手术治疗外阴恶性肿瘤54例临床分析

目的;探讨手术对外阴恶性肿瘤预后的影响。方法;对５４例手术治疗的外阴恶性肿瘤病人进行回顾性分析。有广泛切除轲腹股沟淋巴结清除者３５例,外阴广泛切除或单纯外阴切除１９例。结果：总１,３,５,１０,１５年生存率分别为９８．１％,７０．６％,４７．６％,３８．９％,３３．３％;外阴鳞癌Ⅱ期１,３,５,１０年生存率分别为１００．０％,６８．４％,６６．７％,７５．０％,Ⅲ期分别为１００．０％〉７２．７％,     

外阴恶性肿瘤71例临床分析

目的　为进一步探讨外阴恶性肿瘤的治疗预后情况。方法　对我院１９７１年～１９９７ 年间收治的外阴恶性肿瘤病人共７１例进行回顾性分析。中位发病年龄５７．９岁;Ⅰ期８ 例、Ⅱ期３２例、Ⅲ期２２ 例、Ⅳ期６例、复发者３ 例;鳞癌５２ 例、恶性黑色素瘤９例、其它类型１０例;手术５４ 例,行腹股沟淋巴结清扫者３５ 例,未清扫者１９例,淋巴结阳性１３ 例占３７．１％ 。结果　总１、３、５、１０、１５ 年生存率分别为８８．６％ 、５６．１％ 、３６．８％ 、２８．０％ 、１６．７％ 。手术病人的各年生存率均明显高于未手术者。淋巴结阳性者的５年生存率显著低于淋巴结阴性者。较早期（Ⅰ、Ⅱ）病人远期（５、１０年）生存率均高于晚期（Ⅲ、Ⅳ）,差异显著。结论　手术切除是外阴癌的主要治疗手段,手术方式的选择应个体化,对病期较早淋巴结转移率小的病人可试行单纯外阴切除,术后给予放疗或化疗,但对估计有淋巴结转移可能者,一定要尽早争取淋巴结清扫,术后尽快补充放疗。早期发现、早期诊断、早期治疗对外阴癌的治疗预后尤为重要。外阴复发癌亦应积极创造再治疗机会,如处理得当,可挽救或延长患者生命     

42例手术治疗外阴恶性肿瘤远期随访分析

目的：探讨手术方式对外阴恶性肿瘤预后的影响。方法：对４２例经手术且随访５年以上的外阴恶性肿瘤病人进行回顾性分析。结果：５、１０、１５年生存率分别为４７．６％、３８．９％、３３．３％。２期病人远期生存率显著高于３期、４期,腹股沟林巴结转移者远期生存率明显低于无转移者,腹股沟洒惯清除对２期病人远期生存率影响不明显而对３期病人影响明显。结论：临床分期及腹股沟淋巴结转移对预后影响明显。２期病人应选择手术范     

手术治疗外阴恶性肿瘤临床护理分析

目的：回顾分析外阴恶性肿瘤外科治疗的预后及其影响因素。方法：回顾分析了山东省肿瘤医院1971-1999年收治的71例经手术治疗的外阴恶性肿瘤患者临床资料。结果：中位发病年龄57.9岁，Ⅰ期8例，Ⅱ期32例，Ⅲ期22例，Ⅳ期6例，复发者3例；鳞癌52例，恶性黑色素瘤9例，其他类型10例；行腹股沟淋巴结清除术者45例，未清除者26例，外阴区伤口Ⅰ期全盛合57例（80%），腹股沟区伤口Ⅰ期愈合32例（71.1%)。总5年生存率为50.9%（29/57）,较早期（Ⅰ、Ⅱ）患者5年生存率均高于晚期，伤口愈合情况对预后有一定的影响。结论：（1）早期发现，早期诊断，早期治疗对外阴癌的治疗预后尤为重要。（2）手术切除是外阴癌的主要治疗手段。手术方式的选择应个体化，对病期较早淋巴结转移率小的患者可试行单纯外阴切除。术后给予放疗或化疗；（3）外阴复发癌亦应积极创造再治疗机会，如处理得当，可挽救或延长患者生命。（4）加强护理，促进伤口愈合，及时治疗利于提高生存率。     

