直肠癌围手术期的整体护理研究

目的探讨直肠癌围手术期的护理效果和经验。方法对2008年6月～2009年12月间在我院住院治疗的直肠癌患者38例进行回顾性分析,总结护理效果和经验。结果整体护理后患者SDS及SAS评分明显低于护理前,两组比较差异具有统计学意义(P<0.05)。整体护理后患者呼吸、脉搏、收缩压均优于护理前,两组比较差异具有统计学意义(P<0.05)。本组患者平均住院时间为(20.22±2.67)d,无围手术期死亡病例。满意度调查显示满意度100.00%。结论整体护理措施能帮助直肠癌患者围手术期顺利度过危险期,并能改善患者的预后。     

Transanal extirpation for early rectal cancer

Transanal extirpation was performed in 38 patients with adenocarcinoma of the rectum. In 17 patients (group I) the tumor extended into the submucosa only, and in 14 patients (group II) tumors extended into, but not through, the muscularis propria. There was a significant difference in local recurrence between groups I and II. None of the patients in group I and six of the patients (42.6 percent) in group II developed local recurrences (P=0.02). The 5-year actuarial survival probability was 100 and 82.6 percent, respectively. Transanal extirpation is an alternative to transsphincteric and abdominoperineal resection in the treatment of early well or moderately well-differentiated cancer of the rectum. The surgical procedure is simple and has few complications; however, only tumors extending no deeper than the submucosa are suitable for this treatment. The operation should be followed by frequent sigmoidoscopies and rectal palpation. The procedure should be defined as an excisional biopsy until results from the histologic examination are presented.     

Current evidence-based opinions in the management of adenocarcionoma of the rectum

The management of rectal cancer has drastically evolved over the past two decades as a result of implementation of circular stapling devices and the introduction of neoadjuvant chemoradiation. In spite of current aggressive multimodality treatments, the recurrence rate remains unacceptably high and the expected 5-year survival in patients who develop recurrent disease is dismal. The management of rectal cancer must involve a multidisciplinary approach. An understanding of the biology of rectal tumours may allow for selection of patients who may have an aggressive phenotype allowing for alterations in the operative and neoadjuvant planning. Efforts to improve local control and survival in rectal cancer are the focus of multiple current clinical and preclinical research efforts. Preoperative chemoradiation for and surgical management of rectal cancer, including the laparoscopic approach are areas of dynamic progression. In the present report, we review the current evidence in the new strategies pertaining to the multimodality approach in the management of rectal cancer.     

A phase II trial for the optimisation of treatment position in the radiation therapy of prostate cancer

BACKGROUND: Patient immobilisation and position are important contributors to the reproducibility and accuracy of radiation therapy. In addition the choice of position can alter the external contour of the treated area and has the potential to alter the spatial relationship between internal organs. The published literature demonstrates variation in the use of the prone and supine position for prostate cancer radiation therapy. Previous investigators using different protocols for patient preparation, imaging and target volume definition have demonstrated changes in the calculated therapeutic ratio comparing the two positions. We did not use rigid immobilisation, laxatives, rectal catheters or bladder voiding and assessed if in the prone position would cause a reduction of the dose to the rectum. We performed a prospective comparison of the two positions in 26 patients to determine if the differences in the spatial relation between the rectum and the planning target volume (PTV) would impact on dose-volume histograms to organs at risk (OAR). We also determined if any such improvement might permit dose escalation. MATERIALS AND METHODS: Twenty-six patients with clinically localized prostate cancer consented to participate in this study. All patients underwent a planning CT scan in both the prone and supine treatment positions. The PTV and OAR were drawn on each set of scans by one of the investigators. The PTV included the prostate and seminal vesicles with a 1cm margin except posteriorly where this margin was reduced to 5mm. The outer circumference of the bladder, rectal wall, small bowel (when present) was drawn along with femoral heads. 3D conformal treatment plans were computed using Helax TMS version 6.1B. A 3-field treatment technique was employed with energy of 10/15 MV. The prescribed dose was 70 Gy and the PTV was encompassed by the 95% isodose and the maximum dose was always less than 107%. Cumulative dose-volume histograms were calculated for the PTV, rectum, bladder, femoral heads and small bowel (when present). These non-uniform histograms for both the prone and supine treatment positions were transformed into uniform ones using the effective volume method [Kutcher J, Burman C. Calculation of probability factors for non-uniform normal tissue irradiation: the effective volume method. Med Phys 1987;14:487]. RESULTS: Twenty-one of the 26 (80%) patients had a lower effective volume of rectum irradiated if the prone instead of the supine treatment position was used. The median value of the effective volume in the supine treatment position was 31.74 Gy while the median value in the prone position was 22.48 Gy. The dose escalation was applied to the patients in the prone treatment position until the effective volume for the rectum was the same as that in the supine position. The range of dose escalation possible for these patients was 0.1-7.9 Gy. These patients could potentially have the dose escalated from the prescribed dose of 70 Gy for the supine position without any increase in side effects. For the five patients where no potential benefit was found when changing treatment position, only two patients displayed a significant (>1 Gy) advantage for the supine treatment position. Twenty-one of the 26 patients also showed an advantage for the prone treatment position in relation to bladder dose. CONCLUSION: The use of the prone position reduced the dose to the unprepared rectum and unvoided bladder in the majority of cases. It should be considered particularly in cases where large posterior seminal vesicles cause significant overlap between the planning target volume and the rectum.     

