侵犯气管的甲状腺癌切除后锁骨头带蒂软骨修补术12例报告

目的探讨甲状腺癌侵犯气管的外科处理及预后。方法分析2001年1月至2005年12月对12例甲状腺癌侵犯气管2～4个软骨环,周径<50%的患者,行气管窗式切除后采用自体胸锁关节的锁骨头带骨膜肌瓣软骨修补气管缺损区的疗效。结果本组乳头状癌9例,滤泡状癌1例,髓样癌1例,B细胞淋巴瘤1例,均行甲状腺全切除术加患侧颈淋巴结清扫术。分化性甲状腺癌术后辅助Ⅰ治疗;B细胞淋巴瘤术后辅助化疗。术后半年纤维气管镜检查可见气管修补处已骨化,气管内黏膜拉网脱落细胞检查未找到癌细胞。全组随访6个月至4年,1例滤泡状癌于术后3年气管内局部肿瘤复发行气管镜下微波治疗和再次Ⅰ治疗后病情得到控制,仍然存活,其他病例无复发转移及死亡,生活质量较好。结论甲状腺癌侵犯气管采用前侧壁窗式切除结合自体带蒂软骨修补气管壁缺损是一种有效的治疗方法。     

Adenoid cystic carcinoma of the trachea and main-stem bronchus. A clinical, histopathologic, and immunohistochemical study

Twelve cases of adenoid cystic carcinoma of the trachea and main-stem bronchus were histologically analyzed, and the results were examined with reference to the growth pattern of the tumor and the prognosis. The tumors were histologically classified into tubular, cribriform, and solid subtypes. Three histologic grades were established: grade I, tumors with tubular and cribriform subtypes but without solid subtype; grade II, tumors with tubular and cribriform subtypes in which the solid subtype comprised less than 20% of the area; grade III, tumors in which the solid subtype comprised more than 20% of the area. Three gross infiltrating types were established: type I, entirely intraluminal; type II, predominantly intraluminal; type III, predominantly extraluminal. In most cases histologic grade correlated with gross tumor type; that is, grades, I, II, and III were grossly types I, II, and III, respectively. The tumors infiltrating along the tracheobronchial wall were of the tubular or cribriform subtype, but not of the solid subtype. In two patients who died of distant metastasis, the histologic studies revealed the solid subtype. Immunohistochemical analysis demonstrated that the tubular subtype was the most differentiated form and the solid subtype, the most undifferentiated form. The histologic subtype of adenoid cystic carcinoma of the tracheobronchial tree was an important factor in the growth pattern of the tumor and the prognosis.     

Resection of thyroid carcinoma infiltrating the trachea.

We have treated surgically 11 patients with thyroid carcinoma that had infiltrated into the trachea. Three patients had primary tumours, and eight had recurrent tumours after previous operations. Sleeve resection of trachea was performed where thyroid carcinoma had proliferated; the trachea was reconstructed by end-to-end anastomosis. In two patients 10 rings of the trachea were resected. In three patients the anterior half of the cricoid cartilage was resected along with the cervical trachea. In one patient tracheoplasty was performed using partial extracorporeal circulation because severe tracheal stenosis prevented endotracheal intubation. Two of the 11 patients died from the surgery and one from disseminated metastases. One patient who had undergone tracheal resection for thyroid carcinoma three years and five months previously had a recurrence of the tumour in the trachea adjacent to the anastomosis, and a second tracheal resection was performed. In three patients postoperative laryngeal stenosis occurred. Five patients are alive and well two years and one month to four years and seven months after their operations. The histological pattern of the tumour was papillary adenocarcinoma in all 11 patients.     

