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。     

18F-FDG hPET/CT显像在原发性贲门癌中的应用

背景与目的：dPET／CT检查价格昂贵、而hPET／CT显像检查虽在准确性尚不及dPET，但其性价比较高．有较好的应用前景，本文探讨^18F-脱氧葡萄糖（FDG）双探头hPET／CT显像在原发性贲门癌中的应用价值。方法：26例经组织病理学证实的原发性贲门癌患者进行^18F-FDG双探头hPET／CT显像。图象分析采用视觉及半定量方法，同时与近期CT结果比较。结果：①双探头hPET／CT检出原发性贲门癌的灵敏度为92．3％（24／26例），2例假阴性患者均属印戒细胞癌，原发肿瘤直径〈2cm（T1期）。②19例手术患者中，贲门局部淋巴结转移15例，双探头hPET／CT检出8例，其灵敏度、特异性和准确性分别为71．4％、100％和53．3％，CT检出3例。③双探头hPET／CT检出远处转移7例，CT仅检出3例。结论：^18F-FDG双探头hPET／CT诊断原发性贲门癌较为灵敏，检出贲门局部淋巴结转移和远处转移可能优于CT。因此hPET／CT显像对贲门癌的术前分期和手术方案有一定的指导作用。     

CT staging of pancreatic and periampullary carcinoma.

Sixteen cases of carcinoma head pancreas and seven cases of periampullary carcinoma are staged together on CT scan because of their morphological similarity and similar parameters. Following parameters are considered for CT staging: tumour mass, involvement of splanchnic vessels, locoregional lymph nodes and presence or absence of hepatic metastases. Findings were confirmed on surgical exploration. A contrast enhanced CT scan was 58.3 percent sensitive and 100 percent specific for the involvement of lymph nodes and 100 percent sensitive and 93.4 percent specific for hepatic metastases. The cases diagnosed as non-resectable on CT staging were found inoperable on exploration. Authors believe that for all practical purposes, pancreatic and periampullary malignancies can be grouped together and a contrast enhanced CT scan can provide reliable information for the staging of the tumor.     

胃癌双期动态CT扫描的影像表现及其对肿瘤检出、大体分型的价值

目的分析胃癌双期增强动态ＣＴ扫描的影像表现,进一步评价动态ＣＴ扫描对肿瘤检出及大体分型的价值。方法对６３例经胃镜活检证实为胃癌的患者行双期动态ＣＴ扫描,将胃癌ＣＴ扫描表现、肿瘤检出及大体分型与手术、病理进行对照。结果ＣＴ扫描对早期胃癌和进展期癌的检出率分别为１００．０％和９８．２％。大体分型总的准确率为６５．４％,对早期癌分型准确率为０,对ＢｏｒｒｍａｎｎⅡ、Ⅲ、Ⅳ型的准确率分别为８５．７％、１００．０％和５５．６％。早期胃癌共８例,在增强早期显示为局限性胃壁增厚,其中中等或显著不均匀强化４例,一般不均匀强化４例。进展期胃癌显示为局限性或广泛性胃壁增厚,有溃疡或无溃疡,增强早期为中等或显著不均匀强化,第二时相呈均匀强化。粘液腺癌４例,其中３例见靶征或分层征,２例见钙化。结论（１）增强动态ＣＴ扫描对胃癌诊断有意义,但以在增强早期扫描效果为好。（２）细致的检查方法是提高胃癌诊断准确性的保证。     

Value of abdominal CT scan in the staging of malignant lymphoma

A series of 60 patients with malignant lymphoma was proved by pathology except two with mediastinal lesions. All were admitted for radiotherapy from Oct, 1979 to June 1983 and the abdomen was scanned by CT. There were 29 cases of Hodgkin's disease (HD) and 31 of non-Hodgkin's lymphoma (NHL). The age ranged from 8 to 69 years 5 were scanned before, 32 during and 23 after treatment. The results showed that 18 patients had subdiaphragmatic lesions, of which 10 were HD and 8 NHL. The sites of the 18 positive abdominal scan were 9 lymphatic involvement (para-aortic, coeliac, splenic-hilar, mesenteric, gastric, hepatic-hilar, diaphragmatic posterior group and presacral) and 3 visceral involvement (liver, spleen and adrenal gland). As to the change in clinical staging of malignant lymphoma after CT scan, 5 patients (26%) with stage I were downed to stages II and III; 6 (22%) with stage II to stages III, IV and 1 stage III to stage IV. Altogether 22% of stages I, II and III were down staged. According to our experiences, abdominal CT scan can not take the place of exploration or lymphography because the small lesions in the spleen and liver are not visible on the CT scans using conventional intravenous water soluble contrast media. Lymphography is more accurate in showing the retroperitoneal lymph nodes. The CT scan is valuable in detecting lesions in the upper para-aortic, mesenteric, splenic-hilar, hepatic-hilar and renal-hilar lymph nodes.(ABSTRACT TRUNCATED AT 250 WORDS)     

