胃癌根治术中肿大淋巴结的分析

目的　研究胃癌根治手术中肿大淋巴结实际转移状况并分析淋巴结切除范围与预后的关系。方法　查阅手术记录和术后病理报告并进行 5年随访。记录肿大淋巴结数 ,比较近端胃、远端胃和全胃切除术的淋巴结切除数目并分析其与预后的关系。结果　本组 15 5例胃癌标本中 ,共摘取淋巴结 3 3 0 5枚 (平均 2 1.3 2枚 /例 ) ;肿大淋巴结 10 3 7枚 (平均 6.69枚 /例 ) ;转移淋巴结 42 3枚 (平均 2 .73枚 /例 )。在 15 5例获 5年随访的患者中 ,行D2式手术 10 9例 ,D3式 46例 ,5年生存分别是 3 7例和 11例。结论　手术中肿大淋巴结不一定是转移淋巴结 ;胃癌根治术中淋巴结清扫范围不应盲目扩大 ,而应根据术中冰冻病检结果判断。     

腹腔镜结直肠癌根治术中前哨淋巴结定位方法的探讨

目的：比较、评价纳米碳混悬液与亚甲蓝应用于腹腔镜结直肠癌根治术前哨淋巴结标记的差异、优劣及其临床应用价值。方法：将50例结直肠癌患者随机分为两组,分别于腹腔镜结直肠癌根治术中采用纳米碳、亚甲蓝进行前哨淋巴结定位活检,记录两种方法检出前哨淋巴结的数量及分布情况,比较两组检出总淋巴结数及前哨淋巴结检测的成功率、准确性、敏感性、特异性、假阴性率。结果：两组患者一般资料差异无统计学意义（P〉0.05）。纳米碳组平均检出淋巴结（16.1±1.02）枚,明显多于亚甲蓝组（12.7±1.10,P=0.025）。纳米碳组23例检出前哨淋巴结,共43枚,平均（1.87±0.18）枚;亚甲蓝组20例检出前哨淋巴结,共23枚,平均（1.15±0.11）枚,两组差异有统计学意义（P=0.002）。纳米碳组前哨淋巴结检出成功率、准确性、敏感性、特异性、假阴性率等均优于亚甲蓝组,但差异无统计学意义（P〉0.05）。结论：腹腔镜结直肠癌根治术中使用纳米碳混悬液进行前哨淋巴结活检效果明显优于亚甲蓝,且有助于淋巴结的清扫,并指导病理分期。     

Decision-making for lymph node excision in surgery of thyroid cancer. Extemporaneous examination of the external supraclavicular lymph nodes

Modified neck dissection (MND) is not recommended for surgery of thyroid carcinoma (TC) in the absence of grossly involved nodes, except for medullary thyroid carcinoma, and clinical node recurrence in uncommon at follow-up (3% for us). But several authors report metastatic cancer in non-palpable nodes up to 70% on MND specimens. The fear of overlooking occult metastatic nodes prompted us to sample even normal appearing nodes and to rely on frozen sections (FS) to make a decision whether or not a MND should be done. PATIENTS AND METHODS: 130 among 300 consecutive patients operated for TC were submitted to supraclavicular node sampling with FS. All pathological varieties were covered. In 170 cases, sampling was not done purposely (lack of intraoperative diagnosis of carcinoma: 75) or for other reasons (absence of obvious nodes: 77; unavailable pathologist: 14; miscellaneous: 4). All specimens were reviewed by paraffin sections (PS). RESULTS: Among the 130 patients; 25 had gross metastatic node involvement, confirmed by FS+ and PS+; 1 had grossly equivocal nodes with FS- and PS+; 104 had grossly normal nodes. In 101 (97%) this was confirmed by FS- and PS-. In 3 (3%) FS was +, leading to MND, and PS confirmed metastatic involvement in 2. All 32 specimens of routine node sampling done in 1988 have been reviewed by serial cross sections, one each millimeter (331 sections). One only disclosed one occult metastatic invasion. CONCLUSION: No more than 3% of the grossly normal supraclavicular nodes are metastatic at the time of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

