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.     

治疗性腹腔镜胃癌腹主动脉旁淋巴结清扫术的操作技巧及临床意义

目的探讨治疗性腹腔镜胃癌腹主动脉旁淋巴结清扫术的安全性和有效性。方法回顾性分析2017年1月至2018年12月就诊广东省中医院胃肠外科实施治疗性腹腔镜胃癌腹主动脉旁淋巴结术的6例病人基线资料、术中及术后短期结果。结果6例病人术前经影像学评估均存在第16组淋巴结转移,无其他远处转移,经转化治疗后,均达到部分缓解并顺利完成腹腔镜胃癌D2根治并腹主动脉旁淋巴结清扫术,术中1例因合并胰腺侵犯而联合行胰体尾+脾切除术,无中转开腹、腹腔出血、脏器损伤等并发症发生;中位手术时长482.5(445,510)min;中位淋巴结清扫总数、腹主动脉旁淋巴结(para-aortic lymph nodes,PALN)清扫总数及PALN阳性数目分别为50(16,80)枚、18(3,31)枚、3.5(0,15)枚,其中5例PALN病理阳性,1例阴性;术后1例出现胰瘘,1例胸腔积液,1例腹泻,Clavien-Dindo分级均为2级,经对症治疗后均好转出院;术后中位住院时间17(6,30)天,术后30天内无二次手术及死亡发生;中位随访时间13.25(10~18)月,3例病人因肿瘤复发死亡,术后存活时间10~18月,余3例均未见肿瘤复发转移。结论治疗性腹腔镜腹主动脉旁淋巴结清扫术在技术上是可行的,对于胃癌合并PALN转移的患者。     

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。     

进展期贲门癌腹主动脉左侧淋巴结清扫70例分析

[目的]探讨进展期贲门癌腹主动脉左侧淋巴结清扫的必要性及可行性.[方法]2002年2月～2004年5月对70例进展期贲门癌行腹主动脉左侧淋巴结清扫,分析腹主动脉左侧淋巴结转移与临床病理因素的关系.[结果]70例中发现11例腹主动脉旁淋巴结转移,转移率为15.71%;其中BorrmannⅢ、Ⅳ型腹主动脉旁淋巴结转移率为22.2%,N2～3期为25.6%,肿瘤侵及浆膜者为24.4%.腹主动脉旁淋巴结转移率在BorrmannⅢ、Ⅳ型、N2～3期、肿瘤侵入浆膜者中明显高于Borrmann Ⅰ、Ⅱ型(4.0%)、N0～1期(3.2%)、浆膜未受侵者(3.4%)(P均《0.05).全组无因手术死亡病例,无严重手术并发症发生.[结论]只要严格掌握手术适应证,晚期贲门癌行腹主动脉左侧淋巴结清扫是安全可行的:其对预后的影响有待进一步研究.     

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。     

胃癌根治术中清扫腹主动脉旁淋巴结的研究现状及其临床意义

迄今，以清扫第卫、2站淋巴结为主的胃癌根治术（D2术）已作为一种标准术式而普遍应用于进展期胃癌并取得了一定的疗效。近年来，日本学者通过研究，发现腹主动脉旁淋巴结（Paraaorticlymphnode，第16组）术中是否予以清扫直接影响预后。由此，合并该组淋巴结清扫的胃癌扩大根治术（D4术）已被认为是本世纪胃癌外科治疗中的一个最新课题。本文现就其研究现状及临床意义作一综述。1腹主动脉旁淋巴结的外科解剖就解剖学而言，可将腹主动脉旁淋巴结进一步划分成16a1、16a2、16b1、16b2等4个区，分别由隔肌腹主动脉裂孔、腹腔动脉根部上缘、左…     

系统性淋巴结清扫在Ⅰ期子宫内膜癌治疗中的价值

目的:探讨系统性淋巴结清扫在Ⅰ期子宫内膜癌治疗中的价值.方法:对2006年1月-2013年1月在我院行系统的腹膜后淋巴结清扫术的286例Ⅰ期子宫内膜癌患者进行回顾性分析.结果:286例患者中31例出现淋巴结转移,转移率为10.8％,盆腔淋巴结转移率为8.7％,腹主动脉旁淋巴结转移率为4.9％,其中所有淋巴结转移的患者中19.4％的患者未经盆腔淋巴结而直接转移至腹主动脉旁淋巴结.组织学分化程度、病理类型、肌层浸润深度、淋巴血管间隙浸润与淋巴结转移情况相关(P＜0.05).21例患者因淋巴结转移而分期升级,术后需要辅助化疗和/或放疗.结论:全面的分期手术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.     

