胃类癌的外科治疗

胃类癌是一类少见的胃肠道肿瘤,内镜切除或手术切除是主要的治疗手段。对原发肿瘤,首先应根据分型,其次根据肿瘤的大小、数量、侵犯程度、转移范围和临床症状采取适宜的手术方案,达到根治目的。对于进展期肿瘤患者,在切除原发灶同时,尽可能切除转移病灶,或通过介入方法使肿瘤缩小,达到手术切除的可能。减瘤减期可缓解激素介导的症状,减少肿瘤负荷,减轻局部和全身反应,提高生活质量和改善预后。     

晚期上皮性卵巢癌肠肿瘤切除的作用

目的：分析晚期上皮性卵巢癌行肿瘤细胞减灭术时肠道转移瘤行肠道肿瘤切除的临床应用。方法：回顾性分析1998～2003年52例晚期上皮性卵巢癌行肿瘤细胞减灭术时肠道转移瘤行肠道肿瘤切除的患者,与同期未行肠道肿瘤切除的仅行姑息性手术的16例患者进行比较,采用统计学方法进行处理。结果：68例手术治疗患者中,52例完成肠道肿瘤切除手术,其中34例无肉眼呵见残余肿瘤,8例残余肿瘤〈1cm,10例残余肿瘤〉1cm,其中位生存期分别为28个月、23个月和13个月,16例因肿瘤广泛转移未行肠道肿瘤切除仅行姑息性手术的患者中位生存期为7．66个月,肠道肿瘤广泛转移及肠系膜根部广泛种植是手术失败的关键。结论：晚期上皮性卵巢癌行肿瘤细胞减灭术时行肠道转移瘤切除,达到满意手术效果时对生存期提高足有帮助的,而选择恰当的患者是手术治疗的关键。     

16例大肠类癌临床分析

大肠类癌较为罕见,天津市人民医院自1956年至1986年共收治16例。作者指出大肠类癌的治疗方法以手术为主,肿瘤直径在2厘米以内的早期类癌可行局部切除或局部广泛切除,对于晚期类癌手术应持积极态度,尽可能多切除原发肿瘤、转移淋巴结和肝转移灶,以期达到缓解症状并延长生存期的目的。     

手术结合125Ⅰ粒子植入治疗Ⅳ期直肠癌

目的 探讨姑息性手术结合125Ⅰ粒子植入对Ⅳ期直肠癌的治疗效果.并分析远处转移不能根治Ⅳ期直肠癌的预后因素.方法 回顾性分析1999年1月至2006年3月诊治的152例Ⅳ期直肠癌患者的临床病理资料,单因素和多因素分析评价其预后因素.结果 152例Ⅳ期直肠癌患者,119例合并有梗阻、出血或穿孔,行姑息性手术,包括原发灶姑息切除及肝转移灶切除25例,仅原发灶姑息切除66例,单纯造口术或开腹探查28例.手术治疗患者中有45例接受125Ⅰ粒子植入.全组患者中位生存时间11个月.单因素分析显示,性别、年龄、浸润深度、组织分化程度、淋巴结转移与患者预后无关;原发灶切除、转移灶切除、肿瘤合并症、肿瘤转移范围、CEA水平、是否接受化疗及125Ⅰ粒子植入等因素与预后相关.Cox多因素分析显示肿瘤转移范围及是否切除、CEA水平、是否接受化疗和125Ⅰ粒子植入是患者的独立预后因素.结论 对Ⅳ期直肠癌原发肿瘤引起的梗阻、出血或穿孔等合并症者,应争取积极手术切除,结合岱I粒子植入治疗对改善患者的预后有一定疗效.     

卵巢恶性肿瘤的手术治疗

卵巢恶性肿瘤常采用综合治疗,但最基本、最重要的治疗仍是手术切除。现将有关问题讨论如下。一、观念问题 (1)应强调手术为主,无论早期或晚期,都应考虑手术。早期患者单纯手术切除肿瘤即可治愈;晚期者,缩小肿瘤体积,可以缓解症状,并为化疗、放疗以及免疫治疗等打下基础。手术还可以明确诊断、确定临床分期和组织学类型,对以后选择化疗等提供可靠依据。(2)应打破传统外科的手术原则,即转移与扩散不构成切除的禁忌证。卵巢癌的手术实际是盆腹腔广泛转移瘤的切除手术,局限于卵巢(临床I期)的病例不到30％。所以从现代妇科肿瘤学的观点出发,卵巢癌的手术选择,几乎不应受到什么限制。绝大多数病例,特别是初     

