大肠癌淋巴转移规律对手术根治性的临床意义

目的 研究进展期结直肠癌淋巴转移规律,指导手术根治范围。方法 分析７４例结直肠癌行Ｄ３式根治术后淋巴结６２３个,按肿瘤旁、肠管纵轴和中枢方向行淋巴结分组、分站。结果 肿瘤旁淋巴结转移率和转移度最高各为４７％和３８．６％,阳性淋巴结分布率为６１．２％;肠管纵轴方向淋巴结转移率为２３％,转移度为１８．６％,系膜淋巴结转移率为１７．１％,并与距肿瘤远近和方向有关;中枢方向阳性淋巴结分布率为２１．６％,系     

进展期结直肠癌淋巴转移规律的临床研究

目的 研究进展期结直肠癌淋巴结转移规律。评价手术根治程度。方法 分析１１４例结直肠癌行扩大的Ｄ３式根治术后淋巴结１００５个,按肿瘤旁、肠管纵轴和中枢方向淋巴结分组分站。结果 肿瘤旁、肠管纵轴方向淋巴结转移率、转移度和阳性淋巴结分布率分别为４３．９％、３７．２％和５８．９％及３２．５％￣１５．９％和１７．５％,口 端有淋巴结转移大多在１０ｃｍ以内,而直肠癌肛侧端距肿瘤２．０ｃｍ以内转移率为５．５￣２     

进展期直肠癌淋巴结转移状况与根治术的关系

研究进展期直肠癌淋巴结转移状况,指导手术根治范围。方法：76例直肠癌患者行D3式根治术,按肿瘤旁、肠管纵轴和中枢方向行淋巴结分组,检测侧方和腹膜返折下直肠周围系膜转移淋巴结数,并计算淋巴结转移率。结果：肿瘤旁和肠管纵轴方向边缘动脉旁淋巴结转移率分别为39.5%和9.2%,肛侧端距肿瘤2cm未见转移;沿肠系膜下血管中枢方向淋巴结转移率为18.4%,而肠系膜下动脉(IMA)根部淋巴结转移率为10.5%;侧方淋巴结转移率为11.8%,腹膜返折下直肠周围系膜淋巴结转移率为12.5%。结论：进展期直肠癌可向肠管纵轴和中枢方向淋巴结转移。腹膜返折下直肠癌有侧方淋巴结转移并侵及直肠周围系膜,肿瘤浸润深度超过pT2期和低分化癌者淋巴结转移相应增多。宜行IMA根部结扎整块切除的D3式廓清术,腹膜返折下直肠癌力争行侧方淋巴结清扫和全直肠系膜切除术。     

结肠癌肿瘤浸润范围和淋巴结转移的关系

目的探讨结肠癌的病灶部位、局部浸润与淋巴结转移之间的关系,为结肠癌外科手术方式的改进提供依据。方法结肠癌患者118例,其中行D2式淋巴廓清术者12例,D3式90例,D4式16例。用新鲜标本挤压触诊法行淋巴结检取。统计N1,N2,N3,N4站淋巴结的转移情况。肿瘤的浸润深度（T）按TNM分期。肠旁淋巴结分为距肿瘤上、下缘0～5cm,5～10cm以及〉10cm^3组。各组淋巴结转移的差异。结果淋巴结转移率为41.5%。共检取淋巴结1824个,其中有277个淋巴结发生转移,转移度为15.2%。3组肠旁淋巴结的转移率和转移度分别为34.7%,20.9%,2.5%和14.1%,1.7%,5.6%;0～5cm组与5～10cm组差异有显著性（P〈0.05）,5～10cm组与〉10cm组的差异无显著性（P〉0.05）。左半结肠癌淋巴结转移率为33.8%,其中肠旁淋巴结转移率为28.0%,中枢方向淋巴结转移率为19.1%。右半结肠癌的淋巴结转移率为52.0%,其中肠旁淋巴结转移率为52.0%,中枢方向淋巴结转移率为38.0%。右半结肠肿瘤淋巴结转移率尤其是向中枢方向的明显高于左半结肠（P〈0.05）。按浸润深度统计T2,T3,T4组的N1,N2,N3,N4站淋巴结转移率分别为：18.2%,9.1%,4.5%,0%;40.8%,18.4%,8.2%,2.0%;53.8%,28.2%,12.8%,5.1%。结论N1～N4站淋巴结的转移率随肿瘤浸润深度的增加而增加（P〈0.01）。结肠癌肠旁淋巴结的转移主要集中在距肿瘤上、下缘5cm以内的肠旁淋巴结,〉10cm的肠旁淋巴结很少转移。右半结肠癌肠旁淋巴结及中枢方向淋巴结的转移率均高于左半结肠癌。随着结肠癌肿瘤浸润肠壁深度的增加,其淋巴结的转移率尤其是向中枢方向淋巴结的转移明显增加。结肠癌的手术应以D3术式为基本术式,重点要清扫向中枢方向转移的淋巴结,肠管切除的长度以距肿瘤上、下缘各10cm即可。     