手术治疗外阴恶性肿瘤临床护理分析

目的 :回顾分析外阴恶性肿瘤外科治疗的预后及其影响因素。方法 :回顾分析了山东省肿瘤医院 1971～ 1999年收治的 71例经手术治疗的外阴恶性肿瘤患者临床资料。结果 :中位发病年龄 5 7 9岁 ;Ⅰ期 8例、Ⅱ期 32例、Ⅲ期 2 2例、Ⅳ期 6例、复发者 3例 ;鳞癌 5 2例、恶性黑色素瘤 9例、其他类型 10例 ;行腹股沟淋巴结清除术者 4 5例 ,未清除者 2 6例。外阴区伤口Ⅰ期愈合 5 7例 (80 % ) ,腹股沟区伤口Ⅰ期愈合 32例 (71.1% )。总 5年生存率为 5 0 9% (2 9/ 5 7) ,较早期 (Ⅰ、Ⅱ )患者 5年生存率均高于晚期 ,伤口愈合情况对预后有一定的影响。结论 :①早期发现、早期诊断、早期治疗对外阴癌的治疗预后尤为重要。②手术切除是外阴癌的主要治疗手段 ,手术方式的选择应个体化 ,对病期较早淋巴结转移率小的患者可试行单纯外阴切除 ,术后给予放疗或化疗。③外阴复发癌亦应积极创造再治疗机会 ,如处理得当 ,可挽救或延长患者生命。④加强护理 ,促进伤口愈合 ,及时治疗利于提高生存率     

外阴恶性肿瘤腹股沟淋巴结清扫术后腹股沟区创面处理的临床观察

目的 探讨外阴恶性肿瘤腹股沟淋巴结清扫术手术切口的改良缝合法及腹腔镜下腹股沟淋巴结清扫术的可行性。方法 回顾性分析外阴恶性肿瘤腹股沟淋巴结清扫术手术切口的改良缝合法（改良组）与传统缝合法（传统组）及腔镜下腹股沟淋巴结清扫术（腔镜组）的腹股沟切口的平均愈合时间、Ⅰ期愈合率及延迟愈合率。结果 传统缝合法的16例患者平均愈合时间为（28.0±19.2）天,其中6例为Ⅰ期愈合;改良缝合法的9例患者平均愈合时间为（14.2±6.2）天,其中8例为Ⅰ期愈合;16例腔镜法手术的腹股沟创面的Ⅰ期愈合率为93.8％（其中1例合并糖尿病者延期愈合）。传统组的平均愈合时间显著长于改良组（P＜0.05）。3组延迟愈合率分别为62.5％、11.1％和6.2％,传统组显著高于改良组和腔镜组（P＜0.05）,腔镜组与改良组相比差异无统计学意义（P＞0.05）。 结论 外阴恶性肿瘤腹股沟淋巴结清扫术后腹股沟区皮肤切口的改良缝合法和腔镜下腹股沟淋巴结清扫术后的腹股沟皮肤的愈合情况均显著优于传统缝合方法,值得临床推广和应用。     

外阴癌腹股沟淋巴结转移的多因素分析

目的 探讨用Logistic回归模型预测外阴癌腹股沟淋巴结是否转移,以期提高术前诊断的准确率。方法 我院在1963-1999年间共收治外阴癌389例,其中行外阴广泛切除加双侧腹股沟淋巴结或并盆腔淋巴结清扫的外阴鳞癌256例,本文对此256例患者的临床病理资料进行回顾性分析。结果 下列5个因素与腹股沟淋巴结转移率有关;（1）中线位置易于出现淋巴结转移,且易双仙淋巴结转移;（2）肿瘤直径大于4cm后转移率上升;（3）腹股沟淋巴结的临床状况有一定临床意义,但准确性欠佳;（4）肿瘤细胞低分化组腹股沟淋巴结转移率高于其他组;（5）当肿瘤细胞累及淋管或血管间隙时易于出现腹股沟淋巴结转移。将此5个因素引入Logistic回归模型可将腹股沟淋巴结是否转移的预测准确性提高到87.89%。结论 用Logistic回归模型预测外阴癌腹股沟淋巴结是否转移准确性较高,有助于手术前进行准确的临床分期,也可为外阴癌的个体化治疗选择合适的方案。     