乳癌前哨淋巴结活检

复习近年来的相关文献，综述乳癌前哨淋巴结活检的技术方法及其临床价值，归纳如下：（1）联合应用染料指示及放射性元素示踪法与单用一种方法相比，前者可提高前哨淋巴结的检出率，降低假阴性率。（2）应用连续切片、免疫组化或逆转录多聚酶链反应方法对前哨淋巴结进行病理学检查，可提高微转移灶的检出，有助于腋淋巴结的准确分期。（3）前哨淋巴结活检操作简单，并发症少，并能准确预测腋淋巴结的状态，可望在部分早期乳癌的治疗中取代腋淋巴结清扫术。     

Parasternal lymph node excision in breast cancer]

Comparative analysis of the results of videothoracoscopic parasternal lymphadenectomy and standard mastectomy by Urban--Holdin is presented. In November 1995 to December 1999 205 videothoracoscopic parasternal lymphadenectomies were performed (96--on the left, 104--on the right). Central and medial location of breast cancer was indication for this operation. Age of the patients ranged from 23 to 73 years. Surgery was performed under intravenous anesthesia in the conditions of artificial lung ventilation with separate lung intubation. Mastectomy was performed as the first stage. Further, thoracoports were introduced into pleural cavity in the 5th intercostal space along medioclavicular and mediaxillar lines and in the 4th intercostal space along anterior axillar line. Parietal pleurotemy was performed parallely to internal thoracic vessels, parasternal fat and lymph nodes were removed en-block. Parasternal lymph nodes were involved in 40 (19.5%) patients. The spirometry, cardiomonitoring which were used pre-, intra-, postoperatively demonstrated that parasternal thoracoscopic lymphadenectomy is less traumatic and effective as diagnostic method than mastectomy by Urban--Holdin. Parasternal thoracoscopic lymphadenectomy can be recommended as a method of choice in medial and central breast cancer.     

Intraoperative assessment of sentinel lymph nodes in breast cancer

Background:

Sentinel lymph node biopsy (SLNB) reduces the morbidity of axillary clearance and is the standard of care for patients with clinically node‐negative breast cancer. The ability to analyse the sentinel node during surgery enables a decision to be made whether to proceed to full axillary clearance during primary surgery, thus avoiding a second procedure in node‐positive patients.

Methods:

Current evidence for intraoperative sentinel node analysis following SLNB in breast cancer was reviewed and evaluated, based on articles obtained from a MEDLINE search using the terms ‘sentinel node’, ‘intra‐operative’ and ‘breast cancer’.

Results and conclusion:

Current methods for evaluating the sentinel node during surgery include cytological and histological techniques. Newer quantitative molecular assays have been the subject of much recent clinical research. Pathological techniques of intraoperative SLNB analysis such as touch imprint cytology and frozen section have a high specificity, but a lower and more variably reported sensitivity. Molecular techniques are potentially able to sample a greater proportion of the sentinel node, and could have higher sensitivity. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

后腹腔镜下根治性肾切除术并区域淋巴结清扫术40例报告

目的探讨后腹腔镜下肾癌根治性肾切除术并区域淋巴结清扫术的安全性和疗效。方法2002年1月至2006年7月,行后腹腔镜下肾癌根治区域淋巴结清扫术40例。男22例,女18例,年龄23～70岁,平均53岁。8例以无痛性全程肉眼血尿就诊,32例为体检时B超检查发现。B超检查肿物直径1．5～7．0 cm,平均5．0 cm;肿瘤位于肾上极16例,肾中部10例,肾下极14例。40例均行CT检查,31例行MRI检查,报告肿物大小与B超相符。术前临床分期：T1N0M09例, T2N0M025例,T3N0M06例。结果本组手术时间80～180 min,平均120 min。出血量20～300 ml,平均50 ml。无中转开放手术。术后肠道功能恢复时间（24±12）h,术后住院天数（7±2）d。术后无明显并发症。病理报告：肾透明细胞癌33例,囊性肾细胞癌4例,血管平滑肌脂肪瘤2例,嗜酸细胞瘤1例。送检清扫的淋巴结中,阳性4例,均为透明细胞癌,T21例、T23例。随访6～36个月,平均12个月,1例术后3个月局部复发,后因远处转移死亡,其余39例未发现局部复发和穿刺通道的种植性转移,未发现远处转移,均无瘤生存。结论后腹腔镜下肾癌根治性肾切除术并区域淋巴结清扫术安全可靠,疗效良好。     