右半结肠癌淋巴结转移规律及其临床意义

目的 研究右半结肠癌淋巴转移规律,指导手术根治范围。方法 收集1997年1月至2000年12月根治性切除76例右半结肠癌患的病理资料,按日本结直肠癌临床病理约定（JGR）进行淋巴结分组、分站,分析右半结肠癌的淋巴转移规律。结果 76例患有淋巴结转移49例,转移率64．5％;转移淋巴结184个,转移度17．1％。N1组淋巴结转移率、转移度、阳性淋巴结分布率分别为63．2％、21．5％、53．3％,N2组为39．5％、16．5％、34．2％,N3组为15．8％、9．0％、10．9％,N4组为3．9％、1．5％、1．6％。N1站98个阳性淋巴结沿肠管纵轴分布距肿瘤5cm以内、5－10cm、10－15cm、15－20cm各占68．4％、29．6％、1．0％、1．0％,20cm以上无阳性淋巴结;10cm内外有明显的差异。淋巴转移和结肠癌的组织学类型、浸润深度、肿瘤大小有明显的相关关系。本组发生淋巴结跳跃式转移10例,主要见于组织学分化较差、肿瘤较大、浸润较深,尤其是肿瘤浸润深度达pT3。跳跃式转移的形式以N1（＋）－N2（－）－N3（＋）为主。结论 右半结肠癌淋巴转移主要向中枢方向转移;对低分化癌、肿瘤浸润超过pT3主张把D3式淋巴结廓清作为标准术式;切除结肠肠管的长度以距肿瘤20cm以上为宜。     

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目的 探讨中下段直肠癌侧方淋巴结转移规律及影响因素。方法 对1995－2000年行侧方淋巴结清扫的105例直肠癌病人进行回顾性分析。结果 中下段直肠癌侧方转移率为21％，肿瘤的大小、部位、病理分型、分化程度及浸润深度是影响侧方转移的重要因素。在侧方淋巴结转移阳性病人中，单纯闭孔及髂内淋巴结转移阳性病人占54．5％，单纯髂外及髂总淋巴结转移阳性病人为18．1％。侧方淋巴结转移阴性病人术后局部复发率为6．7％，阳性病人为36．3％。行侧方清扫局部复发率较传统术式由17．6％降至11．4％。侧方转移阴性病人平均生存期为88个月，阳性病人为37个月，二者差异有显著性。结论 侧方淋巴转移是中下段直肠癌淋巴转移的重要途径。闭孔和髂内淋巴结是侧方淋巴结清扫中需要着重清扫的部位。侧方淋巴清扫较传统术式可明显降低局部复发率。     

结直肠癌淋巴结转移多因素分析

目的探讨结直肠癌淋巴结转移的相关因素。方法收集南方医院１９７５～１９９９年间手术治疗的结直肠癌１３７４例,建立全部资料的Ａｃｃｅｓｓ数据库,选择相关的字段进行检索,从不同角度分析各临床及病理因素与淋巴结转移的关系。结果３０岁以下年龄组的淋巴结转移率为５１．９％,５１岁以上年龄组的淋巴结转移率为３１．３％。随着肿瘤浸润深度的增加,其淋巴结转移率增高。随肠管受肿瘤侵犯的周径增大,淋巴结转移可能性增大。     

T_1/T_2期直肠癌淋巴转移的临床病理分析

本文报道62例T_/T_2期直肠癌淋巴转移的临床病理分析结果。T_/T_2期直肠癌的淋巴结转移率为24.19％。转移度为4.92％。低分化肿瘤及粘液腺癌的淋巴结转移率(50.00％)显著高于高、中分化肿瘤(15.22％),P<0.05。侵润型和局限型肿瘤的淋巴结转移率分别为39.29％和11..76％,P<0.025。有静脉侵犯和无静脉侵犯病例的淋巴结转移率分别为46.67％和17.02％,P<0.05。肿瘤侵犯的深度对淋巴结的影响无统计学意义。分析结果提示:高、中分化无静脉侵犯的局限型T_/T_2期直肠癌淋巴结转移率低,对适当的病例可考虑行局部切除术。     