腹腔镜下腹股沟淋巴结切除术治疗外阴癌的临床研究

目的　探讨外阴浸润癌行腹腔镜下腹股沟淋巴结切除术的可行性和手术技巧。方法　２０１０年１１月至２０１１年８月对１０例外阴癌患者行根治性局部外阴切除术和腹腔镜下腹股沟淋巴结切除术,必要时行盆腔淋巴结切除术。结果　１０例患者均在腹腔镜下腹股沟淋巴结切除术后行根治性局部外阴切除。平均每侧腹股沟淋巴结切除手术时间为９１ｍｉｎ（８０～１３０ｍｉｎ）,术中每侧腹股沟淋巴结切除平均出血为６.３ｍｌ（５～１０ｍｌ）,切除淋巴结数平均为７.４个（单侧）,淋巴结转移２例,平均拔管时间为６.８ｄ（５～１０ｄ）,所有患者均未发生腹股沟区皮肤坏死。结论　外阴广泛切除联合腹腔镜下腹股沟淋巴结切除术治疗外阴浸润癌安全、可靠,手术创伤小,术后切口愈合佳,不易发生腹股沟区皮肤缺血坏死。     

42例眼睑恶性肿瘤手术治疗的临床分析

目的 评价眼睑恶性肿瘤采用组织学控制性切除治疗的可行性和可靠性。方法 对42例眼睑恶性肿瘤患者行组织学控制性切除，观察其术后疗效。结果 42例患者除1例因意外车祸死亡无法追踪外，其余41例均无复发，治愈率达100％，绝大多数患者眼睑外观基本恢复原样。结论 采用组织学控制性切除眼睑恶性肿瘤是一种相对简单、安全、高效的治疗方法。     

15例外阴癌手术治疗临床分析

目的：观察手术治疗外阴癌的效果,及术后并发症。方法：回顾性总结15例外阴癌手术治疗结果及并发症。结果：中位年龄60岁,中位病程10个月。病变部位以大阴唇多见,占66．7％。病变大小〈2cm者1例,2—5cm者12例,〉5cm者2例。组织类型：鳞癌13例（86．7％）,腺癌2例。4例伴腹股沟淋巴结转移,转移率为26．7％。病理分期：Ⅰ期1例（6．7％）,Ⅱ期10例（66．7％）,Ⅲ期3例（20．0％）,Ⅳ期1例（6．7％）。手术方式：根治性外阴切除＋双侧腹股沟淋巴结清扫10例,改良根治性外阴切除＋单侧腹股沟淋巴结清扫4例,单纯外阴切除1例。术后并发症主要为切口愈合不良,发生率53．5％。结论：手术是外阴癌有效的治疗方法,但术后切口愈合不良发生率较高。放置有效引流、采用肌瓣或肌皮瓣技术避免切口张力及合理应用术前放化疗等对减少术后并发症具有一定的意义。     

Immunohistochemical analysis of p53 in vulval intraepithelial neoplasia and vulval squamous cell carcinoma

