早期胃癌淋巴结转移规律的临床病理因素研究

目的探讨早期胃癌临床病理因素与淋巴结转移规律的相关性。方法回顾性分析2012年1月—2018年12月期间在陆军军医大学第一附属医院经胃镜下活检病理确诊,并实施外科根治手术的早期胃癌病例,采用单因素分析及Logistic回归多因素分析相关临床病理因素与各组淋巴结转移的关系。结果164例早期癌患者中,34例出现转移。单因素分析显示病理分化程度、浸润深度、肿瘤最大径、脉管浸润与早期胃癌淋巴结转移相关(P均<0.05)。Logistic回归多因素分析结果显示:肿瘤最大径>2 cm(OR=3.2,95%CI:2.305~4.187)、浸润至黏膜下层(OR=2.5,95%CI:2.091~3.859)、病理分化不良(OR=1.7,95%CI:1.029~2.933)及脉管侵犯(OR=2.1,95%CI:1.817~3.176)是早期胃癌淋巴结转移的独立影响因素(P均<0.05)。上部癌中转移率较高的淋巴结依次是第1组(66.7%)、第3组(33.3%);中部癌中转移率较高的淋巴结依次是第3组(75.0%)、第4组(25.0%);下部癌中转移率较高的淋巴结依次是第6组(33.3%)、第3组(25.9%)、第4组(25.9%)及第7组(14.8%)。从转移站别看,分化良好且肿瘤直径≤2 cm的黏膜内早期癌,各部位癌第1站均未见淋巴结转移。结论早期胃癌肿瘤最大径>2 cm﹑浸润至黏膜下层﹑病理分化程度低及脉管受侵犯是淋巴结转移的危险因素。上、中、下部癌均有其各自的高发区域,早期胃癌的淋巴结胃周转移基本符合由近及远的规律。     

可切除性肺癌胸内淋巴结转移的临床研究

目的　探讨可切除性肺癌的胸内淋巴结转移规律。方法　收集１９９２ 年１ 月～１９９８ 年７月可切除性肺癌１６０ 例,在肺癌术中分区摘除肺门淋巴结（Ｎ１） 和纵隔淋巴结（Ｎ２）,记录各区淋巴结的数量、大小和颜色,按区检查每一个淋巴结有无转移癌。结果　１６０ 例肺癌中有淋巴结转移者９９ 例（６１－９％ ）,Ｎ２ 转移者７３ 例（４５－６％ ） 。离肺门或肺根部最近的１１、１０ 、７、５ 和４ 区淋巴结的转移频度较高,较远的９、６、３、２ 和１ 区则明显降低。淋巴结≥２ ｃｍ 的癌转移度为６０－７ ％ 、≥１ ｃｍ 为１５－５％ 、＜ １ｃｍ 为４－３％ 。有转移癌的最小淋巴结为０－２ ｃｍ 。小细胞肺癌（ＳＣＬＣ）的淋巴结转移明显高于非小细胞肺癌（ＮＳＣＬＣ）（ Ｐ＜ ０－０５） 。结论　多数肺癌的淋巴结转移遵循由近向远、由下向上、由肺内经肺门向纵隔顺序转移的规律。淋巴结转移与肿瘤的部位、大小、病程均无关,ＳＣＬＣ更易发生淋巴结转移。确诊淋巴结有无转移癌必须依靠病理检查。     

Clinicopathologic factors and molecular markers related to lymph node metastasis in early gastric cancer