A case of carcinoma of the esophagus involving the trachea undergoing anterior mediastinal tracheostomy with pedicled omental wrapping

A 62-year-old male who complained of dysphagia, body weight loss and hoarseness was admitted to our hospital. Chest x-ray film disclosed right superior mediastinal mass compressing membranous portion of trachea. Esophageal fiberscope revealed carcinoma of cervical esophagus. Bronchofiberscope revealed the paralysis of right recurrent laryngeal nerve and the invasion of esophageal cancer to tracheal membranous portion from the 5th tracheal ring to the 12th. The cancer also invaded the right lobe of thyroid which was shown by echogram. Operation was performed. On dissecting the cervical region, it was found that the tumor invaded both sides of the trachea so that tracheal reconstruction could not be done without injuring left recurrent laryngeal nerve. Sternotomy was added. Anterior mediastinal tracheostomy was done after laryngeal resection with total thoracic esophagectomy and tracheal resection leaving 5 rings long cartilage from carina. The trachea was wrapped with pedicled omentum. Post-operative course was uneventful. This procedure helps to increase blood supply to the tracheal anastomosis and turns to advantage in preventing infectious extension around trachea to mediastinum as well as tracheal compression to major vessels.     

Resectional management of airway invasion by thyroid carcinoma

Invasion of the trachea by thyroid carcinoma is best managed by resection with airway reconstruction. Localized extension of tumor may also require esophageal resection or radical resection including laryngectomy with mediastinal tracheostomy. Twenty-two patients (12 with papillary, 3 with follicular, 4 with mixed papillary and follicular, and 3 with undifferentiated carcinoma) underwent resection--16 with airway reconstruction and 6 with cervicomediastinal en bloc resection with mediastinal tracheostomy. Eleven had prior thyroidectomy. Ten of those having airway restitution required cylindrical tracheal resection, 5 had resection of trachea with a portion of the larynx, and 1 had wedge resection. Three undergoing laryngotracheal resection also needed esophagectomy. Colon reconstruction was used. Fifteen of the 16 having airway reconstruction had good surgical results with speech preservation. One died of complications due to prior irradiation. One of 6 undergoing radical resection died postoperatively. Six of the 20 survivors died of recurrence in 1 2/3 to 9 years, and 2 others died of other diseases. Three who had known pulmonary metastases at the time of palliative operation are alive between 2 and 3 2/3 years postoperatively, and a fourth who has pulmonary metastases is alive 6 1/6 years later. Eight patients are alive without disease from 1/12 to 8 3/4 years. Only two patients had airway recurrence. Resection and primary reconstruction of the trachea invaded by carcinoma of the thyroid should be done in the absence of extensive metastases when technically feasible. It offers prolonged palliation, avoidance of suffocation due to bleeding or obstruction, and an opportunity for cure. In carefully selected patients with massive regional involvement, radical excision with laryngectomy and esophagectomy is also appropriate.     

A clinical study of surgical treatment of patients with carcinoma of the cervical esophagus extending to the thoracic esophagus.

OBJECTIVE: We studied optimum surgery for carcinoma of the cervical esophagus extending to the thoracic esophagus (Ce-Ut carcinoma). METHODS: Subjects were 13 patients diagnosed with Ce-Ut carcinoma treated at our institute from January 1989 to December 1998. Clinicopathologic information such as surgical procedures, pathologic findings, and postoperative complications were analyzed. RESULTS: In 10, laryngoesophagectomy was conducted due to tracheal invasion by the tumor. In 7, mediastinal tracheostomy was done because of the extended resection of the proximal trachea. In 3, the larynx was preserved and, in 2, cricopharyngeal myotomy was added. Lymph node metastasis was found only in the neck and the upper mediastinum at surgery and recurrences were all lung metastasis. The incidence of postoperative complications was very high (76.9%), and 1 patient died due to widespread tracheal necrosis. The cumulative 5-year survival rate for the group was 33.3% and that for the 9 curative cases was 50%, but most of the cases who underwent noncurative resection and/or who received preoperative therapy for widespread invasion to surrounding organs died within a year. CONCLUSION: The prognosis of patients who undergoing curative extended resection of the proximal trachea and suitable lymph node dissection in the neck and upper mediastinum may improve, and larynx-preserving surgery is recommended for patients without tracheal invasion. Despite preoperative chemoradiotherapy, the prognosis of patients with widespread invasion to surrounding organs was very poor, and clinical studies on new therapeutic strategies for these advanced cases are needed to improve the prognosis of Ce-Ut carcinoma patients.     