Human papillomavirus (HPV) is thought to cause some vulval squamous cell carcinomas (VSCC) by degrading p53 product. Evidence on whether HPV-negative VSCC results from p53 mutation is conflicting. We performed immunohistochemistry for p53 product on 52 cases of lone vulval intraepithelial neoplasia (VIN), 21 cases of VIN with concurrent VSCC and 67 cases of VSCC. We had previously performed HPV detection and loss of heterozygosity (LOH) analyses on these samples. Abnormal p53 immunoreactivity (p53-positive) rates in HPV-positive VSCC and HPV-negative VSCC were 22% (12/54) and 31% (4/13), respectively (P<0.74). p53 immunoreactivity was associated with LOH at the p53 locus (P<0.004), but neither technique differentiated between HPV-positive and HPV-negative VSCC. p53 immunoreactivity was associated with overall LOH rates (p53-positive VSCC vs p53-negative VSCC mean fractional regional allelic loss 0.41 vs 0.24, respectively, P<0.027). LOH at 3p25 was more frequent in p53-positive VSCC cf p53-negative VSCC (70 vs 21%, respectively, P<0.007). There was a trend in p53 disruption associated with invasive disease; HPV-positive VSCC demonstrated more disruption than VIN associated with VSCC, which had more disruption than lone VIN III (22 vs 10 vs 0%, respectively, P<0.005). In all, three out of 73 cases of VIN were p53-positive. All three were associated with concurrent or previous VSCC. Meta-analysis of previous studies revealed significantly more p53 disruption in HPV-negative VSCC cf HPV-positive VSCC (58 vs 33%, respectively; P<0.0001). p53 immunoreactivity/mutation in VIN only appeared in association with VSCC. These data suggest that HPV-independent vulval carcinogenesis does not exclusively require disruption of p53, p53 disruption may work synergistically with LOH at specific loci and p53-positive VIN should be checked carefully for the presence of occult invasion.     

Molecular evidence of a common clonal origin and subsequent divergent clonal evolution in vulval intraepithelial neoplasia, vulval squamous cell carcinoma and lymph node metastases

VIN is thought to be the precursor of some VSCCs because it is monoclonal, frequently occurs contiguously with VSCC and shares similar risk factors with a subgroup of VSCC. There has been no conclusive molecular evidence supporting this assumption. We performed X-chromosome inactivation analysis on 9 cases of lone VIN, 10 cases of VSCC and associated contiguous VIN and 11 cases of VSCC and associated noncontiguous VIN. Eight of the 9 cases of lone VIN appeared to be monoclonal. All 7 informative and monoclonal cases of VIN with contiguous VSCC and 6/9 informative cases of VIN with noncontiguous VSCC showed patterns of X-chromosome inactivation consistent with a common monoclonal origin for both VIN and VSCC. Two of the 9 cases of VIN with noncontiguous VSCC showed X-chromosome inactivation patterns consistent with a separate clonal origin. We performed LOH analysis at 6 chromosomal loci on these samples and 7 cases with lymph node metastases. Identical losses occurred 7 times in VIN and contiguous VSCC (random probability 1.2 x 10(-9)), twice in VIN and noncontiguous VSCC (random probability 1.5 x 10(-3)) and 3 times in VSCC and associated metastases (random probability 1.8 x 10(-5)). Some losses occurring in VSCC did not appear in the contiguous VIN or associated metastases and vice versa. These data provide molecular evidence that VIN is the precursor of VIN-associated VSCC, that multifocal disease may arise via either different clones or a single clone and that continued divergent clonal evolution may occur in vulval neoplasia.     

贲门癌手术治疗111例分析

目的探讨贲门癌合理手术径路的选择。方法对我院1998年1月至2003年12月期间外科手术治疗的111例贲门癌病人的临床资料进行分析,对经胸、经腹、胸腹联合三种手术径路的切端阳性率,平均淋巴结清扫数,术后并发症发生率,平均住院时间进行分析总结。结果111例贲门癌病人病人中,经胸19例,经腹83例,胸腹联合9例,三种手术径路的上切缘阳性率和平均淋巴结清扫数无显著性差异(P>0.05),术后并发症发生率和平均住院时间有显著性差异(P<0.05)。结论贲门癌手术方式应以经腹手术为首选。     

Clinical utility of elevated tumor markers in patients with disseminated appendiceal malignancies treated by cytoreductive surgery and HIPEC

Background

Appendiceal malignancies with peritoneal spread have been successfully treated with Cytoreductive Surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study is to clarify the utility of common tumor markers in selecting patients for the combined treatment.