子宫内膜癌腹膜后淋巴结转移的特点及危险因素分析

目的探讨子宫内膜癌腹膜后淋巴结转移的特点及危险因素,为临床选择术式提供依据.方法收集1986年1月～1998年12月行广泛性全子宫双附件切除加腹膜后淋巴结清扫的148例子宫内膜癌病例,分析临床病理因素与淋巴结转移的关系及淋巴结转移的特点.结果盆腔淋巴结转移率为22.97%(34/148),最常见的转移部位为髂内和髂外淋巴结;腹主动脉旁淋巴结转移率为28.00%(14/50),最常见的转移部位是骶前和相当于肠系膜下动脉起始处高度的淋巴结.子宫内膜腺癌、腺鳞癌和浆液性乳头状腺癌盆腔淋巴结转移率分别为16.70%、40.00%、52.17%(P＜0.05);腹主动脉旁淋巴结转移率分别为14.81%、50.00%、50.00%(P＜0.01).当子宫外有病灶时盆腔淋巴结转移率为74.10%、腹主动脉旁淋巴结转移率为44.40%,子宫外无病灶时盆腔淋巴结转移率为11.60%,腹主动脉旁淋巴结转移率为8.70%,前后相比P＜0.001.细胞分化Ⅲ级者盆腔淋巴结转移率为57.14%;腹主动脉旁淋巴结转移率为56.52%与细胞分化Ⅰ、Ⅱ级相比P＜0.001.子宫旁脉管有浸润者盆腔淋巴结转移率为84.21%,腹主动脉旁淋巴结转移率为26.92%,与宫旁无脉管浸润相比,前者P＜0.001;后者P＞0.05;肿瘤浸润子宫肌层超过其厚度的1/2、盆腔和腹主动脉旁淋巴结转移率分别为58.30%和37.14%(P＜0.001、P＜0.05).当肿瘤位于宫体下段时,盆腔和腹主动脉旁淋巴结转移率分别为34.00%和36.40%,前者P＜0.05;后者P＞0.05.结论腺鳞癌、浆液性乳头状腺癌、子宫外有转移灶和肿瘤细胞分级是腹主动脉旁淋巴结转移的主要危险因素;宫旁脉管浸润是盆腔淋巴结转移中最重要的,独立的危险因素.原发病灶部位、肌层浸润深度主要影响盆腔淋巴结转移.对有高危因素的子宫内膜癌应行根治性子宫切除术加系统的腹膜后淋巴结清扫术.这不仅能切除阳性淋巴结,提高生存质量,而且可以准确分期、指导治疗和判断预后.     

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。      

胃下部癌肠系膜上静脉旁淋巴结清扫的研究现状

淋巴结转移状况是影响胃癌术后患者预后的重要因素。2010年第14版日本《胃癌处理规约》中行D2手术时不包括肠系膜上静脉旁淋巴结(即No.14v)清扫,目前大部分临床研究也不支持胃癌根治术中行No.14v的清扫。作者通过总结近些年关于No.14v的研究进展,归纳No.14v的转移情况、转移的危险因素以及该组淋巴结清扫的临床疗效,得出:若术前、术中证实为T4、M1及Ⅳ期胃癌,术中探查发现No.14v可疑阳性、No.6转移、肿瘤直径≥4cm等情况时应考虑行No.14v清扫。     

Lymphatic flow in carcinoma of the head of the pancreas.

The lymphatic pathway from the head of the pancreas to the para-aortic lymph nodes was examined on the basis of the frequency of lymph node involvements. Forty-four patients were examined. All patients had extended radical operations. Thirty-one of 44 (70.5%) patients had lymph node involvement. The lymph nodes that had a high metastatic rate included the following: (1) lymph nodes around the common hepatic artery (number 8 lymph node); (2) lymph nodes of the hepatoduodenal ligament (number 12 lymph node); (3) the posterior pancreaticoduodenal lymph node (number 13 lymph node); (4) lymph nodes around the superior mesenteric artery (number 14 lymph node); (5) para-aortic lymph nodes (number 16 lymph node); and (6) the anterior pancreaticoduodenal lymph node (number 17 lymph node). Twenty-eight of these 31 patients had disease in the posterior pancreaticoduodenal lymph node. The patterns of lymph node involvement consisted of four combinations: number 13-number 17, number 13-number 14, number 14-number 16, and number 17-number 8. All of the patients with number 16 nodal involvement had number 14 lymph node metastasis. However, there was no relationship between tumor size and lymph node involvement. Based on these results, the main lymphatic pathway from the head of the pancreas to the para-aortic lymph nodes was thought to be via the lymph nodes around the superior mesenteric artery, assuming that lymphatic flow is anterograde. In addition, this study demonstrates that it is necessary to perform an extensive lymph node dissection, including the para-aortic lymph node, even in patients with small tumors.     

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.     