Aggressive surgical approach for locally invasive papillary carcinoma of the thyroid in patients over forty-five years of age

Aggressive radical resection was performed on 18 of 21 elderly patients with locally invasive-papillary carcinoma of the thyroid. Diagnostic studies, including computed tomographic and endoscopic examinations, were useful in allowing accurate determination of tumor extent. Radical resection usually consisted of total or subtotal thyroidectomy and neck dissection combined with excision of the affected organs, which in one case included a laryngotracheoesophagectomy (reconstruction of the digestive tract with a forearm free flap), a sleeve, or a window resection of the trachea in nine cases (immediate end-to-end anastomosis in all but one), a partial esophagectomy in two cases, and resection of the outer layer of the trachea or esophagus in six cases. After these operations, one patient died of rupture of the carotid artery, one died of cancer in 4 years, and one other died of unrelated disease. The other 15 patients are alive and well 1 to 5 years postoperatively, although additional exploration for nodal metastases was required in three patients. Aggressive resection therefore appears to be justified for control of locally advanced, differentiated carcinoma of the thyroid.     

临床病理因素和手术方法对胆囊癌预后的影响

目的 分析与胆囊癌预后有关的临床病理因素.方法 回顾性分析2001-2006年61例进展期胆囊癌外科治疗资料.结果 按第6版UICC/AJCC的胆囊癌临床分期标准,ⅠB期8例,ⅡA期22例,ⅡB期11例,Ⅲ期14例,Ⅳ期6例.姑息性胆囊切除和/或胆道引流术26例;胆囊切除、局部淋巴结清扫14例,保留肝外胆管的根治性切除7例,联合肝外胆管切除的根治术13例;肝胆胰脏器联合切除1例.37例中有18例淋巴结阳性.52例术后得到随访.满6个月生存为41例(67.2%);满1年生存26例(42.6%);存活2年以上者10例(16.4%);3年以上存活7例(11.5%);1例存活5年以上(1.6%).术后2年内死亡的51例中,31例随访到死亡前症候:21例有进行性黄疸;14例有肝脏内多个转移;12例有顽固性腹水.非明确胆道病原因死亡者5例.结论 临床分期和手术方式与胆囊癌患者的预后有关.     

肾癌的病理类型与预后的关系

目的探讨肾癌的病理类型与预后的关系。方法对315例肾癌患者根据病情选择相应的手术治疗和病理分型,并进行病例随访。以Kaplan-Meier法计算生存率。Cox回归模型对预后影响因子进行分析。结果其中透明细胞癌202例(71.9%),颗粒细胞癌51例(18.1%),混合性腺癌15例(5.3%),乳头状腺癌7例(2.5%),集合管癌4例(1.4%),肉瘤样肾癌2例(0.7%)。Cox回归模型多因素分析显示病理类型可能是一个独立的影响预后的因子。透明细胞癌、颗粒细胞癌和混合性腺癌患者的3年、5年生存率差别无统计学意义。7例乳头状腺癌仅1例死亡。4例集合管癌和2例肉瘤样癌均已死亡,两者平均存活时间分别为6.3和5.5月。结论肾癌的病理分型对预后有一定的预测价值;乳头状腺癌预后优于其他类型肾癌;集合管癌和肉瘤样癌预后较差。     

肾肿瘤伴下腔静脉癌栓完全梗阻的手术治疗

目的：提高肾肿瘤根治术的治疗效果。方法：回顾性分析7例肾肿瘤伴下腔静脉癌栓完全梗阻患者的治疗，6例行下腔静脉整段切除术加右肾根治性切除术．1例行右肾肿瘤根治术加腔静脉切开取栓术。结果：全组患者术后血尿素氮、肌酐水平无明显上升。2例因肿瘤转移分别于术后1年3个月及1年6个月死亡。1例3年后失访，4例健在。结论：无远处重要器官转移的伴有下腔静脉癌栓完全梗阻的肾肿瘤患者仍是积极手术治疗的指征。     

Regional pancreatectomy for cancer of the pancreas, ampulla, and other related sites. Tumor staging and results