手缝法低位结-直肠吻合术在卵巢癌直肠转移肠段切除术中的应用

目的；探讨手缝法低位结-直肠吻合术在晚期卵巢癌直肠转移肠段切除吻合术中的价值。方法：于盆底腹膜外游离直肠下段，距离癌灶缘3cm以外切除受侵肠管，行手缝低位结-直肠吻合术。手术结束后于骶前间隙放置引流管，以防渗液蓄积继发感染。结果：10例中除1例术后9d出现吻合口瘘外，，余9例吻合口均甲级愈合。术后以PAC方案为主行腹腔和静脉联合化疗，效果良好。随访6～36个月患者均存活，其中7例临床完全缓解。结论：手缝法低位结-直肠吻合术不需借助特制器械，避免了肠造瘘的痛苦，提高了生活质量。     

Evidence for the existence of different types of large bowel tumor: suggestions from the clinical data of a population-based registry

The clinical findings of a population-based colorectal tumor registry have been analyzed to determine elements of supporting or not supporting the existence of different types of large bowel cancer. Age-specific incidence rate of the 409 registered patients rose sharply with increasing age in all segments of the large bowel; however, regarding left colon and rectum, the male: female ratio showed a marked male preponderance, more evident in the more advanced age groups. Histopathology, studied in 87% of patients, revealed adenocarcinoma as the most frequent feature; however, adenocarcinoma with concomitant adenoma (i.e., presumably arising in adenoma) was observed in 14.3% of cancers of the left colon, in 17.7% of rectal tumors, but in only 5.7% of neoplasms of the proximal colon (P less than 0.05 and P less than 0.01, respectively, vs. left colon and rectum). Some histological features (carcinoid and mucinous carcinoma) were observed in right-side tumors only. Analysis of the familial occurrence of cancer showed that a significantly larger proportion of patients with neoplasms located in proximal colonic segments had three or more first-degree relatives affected by (or deceased from) cancer of all sites. Similarly, colorectal tumors among relatives were more frequent in patients with right-side cancer. The location of the 793 polyps observed during 3 years of registration showed that more than 70% of adenomas were located beyond the splenic flexure, overlapping the distribution of cancers. In conclusion, the differences of sex ratio at different colonic subsites, the higher fraction of adenocarcinomas with adenomas in cancer of the more distal tracts of the large bowel, and the more marked familial occurrence of colorectal cancer in patients with right-side neoplasms tend to support the view that cancer of the proximal colon, cancer of the distal colon, and cancer of the rectum may actually be three different types of tumors.     