孤立性肺转移瘤的外科治疗：（附17例分析）

本文报告了自1975年6月～1990年12月对17例孤立性肺转移瘤手术治疗的初步临床结果。认为,其原发瘤来自女性生殖系统者居多,占65％。原发肿瘤术后定期胸部X线检查对本病诊断有决定性意义。手术治疗的重要问题是对病人的选择。对原发肿瘤组织学条件好,治疗后局部情况稳定,肺内转移局限并能耐受手术者,手术切除是有益的。本组3年、5年生存率均为66.6％。并提出了对肺转移瘤的切除做为肿瘤的减量或减症的手术概念。转移瘤的肺门,纵隔累犯明显影响预后。     

如何确定恶性肿瘤手术切除的合理范围

据统计，恶性肿瘤已居各种死因的第二位，成为目前严重威胁人类健康及生存的重要疾病之一。手术治疗是目前众多肿瘤治疗的主要手段，在手术治疗范围上，早期肿瘤通过局部根治性切除可取得良好的预后；晚期有广泛转移的非局限性肿瘤，在综合治疗基础上姑息性肿瘤切除以暂时性缓解症状的手术方式已达成共识。但位于两者之间的局部进展期肿瘤，在手术治疗范围上，一直争议颇大。尤其是随着科技进步，外科治疗安全性的提高，使在原有基础上扩大或缩小化肿瘤手术成为可能。     

晚期卵巢上皮癌术前化疗

卵巢深居盆腔 ,发生恶性肿瘤时症状十分隐蔽 ,等患者感到不适就诊时 ,病变已进入晚期 ,常伴有广泛腹腔及远处转移 ,手术难以切除。我们对晚期难以切除的卵巢癌病例采用术前化疗 ,以达到有效减瘤的目的 ,效果良好 ,现报告如下。1　资料与方法1.1　一般资料　 1991年— 2 0 0 0年施行术前化疗的卵巢上皮癌患者 2 9例 ,年龄3 2岁～ 68岁 ,中位年龄 47岁 , C期患者 2 4例 , 期 5例 ,彩超、CT检查示盆腔内大包块 ,伴腹腔内不同程度的转移 ,妇科检查肿瘤大 ,固定 ,合并腹腔积液者2 3例 ,3例合并胸腔积液 ,1例锁骨上淋巴结转移 ,1例腋下淋巴结转…     

原发性小肠肿瘤305例临床分析

目的总结原发性小肠肿瘤的诊断与治疗经验。方法回顾性分析经手术及病理证实的305例原发性小肠肿瘤的诊断与治疗。结果良性肿瘤42例,恶性肿瘤263例;良、恶性之比为1:6.26。恶性肿瘤主要包括腺癌(135例)、恶性间质瘤(57例)、恶性淋巴瘤(37例)和类癌(20例)等,其临床表现大多为非特异性及症状不典型。慢性隐匿性失血、隐匿体重下降及脐周隐痛(三隐症状)是小肠肿瘤的常见症状,也是小肠肿瘤早期诊断的警示信号。小肠肿瘤术前确诊率为57.0%(174/305),其中十二指肠肿瘤的确诊率为67.2%(92/137);空、回肠为51.9%(82/168)。42例良性肿瘤患者行局部或肠段切除;263例恶性肿瘤患者中,153例行根治术,34例行姑息性切除或减瘤荷手术,76例行捷径及取活组织检查手术。153例根治性切除术的患者,中位生存时间为92个月,明显优于姑息性切除术或减瘤荷手术者。结论全消化道钡剂造影和内窥镜检查及肠系膜上动脉造影是诊断和定位原发性小肠肿瘤的主要手段,早期治疗是提高小肠恶性肿瘤预后的关键,凡无远处转移的患者,应积极施行根治手术。     

胃癌综合治疗的现状与展望

几年来胃癌的手术治疗和辅助治疗方法及策略取得了一些进展。作为标准术式的D2根治手术及扩大根治术并非适用于所有的胃癌病例,应根据分期调整治疗策略。早期胃癌可以通过内镜下切除或经腹腔镜手术治疗,一些神经保护技术也可用于早期胃癌治疗。胃癌的联合脏器切除和扩大切除一直存在争议。对于局部进展期胃癌,术前化疗或放化疗可以提高切除率,术后的化疗或放化疗则带来生存获益。随着靶向药物的出现,靶向药物联合化疗有可能成为进展期胃癌标准的治疗方案。对于腹腔种植转移的进展期胃癌,减瘤手术联合腹腔化疗已经成为治疗的选择之一。      

原发性气管肿瘤治疗进展

原发性气管肿瘤是呼吸系统的少见疾病,早期临床症状无特异性,易误诊为哮喘、慢性肺疾病等呼吸道疾病而延误诊断。其目前缺乏统一规范的治疗策略,以手术为主的综合治疗是目前的主要治疗模式,但对于手术切除范围、放疗范围、方式及剂量、化疗的作用、方案等方面仍缺乏共识。随着内镜技术的提高,内镜下治疗也成为治疗原发性气管肿瘤的局部治疗措施,但手术治疗仍是不容置疑的治愈手段。     

Stellenwert der Tumorresektion in der interdisziplinären Behandlung hirneigener Tumoren

High grade gliomas, i.e. anaplastic tumors and glioblastomas, are the most common primary intrinsic brain tumors in adulthood, followed by diffuse infiltrating WHO grade II gliomas. The importance of surgical resection of these high grade tumors with respect to overall survival is evidenced by recent studies. For low grade tumors high quality studies are still pending, however, there is increasing evidence for a beneficial effect of tumor resection with respect to malignant tumor progression and overall survival.     