Fused FDG–PET/contrast-enhanced CT detects occult subdiaphragmatic involvement of Hodgkin's lymphoma thereby identifying patients requiring six cycles of anthracycline-containing chemotherapy and consolidation radiation of spleen

BackgroundSpleen and liver assessment for occult involvement of Hodgkin's lymphoma (HL) challenges current staging procedures.Patients and methodsWe prospectively evaluated event-free survival (EFS) in 103 HL patients staged with fused 2-[fluorine-18]fluoro-2-deoxy-D-glucose–positron emission tomography (FDG–PET)/contrast-enhanced computed tomography (CT) to identify those at greatest risk for abdominal relapse. The EFS of this series was compared with that of a historical cohort of 100 HL patients staged with separate FDG–PET and diagnostic CT acquisitions.ResultsThirty-one of the 103 patients staged with FDG–PET/contrast-enhanced CT were found to have spleen involvement and 10 patients liver involvement, whereas 14 of the 100 patients staged with separate procedures were found to have spleen involvement and 3 patients liver involvement. There were significantly more intensive treatments (six courses of anthracycline-containing chemotherapy and spleen radiation) in the fused PET/CT group than in the historical cohort (P ≤ 0.04). At a median follow-up of 27 months, five events occurred in the fused PET/CT group (HL relapse, 4 patients; carcinoma, 1 patient) and 19 events in the historical cohort (HL relapse, 18 patients; acute promyelocytic leukemia, 1 patient). Ten of the 18 relapses in the historical cohort were localized in the spleen and/or liver area. None of the four relapses in the fused PET/CT group was localized below the diaphragm. Thus, FDG–PET/contrast-enhanced CT-guided treatment resulted in a 95% EFS, whereas separate FDG–PET and diagnostic CT-guided treatment resulted in an 81% EFS (P = 0.002).ConclusionFDG–PET/contrast-enhanced CT is an accurate frontline single imaging diagnostic tool enabling effective tailored treatment in HL patients.     

螺旋CT对直肠癌术后复发的诊断价值

目的探讨螺旋CT对直肠癌术后复发的诊断价值.方法采用螺旋CT结合三维重建,对48例直肠癌术后复发的患者进行检查.结果 48例患者中,37例局部复发的CT表现为吻合口区肠壁不规则结节状、新月状软组织密度影,向腔内或肌层生长;其中16例伴侵犯邻近组织器官,(6例侵犯膀胱、前列腺、一侧或两侧精囊腺,3例侵犯子宫、阴道,7例侵犯骶骨及骶骨前软组织、直肠浆膜外脂肪层).19例为远处转移(伴局部复发8例),多见于肝脏.结论螺旋CT扫描结合三维重建,对诊断直肠癌术后复发具有重要的临床应用价值.     

A case of small cell carcinoma of the stomach

We report a rare case of small cell carcinoma of the stomach with metastasis to the liver and invasion of the pancreas, which was associated with acute peritonitis due to perforation of the stomach. CPT-11/CDDP chemotherapy achieved a partial response. A 60-year-old man suddenly developed abdominal pain and visited the emergency room. We diagnosed acute peritonitis due to perforation of the digestive tract because CT scan showed free air in the abdominal cavity. An emergency operation was performed with an omental patch for closing the perforated hole in the stomach. Excisional biopsy was performed to the small liver nodule. Histological findings showed that the liver nodule was metastasis from small cell carcinoma. There was no finding from the thoracic CT scan, but gastroscopy revealed a giant tumor, which was diagnosed as small cell carcinoma in histology. Therefore, we diagnosed small cell carcinoma of the stomach with liver metastasis and invasion of the pancreas. After operation, one course of FP chemotherapy was performed, but the liver metastasis increased in size. Then we changed to CPT-11/CDDP chemotherapy as second-line therapy, and achieved partial remission (PR) of both the liver metastasis and gastric tumor.     

