多学科诊疗理念下皮肤恶性黑色素瘤的外科治疗与探索北大核心

皮肤恶性黑色素瘤(cutaneous malignant melanoma,CMM)是皮肤外科较为常见的一种高度恶性体表肿瘤,因传统诊断路径的早期确诊率和分期准确性不高,且单一外科手术治疗预后不佳,导致患者的5年生存率较低。多学科协作模式(multidisciplinary team,MDT)理念下将现有各学科的诊疗方法优化整合,实现CMM患者的全程、连续、个体化精准诊疗,逐渐发展为外科治疗CMM的国际新趋势。本文总结近年来CMM外科治疗的新进展,探讨多学科协作诊疗理念下CMM外科治疗的优势,并对未来建立和发展MDT提出思考。     

肢体恶性黑色素瘤的外科治疗

目的 探讨外科治疗在肢体恶性黑色素瘤中的临床作用.方法 回顾性分析1993年8月-2007年12月就诊于我院骨肿瘤科22例肢体恶性黑色素瘤病例.男性12例,女性10例;年龄20～73岁,平均50.1岁;发病部位足底14例,足背1例,第二足趾1例,拇指甲下2例,腹股沟、大腿、膝部软组织各1例,胫骨1例.按照AJCC外科分期,Ⅱ期8例,Ⅲ期12例,Ⅳ期2例.保肢14例,截肢（趾）8例;保肢病例中局部切除后采用游离植皮或转移皮瓣重建10例,胫骨病变1例采用瘤段截除、人工关节置换术.外科边界：边缘切除4例,广泛切除14例,根治性切除4例.二期行区域淋巴结清扫14例.术后辅助达卡巴嗪化疗6例（同时加用放疗1例）,干扰素和白介素生物治疗13例,中医药辅助治疗3例.有完整随访资料的17例,随访时间3-96个月,平均随访时间34.2个月.结果 Ⅱ期患者8例中1例术后91个月局部复发,1例随访19个月后出现骨转移,1例术后12个月腹股沟淋巴结转移,均再次行手术治疗;余5例随访未发现局部复发及远隔转移.Ⅲ期患者12例均行淋巴结清扫术,2例随访肺转移死亡,4例失访,余6例随访无局部复发及远隔转移.Ⅳ期患者2例,1例术后3个月因肺转移死亡.最终完整随访资料的17例患者中13例随诊无进展生存,原病灶局部无复发,植皮或转移皮瓣均成活或经过二期处理后愈合良好.结论 肢体黑色素瘤手术治疗后局部肿瘤可得到良好控制,并为肿瘤的综合治疗奠定基础.     

皮肤黑色素瘤的外科治疗现状及研究进展

皮肤黑色素瘤是恶性程度极高的皮肤恶性肿瘤,其恶性程度和死亡率在皮肤恶性肿瘤中占据首位。虽然近年来靶向治疗、免疫治疗、化疗等治疗手段取得了突破性进展,但肿瘤外科手术仍是目前皮肤恶性黑色素瘤患者获得长期生存的主要治疗手段。作者通过对大量皮肤黑色素瘤的外科治疗相关性研究文献的阅读,系统论述了皮肤黑色素瘤的外科治疗的规范。     

皮肤多发性转移性恶性黑色素瘤1例

1临床病理资料 患者男,60岁,因发现全身皮下多发性结节2月余入院.始初结节较小,且局限于四肢屈侧,后见结节逐日增多、增大,压之微痛而来我院就诊.     

肺癌外科治疗研究进展

肺癌的外科治疗始终在不断进展,2011年世界肺癌大会对近年的肺癌外科治疗的进展做了比较全面的总结.其中日本学者Hisao Asamura以"State of The Art Surgery in 2011"为题对肺癌外科领域经常遇到的问题也做了概述,给出不少有益的介绍(Abs NO.PLO3).肺癌的外科治疗术式从最初的全肺切除逐渐转为肺叶切除,与此同时,淋巴结清扫问题也日益受到重视,目前为止,肺叶切除加淋巴结清扫成为了肺癌手术的标准术式,仅在一些无法完成肺叶切除的条件下才行全肺切除术.     

