肺癌手术治疗中纵隔淋巴结的外科处理

非小细胞肺癌患者纵隔淋巴结的外科切除范围目前仍然存在争议.一些医学中心主张将可疑癌转移的纵隔淋巴结摘除,即纵隔淋巴结采样术,而也有主张实行系统性纵隔淋巴结清扫术.文章综合分析有关肺癌淋巴结切除有效性的研究文献,阐明两种切除方式的优劣.     

T1期非小细胞肺癌纵隔淋巴结转移规律及清扫方式研究进展

肺癌是我国发病率和死亡率最高的恶性肿瘤。非小细胞肺癌(non-small cell lung cancer,NSCLC)约占肺癌80%。临床上,早期NSCLC以手术治疗为主要治疗方式,淋巴结分期及手术中清扫程度直接影响着患者的预后。不同肺叶原发NSCLC的淋巴结转移区域存在一定规律。解剖性肺叶切除加系统性淋巴结清扫一直以来被认为是NSCLC的标准手术方式,但近年来T1期NSCLC手术中纵隔淋巴结清扫的程度存在较大争议,选择性淋巴结清扫已逐渐被大多数学者所重视。     

非小细胞肺癌淋巴结大小与转移的关系

目的:评估非小细胞肺癌淋巴结大小与转移的相关性.方法:从形态测量学角度,分析258例非小细胞肺癌患者纵隔和肺门的淋巴结.记录每例淋巴结数目、最大径及病理结果.计算转移频数与淋巴结大小的相关性.回顾性分析其中80例患者术前CT扫描的淋巴结所见,与组织病理学诊断相对照.结果:检查258例标本的2 892枚淋巴结.140例患者为pN0期,118例为淋巴结阳性.2 487枚淋巴结(86.0%)无转移,405枚淋巴结(14.0%)有转移.无转移淋巴结平均直径是(7.05±3.7)mm,转移淋巴结是(10.7±4.7)mm,(P＜0.005).1 954枚无转移淋巴结(78.5%)和180枚转移淋巴结(44.3%)直径＜10mm.140例无转移淋巴结的患者中,102例(72.9%)至少有一枚淋巴结＞10mm118例转移患者中,13.0%淋巴结＜10mm.80例CT扫描评估的敏感性是57.0%,特异性80.2%结论:淋巴结大小不能作为评估非小细胞肺癌转移浸润的可靠参数.     

早期非小细胞肺癌淋巴结转移规律与清扫方式研究进展

目前,肺癌已是全球范围内发病率及死亡率最高的恶性肿瘤,非小细胞肺癌（non-small cell lung cancer, NSCLC）约占肺癌80%。手术治疗在早期NSCLC治疗中占主导地位,而淋巴结分期及手术中清扫程度直接影响着患者术后生活质量及患者的预后。解剖性肺叶切除加系统性淋巴结清扫一直以来被认为是NSCLC的标准手术方式,但对早期NSCLC患者纵隔淋巴结清扫程度问题上一直存在较大争议,精确评估区域淋巴结的转移及淋巴结清扫的程度是影响患者围手术期并发症和预后的重要因素。对于早期肺癌行肺叶特异性或选择性淋巴结清扫已逐渐为国内外学者接受,并可能成为临床I期NSCLC患者标准淋巴结清扫方式。     

食管癌术后纵隔淋巴结转移的放疗和放化疗疗效分析

目的　评价食管癌术后纵隔淋巴结转移的放疗和放化疗的疗效。方法　 82例食管癌术后病例随机分成放疗组和放化疗两组。两组病人均采用 6MVX射线常规放疗至DT 40Gy后用后程超分割DT 1 4GyBid间隔 4～ 6h总量照至DT 65Gy左右。放化疗组放疗同时第 1和第 4周同时给予FP方案化疗 ( 5 Fu DDP)。结果　两组 1,2 ,3年生存率分别是 48 8% ,2 4 4% ,19 5 %与 2 6 8% ,14 65 % ,4 9% (P <0 0 5 ) ,5年局部控制率分别是 3 4 1% ( 14 /4 1)和 17 1% ( 7/4 1) ,两者差别不显著 (P >0 0 5 )。结论　放疗联合化疗能提高患者的近期生存率和局部控制率 ,不能提高 5年生存率。     

Frequency and Predictors of Axillary Lymph Node Metastases in Iranian Women with Early Breast Cancer