AIM: To analyze predictive factors for lymph node metastasis in early gastric cancer.METHODS: We analyzed 1104 patients with early gastric cancer(EGC) who underwent a gastrectomy with lymph-node dissection from May 2003 through July 2011. The clinicopathologic factors and molecular markers were assessed as predictors for lymph node metastasis. Molecular markers such as microsatellite instability, human mut L homolog 1, p53, epidermal growth factor receptor(EGFR) and human epidermal growth factor receptor 2(HER2) were included. The χ2 test and logistic regression analysis were used to determine clinicopathologic parameters.RESULTS: Lymph node metastasis was observed in 104(9.4%) of 1104 patients. Among 104 cases of lymph node positive patients, 24 patients(3.8%) were mucosal cancers and 80 patients(16.7%) were submucosal. According to histologic evaluation, the number of lymph node metastasis found was 4(1.7%) for well differentiated tubular adenocarcinoma, 45(11.3%) for moderately differentiated tubular adenocarcinoma, 36(14.8%) for poorly differentiated tubular adenocarcinoma, and 19(8.4%) for signet ring cell carcinoma. Of 690 EGC cases, 77 cases(11.2%) showed EGFR overexpression. HER2 overexpression was present in 110 cases(27.1%) of 406 EGC patients. With multivariate analysis, female gender(OR = 2.281, P = 0.009), presence of lymphovascular invasion(OR = 10.950, P 0.0001), diameter(≥ 20 mm, OR = 3.173, P = 0.01), and EGFR overexpression(OR = 2.185, P = 0.044) were independent risk factors for lymph node involvement.CONCLUSION: Female gender, tumor size, lymphovascular invasion and EGFR overexpression were predictive risk factors for lymph node metastasis in EGC.     

颈部淋巴结转移与甲状腺乳头状癌的治疗及预后

颈部淋巴结转移在甲状腺乳头状癌中较为普遍.尽管颈部淋巴结转移可独立预测甲状腺乳头状癌的复发,但其对于肿瘤预后的影响仍有争议.预防性中央区淋巴结对甲状腺乳头状癌患者的价值尚不清楚,尤其是术前无颈部淋巴结转移的临床或影像学证据时.对于存在危险因素的甲状腺乳头状癌患者,如男性、年龄大于45岁、肿瘤直径＞4 cm、多灶性和甲状腺外侵犯以及BRAF基因突变阳性等,术前应认真评估颈部淋巴结,必要时可行预防性中央区淋巴结清扫.     

胃癌淋巴结转移规律及其清扫范围探讨

目的　探讨胃癌淋巴结转移规律及其清扫范围。方法　对188例接受手术治疗的胃癌患者,于术中用美蓝-胃癌单克隆抗体(MAb)3H11标记淋巴结,并对染色淋巴结进行清扫,术后统计切除标本的淋巴结转移情况及病理特征。结果 188例胃癌患者的淋巴结转移率为62.8％(118／188)。胃上1／3(U区)、中1／3(M区)、下1／3(L区)及全胃癌患者的淋巴结转移率分别为61.9％、60.0％、57.5％及95.0％。早、中、晚期胃癌患者淋巴结转移率依次呈递增趋势,P<0.05。浸润型(Ⅲ、Ⅳ型)转移率(76.1％)明显高于局限型(Ⅰ、Ⅱ型)(44.3％),P<0.05。肿瘤直径≤4cm、-7cm和≥8cm者的淋巴结转移率依次增加,差异有显著性,P均<0.01。结论 胃癌淋巴结转移率较高。尤其晚期、浸润型及直径>4cm的胃癌,其淋巴结转移率更高,术中应按胃癌的临床病理分期、部位、大小及Borrman分型,选择淋巴结清扫范围。如果根据术中美蓝-MAb3H11标记结果确定淋巴清扫范围将更准确可靠。     

Risk factors for lymph node metastasis and evaluation of reasonable surgery for early gastric cancer

AIM: To give the evidence for rationalizing surgical therapy for early gastric cancer with different lymph node status. METHODS: A series of 322 early gastric cancer patients who underwent gastrectomy with more than 15 lymph nodes retrieved were reviewed in this study. The rate of lymph node metastasis was calculated. Univariate and multivariate analyses were performed to evaluate the independent factors for predicting lymph node metastasis. RESULTS: No metastasis was detected in No.5, 6 lymph nodes (LN) during proximal gastric cancer total gastrectomy, and in No.10, 11p, 11d during for combined resection of spleen and splenic artery and in No.15 LN during combined resection of transverse colon mesentery. No.11p, 12a, 14v LN were proved negative for metastasis. The global metastastic rate was 14.6% for LN, 5.9% for mucosa, and 22.4% for submucosa carcinoma, respectively. The metastasis in group Ⅱ?was almost limited in No.7, 8a LN. Multivariate analysis identified that the depth of invasion, histological type and lymphatic invasion were independent risk factors for LN metastasis. No metastasis from distal cancer (≤ 1.0 cm in diameter) was detected in group Ⅱ?LN. The metastasis rate increased significantly when the diameter exceeded 3.0 cm. All tumors (≤ 1.0 cm in diameter) with LN metastasis and mucosa invasion showed a depressed macroscopic type, and all protruded carcinomas were > 3.0 cm in diameter. CONCLUSION: Segmental/subtotal gastrectomy plus D1/D1 No.7 should be performed for carcinoma (≤ 1.0 cm in diameter, protruded type and mucosa invasion).Subtotal gastrectomy plus D2 or D1 No.7, 8a, 9 is the most rational operation, whereas No.11p, 12a, 14v lymphadenectomy should not be recommended routinely for poorly differentiated and depressed type of submucosa carcinoma (> 3.0 cm in diameter). Total gastrectomy should not be performed in proximal, so does combined resection or D2 /D3 lymphadenectomy.     