Regional pancreatectomy refers to an en bloc removal of a tumor in or adjacent to the pancreas with an adequate soft tissue margin and with its regional lymphatic drainage. The pancreatic segment of portal vein is part of the en bloc resection with venous reconstruction by end-to-end anastomosis without a graft. This operation, called a Type I regional pancreatectomy, may utilize either a total or subtotal removal of the pancreas. Localized arterial involvement by a neoplasm necessitates adding a segmental resection of the artery with vascular reconstruction, a Type II procedure. Sixty-one patients have had this procedure from 1972 through 1982. They are a subset of the 270 patients with cancer of the pancreas, ampullary and periampullary regions, duodenum, or terminal portion of the common bile duct who were treated by the author during this period. The 61 consist of 35 patients who had an infiltrating duct adenocarcinoma of the pancreas and 21 who had other kinds of malignant tumors. In addition, four were classified as having pancreatitis and a fifth patient had a pseudolymphoma. The resectability rate is about 30%. The present operative mortality rate is 8%. Approximately one-third of the patients are alive; 43% of the 21 patients with malignant tumors other than infiltrating duct adenocarcinoma of the pancreas are alive with a median survival time of 40 months (3-92 months). Forty-three per cent were Stage I but more than half were T3 or T4 lesions. Twenty-five per cent of patients with Stages II or III are alive. Twenty per cent of patients with infiltrating duct carcinoma of the pancreas are presently alive, 28% died of recurrent disease, and 26% died of other causes; more than 90% of these patients had advanced stage disease (Stage II or III).     

成人 Xp11．2易位/TFE3基因融合相关性肾癌的临床分析

目的：探讨成人 Xp11．2易位/TFE3基因融合相关性肾癌的临床特点和诊治方案.方法结合文献,回顾性分析2009年5月至2015年6月我院收治的8例经病理检查确诊为Xp11．2易位/TFE3基因融合相关性肾癌成人患者的临床资料.结果8例患者结合组织病理学和免疫组化结果得以确诊,均行手术治疗,3例辅助靶向治疗,术后随访3~69个月,5例无瘤存活,3例复发死亡.结论 Xp11．2易位/TFE3基因融合相关性肾癌是一种罕见的肾癌亚型,成年患者预后欠佳,早期诊断、积极治疗、密切随访能有效改善预后.     

Cervical interventions on the airway and esophagus in infiltrating thyroid cancer]

In 1989 und 1990 a resection within the region of the cervical airways and/or oesophagus was performed for an infiltrating tumor in 9 out of 95 patients (9.5%) suffering from thyroid carcinoma and in one patient with lymph node metastases from a carcinoma of the uterine cervix. There was no operative mortality. One patient died six weeks after resecting the anterior wall of the trachea of an intratracheal arterial bleeding due to radiation therapy. In one case the reconstruction of the trachea was performed with autologous material, in three patients alloplastic material was used. The oesophagus was reconstructed preferably by means of free microvascular jejunum autografts (n = 4), using a colon interposition in another two patients. In locally advanced differentiated and medullary thyroid carcinoma curative operations of the cervical hollow organs using microsurgical techniques can be performed with an acceptable operative risk and good functional results. They may markedly improve the otherwise limited prognosis of the disease.     

Laryngeal involvement by differentiated thyroid carcinoma

BACKGROUND: Invasion of the larynx by differentiated thyroid gland carcinoma is uncommon but causes serious morbidity and mortality when present. METHODS: The clinicopathologic characteristics of 5 patients in which a total laryngectomy had to be performed for differentiated thyroid carcinoma are analyzed. Special reference is paid to the histologic intralaryngeal tumor spread, which is evaluated on whole-organ section. RESULTS: All patients presented with hoarseness and/or dyspnea. Two patients are alive at 44 and 115 months. One patient died of intercurrent disease 2 months and 2 patients with disease 6 and 14 months after surgery. In all cases, intralaryngeal tumor spread was observed. Invasion of the larynx occurs by direct extension or by posterior tumor growth around the edge of the thyroid cartilage. CONCLUSION: In rare cases, differentiated thyroid carcinoma can widely infiltrate the larynx, making total laryngectomy unavoidable. The diagnosis of intralaryngeal tumor spread is done by imaging and endoscopy.     