Background: Axillary lymph node metastasis is the most important predictive factor for recurrence risk andsurvival in patients with invasive breast carcinoma. The aim of this study was to determine factors associated withmetastatic involvement of axillary lymph nodes in Iranian women with early breast cancer. Methods: This article reportsa retrospective study of 774 patients with T1-T2 breast cancer who underwent resection of the primary tumor and axillarystaging by SLNB and/or ALND between 2005 and 2015 at our institution. Results: Of the 774 patients included in thisstudy, 35.5% (275 cases) had axillary lymph node involvement at the time of diagnosis. Factors associated with nodalinvolvement in univariate analyses were tumor size, lymphovascular invasion (LVI), tumor grade, ER/PR status andHER2 expression. All factors identified with univariate analyses were entered into a multivariate logistic regressionmodel and tumor size (OR= 3.01, CI 2.01–4.49, P <0.001), ER/PR positivity (OR = 1.74, CI 1.1.16–2.62, P = 0.007)and presence of LVI (OR = 3.3.8, CI 2.31–4.95, P <0.001) remained as independent predictors of axillary lymph nodeinvolvement .Conclusions: In conclusion, the results of this study suggests that positive hormonal receptor status, LVIand tumor size are predictive factors for ALNM in Iranian women with early breast cancer.     

食管癌术后颈部和纵隔淋巴结转移放疗的临床观察

目的　探讨食管癌术后颈部和纵隔淋巴结转移放疗的意义和效果。方法　回顾性分析 5 6例食管癌根治术后发生颈部、纵隔转移患者。放射治疗采用60 Co常规分割照射 ,大多数患者的放射剂量为 5 0～ 70Gy。结果　全组病人 1、2、3、5年存活率分别为41.1% ( 2 3 /5 6)、17.9% ( 10 /5 6)、7.1% ( 4 /5 6)、2 .1% ( 1/4 8)。结论　放疗对食管癌术后颈部和纵隔淋巴结转移的局部控制率有效 ,且可延长患者的生存时间。     

子宫内膜癌前哨淋巴结的研究进展

子宫内膜癌是常见的妇科恶性肿瘤,分期手术为全子宫切除+双侧输卵管卵巢切除+盆腔和(或)腹主动脉旁淋巴结切除。绝大部分患者诊断时尚处早期,病情仅局限于子宫,淋巴结转移风险小,若行系统性淋巴结切除术,可能未改善患者的生存状况,反而增加了术后并发症。前哨淋巴结活检可检测肿瘤区域的淋巴结转移情况并评估预后,适合子宫内膜癌早期患者,可避免过大的手术范围,提高生存质量。随着淋巴解剖、定位技术、病理评估等不断改善,前哨淋巴结的识别率以及淋巴结转移的检出率不断提高,能够更加精准地指导手术治疗。     

早期肺癌特异性淋巴清扫的临床回顾研究

背景与目的 本研究旨在探讨不同淋巴结清扫方式对Ⅰ期肺癌患者生存率的影响,考察影响预后的相关因素,探讨肺叶特异性淋巴结清扫的临床应用指征.方法 回顾性分析1998年-2005年上海市胸科医院病理Ⅰ期且符合完全性切除的379例肺癌患者,其中系统性淋巴结清扫组148例,肺叶特异性淋巴结清扫组150例,术后病理均为T1a-2aN0M0,比对研究两组手术相关因素并进行预后分析.结果 两组临床病理特征无统计学差异(P＞0.05);两组总体3年及5年生存率无统计学差异(P＞0.05),但不同病理分期、病理类型和肿瘤直径之间的生存率存在明显差异(P＜0.01);在手术时间、术中失血、胸管引流量、拔管时间及住院天数等方面,两组存在明显差异(P＜0.01);两组术后并发症亦有统计学差异(P＜0.05).结论 系统性淋巴结清扫并未增加Ⅰ期肺癌患者5年生存率;病理分期、病理类型和肿瘤直径是影响患者预后的重要因素;肺叶特异性淋巴结清扫可明显减少手术并发症并降低围手术期风险.     