食管癌高发区队列内镜筛查随访分析

目的：分析食管癌高发区大人群内镜加碘染色筛查敏感性和漏诊率。方法：根据2002年5月河北省磁县40～65岁2013例内镜队列筛查样本,通过以2006年1月～3月随访所证实发生的食管鳞癌、贲门腺癌和胃癌病例为数据计算敏感性和漏诊率。结果：在内镜筛查后的6个月～36个月中,随访证实新发生食管鳞癌2例,贲门腺癌4例,胃窦腺癌1例,其他癌6例,死因不详1例。失访11例,随访率99.4%。经计算内镜筛查食管鳞癌灵敏度97.1%,漏诊率2.9%;贲门腺癌分别为80.0%和20.0%。结论：食管癌高发区内镜加碘染色筛查,贲门癌的灵敏度低于食管癌。     

贲门癌切除可能性临床分析

作者通过随机抽取贲门癌单纯探查和手术切除各150例,从临床表现及X线征象进行对照分析,结合探查组未能切除原因,认为病程长、食量明显减少、体质弱提示病变已届晚期。上腹部持续性钝痛、剑突下深压痛、近期腰背痛为肿瘤外侵的临床征兆。影响切除可能性的X线征象为:侵及食管下端的贲门区巨大软组织影,胃气泡缩小且胃底壁厚度>1cm,胃脊椎间致密且距离>5cm,胃小弯缩短、成角改变。提出术前行贲门胃底三重造影、B超、CT检查对估计贲门癌切除可能性有一定的价值。     

腹膜后神经源性肿瘤CT征象与病理分类相关性分析

目的:分析腹膜后神经源性肿瘤的CT影像学征象与病理类型的相关性,提高对腹膜后神经源性肿瘤的影像学诊断和鉴别诊断。方法:对44例经手术、病理证实的腹膜后神经源性肿瘤的CT征象进行回顾性分析,并与手术后的病理结果进行对照、研究。结果:44例腹膜后神经源性肿瘤均位于从膈肌下至盆腔腹膜后间隙内。其中,良性36例,恶性8例;神经鞘瘤9例,神经纤维瘤9例,节细胞神经瘤17例,副神经节瘤5例,神经母细胞瘤4例;肿瘤生长在肝肾隐窝、脾肾隐窝及双侧肾上极区17例,腹主动脉及下腔静脉间或旁4例,肾前间隙及肾内缘12例,双侧腰大肌前缘及前外侧7例,骶骨前缘及盆腔内2例,其它部位2例;肿瘤外形呈圆形或类圆形30例,不规则形14例。结论:腹膜后神经源性肿瘤的CT征象有其一定的特征性,通过对病理类型与肿瘤CT征象的关系分析,能提高CT检查对腹膜后神经源性肿瘤的诊断并在临床有较好的应用。     

18F-FDG PET/CT显像在肝脏恶性肿瘤的初步应用

目的：评价^18F-FDGPET／CT对于肝脏恶性肿瘤的诊断、分期及疗效评判的价值。方法：对55例肝脏恶性肿瘤患者的PET／CT检查资料进行回顾性分析。原发性肝细胞性肝癌（PHC）11例,胆管细胞性肝癌1例,转移性肝癌40例,白血病肝浸润1例,淋巴瘤肝浸润2例。其中原发性肝癌经手术或穿刺证实,继发性肝脏恶性肿瘤均有明确肿瘤病史或临床检查随访证实。所有患者均行双时相全身PET／CT显像检查。结果：低分化PHC4例及胆管细胞癌1例,^18F—FDG异常高摄取,延迟后大部分病灶^18F—FDG摄取SUVmax上升;高分化原发性肝癌7例,其中^18F-FDG等摄取5例,相对肝本底为略低摄取2例;9例PHC及1例胆管细胞癌CT表现为低密度灶,2例PHC为等密度,7例患者有肝炎肝硬化基础,另外同时发现肝外病灶6例。继发性肝脏恶性肿瘤43例（含淋巴瘤、白血病肝浸润）中PET／CT上共发现109个病灶;其中99个肝内病灶表现为^18F-FDG高摄取,31个病灶CT未显示,另外有2例患者有4个病灶经手术证实有肝内微小病灶而PET／CT未检出;而淋巴瘤、白血病肝浸润表现为大片状或弥漫性^18F—FDG明显异常高摄取;大部分患者改变了原有的治疗方案。结论：^18F-FDGPET／CT在肝脏恶性肿瘤诊断、分期、评价分化程度及治疗方案的选择有较好的临床价值,PET／CT诊断肝脏恶性肿瘤明显优于单纯PET。充分认识PET／CT在肝脏恶性肿瘤中的应用价值及局限性,有利于临床对肝脏恶性肿瘤的诊治。     