Usefulness of chemotherapy as prophylaxis of tumor recurrence after liver transplantation in advanced hepatocellular carcinomas

INTRODUCTION: The effectiveness of chemotherapy as prophylaxis of tumor recurrence after liver transplantation in patients with advanced hepatocellular carcinoma is controversial. AIM: Our goal was to assess the outcomes of patients with advanced hepatocellular carcinoma treated with chemotherapy after liver transplant. METHODS: Ten patients with liver transplants performed between 1993-2002 were men of mean age 55 years. The etiology of cirrhosis was hepatitis C in four patients, alcoholic cirrhosis in four, and cryptogenic cirrhosis in two. Immunosuppressive therapy was cyclosporine in five patients and tacrolimus in five. The chemotherapy regimen used adriamycin (20 mg/m2 weekly for 20 weeks). Six patients were stage IVA and four stage III. Hepatocellular carcinoma was known in five patients and incidental in the other five. Pathology revealed well-differentiated hepatocellular carcinoma in six patients and moderately differentiated hepatocellular carcinoma in four. Five patients had vascular invasion. RESULTS: After a mean posttransplant follow-up of 28 months, six patients (60%) were alive without tumor recurrence, three (30%) had died from tumor recurrence and one due to P. carinii pneumonia. Disease-free survival among patients with stage III was 50% and 80% for stage IVA. Three patients with vascular invasion died of tumor recurrence, and the other two are alive and free of disease. Disease-free survival rates were 83% in patients with well-differentiated hepatocellular carcinoma and 25% in those with moderately differentiated hepatocellular carcinoma. Tolerance of chemotherapy was good with two withdrawals due to nephrotoxicity and myelotoxicity and one death from pneumonia. CONCLUSION: The use of adriamycin in patients undergoing liver transplant due to advanced hepatocellular carcinoma may be useful to prevent tumor recurrence; it is well tolerated. The presence of vascular tumor invasion and a lower grade of histologic differentiation were associated with a poor prognosis.     

Clinical and histological differences in anaplastic thyroid carcinoma.

OBJECTIVE: To report our experience in patients with anaplastic thyroid carcinoma and try to establish differences between cases in which the histological study showed that there was an associated thyroid carcinoma and those that were strictly anaplastic or pure. DESIGN: Retrospective study. SETTING: University hospital, Spain. SUBJECTS: 14 patients with anaplastic thyroid cancer treated over a period of 26 years; 7 presented with associated thyroid tumours and 7 were pure. MEAN OUTCOME MEASURES: Clinical data (age, sex, symptoms), treatment, histological study (associated thyroid disease, spread, involved lymph nodes) and follow-up. RESULTS: 13 of the 14 tumours had spread locally. 5 patients were treated by total thyroidectomy, 3 subtotal thyroidectomy, 5 excision of the tumour, and 1 patient had a biopsy alone. There were associated thyroid tumours in 7 cases: 2 follicular, 2 tall cell papillary, 1 solid papillary, 1 medullary and 1 Hurthle cell tumour. 12 patients died. Another 2 are still alive having survived 61 and 70 months respectively, both with associated anaplastic cancers (follicular and solid). The mean survival was 14 months (24 for associated anaplastic carcinoma and 4 for pure anaplastic carcinoma). CONCLUSION: There is a subgroup of anaplastic cancers in which a better differentiated thyroid carcinoma coexists with the anaplastic carcinoma. The prognosis in this subgroup is better than that for primary pure anaplastic carcinoma.     

Radical operation for thyroid carcinoma invading the trachea

We report 12 cases of well-differentiated thyroid carcinoma that invaded the trachea. In all of these cases, we performed a hemithyroidectomy, including the isthmus, with an accompanying neck dissection and resection of the trachea. Six of 12 patients experienced hemoptysis, and a diagnosis of tracheal invasion was made preoperatively in nine patients by tracheal endoscopy and computed tomography. Histologic diagnosis was confirmed by a preoperative biopsy in one case only. An end-to-end anastomosis of the trachea was performed in five patients, an anastomosis between the cricoid cartilage and the trachea was performed in five patients, and an anastomosis between the thyroid cartilage and the trachea was performed in two patients. One patient with a recurrence of tumor died of tracheal bleeding 11/2 years later. One patient died of massive gastrointestinal bleeding postoperatively. The remaining ten patients have been doing well from three months to five years two months postoperatively.     