Twist-1表达促进胃癌细胞淋巴结转移的可能机制

目的 检测胃癌组织及转移淋巴结基因谱的表达变化,筛选表达差异基因,并探讨其在胃癌转移中的可能机制.方法 利用U133plus 2.0基因芯片技术检测胃癌组织和转移淋巴结组织上皮细胞的基因表达谱变化,筛选出差异基因Twist-1,Western blot法检测过表达与敲除Twist-1细胞上皮-间质转化相关蛋白( E-Cadherin、Vimentin)的表达变化.结果 与胃癌组织比较,Twist-1在淋巴转移组织中表达明显升高分别为(2.07±0.71比12.12±3.21).阴性对照、空载体对照和Twist-1表达细胞增殖吸光度分别为0.84±0.16、0.74±0.06和0.71±0.07,细胞凋亡率分别为(2.05±0.08)％、(4.31±0.07)％和(3.95±0.09)％,表达Twist-1与细胞增殖及凋亡无明显相关.但细胞迁移能力增高.结论 Twist-1基因的改变可能与胃癌转移相关,并可能通过皮-间质转化方式实现.     

Prognostic impact of metastatic lymph node ratio in advanced gastric cancer from cardia and fundus

AIM： To investigate the prognostic impact of the metastatic lymph node ratio （MLR） in advanced gastric cancer from the cardia and fundus. METHODS： Two hundred and thirty-six patients with gastric cancer from the cardia and fundus who underwent D2 curative resection were analyzed ret- rospectively. The correlations between MLR and the total lymph nodes, positive nodes and the total lymph nodes were analyzed respectively. The influence of MLR on the survival time of patients was determined with univariate Kaplan-Meier survival analysis and mul- tivariate Cox proportional hazard model analysis. And the multiple linear regression was used to identify the relation between MLR and the 5-year survival rate of the patients. RESULTS： The MLR did not correlate with the total lymph nodes resected （r = -0.093, P = 0.057）. The 5-year overall survival rate of the whole cohort was 37.5%. Kaplan-Meier survival analysis identified that the following eight factors influenced the survival time of the patients postoperatively： gender （χ2 = 4.26, P = 0.0389）, tumor size （χ2 = 18.48, P 〈 0.001）, Borrmann type （χ2 = 7.41, P = 0.0065）, histological grade （χ2 = 5.07, P = 0.0243）, pT category （χ2 = 49.42, P 〈 0.001）, pN category （χ2 = 87.7, P 〈 0.001）, total number of re- trieved lymph nodes （χ2 = 8.22, P = 0.0042） and MLR （χ2 = 34.3, P 〈 0.001）. Cox proportional hazard model showed that tumor size （χ2 = 7.985, P = 0.018）, pTcategory （χ2 = 30.82, P 〈 0.001） and MLR （χ2 = 69.39, P 〈 0.001） independently influenced the prognosis. A linear correlation between MLR and the 5-year survival was statistically significant based on the multiple lin- ear regression （β = -0.63, P 〈 0.001）. Hypothetically, the 5-year survival would surpass 50% when MLR was lower than 10%. CONCLUSION： The MLR is an independent prognostic factor for patients with advanced gastric cancer from the cardia and fundus. The decrease of MLR due to adequate number of total resected lymph     