贲门癌前纵隔胸骨旁淋巴结转移—附5例报道

目的:报道5例贲门癌前纵隔胸骨旁淋巴结转移。方法:2009年5月至2013年5月我院就诊的贲门癌根治术后患者5例,4例经CT检查发现有腹腔和纵隔淋巴结转移及胸骨旁淋巴结肿大,1例超声检查发现有胸骨旁淋巴结肿大,全部患者在超声定位引导下行胸骨旁肿大淋巴结穿刺病理活检。结果:穿刺活检组织病理结果全部发现癌组织,提示腺癌。结论:贲门癌发生纵隔淋巴转移时有可能通过隔上淋巴结转移至胸骨旁淋巴结。     

Image-guided radiotherapy for liver cancer using respiratory-correlated computed tomography and cone-beam computed tomography

PURPOSE: To evaluate a novel four-dimensional (4D) image-guided radiotherapy (IGRT) technique in stereotactic body RT for liver tumors. METHODS AND MATERIALS: For 11 patients with 13 intrahepatic tumors, a respiratory-correlated 4D computed tomography (CT) scan was acquired at treatment planning. The target was defined using CT series reconstructed at end-inhalation and end-exhalation. The liver was delineated on these two CT series and served as a reference for image guidance. A cone-beam CT scan was acquired after patient positioning; the blurred diaphragm dome was interpreted as a probability density function showing the motion range of the liver. Manual contour matching of the liver structures from the planning 4D CT scan with the cone-beam CT scan was performed. Inter- and intrafractional uncertainties of target position and motion range were evaluated, and interobserver variability of the 4D-IGRT technique was tested. RESULTS: The workflow of 4D-IGRT was successfully practiced in all patients. The absolute error in the liver position and error in relation to the bony anatomy was 8 +/- 4 mm and 5 +/- 2 mm (three-dimensional vector), respectively. Margins of 4-6 mm were calculated for compensation of the intrafractional drifts of the liver. The motion range of the diaphragm dome was reproducible within 5 mm for 11 of 13 lesions, and the interobserver variability of the 4D-IGRT technique was small (standard deviation, 1.5 mm). In 4 patients, the position of the intrahepatic lesion was directly verified using a mobile in-room CT scanner after application of intravenous contrast. CONCLUSION: The results of our study have shown that 4D image guidance using liver contour matching between respiratory-correlated CT and cone-beam CT scans increased the accuracy compared with stereotactic positioning and compared with IGRT without consideration of breathing motion.     

贲门小细胞癌的诊断和治疗

目的总结贲门小细胞癌的临床特征,并探讨影响其预后的因素.方法对我科1998年12月～2001年10月手术的20例贲门小细胞癌患者的资料进行分析.结果贲门小细胞癌占同期贲门癌手术例数的2.0%(20/996),男女之比为9:1,术前均未得到确诊.全组手术切除率为100%,1,2年生存率分别为100%和33.3%.目前只有1例生存期超过3年.结论贲门小细胞癌是一种恶性度高的少见肿瘤,预后差;对贲门小细胞应给予包括化疗在内的综合治疗.     