子宫内膜癌与宫颈癌淋巴结转移分布的比较

目的:分析子宫内膜癌淋巴结转移模式并比较子宫内膜癌与宫颈癌淋巴结转移分布的不同.方法:回顾性分析接受系统的盆腔和腹主动脉旁淋巴结切除的104例子宫内膜癌以及253例宫颈癌患者淋巴结转移情况,比较二者的不同.结果:与宫颈癌相比,子宫内膜癌淋巴结转移率较高(22.1%vs 16.2%),并且子宫内膜癌的淋巴结转移与病理分级(G_1:12.1%;G_2:21.4%;G_3:34.5%)、肌层浸润深度(≤1/2:11.9%>1/2:29%)有关;子宫内膜癌单纯盆腔淋巴结转移率偏低(34.8% vs 68.3%),单纯腹腔淋巴结转移率偏高(4.3%vs 0),盆腹淋巴结共同受累的发生率偏高(60.9%vs 31.7%).宫颈癌中腹主动脉旁淋巴结转移的患者100%有盆腔淋巴结转移,而内膜癌93.3%的腹主动脉旁淋巴结阳性的患者有盆腔淋巴结转移.内膜癌与宫颈癌最易受累淋巴结均为闭孔淋巴结(内膜癌:73.9%、宫颈癌:70.7%),受累最少的均为腹股沟淋巴结(内膜癌:8.7%、宫颈癌:7.3%),与宫颈癌相比,子宫内膜癌腹主动脉旁淋巴结(65.2%vs 31.7%)、骶前淋巴结(21.7%vs 17.1%)的受累几率较高,而髂外淋巴结受累的几率偏低(17.4%vs 41.5%).结论:子宫内膜癌淋巴结转移方式不同于宫颈癌,虽然内膜癌主要向盆腔淋巴结转移,但是仍然存在直接向腹主动脉旁淋巴结转移的病例并且各病理分级的内膜癌均有淋巴结转移的可能.     

进展期胃癌根治术中淋巴结示踪新方法

Objective

The aim of this study was to explore a new method of lymph node tracing in radical gastrectomy for advanced gastric carcinoma (AGC).

Methods

Ninety-two patients who suffered from gastric angle carcinoma with metastasis in No. 3 group lymph nodes were carried out radical gastrectomy. During the operation methylene blue was injected inside or around the circum of the metastatic No. 3 group lymph nodes. Secondary sentinel lymph nodes (SSLNs) were the nearest blue lymph nodes to No. 3 group lymph nodes that were searched in 5 to 10 min after injecting methylene blue. These SSLNs were resected and carried out hematoxylin-eosin (HE) staining as well as immunohistochemistry (IHC) staining to demonstrate whether there were metastasis.

Results

SSLNs were found successfully in 76 patients with a positive rate of 82.6% (76/92) by methylene blue staining, among which, 34 patients were demonstrated existing metastasis in SSLNs by HE staining, 26 patients were demonstrated existing metastasis in SSLNs by IHC staining which were not demonstrated existing metastasis by HE staining. Totally, 60 patients were demonstrated existing metastasis in SSLNs by HE staining and IHC staining with a positive rate of 78.9% (60/76). 136 SSLNs were found in total and 104 SSLNs were demonstrated existing metastasis with a positive rate of 76.4% (104/136). There were 14, 18, 10, 80, 6 and 8 SSLNs in No. 4, No. 5, No. 6, No. 7, No. 8 and No. 9 group lymph nodes respectively. And there were 10, 18, 8, 62, 2 and 4 SSLNs were demonstrated existing metastasis with a positive rate of 71.4%, 100%, 80.0%, 77.5%, 33.3% and 50.0% in No. 4, No. 5, No. 6, No. 7, No. 8 and No. 9 group lymph nodes respectively. However, there were no significant correlations between the tumor’s size and the positive rate of SSLN as well as the degree of tumor’s differentiation and the positive rate of SSLN.

Conclusion

The technique of SSLN tracing expands the application range of sentinel lymph node (SLN) tracing and provides a new thinking for researching of SLN in AGC.     

Y a-t-il un intérêt au curage lomboaortique dans les cancers de l'endomètre opérables ?

The indication and extent of lymph node dissection in the surgical management of endometrial cancer remains controversial especially concerning the para-aortic lymph nodes. The therapeutic benefit of the lymph node dissection is criticized mainly for low-risk patients for extra-uterine spread. Surgically staging patients is the best method to predict node involvement and it allows an optimal decision for adjuvant therapy to be taken. The different prognostic factors for para-aortic lymph nodes metastasis are histological grade and size of the tumour, myometrial wall invasion and lymphovascular dissemination, as well as positive pelvic lymph nodes. However, these elements are not correctly evaluated before and during the surgery. Positive para-aortic lymph nodes can be found without a lymphatic spread to the pelvic area. Even though the prevalence of para-aortic node involvement is weak, it seems legitimate to propose in selected cases of important lymph node involvement, it's complete dissection if a pelvic lymphadenectomy is indicated and if it is surgically possible.     