Unveiling lymph node metastasis in early gastric cancer

With respect to gastric cancer treatment,improvements in endoscopic techniques and novel therapeutic modalities[such as endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD)]have been developed.Currently,EMR/ESD procedures are widely accepted treatment modalities for early gastric cancer(EGC).These procedures are most widely accepted in Asia,including in Korea and Japan.In the present era of endoscopic resection,accurate prediction of lymph node(LN)metastasis is a critical component of selecting suitable patients for EMR/ESD.Generally,indications for EMR/ESD are based on large Japanese datasets,which indicate that there is almost no risk of LN metastasis in the subgroup of EGC cases.However,there is some controversy among investigators regarding the validity of these criteria.Further,there are currently no accurate methods to predict LN metastasis in gastric cancer(for example,radiologic methods or methods based on molecular biomarkers).We recommend the use of a 2-step method for the management of early gastric cancer using endoscopic resection.The first step is the selection of suitable patients for endoscopic resection,based on endoscopic and histopathologic findings.After endoscopic resection,additional surgical intervention could be determined on the basis of a comprehensive review of the endoscopic mucosal resection/endoscopic submucosal dissection specimen,including lymphovascular tumor emboli,tumor size,histologic type,and depth of invasion.However,evaluation of clinical application data is essential for validating this recommendation.Moreover,gastroenterologists,surgeons,and pathologists should closely collaborate and communicate during these decisionmaking processes.     

胃癌淋巴结转移相关分子研究

淋巴结转移是评价胃癌预后及治疗策略的重要因素。然而,胃癌术前确诊是否存在淋巴结转移非常困难。为此,此文总结近年来国外相关文献,综述胃癌淋巴结转移相关分子学水平的研究,即阐述与胃癌淋巴结转移密切相关的蛋白分子,以探索胃癌淋巴结转移新的诊断方法,为临床胃癌治疗提供新的靶点。     

Seven synchronous early gastric cancer with 28 lymph nodes metastasis

An 85 year male patient complaining epigastric discomfort was admitted.From the esophagogastroduodenoscopy,three early gastric cancer(EGCa)lesions had been identified and these were diagnosed as adenocarcinoma with poorly differentiated cell type.The patient underwent operation.From the post-operative mapping,however,additional 4 EGCa lesions were found,and the patient was diagnosed with 7 synchronous EGCa.Out of the 7 EGCa lesions,6 had shown invasion only to the mucosal layer and one had shown invasion into the 1/3layer of submucosa.In spite of such superficial invasions,28 of 48 lymph nodes had been identified as metastases.The multiple lesions of EGCa do not increase the risk of lymph node metastasis,but if their differentiations are poor or if they have lympho-vascular invasion,multiple lymph node metastases could incur even if the depth of invasion is limited to the mucosal layer or the upper portion of the submucosal layer.     

胃癌组织内微血管定量的意义

目的：研究胃癌组织中微血管数量（MVC）与临床病理因素及预后的关系。方法：材料取自瑞金医院1988年～1991年胃癌手术切除标本，共128例。抗因子Ⅷ相关抗原（F-ⅧRAg）的单克隆抗体和免疫组化试剂盒购自Dako公司。研究方法按LSAB法免疫组织化学操作技术常规进行；微血管定量以镜下200倍，肿瘤内5个最高微血管密度区的MVC均数表示；分析MVC与临床病理因素之间关系，并对有完整5年随访资料的86例胃癌患者预后与MVC关系进行探讨。结果：所有胃癌组织中的平均MVC为16.5±8．5，MVC随TNM分期增加而增加，有淋巴结转移患者的MVC（18．3±8.7）明显高于无淋巴结转移患者（13．8±7．4）（P＜0．01），高MVC（≥16）胃癌患者比低MVC（＜16）患者预后明显为差，5年生存率分别为42.5％和58．7％（P＜0．05）。结论：MVC在胃癌患者是一个有意义的预后指标．     

Prognostic impact of dissected lymph node count on patients with node-negative gastric cancer