Surgical Resection for Patients with Benign Primary Brain Tumors and Low Grade Gliomas

'Benign' brain tumors are a heterogeneous group of primary neoplasms representing 40% of primary brain tumors. Amongst neuroepithelial tumors, astrocytic neoplasms predominate, followed by oligodendroglial and mixed glial and glial-neuronal neoplasms. Less common are tumors of the ependyma, choroid plexus and neuroepithelial tumors of unknown origin such as chordoid glioma of the third ventricle. Neurosurgical intervention is indicated in order to establish a diagnosis, alleviate symptoms of mass effect, hydrocephalus, or hemorrhage, remove a seizure focus and decrease the cell pool at risk of malignant degeneration. As the majority of patients survive their tumor for years after initial diagnosis, the benefits of therapy must be carefully weighed against adverse treatment effects. This article, with a particular focus on surgical management, reflects the authors approach to the treatment of low-grade tumors of the brain parenchyma in the adult and reviews the pertinent literature published on this controversial issue.     

Prise en charge des métastases hépatiques synchrones d'origine colorectale

At time of diagnosis, 10 to 25% of patients with colorectal cancer present synchronous liver metastases. The treatment of such patients remains controversial without any evidence based organization. Therapeutic sequences are discussed including chemotherapy, colorectal surgery, liver resection and even radio-chemotherapy for some rectal cancers. In case of resectable liver metastases, preoperative chemotherapy offers the advantage of earlier treatment of micro-metastases as well as evaluation of tumor responsiveness, which can help shape future therapy. In this setting, different surgical strategies can be chosen (classical staged procedures with colorectal surgery followed by liver surgery, simultaneous resections or liver first approach) depending on the importance of the primary and metastatic tumors. The literature remains limited, but the results of these strategies seem identical in term of postoperative morbidity and long-term survival. Staged procedures are preferred in case of major liver resection. Location of the primary tumor on the low or mid rectum will necessitate preoperative long course chemoradiotherapy and a more complex multidisciplinary organization. For patients with extensive liver metastases, non-resectability must be assessed by experienced surgeon and radiologist before treatment and during chemotherapy. In this group of patients, improved chemotherapy regimen associated with targeted therapies and new surgical strategies (portal vein embolization, ablation, staged hepatectomies…) have improved resection rate (15 to 30-40%) and long-term survival. Treatment organization for the primary tumor remains controversial. Resection of the primary to manage symptoms such as obstruction, perforation or bleeding is advocated. For patients with asymptomatic primary a non-surgical approach permits to begin rapidly chemotherapy and obtain a better control of the disease. On the other hand, initial resection of the primary may avoid complications and the need for urgent surgical procedures. Both of these strategies are practiced without definitive evidence supporting one treatment option over the other.     

Update on the management of parathyroid tumors

Parathyroid tumors are virtually always benign with an estimated incidence of parathyroid carcinoma causing hyperparathyroidism in only .017% of cases. Virtually all parathyroid neoplasms, including the rare parathyroid carcinoma, are functional and discussion of the management of parathyroid tumors is tantamount to the discussion of primary hyperparathyroidism. The biochemical diagnostic criteria with rare exception is definitive, and the key issue with this functional benign endocrine neoplasm is when to recommend operation and how to ensure optimal results in this curable disease. Patients symptomatic with nephrolithiasis, significant osteoporosis, bone pain, and in some cases constitutional symptoms should undergo a surgical therapy. Also, patients with markedly abnormal laboratory values including a calcium 12.0 mg/dL, or 24-hr urinary calcium >400 mg/day should be treated surgically. The sestamibi nuclear medicine scan has become the best tool available for imaging of abnormal parathyroid glands. This study is positive between 60% and 90% of initial operations and in between 40% and 70% of reoperations. For multi-gland parathyroid disease or hyperplasia, the sensitivity of this test is decreased. Understanding of the ectopic locations of parathyroid adenoma is of utmost importance in the conduct of the parathyroidectomy. For the rare patients with parathyroid carcinoma, aggressive surgical resection with en bloc removal of any adjacent invading structures is the best chance for cure leading to 10-year survival rates of 49%.     