Skipping Metastasis to Mediastinal Lymph Nodes in Non-small Cell Lung Cancer: A Clinical Study on the Reasonable Extent of Dissection

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非小细胞肺癌手术淋巴结的清扫数目与术后胸腔引流量及预后的相关性

目的：探讨非小细胞肺癌手术淋巴结清扫数目与术后胸腔引流量及预后的相关性。方法收集行开胸或胸腔镜肺叶切除并淋巴结清扫的非小细胞肺癌患者148例,并随机分为对照组（74例）和实验组（74例）。通过对比研究2组患者术中淋巴结清扫数目以及术后胸腔引流量的关系。结果2组患者在手术时间、术中出血量方面比较,差异具统计学意义（P＜0．05）;而在术后胸腔第1天引流量、术后胸腔总引流量、术后带管时间及术后住院时间上没有明显差异（ P＞0．05）。实验组清扫淋巴结总数多于对照组,两者差异具有统计学意义（ P＜0．05）。2组淋巴结转移率以及转移度比较无明显差异（P＞0．05）。实验组术后肿瘤复发率为7．69％,相比于对照组术后肿瘤复发率10．26％,差异具有统计学意义（P＜0．05）;实验组术后肿瘤的转移率为11．54％,相对于对照组肿瘤转移率16．67％,差异具有统计学意义（P＜0．05）。对照组和实验组患者在术后死亡率上差异没有统计学意义（P＞0．05）。结论非小细胞肺癌手术的淋巴结清扫数目与术后胸腔引流量无明确的相关性,但淋巴结清扫数目关系到患者的肿瘤转移和复发,对患者的预后有积极作用。     

Prognostic Factors for Lymph Node Negative Stage I and IIA Non-small Cell Lung Cancer: Multicenter Experiences

Background: Surgery is the only curative treatment for operable non-small lung cancer (NSCLC) and theimportance of adjuvant chemotherapy for stage IB patients is unclear. Herein, we evaluated prognostic factorsfor survival and factors related with adjuvant treatment decisions for stage I and IIA NSCLC patients withoutlymph node metastasis. Materials and Methods: We retrospectively analyzed 302 patients who had undergonecurative surgery for prognostic factors regarding survival and clinicopathological factors related to adjuvantchemotherapy. Results: Nearly 90% of the patients underwent lobectomy or pneumonectomy with mediastinallymph node resection. For the others, wedge resection were performed. The patients were diagnosed as stageIA in 35%, IB in 49% and IIA in 17%. Histopathological type (p=0.02), tumor diameter (p=0.01) and stage(p<0.001) were found to be related to adjuvant chemotherapy decisions, while operation type, lypmhovascularinvasion (LVI), grade and the presence of recurrence were important factors in predicting overall survival (OS),and operation type, tumor size greater than 4 cm, T stage, LVI, and visceral pleural invasion were related withdisease free survival (DFS). Multivariate analysis showed operation type (p<0.001, hazard ratio (HR):1.91) andthe presence of recurrence (p<0.001, HR:0.007) were independent prognostic factors for OS, as well visceralpleural invasion (p=0.01, HR:0.57) and LVI (p=0.004, HR:0.57) for DFS. Conclusions: Although adjuvantchemotherapy is standard for early stage lymph node positive NSCLC, it has less clear importance in stage Iand IIA patients without lymph node metastasis.     

淋巴结转移度对食管癌患者预后的影响

目的：探讨食管癌患者标准淋巴结清扫术后淋巴结转移度对预后的影响。方法:回顾性分析食管癌患者临床病理因素和随访资料,通过Kaplan-Meier曲线和Cox多因素回归模型分析来评估这些因素与生存期的关系。结果:245例手术患者共切除淋巴结1 758个,病理学报告112例患者共有220个淋巴结发生转移,总体转移率为45.71%,淋巴结转移度为0.13。单因素分析结果显示肿瘤残留状态、淋巴结状态和淋巴结转移度对患者5年生存率差异存在统计学意义(P<0.05）。在排除混杂因素的影响后,Cox多因素回归分析显示组织学类型、肿瘤残留状态、浸润深度、淋巴结状态和淋巴结转移度均可作为影响患者预后的独立危险因素(P<0.05）。结论:食管癌手术采用标准的淋巴结清扫术,淋巴结转移的个数不能明确影响pN1患者的预后,而淋巴结转移度对患者的预后有较强的敏感度,具有一定的参考价值。     