Anaplastic carcinoma in mucinous ovarian tumors: a clinicopathologic study of 34 cases emphasizing the crucial impact of stage on prognosis, their histologic spectrum, and overlap with sarcomalike mural nodules

Several types of mural nodules may develop in the wall of mucinous tumors of the ovary. The histopathologic features and prognosis of foci/nodules of anaplastic carcinoma are not well known. Although they were first thought to carry an invariably unfavorable prognosis, recent data indicate that this does not necessarily apply to stage Ia tumors. Slides from 34 consultation cases of mucinous ovarian tumors with foci/nodules of anaplastic carcinoma were reviewed and classified on the basis of their morphologic features. Cytokeratin stains were done in selected cases. Staging, treatment, and follow-up information were obtained. The foci/nodules of anaplastic carcinoma were classified histologically into 3 groups: (a) rhabdoid (n=12) having a diffuse arrangement of cells with large, bright, eosinophilic cytoplasms, eccentric nuclei, and one or more prominent nucleoli; (b) sarcomatoid (n=10) characterized by a spindle cell proliferation, with atypical and vesicular nuclei often with herringbone pattern; and (c) pleomorphic (n=12) exhibiting overlapping features of the first 2 categories. International Federation of Gynecology and Obstetrics (FIGO) stage was available in 31 cases: 15 were stage Ia, 6 stage Ic, 2 stage II, 7 stage III, and 1 stage IV. Follow-up was obtained in 21 cases. Seven patients died of the disease after a median time of 8 months: 3 stage IC, 1 stage II, 1 stage III, 1 stage IV, and the other was unstaged. Ten patients were alive and clinically free of disease after a median follow-up of 5 years: they were all stage Ia. Three patients (2 stages III and 1 stage IV) were alive with disease at 3 years, 9 months, and 7 months. The other patient (stage Ia) died of an unrelated cause. Thus, only 1 patient with stage Ia disease died, and she died of causes other than ovarian cancer. The presence of foci/nodules of anaplastic carcinoma in unruptured stage I mucinous tumors of the ovary does not necessarily carry an adverse prognosis. These foci/nodules may exhibit rhabdoid, sarcomatoid (spindle cell), or pleomorphic features.     

Histological appearance of carcinoma of the upper bile duct and the mode of its spread

The histopathology of 34 resected cases of carcinoma of the upper bile duct was reviewed in relation to its mode of spread and prognosis of the patients. The patients with papillary adenocarcinoma showed 3-year survival rate of 75 percent which was better than those with carcinoma of other histologic types. There were no 2-year survivals in patients with poorly differentiated adenocarcinoma. Infiltration to the serosa of the bile duct and to the liver, lymph node metastasis, and venous, lymphatic or perineural invasion of carcinoma were thought to be important prognostic factors, since the chance for survival was definitely better for patients without those factors than with those factors. In four patients with papillary adenocarcinoma, no involvement of hepatic parenchyma and lymph node metastasis was found. Three of these patients had no cancer infiltration to the serosa of the bile duct. Most cases of poorly differentiated adenocarcinoma, in contrast, had positive and extensive association of those prognostic factors. Seventy-five percent of patients with papillary adenocarcinoma and only 22 percent of those with poorly differentiated adenocarcinoma were microscopically considered curable by resection. It is noteworthy that histological appearance of carcinoma may be valid as a fundamental factor to determine mode of spread of carcinoma of the upper bile duct and prognosis of the patients.     

Parathyroid carcinoma: multicenter study of 17 patients

PURPOSE OF THE STUDY: To evaluate clinical characteristics and survival of patients treated for parathyroid carcinoma. STUDY DESIGN: A retrospective multicenter chart review of patients treated for parathyroid carcinoma between January 1979 and January 2005. RESULTS: 17 patients (10 women, 7 men) presenting with parathyroid carcinoma underwent surgical resection. Symptoms were largely related to hypercalcemia. Mean postoperative follow-up was seven years. Local recurrence was noted in four patients (24%) and three patients had late distant metastasis (18%). At the end of the study, nine patients were alive without evidence of recurrence (53%) and one patient was alive with recurrence at 5 years. Seven patients had died, four of whom died as a result of their parathyroid disease. CONCLUSION: Even when symptoms and findings are suggestive, the diagnosis of parathyroid carcinoma is oftentimes difficult. An adequate resection at the first intervention (complete tumor resection including a homolateral thyroid lobectomy and parathyroidectomy with resection of central lymph nodes) is recommended.