Sentinel lymph node biopsy in breast cancer: an analysis of the maximum number of nodes requiring excision

Sentinel lymph node biopsy (SNB) is now the standard of care in assessment of patients with clinically staged T1-2, N0 breast cancers. This study investigates whether there is a maximum number of sentinel lymph nodes (SLN) that need to be excised without compromising the false-negative (FN) rate of this procedure. Data were prospectively collected for 319 patients undergoing SNB between February 2001 and December 2006 at our institution. This data were analysed, both in terms of the order of SLN retrieval and relative isotope counts of the SLNs, in order to determine the maximum number of SLNs that need to be retrieved without increasing the FN rate. Furthermore, we investigated the relationship between SLN blue dye concentration and the presence of SLN metastases. The SLN identification rate was 97% with no false-negative cases amongst patients undergoing simultaneous axillary clearance historically during technique validation. In patients with SLN metastases, excision of the first 4 SLNs encountered results in the identification of a metastatic SLN in all cases. Although the majority (86%) of SNB metastases are in the hottest node, the SLN containing the metastasis is in the first 4 hottest nodes in 99% of patients with nodal metastases. The remaining 1% of SLN metastases were identified by blue dye. There was no statistically significant association between the SLN blue dye concentration and the presence of SLN metastases. A policy to remove a maximum of four blue and/or hot SLNs along with any palpably abnormal lymph nodes does not result in an increased false-negative rate of detection of SLN metastases.     

Significance of perivesical lymph nodes in radical cystectomy for bladder cancer

ObjectiveThe location of positive lymph nodes (LNs) is important for bladder cancer staging. Little is known regarding the impact of perivesical (PV) lymph node (PVLN) involvement on survival. This study characterized PVLN identified after radical cystectomy (RC) and analyzed their impact on recurrence and survival.Materials and methodsWe reviewed our institutional review board–approved database including all patients who underwent RC with pelvic lymphadenectomy for curative intent for urothelial carcinoma. Clinical and pathologic data were obtained. Patients were analyzed in groups according to the location of positive LNs: PV+/other LN (ON)+, PV+/ON?, and PV?/ON+. Kaplan-Meier curves were used to estimate recurrence-free survival (RFS) and overall survival (OS). Multivariable Cox regression (including pathologic T category, number of positive LNs, highest level of positive LNs, chemotherapy, and margin status) was performed to evaluate associations between PVLN status and survival.ResultsIn total, 2,017 patients met inclusion criteria and 465 (23%) were LN+. PVLNs were identified in 936 patients (47%), positive in 197 patients (10%), and represented isolated LN+disease in 101 patients (5%). On univariate analysis, RFS and OS were significantly worse in the PV+/ON+group compared with the PV+/ON? and PV?/ON+ groups. There were no significant differences in RFS or OS between the PV+/ON? and PV?/ON+ groups. On multivariable analysis, PV+/ON+disease was independently associated with worse RFS and OS when compared with PV?/ON+ disease.ConclusionsPVLNs were identified in a significant number of patients after RC. Positive PVLN, when in combination with other positive LNs, portends worse survival even when correcting for the number of positive nodes.     

Ultrasonographic detection of metastatic axillary lymph nodes in breast cancer

Metastatic involvement of the axillary lymph nodes is the most important prognostic factor in breast cancer. Preoperative knowledge of lymph node status would be useful in planning the therapy for breast cancer. The aim of our study was to find how accurately metastatic lymph nodes can be detected with ultrasonography (US). Our study consisted of 63 breast cancer patients having 65 breast cancers. Their axillae were examined preoperatively with US (with a 7.5 Mhz linear-array transducer). 27.7% of these patients had metastatic axillary lymph nodes. With US we could detect 12 of these 18 axillary metastases. In 2 of our 6 false negative results only micrometastases were found on histological examination. In our study the sensitivity of US was 66.6%. There was only one axilla, in which nodes were detected with US, but on histological examination no metastases were found, thus giving a specificity of 97.9%. Our study indicates that in the axilla normal nodes are not visible with US.