经腹胃底贲门癌根治术47例分析

目的　探讨经腹施行胃底贲门癌根治术式。方法　对 1997— 2 0 0 2年经腹部采用GF -I型吻合器进行食管胃吻合 3 5例 ,食管空肠吻合 12例进行回顾性分析。结果　根治性切除胃底贲门癌时 ,在切除肿瘤及其上方 6～ 7cm食管的同时 ,清除纵隔下部淋巴结。全组病例无手术死亡 ,无吻合口瘘 ,亦无食管切缘癌残留 ,1例出现吻合口狭窄。并发症低于开胸手术。结论　经腹行胃底贲门癌根治术食管胃 (空肠 )机械吻合术 ,操作简便 ,术野暴露良好 ,创伤及生理扰乱较小 ,且便于扩大腹部淋巴结清除范围。     

贲门癌组织中多药耐药基因和多药耐药相关蛋白基因表达的临床研究

目的了解多药耐药基因（ＭＤＲ１）和多药耐药相关蛋白基因（ＭＲＰ）在贲门癌组织中的表达及其临床意义。方法采用反转录聚合酶链反应（ＲＴ－ＰＣＲ）技术,检测了４６例贲门癌及癌旁组织中ＭＤＲ１和ＭＲＰ６４表达。结果癌组织中ＭＤＲ１和ＭＲＰ表达的阳性率分别６３％和５０％,均高于癌旁组织（Ｐ＜０．０５）;术前化疗的ＭＤＲ１ｍＲＮＡ和ＭＲＰｍＲＮＡ表达水平高于未化疗者（Ｐ＜０．０５）;中低分化肿瘤的ＭＤＲ１ｍＲＮＡ和ＭＲＰｍＲＮＡ表达水平高于高分化肿瘤（Ｐ＜０．０５）;结论贲门癌组织中具有内源和获得性多药耐药性;ＭＤＲ１和ＭＲＰ表达与贲门癌的ＴＮＭ分期无关,其高表达状态可预示肿瘤组织的分化不良。     

Three advanced gastric cancer patients successfully treated by combination therapy of docetaxel and TS-1

We have experienced three gastric carcinoma cases successfully treated by the combination therapy of docetaxel and TS-1. Case 1: 66-year-old male with advanced gastric cancer invading the pancreas with metastasis to the liver and left neck lymph nodes. Case 2: 50-year-old female with scirrhous gastric carcinoma causing huge amount of malignant ascites. Case 3: 59-year-old male with recurrent gastric cancer of the remnant stomach presenting with obstruction and vessel involvement. Primary and metastatic diseases of these patients were remarkably improved with the combination therapy, indicating that the combination therapy of docetaxel and TS-1 can be a new therapeutic tool for advanced and recurrent gastric cancer patients.     

介入治疗贲门癌伴肝转移24例临床观察

目的探讨肝固有动脉＋胃左动脉化疗栓塞术治疗贲门癌伴肝转移患者的临床应用价值。方法对24例贲门癌伴肝转移的首治患者,采用Seldinger穿刺插管技术,选取：5-Fu、ADM（EADM、THP）、DDP（L—OHP）、MMC中的2～3种灌注,胃左动脉选用明胶海绵栓塞,肝固有动脉则采用碘化油栓塞。结果第2次介入治疗4周后进行评价。除去3例仅作1次介入治疗患者,治疗后吞咽困难：0级2例、Ⅰ级6例、Ⅱ级10例、Ⅲ级2例、Ⅳ级1例;生存质量：差2例、一般4例、较好10例、良好5例;疗效评价：CR0例（0）、PR14例（58．3％）、SD7例（29．2％）、PD3例（12．5％）,有效率为58．3％;生存期1、2、3、4年分别为75．0％、37．5％、12．5％、4．2％。结论对贲门癌肝转移的患者,行肝固有动脉＋胃左动脉化疗栓塞术,具有改善吞咽困难症状、提高生存质量、延长生存期、疗效相对满意、不良反应可控制、适宜人群广的优点,应推广应用于临床。     

胸腹联合切口切除贲门癌598例体会

目的：探讨胸腹联合切口在贲门癌手术中的应用。方法：回顾性分析1996年6月～2006年2月采用胸腹联合切口治疗贲门癌598例临床资料。结果：根治性切除576例（切除率96.3%）,姑息性切除15例,单纯探查7例。并发症发生率为4.7%（28/598）,其中吻合口瘘4例,吻合口狭窄3例,呼吸衰竭3例,肺部感染11例,脓胸2例,乳糜胸1例,心衰4例（死亡1例）。结论：经胸腹联合切口治疗贲门癌有利于肿瘤切除及周围淋巴结清扫,能够提高手术切除率,并发症少,在一定程度上优于左侧单纯开胸或剖腹手术。