AIM： To investigate the long-term effect of the number of resected lymph nodes （LNs） on the prognosis of patients with node-negative gastric cancer. METHODS： Clinical data of 211 patients with gastric cancer, without nodal involvement, were analyzed retrospectively after D2 radical operation. We analyzed the relationship between the number of resected LNs with the 5-year survival, the recurrence rate and the post-operative complication rate. RESULTS： The 5-year survival of the entire cohort was 82.2%. The total number of dissected LNs was one of the independent prognostic factors. Among patients with comparable depth of invasion, the larger the number of resected LNs, the better the survival （P 〈 0.05）. A cut-point analysis provided the possibility to detect a significant survival difference among subgroups. Patients had a better long-term survival outcomes with LN counts ≥ 15 for pT1-2, ≥ 20 for pT3-4, and ≥ 15 for the entire cohort. The overall recurrence rate was 29.4% within 5 years after surgery. There was a statistically significant, negative correlation between the number of resected LNs and the recurrence rate （P 〈 0.01）. The post-operative complication rate was 10.9% and was not significantly correlated with the number of dissected LNs （P 〉 0.05）.CONCLUSION： For node-negative gastric cancer, sufficient number of dissected LNs is recommended during D2 lymphadenectomy, to improve the long-term survival and reduce the recurrence. Suitable increments of the dissected LN count would not increase the postoperative complication rate.     

Prediction of risk factors for lymph node metastasis in early gastric cancer

AIM:To explore risk factors for lymph node metastases in early gastric cancer(EGC) and to confirm the appropriate range of lymph node dissection.METHODS:A total of 202 patients with EGC who underwent curative gastrectomy with lymphadenectomy in the Department of Surgery,Xinhua Hospital and Ruijin Hospital of Shanghai Jiaotong University Medical School between November 2003 and July 2009,were retrospectively reviewed.Both the surgical procedure and the extent of lymph node dissection were based on the recommendations of the Japanese gastric cancer treatment guidelines.The macroscopic type was classified as elevated(type Ⅰ or Ⅱa),flat(Ⅱb),or depressed(Ⅱc or Ⅲ).Histopathologically,papillary and tubular adenocarcinomas were grouped together as differentiated adenocarcinomas,and poorly differentiated and signet-ring cell adenocarcinomas were regarded as undifferentiated adenocarcinomas.Univariate and multivariate analyses of lymph node metastases and patient and tumor characteristics were undertaken.RESULTS:The lymph node metastases rate in patients with EGC was 14.4%.Among these,the rate for mucosal cancer was 5.4%,and 8.9% for submucosal cancer.Univariate analysis showed an obvious correlation between lymph node metastases and tumor location,depth of invasion,morphological classification and venous invasion(χ 2 = 122.901,P = 0.001;χ 2 = 7.14,P = 0.008;χ 2 = 79.523,P = 0.001;χ 2 = 8.687,P = 0.003,respectively).In patients with submucosal cancers,the lymph node metastases rate in patients with venous invasion(60%,3/5) was higher than in those without invasion(20%,15/75)(χ 2 = 4.301,P = 0.038).Multivariate logistic regression analysis revealed that the depth of invasion was the only independent risk factor for lymph node metastases in EGC [P = 0.018,Exp(B) = 2.744].Among the patients with lymph node metastases,29 cases(14.4%) were at N1,seven cases were at N2(3.5%),and two cases were at N3(1.0%).Univariate analysis of variance revealed a close relationship between the depth of invasion and lymph node me     

Predictive factors for lymph node metastasis in early gastric cancer

AIM: To analyze the predictive factors for lymph node metastasis (LNM) in early gastric cancer (EGC). METHODS: Data from patients surgically treated for gastric cancers between January 1994 and December 2007 were retrospectively collected. Clinicopathological factors were analyzed to identify predictive factors for LNM. RESULTS: Of the 2936 patients who underwent gas-trectomy and lymph node dissection, 556 were diag-nosed with EGC and included in this study. Among these, 4.1% of patients had mucosal tumors ...     

Patterns of lymph node metastasis are different in colon and rectal carcinomas

AIM:To describe patterns of lymph node metastasis in invasive colon and rectal carcinomas.METHODS:Clinical data of 2340 patients with colorectal carcinoma(stageⅠ to Ⅲ) who received radical resection,was retrospectively reviewed.Of the 2340 patients,1314 patients suffered from rectal carcinoma and 1026 from colon carcinoma.Patients with rectal cancer who received neoadjuvant chemoradiation therapy were excluded.Statistical analysis was performed using MannWhitney,χ 2 and Cochran's and Mantel-Haenszel tests(S...     