Parathyroid tumors

Opinion statement Parathyroid tumors causing primary hyperparathyroidism are common and often remain undiagnosed, despite that the diagnostic work-up is uncomplicated in most patients. The patients often do not receive the appropriate curative treatment, which is surgical. Recent studies show that surgery is beneficial in patients with mild asymptomatic disease, especially in the reversal of bone disease, neuropsychologic symptoms, and dyslipoproteinemia. All patients with the disease deserve a referral to an endocrine surgeon for discussions regarding surgical intervention. Minimally invasive techniques performed in the ambulatory setting have evolved rapidly and show an extraordinary high success rate, low-morbidity rate, and are likely to become the standard treatment for most patients with primary hyperparathyroidism.     

Influence of surgical removal and effect of levamisole on cytotoxic T-cell-mediated antitumor immunity in mice

In BALB/c mice bearing syngeneic fibrosarcoma Meth 1 tumors, effects of surgical removal and levamisole (LMS) on the growth of reinoculated Meth 1 cells were investigated. The growth of secondary tumors in mice with surgical removal of primary tumors was significantly inhibited as compared with that of secondary tumors in primary tumor-bearing mice without surgical removal. LMS (2.5 mg/kg) augmented the growth inhibition of secondary tumors. Its effect was significant only in mice bearing primary tumors without surgical removal. Cytotoxicity, which was detected in the spleen cells of Meth 1-bearing mice, was mediated by tumor-specific cytotoxic T-cells and augmented after surgical removal of the tumors. LMS augmented the cytotoxicity when it was administered before surgical removal of the tumors but not after surgical removal. The spleen cells of Meth 1-bearing mice in the last stage of tumor development did not exhibit cytotoxicity, but rather exhibited suppressor activity on the in vitro generation of cytotoxicity. In this stage, effect of LMS was not detected. For the induction of cytotoxic T-cells in vitro, the cooperation of nylon wool-nonadherent cells and antigen-presenting cells appeared to be necessary. Nylon wool-adherent cells exhibited the suppressor activity. LMS stimulated the activity of nonadherent cells and partially modulated the suppressor activity of adherent cells. These effects of LMS were suggested to result in the augmentation of the cytotoxicity of the spleen cells and the growth inhibition of the secondary tumors in Meth 1-bearing mice.     

Surgical standards in the primary care of melanoma patients

Excisional biopsy is recommended as the procedure of choice whenever there is suspicion of malignant melanoma. There are only few indications for incisional biopsies, which--in contrast to former opinions--do not worsen the prognosis. For nearly 70 years the debate about the optimal resection safety margin around the primary tumor was influenced by historical case reports and paradigms. Recently, controlled clinical studies provided new insights. Accumulating evidence over the past two decades showed that narrower surgical margins do not have any influence on the rate of advanced metastatic disease. Local recurrence is rare (approximately 0.1%) when primary tumors are thin and is seen more often (approximately 10%) in primary tumors of greater thickness (>4 mm). Analysis of the overall survival in randomized trials shows equal prognosis for malignant melanoma for narrow and wide resection margins. Due to these findings in-toto excisional biopsy for in-situ melanoma, a resection margin of 1 cm for primary tumors with a tumor thickness up to 2 mm and a resection margin of 2 cm for primary tumors greater than 2 mm appears sufficient. By this procedure primary closure of wounds will be possible in nearly all cases, morbidity and costs of surgical approaches will be reduced. For a long time it has been discussed whether prophylactic removal of lymph nodes ('elective lymph node dissection') is of benefit for melanoma patients. More recently 'selective' lymphadenectomy ('sentinel node biopsy', SNB) has been proposed to evaluate the status of the first draining lymph node ('sentinel node') of the regional basin. Several studies now demonstrate that the sentinel node evaluation for underlying metastatic disease reflects the status of the entire lymph node region and is therefore a useful prognostic factor superior to measurement of tumor thickness in primary melanoma. However, it is unclear whether sentinel node biopsy is of benefit for a better survival in affected patients.     

Early diagnosis of metastatic brain tumor

For the early diagnosis of metastatic brain tumor, careful and long-term follow-up is important when the primary tumor has already been found. Metastatic brain tumor should be suspected whenever neurological symptoms develop in such a patient. In the cases of lung cancer or lung metastases, CT scan of brain should be taken even if the patients have no neurological symptoms, because lung cancer frequently metastasizes to the brain and other cancers metastasize to the brain via the lung. When the primary sites are unknown, primary brain tumors should be distinguished. Relatively rapid progression of symptoms including mental disturbance, multiple lesions on CT scan, lesions on chest X ray film, careful cerebral angiogram and MRI are helpful for the differential diagnosis.