经直肠超声联合弹性成像与超声造影在早期前列腺癌诊断的应用价值

目的 探讨经直肠实时组织超声弹性成像及经直肠前列腺超声造影检查技术在前列腺癌早期诊断的应用价值。方法 对119例可疑前列腺癌患者行经直肠超声成像、经直肠实时组织超声弹性成像及经直肠前列腺超声造影检查,按照经直肠超声引导下穿刺活检的病理Gleason 评分结果分为低危组（≤6分,n=21）、中危组（7分,n=24）、高危组（≥8分,n=28）、良性前列腺增生组（n=46）。分析对比各项超声技术在不同Gleason评分前列腺癌的诊断价值。结果 经直肠超声成像联合经直肠实时组织超声弹性成像及经直肠超声成像联合经直肠前列腺超声造影的诊断符合率在前列腺癌低危组与前列腺增生组之间差异无统计学意义,在前列腺癌中危组、高危组与前列腺增生组组间差异有统计学意义（P<0.05）,经直肠实时组织超声弹性成像联合经直肠前列腺超声造影诊断符合率在低危组、中危组、高危组与前列腺增生组组间均差异有统计学意义（P<0.05）,经直肠超声成像诊断前列腺癌的敏感性、特异性、阴性预测值及阳性预测值分别为46.77%、58.18%、49.23%及55.77%,经直肠实时组织超声弹性成像的敏感性、特异性、阴性预测值及阳性预测值分别为66.13%、70.91%、65.00%及71.93%,经直肠前列腺超声造影的敏感性、特异性、阴性预测值及阳性预测值分别为80.64%、81.82%、78.95%及83.33%,经直肠前列腺超声造影联合经直肠实时组织超声弹性成像的敏感性、特异性、阴性预测值及阳性预测值分别为90.32%、85.45%、88.68%及87.50%,各检查方法比较差异均有统计学意义（P<0.05）。结论 经直肠实时组织超声弹性成像和经直肠前列腺超声造影技术均在前列腺癌早期诊断中有临床价值,二者联合在Gleason评分≤6分的前列腺癌早期诊断中亦有临床应用价值。     

MR staging of primary colorectal carcinoma: comparison with surgical and histopathologic findings

Background: We retrospectively evaluated the accuracy of magnetic resonance (MR) imaging in staging colorectal cancer and assessing local tumor extent, nodal involvement, and distant abdominal and pelvic metastases. Methods: Forty-eight patients with primary colorectal carcinoma were referred for presurgical abdominal and pelvic MR imaging. MR imaging included T1-weighted, fat-suppressed T2-weighted, and fat-suppressed gadolinium-enhanced spin gradient-echo imaging. The prospective interpretations of the MR examinations were reviewed. MR depiction of local tumor extent, nodal involvement, and distant metastases at 18 anatomic locations was noted and compared with subsequent surgical and histopathologic findings. Results: Overall TNM MR staging agreed with surgical and pathologic staging in 41 (85%) of 48 patients, including 21 (78%) of 27 colon cancers and 20 (95%) of 21 rectal cancers. For depth of tumor penetration, which was evaluable in 44 patients, MR imaging agreed with pathologic results in 38 (86%) of 44 patients, including 22 (88%) of 25 colon cancers and 16 (84%) of 19 rectal cancers. In 42 (95%) of 44 patients, MR images correctly distinguished tumor confined to the bowel wall (T0, T1, and T2) from tumor with transmural tumor extension (T3 and T4). Regional nodal metastases were depicted in 15 of 22 patients (sensitivity, 68%; accuracy, 83%). Nodal metastases were better depicted for rectal cancer in eight of nine patients, compared with colon cancer in seven of 13 patients. Distant metastases were correctly depicted on MR imaging in 13 of 14 patients (sensitivity, 93%; accuracy, 98%). In the site-by-site analysis, MR imaging prospectively depicted 66 of 77 sites of surgically confirmed metastatic tumor in the abdomen and pelvis (sensitivity, 86%; specificity, 99%; accuracy, 98%). Conclusion: MR imaging using currently available techniques can effectively image local tumor extent and distant metastases in patients with colorectal carcinoma. Especially for colon cancer, incomplete depiction of nodal metastases in normal-size lymph nodes remains a limitation of cross-sectional imaging studies.     

低位直肠癌患者行肠造口围手术期的护理

目的：探讨低位直肠癌行miles手术前后的护理。方法：术前对26例低位直肠癌患行心理护理，彻底的肠道准备和维持足够的营养，术后做好常规护理，饮食指导，肠造口护理和康复宣教。结果：本组术后无1例发生并发症，惠对肠造口满意率为100％。结论：围手术期周到细致的护理是手术成功的重要保证。     

Colitis cystica profunda: MRI appearance

Colitis cystica profunda (CCP) is an uncommon benign condition characterized by mucin-filled cysts located in the submucosa, frequently associated with the solitary ulcer and rectal prolapse syndromes. The diagnosis of this entity is important as it can mimic rectal cancer and therefore may result in unnecessary surgical resection. Endoscopic examination and barium enema findings are suggestive but not specific, neither are superficial biopsy findings. Transrectal ultrasound is helpful in the diagnosis by imaging the layers of the rectal wall. The authors report a 16-year-old male with a rectal lesion mimicking malignant mass on endoscopic examination. The lesion was defined as CCP, based on MR imaging findings which disclosed multiple noninfiltrating submucosal cysts, confirmed by histopathological examination. To our knowledge, this is the first case of CCP in the radiology literature describing MRI findings.