食管癌根治术后腹腔淋巴结复发区域对术后放疗靶区确定的指导意义

目的 分析胸段食管鳞癌根治术后腹腔淋巴结复发区域,探讨术后辅助放疗靶区的设计。方法 对2005—2013年间我院收治的胸段食管鳞癌R₀根治术后经影像学检查证实术后有腹腔淋巴结转移患者,按第7版AJCC胃癌分组标准对腹腔淋巴结转移具体部位分组并进行回顾分析。组间差异行χ²检验。结果 1593例中术后腹腔淋巴结转移148例,总转移率为9.3%,其中食管胸上、中、下段腹腔淋巴结转移率分别为2.3%、7.8%、26.6%(P=0.000),术后病理为T₁+T₂、T₃+T₄期的分别为8.7%、9.5%(P=0.601),术后病理淋巴结转移为0~2、≥3个的分别为4.8%、20.1%(P=0.000)。腹腔淋巴结转移率从高到低依次为腹主动脉旁的16a2、16a1、腹腔干、胰头后及肝总动脉转移率分别为64.9%、41.2%、37.8%、32.4%、20.9%,其总转移率为91.9%。结论 食管癌根治术后腹腔淋巴结转移主要部位是腹主动脉旁16a2和16a1、腹腔干、胰头后以及肝总动脉淋巴结引流区,是术后辅助放疗的腹腔靶区。     

333例声门型喉癌颈淋巴结转移与预后的关系

背景与目的:声门型喉癌颈淋巴结转移率不高,颈部处理尚无统一认识.本研究探讨声门型喉癌颈淋巴结转移的预后及其影响因素.方法:收集1992年1月1日至2000年12月31日中山大学肿瘤防治中心收治的333例声门型喉癌患者的临床资料,对颈淋巴结转移情况、预后及颈部处理进行回顾性分析.结果:全组患者总的颈淋巴结转移率9.61%(32/333),隐性淋巴结转移率6.23%(20/321).绝大多数转移淋巴结位于同侧Ⅱ、Ⅲ、Ⅳ区(28/32).病理分化级别与总的淋巴结转移率(P=0.092)及隐性淋巴结转移率(P=0.067)无明显相关性.总的淋巴结转移率(P=0.002)及隐性淋巴结转移率(P=0.015)随T分期升高而增高.cN0患者颈选择性放疗对隐性淋巴结转移率的影响无显著性(P=0.363).初治cN 组(3、5年生存率分别为56.25%、46;67%)预后差于初治cN0组(3、5年生存率分别为88.70%、85.37%)(P＜0.001);初治cN0组中出现隐性淋巴结转移的预后(3、5年生存率分别为68.18%、63.31%)差于未出现隐性淋巴结转移(3、5年生存率分别为89.00%、85.55%):初治cN 组有淋巴结转移的预后(3、5年生存率分别为41.67%、16.67%)差于初治cNO组中出现隐性淋巴结转移组(3、5年生存率分别为68.18%、63.31%)(P=0.004).结论:声门型喉癌绝大多数转移淋巴结位于同侧Ⅱ、Ⅲ、Ⅳ区,最多位于同侧Ⅱ区;声门型喉癌颈淋巴结转移影响预后.     

局部晚期喉鳞癌cN0临床观察

目的：探讨喉癌cN0患者颈部处理的方法，降低颈淋巴结转移癌的复发率。方法：回顾分析87例T3、T4期cNo喉癌患者的临床资料，颈部处理方式为颈改良性清扫术或颈分区清扫术，分析手术组阳性淋巴结的分布情况及病理特点，观察颈清扫术对预后的影响，采用Kaplan—Meier方法计算肿瘤复发及生存趋势。结果：87例颈部淋巴结隐性转移率为36．8％，声门上型喉癌40．4％，声门型喉癌32．5％；淋巴结转移分布为：声门上型喉癌89．5％（17／19）位于Ⅱ和Ⅲ区，声门型喉癌92．3％（12／13）位于Ⅱ和Ⅲ区；5年颈部复发率：隐性淋巴结转移复发率为13．5％，无隐性淋巴结转移复发率6．7％；5年生存率：有淋巴结隐性转移生存率为53．8％，无隐性转移为71．1％。结论：晚期喉癌隐性转移率较高，分区清扫术后，隐性转移复发率与无隐性转移复发率无差别，分区清扫术十分必要，注意双侧Ⅱ、Ⅲ区的淋巴结清扫。