Methods

Data on 56 patients with appendiceal neoplasms treated with CRS and HIPEC were prospectively collected. Chi square test was used to analyze a link between common tumor markers and completeness of cytoreduction score (CC score) and preoperative peritoneal cancer index score (PCI score). Cox proportional hazard model was used to perform survival analysis.

Results

Forty-two patients were alive after 3 years of follow-up. Hazard ratio of disease related death was 5.6 (95% CI, 1.8–17.2) among patients with high CC score as compared to those with low CC score. Number of abnormal tumor markers (0 vs 1/2/3) correlated with PCI score 16.2 vs 32.5 (p < 0.001) but not with completeness of cytoreduction or survival. The 3-year survival rates in patients with normal vs abnormal CA 125 levels were 83% vs 52%(p = 0.003).

Conclusions

Multiple abnormal tumor markers were not useful as an exclusion criterion for patients undergoing CRS. Elevation in CA 125 was an important indicator of survival in these patients. Complete cytoreduction was crucial for long-term survival.     

High frequency of loss of heterozygosity in vulval intraepithelial neoplasia (VIN) is associated with invasive vulval squamous cell carcinoma (VSCC).

Vulval intraepithelial neoplasia (VIN) is thought to be the premalignant phase of human papillomavirus (HPV)-associated vulval squamous cell carcinoma (VSCC). Various molecular events have been suggested as markers for progression from VIN to VSCC, but loss of heterozygosity (LOH) in vulval neoplasia has rarely been studied in this context. We performed LOH analysis by polymerase chain reaction (PCR) amplification of polymorphic microsatellite markers at 6 chromosomal loci (17p13-p53, 9p21-p16, 3p25, 4q21, 5p14 and 11p15). The presence of HPV was assessed using consensus PCR primers and DNA sequencing. To examine any association between LOH and the presence of invasive disease, we analyzed 43 cases of lone VIN III, 42 cases of lone VSCC and 21 cases of VIN with concurrent VSCC. HPV DNA was detected in 95% of lone VIN III samples and 71% of lone VSCC samples. Fractional regional allelic loss (FRL) in VIN associated with VSCC was higher than in lone VIN (mean FRL 0.43 vs. 0.21, p < 0.005). LOH at 3p25 occurred significantly more frequently in HPV-negative VSCC than in HPV-positive VSCC (58% vs. 22%, p < 0.04). These data suggest that genetic instability in VIN, reflected by LOH, may increase the risk of invasion. In addition, molecular events differ in HPV-positive and -negative VSCC and 3p25 may be the site of a tumor suppressor gene involved in HPV-independent vulval carcinogenesis.     

123例贲门癌外科治疗的临床分析

背景与目的：贲门癌的发病率逐年增高,对其研究逐渐深入,但在临床上还有很多争论。本文总结我们在贲门癌临床外科治疗中的经验。方法：123例手术治疗的贲门癌患者：经胸手术组72例,经腹手术组40例,胸腹联合手术组11例,分析术前检查（腹部B超、胸腹CT、内镜和上消化道造影）、手术入路、淋巴结清扫和术后病理情况。结果：腹部B超对浆膜受侵、淋巴结转移、下段食管受侵、肝转移病变外侵腹水的判断与术后病理的符合率分别达到了71．2％、62．2％、47．8％、100％,胸腹CT则为78．6％、72．7％、51．9％、100％,内镜指示肿瘤距门齿的长度,上消化道造影则显示肿瘤与膈肌的关系。手术切除率94．3％（116／123）．116例切除病例中,贲门腺癌108例,占93．1％,腺鳞癌、鳞癌、不典型类癌、类癌各2例,占6．9％,84例腹腔淋巴结转移（72．4％）,6例胸腔淋巴结转移（7．1％）,40例（34．5％）下段食管受侵。结论：术前腹部B超和胸腹CT检查对判断肿瘤切除有极大帮助。内镜和上消化道造影有助于判断是否开胸。淋巴结转移以腹腔为主。三种手术途径各有优劣,没有任何一种占绝对优势,要依托Siewert分型,因病而定、因人而异。