皮肤恶性黑色素瘤的外科治疗进展

外科治疗仍然是目前皮肤恶性黑色素瘤患者获得长期生存的最大希望。外科切缘通过多个前瞻性随机试验后取得了一定的共识。前哨淋巴结活检已成为评价区域淋巴结状态的一种重要手段。     

黑色素瘤个体化治疗研究进展

黑色素瘤是近年来发病率增长最快的恶性肿瘤之一，仅次于女性非小细胞肺癌，2008年美国新增诊断病例约62480例，死亡病例约8420例，这还不包括在门诊治疗未报告的表浅和原位黑色素瘤。黑色素瘤分期采用美国抗癌联合会2002年的TNM分期系统，分期早晚对黑色素瘤患者的预后起决定性作用。     

皮肤和肢端恶性黑色素瘤的外科治疗规范中国专家共识1.0

恶性黑色素瘤是临床上较为常见且危害严重的恶性肿瘤之一。尽管在我国的发病率较低, 但近年来, 其发病率和死亡率均呈现快速增长趋势。规范化的外科治疗是早中期恶性黑色素瘤获得治愈的关键, 也有助于改善晚期患者的预后, 中国抗癌协会肉瘤专业委员会软组织肿瘤及恶性黑色素瘤学组专家根据中国国情, 以中国临床肿瘤学会黑色素瘤诊疗指南为蓝本, 参考美国国立癌症网络皮肤黑色素瘤诊疗指南、澳洲和新西兰黑色素瘤诊疗指南以及相关国内外黑色素瘤临床研究和荟萃分析, 制订了针对皮肤和肢端黑色素瘤外科治疗的专家共识。此专家共识涵盖了皮肤和肢端黑色素瘤外科治疗各个环节的规范细节和操作要点, 旨在推广皮肤和肢端恶性黑色素瘤的规范外科治疗, 尽可能达到外科治疗目的并最终改善患者的预后。     

综合治疗足底皮肤恶性黑色素瘤

 目的 探讨足底皮肤恶性黑色素瘤的手术疗效. 方法 回顾性分析我院1998～2004年共收治的31例足底皮肤恶性黑色素瘤患者,均有病理学证实,采取手术、Ⅰ期腹股沟淋巴结清扫术为主的综合方式治疗足底皮肤恶性黑色素瘤.用Kaplan-Meier法统计生存率,用Log-rank检验模型对患者肿瘤大小、厚度、手术切除范围等影响因素进行分析. 结果 31例足底皮肤恶性黑色素瘤患者至今生存22例,5年生存率为70%（22/31,P＝0.0366）,无局部复发,Ⅰ期行腹股沟淋巴结清扫术28例,9例出现腹股沟淋巴结转移,4例出现全身多处转移,死亡9例.T〈1.5mm,1.5mm〈T〈2.5mm,2.5mm〈T〈4.0mm,T〉4.0mm,5年生存率分别是66.7%,63.64%,30%,0%. 结论 足底皮肤恶性黑色素瘤恶性程度高,易远处转移.综合方式治疗可降低转移率,使大部分患者的生存期得到延长.     

面部皮肤恶性黑色素瘤整复治疗的临床观察

目的 探讨治疗面部皮肤恶性黑色素瘤切除后皮肤缺损的手术方法 ,并评价其临床疗效。方法 2007年2月至2014年3月本科收治9例面部皮肤恶性黑色素瘤,均采用手术扩大切除病灶;术中常规冰冻切片监测手术切缘,病灶切除后皮肤软组织缺损,分别采用游离皮片移植2例,邻近任意皮瓣6例,游离皮瓣1例,术后常规辅以免疫治疗。结果 9例皮片及皮瓣均成活,伤口Ⅰ期愈合。局部形态较好,术区平整,瘢痕不明显。9例患者获随访3个月~7年,死亡2例,其中1例因其他疾病术后2年死亡;其余病例外形良好,未见局部复发。结论 面部皮肤恶性黑色素瘤手术治疗联合术后辅助免疫治疗疗效肯定,皮瓣修复可取得较为理想的局部外形,术中常规冰冻切片是保证肿瘤根治的一项重要手段。     

Primary cutaneous melanoma: surgical management and other treatment options

Opinion statement The incidence of primary cutaneous melanoma continues to increase and is a growing public health problem. By virtue of its metastatic potential, melanoma accounts for most of the deaths from cutaneous malignancies. Management of cutaneous melanoma has undergone a paradigm shift in recent years. Clinical studies have furthered our understanding of the biology of this disease and have changed the standards of care. Specifically, sentinel node biopsy and interferon as the first effective postsurgical therapy have had a significant impact on the treatment of patients with melanoma. Surgery remains the primary treatment modality for cutaneous melanoma. An adequate excision of the primary lesion accomplishes durable local control and is curative for patients without micrometastatic disease. Although the extent of surgical resection has decreased in recent years, the standard treatment for primary cutaneous melanoma remains wide surgical excision with histologically negative margins. The extent of excision is based on the theory that the incidence and radial extent of local recurrences can be predicted by specific primary tumor histopathologic characteristics. Tumor thickness and ulceration are the most important histologic features associated with prognosis and are the basis for the current recommendations for surgical treatment of the primary tumor. The extent of surgical therapy for primary melanoma is an area of ongoing debate. No clinical trial has shown a survival disadvantage for narrow versus wide excision regimens for melanoma of any thickness. Ongoing clinical trials will determine the relationship between the extent of surgical therapy for the primary tumor and the outcomes of recurrence and survival in patients with melanoma.     

