentinel lymph node (SLN) biopsy was developed as a low morbidity technique to stage the lymphatic basin without the potential morbidity of lymphedema and nerve injury. The presence or absence of metastatic melanoma in the SLN accurately predicts the presence or absence of metastatic melanoma in that lymph node basin. When performed by experienced centers, the false-negative rate of SLN biopsy is very low. As such, the nodal basin that contains a negative SLN will usually be free of microscopic disease. Since occult micrometastatic disease affects only 12% to 15% of patients with melanoma, selective SLN dissection allows up to 85% of patients with melanoma to be spared a formal lymph node dissection, thus avoiding the complications usually associated with that procedure. While standard pathologic evaluation of lymph nodes may miss metastatic melanoma cells, more sensitive techniques are developing which may identify micrometastases more accurately. The clinical significance of these micrometastases remains unknown and is the subject of active investigations.     

Primary malignant mucosal melanoma of the head and neck region: pooled analysis of 60 published cases from India and review of literature.

Malignant melanoma arising in the head and neck mucosa is a rare entity with incidence ranging from 2% to 10%. Because of the lack of data, the biological behaviour of these lesions still remains unpredictable and outcome dismal. We carried out a literature review for cases of mucosal melanoma of the head and neck reported from India and performed a pooled analysis on the available data. A total of 60 cases of head and neck melanomas were reported, of which 46 were in men. Palate and alveolus were the commonest sites. A total of 29 (48.3%) patients had regional node metastasis at presentation while five (12%) had distant metastasis. Three-year overall survival of 27.7% was observed. However, the disease-free survival rates at 3, 5 and 6 years were 39.4%, 39.4% and 13.1%, respectively. Metastasis at presentation and use of adjuvant radiotherapy were found to be the only significant predictors of survival. Malignant mucosal melanoma has aggressive biological behaviour and poor outcome. Radical surgery and adjuvant radiotherapy may provide a better local control and may help in improving survival.     

New fields of application of the sentinel lymph node biopsy in the pathologic staging of solid neoplasms: review of literature and surgical perspectives

Sentinel lymph node (sN) biopsy has gained special attention among surgical and medical oncologists as it represents an accepted technique for detecting occult nodal disease in regional lymph nodes of patients with melanoma and breast cancer. The histopathologic examination of the sN may well predict regional lymph node status in order to define the most suitable loco-regional and systemic treatment. Recently, this technique has also been applied to other solid tumor types such as gynecologic and urologic malignancies, squamous head and neck cancer, thyroid cancer, non-small-cell lung cancer, Merkel cell carcinoma, and gastric cancer. The aim of this literature review is to define the rationale of sN biopsy in these tumor sites, the most effective procedure for sN detection, and the accuracy of the sN in predicting regional nodal status, as well as the surgical perspectives of sN biopsy application.     

甲状腺癌颈部淋巴结转移区域的超声特点研究

目的：探究甲状腺癌颈部淋巴结转移区域的超声特点。方法回顾性分析58例甲状腺癌患者的临床资料。将患者术前颈部淋巴结转移区域的超声诊断与患者的病理诊断进行比较,分析其超声表现的特点。结果58例患者中经术前超声诊断显示,有36例（62．07％）颈部淋巴结转移,其中3例单纯中央区淋巴结转移、18例单纯颈侧区淋巴结转移、15例颈侧区合并中央区淋巴结转移;中央区淋巴结转移率为31．03％,显著低于颈侧区淋巴结转移率56．89％。病理诊断结果显示,58例患者中有33例（56．89％）颈部淋巴结转移,其中21例单纯中央区淋巴结转移,2例单纯颈侧区淋巴结转移,10例颈侧区合并中央区淋巴结转移;中央区淋巴结转移率为53．44％,显著高于颈侧区淋巴结转移率20．68％。超声诊断颈部转移性淋巴结的特异性为80．0％（12／15）,敏感性为100．0％（33／33）。超声检查对中央区转移性淋巴结的检出率为58．06％（18／31）,显著低于颈侧区转移性淋巴结的检出率100．0％（12／12）。超声诊断颈侧区淋巴结转移与病理结果的符合率为36．36％（12／33）,显著低于中央区淋巴结转移与病理结果的符合率58．06％（18／31）,差异具有统计学意义（P＜0．05）。颈侧区和中央区中淋巴门回声消失和低回声占较高的比例,且颈侧区和中央区颈侧区转移性淋巴结中L／T＜2所占的比例差异具有统计学意义（P＜0．05）。结论甲状腺癌多转移至颈部中央区淋巴结,采用超声检查具有较高的特异性,对中央区淋巴结的诊断有十分重要的意义。