子宫内膜癌淋巴结转移规律探讨

目的　探讨子宫内膜癌淋巴结转移规律。方法　对接受全子宫、盆腔淋巴结切除术的160例子宫内膜癌患者,观察并记录其肿瘤所处子宫腔位置、子宫肌层浸润深度、分期、病理类型、细胞学分级及切除淋巴结位置、总数及阳性淋巴结数,并进行相关分析。结果 肿瘤位于宫底部、体部、累及宫颈者淋巴结转移率分别为19.2％、21.2％、35.9％,均以髂外淋巴结转移最常见。病灶局限于宫底、宫体部者多为髂外、闭孔淋巴结转移;累及宫颈者以髂外、髂总淋转移为常见;前者髂总淋巴结转移率为25％,后者为71.3％,P<0.01。所有腹主动脉旁淋巴结阳性及累及宫颈者的髂总淋巴结均有转移,而病灶限于宫体的腹主动脉旁淋巴结转移者仅有30％髂总淋巴结阳性。肿瘤的肌层浸润深度、病理类型及分化程度与盆腔淋巴结转移密切相关。结论 宫体部子宫内膜癌可直接或由宫颈转移至髂外淋巴结,宫颈受累者最易发生髂总和髂外淋巴结转移。宫颈受累者髂总淋巴结可作为腹主动脉旁淋巴结的前哨淋巴结。     

Single skip metastasis in sentinel lymph node: In an early gastric cancer

Lymph node status is considered a key prognostic and predictive factor in patients with gastric cancer(GC).Although there is a practical approach to the intraoperative detection of sentinel lymph nodes(SLNs),such a procedure is not included in the European surgical protocol.In this report,we present a practical approach to SLN mapping in a representative case with early gastric cancer(EGC).A 74-year-old female was hospitalized with an endoscopically observed,superficially ulcerated tumor located in the antral region.Subtotal gastrectomy with D2 lymphadenectomy and SLN mapping was performed by injecting methylene blue dye into the peritumoral submucosal layer.An incidentally detected blue-stained lymph node located along the middle colic artery was also removed.This was detected 40 min after injection of the methylene blue.Histopathologic examination showed a p T1b-staged well-differentiated HER-2-negative adenocarcinoma.All of the 41 LNs located at the first,third,and fifth station of the regional LN compartments were found to be free of tumor cells.The only lymph node with metastasis was located along the middle colicartery and was considered a non-regional lymph node.This incidentally identified skip metastasis indicated stage Ⅳ GC.A classic chemotherapy regimen was given,and no recurrences were observed six months after surgery.In this representative case,low-cost SLN mapping,with a longer intraoperative waiting time,totally changed the stage of the tumor in a patient with EGC.     

分化不良型早期胃癌淋巴结转移的危险因素分析

目的评估分化不良型早期胃癌患者淋巴结转移的危险因素,探讨其内镜治疗的可能性。方法回顾性分析2002年9月-2008年12月经手术证实的100例分化不良型早期胃癌患者,对其年龄、性别、肿瘤大小、部位、大体类型、溃疡、组织学类型、浸润深度及淋巴管肿瘤浸润与淋巴结转移的关系进行单因素和多因素分析。结果分化不良型早期胃癌的淋巴结转移率达18．00％。多变量分析显示肿瘤大小（〉2cm）、侵犯至黏膜下层、淋巴管肿瘤浸润均是分化不良型早期胃癌淋巴结转移的独立危险因素（P〈0．05）。肿瘤大小和淋巴管肿瘤浸润是分化不良型黏膜内早期胃癌的淋巴结转移的独立危险因素。在直径≤2cm且无淋巴管肿瘤浸润的分化不良型黏膜内早期胃癌中未发现淋巴结转移。结论直径≤2cm且无淋巴管肿瘤浸润的分化不良型黏膜内癌患者可考虑内镜治疗,术后需密切随访。