低位直肠癌保肛手术中扩大根治术的临床意义

低位直肠癌中选择部分病例实施保肛手术是可行的。报道了选择６２例低位直肠癌在扩大根治术基础上，保留肛门括约肌，术式为经肛门环扎式结肠－直肠（肛管）吻合术。术后上方淋巴结转移率５３．４％，侧方淋巴结转移率１７．２％，下方淋巴结转移率０％，转移率９．１％。随访１￣３年，未见盆腔软组织、淋巴结、吻合口复发。因肝转移死亡５例。影响低位直肠癌保肛术后生存率主要原因是血行转移，不是局部复发。低位直肠癌中合理选择     

食管癌淋巴结转移特点及其危险因素

目的 探讨食管癌淋巴结转移情况及其危险因素,为外科手术行淋巴结清扫提供参考。方法回顾总结2006年1月至2010年12月在复旦大学附属肿瘤医院胸外科行三野淋巴结清扫食管癌根治术308例患者的临床资料．分析淋巴结的转移规律及特点。结果308例患者平均清扫淋巴结（35．6±14．5）枚,197例（64％）患者出现淋巴结转移。Logistic单因素分析结果显示,脉管（淋巴管及血管）侵犯（P=0．019）及肿瘤浸润深度（P〈0．001）是发生淋巴结转移的危险因素。各站淋巴结中,胸部气管旁淋巴结转移率最高（25．0％）。上段食管癌腹部淋巴结转移率显著低于中段或下段食管癌（P=0．001）,而各段食管癌颈胸部淋巴结转移率比较,差异无统计学意义（P〉0．05）。颈胸部和颈胸腹部淋巴结转移率分别为14．6％和11．0％,而颈腹部和胸腹部则分别为3．6％和4．9％。脉管侵犯（P〈0．001）和胸部气管旁淋巴结转移（P=0．014）是食管癌发生颈部淋巴结转移的危险因素。结论食管癌淋巴结转移具有上、下双向和跳跃性的特点．胸部气管旁淋巴结转移可作为行颈部淋巴结清扫的指征。     

Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer

BACKGROUND: Lateral lymph node metastases occur in some patients with low rectal cancer and may cause local recurrence after total mesorectal excision. The aims of this study were to identify risk factors for lateral node metastases in patients with pathological tumour (pT) stage 3 or pT4 low rectal adenocarcinoma, and to evaluate the prognostic significance of lateral node metastases. METHODS: A retrospective analysis was performed of the outcome of 237 patients with pT3 or pT4 low rectal adenocarcinoma who underwent R0 resection with systematic lateral node dissection. RESULTS: Lateral lymph node metastases were found in 41 patients (17.3 per cent). Increased risk of lateral lymph node metastases was associated with a distal tumour margin close to the anal margin, histological type other than well or moderately differentiated adenocarcinoma, and the presence of mesenteric lymph node metastases. Patients with lateral node metastases had a significantly shorter postoperative survival (5-year survival rate 42 versus 71.6 per cent; P < 0.001) and an increased risk of local recurrence (44 versus 11.7 per cent; P < 0.001) compared with those without lateral node metastases. CONCLUSION: Tumour site, histological type and the presence of mesenteric lymph node metastasis are factors predicting the risk of lateral node metastasis. The poor prognosis of patients with lateral lymph node metastases after systematic lateral dissection suggests the need for adjuvant therapy.     

盆腔侧方淋巴结转移对低位直肠癌预后的影响

目的 探讨盆腔侧方淋巴结转移对低位直肠癌预后的影响.方法 对1994年至2005年行根治性切除联合盆腔侧方淋巴结清扫的176例低位直肠癌患者的资料进行回顾性分析.探讨低位直肠癌患者盆腔侧方淋巴结转移对其预后的影响.结果 全组盆腔侧方淋巴结转移33例(18.8%),其中髂内及直肠中动脉根部淋巴结转移占51.5%,闭孔淋巴结转移占39.4%.年龄≤40岁、浸润型癌、T3-4期、上方淋巴结转移患者的盆腔侧方淋巴结转移率较高(P＜0.05).全组5年生存率为64.1%,TNM分期Ⅰ、Ⅱ、Ⅲ期患者5年生存率分别为94.1%、79.1%、42.1%.癌灶大小、浸润深度、上方淋巴结转移、盆腔侧方淋巴结转移是影响低位直肠癌患者预后的重要因素(P＜0.05).盆腔侧方淋巴结阴性患者5年生存率为73.6%,而侧方淋巴结转移患者为21.4%,两组差异具有统计学意义(P＜0.05).结论 盆腔侧方淋巴结转移是影响低位直肠癌预后的重要因素.     