非小细胞肺癌组织中E-cad、vegf表达与化疗表达疗效及预后相关性研究

目的 分析E-cad、vegf在非小细胞肺癌中的表达及其与化疗疗效及非小细胞肺癌发生发展及预后的关系.方法 非小细胞肺癌手术切除的病理样本共计30例,对这30例非小细胞肺癌样本采用免疫组织化学方法检测钙粘附蛋白E(E-cad)、血管内皮生长因子(vegf)的表达,采用多西他赛联合顺铂治疗,分析治疗有效率(ORR)、无进展生存时间(PFS)以及检测E-cad和vegf的表达,分析E-cad、vegf表达与疗效的关系.结果 E-cad、vegf表达水平与患者的一般资料如年龄、性别、以及肿瘤特征如大小、侵袭深度,肿瘤分期及分化程度、是否转移等并不存在相关性(P＞0.05);而淋巴受累组E-cad相对表达量明显下调、vegf相对表达量明显上调(P＜0.05),而无淋巴受累组的相对表达量与正常组相比差异无统计学意义(P＞0.05),E-cad、vegf相对表达量明显上调与淋巴结受累转移的风险有关;多西他赛联合顺铂治疗后vegf高表达患者ORR为11.2％,PFS为2.1个月,均低于vegf低表达患者(ORR为46.3％.PFS为6.6个月)(P＜0.05),E-cad高表达患者ORR为46.3％,PFS为6.6个月,与E-cad低表达患者(ORR为31.8％,PFS为3.5个月)(P＜0.05).结论 E-cad、vegf相对表达量水平与非小细胞肺癌的淋巴结转移及预后有一定的相关性,预后与vegf表达呈负相关,vegf低表达者有效率较高;与E-cad呈正相关,E-cad高表达者有效率较高,但还需进一步分析.     

淋巴管癌栓和淋巴结转移对胃癌术后生存率的影响

目的：探讨淋巴管癌栓与胃癌临床病理特点的关系。方法：比较淋巴管栓和淋巴结转移对胃癌预后的影响。结果：１）浸润深度及生长方式影响淋巴管癌栓的发生;２）只有在元淋巴结转移的条件下,淋这癌栓才会影响胃癌患者的预后。结论：淋巴结转移对一影响明显高于淋巴管癌栓。     

非小细胞肺癌脏器转移数目对预后的影响

[目的]探讨非小细胞肺癌脏器转移数目对生存期的影响。[方法]回顾分析非小细胞肺癌238例,转移出现时间、部位、数目对生存期影响。[结果]生存分析显示,患病期间脏器转移总数目,初诊时脏器转移的数目,首发转移时转移脏器数目对生存影响显著（P分别为0．0095,0．0001和0．0001）。COX分析提示初诊和首发脏器转移数目是独立预后因素（P分别为0．001,0．02）。[结论]脏器转移的数目对非小细胞肺癌的预后有影响。     

乳腺癌前哨淋巴结的临床研究

目的：探讨前哨淋巴结活检（sentinel lymph node biopsy，SLNB）在乳腺癌临床应用中的可行性、准确性。方法：术前肿瘤表面或活检腔周围皮内注射99mTc-DX，进行前哨淋巴结（sentinel lymph node，SLN）显像、体表定位；术中r-探测仪识别SLN，先行SLNB，再行乳腺癌根治术或改良根治术，术后对SLN和腋窝淋巴结清扫（axillary Lymph Node Dissectio，ALND）的病理结果进行综合分析。结果：淋巴闪烁显像和r-探测器联合应用检测SLN准确率为96.9％，敏感度为90.9％，假阴性率为9.1％，假阳性率为0。结论：SLNB是乳腺癌治疗中的一项新技术，能高灵敏度反应腋淋巴结状态。     

Clinicopathologic Significance of False-Positive Lymph Node Status on FDG-PET in Lung Cancer

Introduction2-[¹⁸F] Fluoro-d-deoxyglucose (FDG) positron emission tomography (PET) is a relevant diagnostic procedure for staging lung cancer. However, accurate evaluation of lymph node metastases by PET is controversial because of false-positive FDG uptake.Patients and MethodsA total of 245 patients with lung cancer were retrospectively analyzed. Standardized maximum uptake values (SUV_max) of the primary tumor and lymph nodes were compared to pathologic lymph node metastases to correlate PET findings with clinicopathologic variables and patient outcomes.ResultsThe SUV_max values of metastatic lymph nodes were significantly higher than those of lymph nodes without metastases (P = .0036). When SUV_max ≥ 4 was defined as PET positive for metastasis, the sensitivity, specificity, and accuracy were 48.1%, 79.8%, and 73.1%, respectively. Multivariate logistic regression analysis showed that age > 75 years, bilateral hilar FDG uptake, and no lymph node swelling were significant factors related to false-positive lymph node metastases. Smoking status, FDG uptake in the primary tumor, and concurrent lung diseases were not significant factors.ConclusionMetastatic lymph nodes show higher FDG uptake than false-positive lymph nodes, and older patient age, bilateral hilar FDG uptake, and no swollen nodes are associated with no metastases. Patients with lymph node metastases have worse survival than those with false-positive FDG-PET findings. However, abnormal FDG uptake in the lymph node is an important prognostic factor.