皮肤恶性黑素瘤的外科治疗

目的:探讨皮肤恶性黑素瘤的外科治疗方式.方法:回顾性分析2007年10月—2011年12月共93例皮肤恶性黑素瘤患者的临床资料、外科手术方式和预后.按照美国癌症联合委员会(American Joint Committee on Cancer,AJCC)外科分期标准: ⅠA期1例, Ⅰ B期2例,Ⅱ A期8例,Ⅱ B期9例,Ⅱ C期20例,Ⅲ A期18例,Ⅲ B期17例,Ⅲ C期16例,Ⅳ期2例;外科手术方式:广泛切除术26例,广泛切除术十游离植皮或转移皮瓣重建术7例,截指(趾)8例,髂腹股沟淋巴结清扫术32例,腋窝淋巴结清扫术3例,广泛切除术十一期髂腹股沟淋巴结清扫术15例,广泛切除术十一期腋窝淋巴结清扫术2例;术后辅助化疗53例,干扰素或白细胞介素治疗78例.对77例患者进行了随访,平均随访时间为20 (2～50)个月.结果:Ⅰ期3例患者均存活;Ⅱ期获随访的28例患者中,8例于术后12个月时出现腹股沟淋巴结转移,2例于术后18个月时出现骨转移,6例于术后36个月时出现皮内转移;Ⅲ期获随访的44例患者中,11例于随访期间死于肺转移,5例死于肝转移;Ⅳ期2例患者中,1例于术后12个月时因肺转移而死亡,1例于术后11个月时因肝转移而死亡.随访期间,77例患者中的43例患者为无进展生存.结论:早期发现以及早期手术治疗皮肤恶性黑素瘤可以获得较好的疾病控制率,规范化的区域淋巴结清扫术是控制疾病进展的重要手段,术后辅助治疗可使生存获益.     

Conservative surgical management of superficially invasive cutaneous melanoma

Between 1976 and 1980, 136 patients were evaluated for primary treatment of cutaneous melanoma. Forty-nine lesions were invasive to Clark's Level II (38 patients) or III (11 patients) with a thickness of 0.3 to 1.2 mm. Conservative re-excision was advised as definitive therapy for these patients. The margin of resection was defined as the maximum excision that would allow primary closure of the wound. Pathology reports of the re-excised specimens revealed the narrowest margins to be 0.7 to 4 cm. Unexpected residual tumor was present in 2 specimens and melanocytic hyperplasia in 12 specimens. After a follow-up period of 2.5 to 7.0 years, there have been no local recurrences. One patient developed regional lymph node metastases 16 months and, then central nervous system (CNS) metastases 25 months after primary treatment. A second patient died with pulmonary metastases 4.5 years after initial therapy. Melanomas that are not deeply invasive do not require wide excision and skin grafting for local control. Occasionally these thin lesions do produce systemic metastases, emphasizing the need for long-term follow-up of even "low-risk" patients.     

脊柱转移瘤的外科治疗进展

骨是肿瘤继肺、肝之后第三大转移部位。随着相关学科的发展、多学科治疗模式的推进,尤其是靶向药物和免疫药物取得的进展,肿瘤患者生存期逐渐延长,出现骨转移概率逐渐增大,尤其是脊柱转移,严重影响患者的生活质量和预后。有关脊柱转移瘤的治疗,近年临床研究取得了较大的进展,治疗模式不断发生变化。在外科治疗方面,外科手术微创化,影像导航下的内镜手术或机器人协助下的微创手术逐渐成为未来发展的趋势。      

The effects of surgical treatment on survival and local recurrence of cutaneous malignant melanoma.

All patients with a diagnosis of cutaneous malignant melanoma (CMM) in Western Australia from 1980 to 1981 were observed for up to 6 years to determine vital status and to detect the development of local recurrences of the primary lesion. Approximately 35% of all patients had their tumors excised with surgical margins of less than 1 cm. When compared with patients whose tumors were excised with margins of at least 2 cm, the fatality rate in those with narrow margins was slightly less (rate ratio, 0.60; 95% confidence interval [CI], 0.20% to 1.80% for margins of 5 to 9 mm; rate ratio, 0.69; 95% CI, 0.26% to 1.87% for margins of 1 to 4 mm); however, this difference could have been caused by chance alone. The risk of local recurrence within 5 years after diagnosis was 2% (95% CI, 1% to 4%). The risk was strongly related to age and tumor thickness, but did not appear to be influenced by the width of excision (greater than 1 cm versus less than 1 cm: rate ratio, 1.03; 95% CI, 0.25% to 4.34%). The apparent lack of effect could be caused by to chance alone because the number of local recurrences was small.