Long-term outcome of per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer

OBJECTIVE: The authors have performed per anum intersphincteric rectal dissection. With direct coloanal anastomosis for cases of lower rectal cancer in which the distal surgical margin is difficult to secure by the double stapling technique. The aim of this study was to evaluate the long-term outcome and to clarify the surgical indications for this operation. PATIENTS AND METHODS: Between 1993 and 2002, 31 patients underwent per anum intersphincteric rectal dissection with direct coloanal anastomosis. Of these, two patients (one stage 0 and one stage IV) were excluded from the analysis of oncological outcome. The remaining 29 patients formed the basis of this study. The median follow-up was 57 months (range 6-106 months). RESULTS: Local recurrence and distant metastasis developed in 9 and 3 patients, respectively. Local recurrence rate for pT1 was significantly lower than that for pT2/T3 disease. The local recurrence rate cases with tumours less than 3 cm was significantly lower than that for tumours sized 3 cm or more. The distant metastasis rate for cases with lymph node metastasis was significantly higher than that for cases without lymph node metastasis. There was an association between distant metastasis and TNM or pT stage. The overall survival rates for stage I, II and III were 85%, 80% and 89%, respectively. No significant difference was seen in total Cleveland Clinic incontinence score between per anum intersphincteric rectal dissection with direct coloanal anastomosis and the double stapling technique. CONCLUSION: The surgical indications of this operation should be limited to patients with T1 rectal cancer or tumours less than 3 cm.     

Major anatomical hepatic resection with regional lymph node dissection for liver metastases from colorectal cancer

Sixty-four patients with liver metastases from colorectal cancer were studied to clarify the characteristics of the regional spread of liver metastases (secondary invasive factors) and the effects of major anatomical hepatic resection with lymph node dissection on reducing liver recurrence. No secondary invasive factors, i.e., lymph node metastasis, portal or hepatic vein involvement, bile duct involvement, micrometastasis, and direct invasion, were observed in patients with liver metastases less than 3 cm in diameter (5-year survival rate; 100%). Secondary invasive factors were seen in 19.2% of the patients with liver metastases from 3 cm to less than 6 cm (5-year survival rate; 28.7%), and in 45.2% of those with liver metastases 6 cm and over (5-year survival rate; 14.6%). Secondary invasive factors were noted in 45% of the patients with recurrence in the remmant liver. Although 31% of all 64 patients exhibited secondary invasive factors, major anatomical hepatic resection with lymph node dissection achieved a low liver recurrence rate of 31.3%. In conclusion, considering the risks attributed to secondary invasive factors, major anatomical hepatic resection with lymph node dissection is an appropriate surgical procedure for patients with liver metastases exceeding 3 cm in diameter.     

Histopathologic Criteria for Local Excision of Colorectal Cancer: Multivariate Analysis

Background: Local treatment of colorectal cancer, including endoscopic removal of colonic polyps and transanal resection of rectal tumors, has become widely accepted. However, risk factors predicting the presence of lymph node metastasis have not been fully investigated. To determine the criteria for local excision of colorectal cancer, histopathologic factors independently predicting the lymph node metastasis were investigated.Methods: We performed a retrospective histopathologic study on 335 patients who underwent resection of colorectal cancer and dissection of regional lymph nodes between 1982 and 1996. Features of node-positive tumors (n = 150) were compared with those of node-negative tumors (n = 185), with special reference to the histopathologic findings of the resected tumor. Multivariate analysis was done using the stepwise logistic regression test.Results: Node-positive tumors, when compared with node-negative tumors, were characterized by tumor larger than 6 cm (42% vs. 22%), serosal invasion (88% vs. 56%), lymphatic invasion (32% vs. 5%), venous invasion (9% vs. 2%), and histology other than well-differentiated (66% vs. 29%). Multivariate analysis showed that factors independently associated with lymph node metastasis were serosal invasion, lymphatic invasion, and histologic type. When these three risk factors were negative, lymph node metastasis was rare (5%). When one, two, or three factors were positive, the frequency of lymph node metastasis was 38%, 66%, and 85%, respectively.Conclusions: In colorectal cancer, factors independently associated with lymph node metastasis are serosal invasion, lymphatic invasion, and histologic type. When these three parameters are favorable, local treatment of colorectal cancer does not require additional lymph node dissection.     

Lateral pelvic node dissection after neoadjuvant chemoradiation in rectal cancer with right internal iliac node metastasis but without regional node metastasis: A case report

Introduction and importanceTotal mesorectal excision (TME) with lateral pelvic node dissection was routinely done in low clinical T3 rectal tumors below the peritoneal reflection as stated in the Japanese guidelines for colorectal cancer. Our institution follows the same practice in selected patients. This is our first reported case wherein a patient with rectal cancer underwent total mesorectal excision with lateral lymphadenectomy after neoadjuvant treatment with a positive lateral node on histopathology.Case presentationA 49 year old female rectal had rectal adenocarcinoma 4 cm FAV. Pelvic MRI revealed a low rectal tumor abutting the mesorectal fascia anteriorly, anal sphincters not involved, and confluent enlarged right iliac nodes. After neoadjuvant treatment, interval decrease in size of the rectal lesion and the right iliac nodes were noted. Patient underwent partial intersphincteric resection, lateral pelvic node dissection and protective loop ileostomy.Clinical discussionHistopathology revealed a rectal adenocarcinoma with one right internal iliac lymph node was positive for tumor involvement. Circumferential resection margin was 4.0 mm. Patient is currently on 4th cycle of adjuvant chemotherapy. Preoperative chemoradiation could not completely eradicate lateral pelvic node metastasis. Therefore, lateral pelvic node dissection should be considered if lateral pelvic lymph node metastasis is suspected even after neoadjuvant therapy.ConclusionUnlike TME, performance of a routine lateral lymphadenectomy in rectal cancer surgery varies by geographic location. Reports from Asian countries and our practice in our institution shows that it can be performed safely. This could improve the oncologic outcomes of patients especially if combined with neoadjuvant chemoradiotherapy.     

中低位直肠癌侧方淋巴结转移的危险因素分析

目的探讨影响中低位直肠癌患者侧方淋巴结转移的相关因素。方法回顾性分析新疆医科大学附属肿瘤医院2004年6月至2010年6月间行根治性切除并侧方淋巴结清扫的203例中低位直肠癌（距肛缘10cm以内）患者的临床资料,采用多因素Logistic回归模型分析侧方淋巴结转移的危险因素。结果203例中低位直肠癌患者共清扫侧方淋巴结3349枚,平均清扫17枚／例,阳性淋巴结数221枚。侧方淋巴结转移度为6．6％（221／3349）。单因素分析显示,年龄、家族史、肿瘤长度、大体类型、组织类型、分化程度、浸润深度、侵犯周径、术前CEA、脉管癌栓、上方淋巴结转移与中低位直肠癌侧方淋巴结转移有关（均P〈0．05）。多因素分析显示,低龄、低分化、浸润型、T4期及存在上方淋巴结转移是中低位直肠癌患者侧方淋巴结转移的独立高危因素（均P〈0．05）。结论对于低龄、低分化、浸润型、T4期及存在上方淋巴结转移等中低位直肠癌患者,由于具有较高的侧方淋巴结转移概率．采用选择性侧方淋巴清扫的手术方案更为合理。     

462例中下段直肠癌淋巴转移规律与淋巴清扫范围的分析

目的 探讨中下段直肠癌的淋巴转移规律和淋巴清扫范围。方法 对1990－1999年行传统直肠癌根治术的373例和行传统直肠癌根治术加盆腔侧方淋巴清扫术（简称侧方清扫术）的89例中下段直肠癌患者进行回顾性分析。结果 全组淋巴转移率为41．8％,患者年龄、癌灶浸润深度、大体分型、癌灶大小是影响淋巴转移率的重要因素（P＜0．05）。89例侧方清扫术的盆腔侧方淋巴转移率为15．7％,其中85．7％位于癌灶同侧。有盆腔侧方淋巴结转移者均为浸润深度T3、T4者;癌灶＞3cm、溃疡型或浸润型、年龄＜60岁者盆腔侧方淋巴结转移较高。侧方清扫术组的盆腔复发率为5．6％,明显低于传统直肠癌根治术组的17．7％（P＜0．05）;侧方清扫术组和传统直肠癌根治术组的5年生存率分别为46．7％和47．9％（P＞0．05）。结论 应提高对中下段直肠癌淋巴转移规律的认识,对怀疑或证实有淋巴结转移、癌灶侵犯浆膜或穿透肠壁、癌灶＞3cm、溃疡型或浸润型、年龄＜60岁者建议行侧方清扫术。