人淋巴结支架中血管三维结构重建的病理意义

淋巴结支架包括血管、淋巴管和网状支架。目前国内对人淋巴结支架三维结构的研究不多见。淋巴结内的血管具有特殊性,在整个支架系统中的作用相对重要一些,也是研究的重点。利用计算机重建其组织切片的三维结构,建立一个直观又清晰的血管三维关系图,为病理诊断及临床治疗提供可靠的依据。     

The use of Doppler ultrasound in evaluation of breast cancer metastasis to axillary lymph nodes

The formation of microvessels in tumors by angiogenesis is considered to be an important prognostic factor, and closely correlates with lymph node metastasis. We used color Doppler ultrasound to examine the relationship between the amount of blood vessels in tumors and pulsatility index (PI), and tumor size in breast cancers, with and without regional lymph node metastasis. Doppler ultrasound was performed on 80 patients with breast cancer prior to surgery. The concentration of vascular endothelial growth factor (VEGF) within the tumors was measured following surgery in 42 cases chosen at random. In the negative metastatic nodes group, the number of vessels in the tumor correlated positively with tumor diameter. In the positive metastatic nodes group, however, the number of blood vessels in the tumor did not correlate with tumor diameter. Differences in tumor vascularity between node positive and negative groups were useful in determining the status of node metastasis in subsequent analysis. Fifteen of 17 cases of tumors that measured <20 mm, and in which there were no blood vessels, were node-negative. There were no node-negative tumors measuring >20 mm in diameter (p=0.003). Conversely, in nodes with positive metastasis, blood vessels were observed in 5 of 7 tumors that measured <15 mm in diameter (p=0.019). These findings may be useful in estimating the likelihood of metastasis to regional lymph nodes. PI was directly proportional to tumor size in the negative nodes group (r=0.47). There was no such correlation in the positive nodes group. There was no correlation between VEGF concentration in the tumor and the number of blood vessels in that tumor. In conclusion color Doppler analysis of blood vessels appears to be useful in predicting lymph node metastasis, especially for small tumors.     

Lymph node metastases in patients with cutaneous melanoma: improvements in diagnosis by signal-enhanced color Doppler sonography

The purpose of the study was to evaluate whether signal-enhanced color Doppler sonography (CDS) is superior to native CDS in detection of characteristic vascularity patterns that are important for the differentiation between benign and malignant lymphadenopathy in patients with cutaneous melanomas. Twenty-two melanoma patients presenting with 24 structures suspicious for metastases in B-Mode sonography were examined using native and signal-enhanced CDS in a prospective two-center study. Presumptive sonographic diagnoses were compared with results of histopathological and follow-up examinations. Signal-enhanced CDS gave additional information about vascularization of lymph node metastases and reactive lymph nodes, which was indicative for the differential diagnosis in 12 of 24 examinations. For lymph node metastases, signal enhancement improved the visualization of accessory peripheral vessels in four of 10 examinations. Concerning reactive lymph nodes, hilar vessels in part with branching to the lymph node periphery could be better identified after application of the contrast enhancer in eight of 13 examinations. Signal-enhanced CDS is demonstrated as an important additional diagnostic tool for improved differentiation between malignant and reactive lymph nodes and may be of special value in preventing unnecessary lymphadenectomy in small reactive lymph nodes.     

Contributions of vascularized lymph-node metastases to hematogenous metastasis in a rat mammary carcinoma

Rats received hind-foot-web (FWI) injections of MT-100-TC mammary carcinoma cells; the resultant tumor metastasized first to the popliteal lymph nodes. Over the course of 4 weeks, in association with increases in tumor weight, the blood-flow to the popliteal nodes increased 18-fold, and their vascular densities increased 2-fold. In spite of this vascularization, cancer cells were detected in only 3 of 648 blood vessels associated with involved, ipsilateral lymph nodes compared with intravascular cells in 82 of 314 vessels associated with "primary" foot-pad lesions. The presence of tumorigenic cancer cells in the right ventricular blood of animals bearing these tumors is, therefore, considered to result from their direct entry into blood vessels from the "primary" lesions, and/or from extra-nodal invasion of vessels in tissues to which nodal tumors were adherent, as distinct from passage via lymphatico-venous communications between tumors and nodal blood-vessels. The reconstructed events occurring in the rat model, with effective restriction of regional node metastases to the nodes themselves for a time, could possibly account for the long-term survival of some patients with breast cancer and regional-node metastases, following surgery.     

Internal mammary chain sentinel lymph node identification in breast cancer

BACKGROUND AND OBJECTIVES: Sentinel lymph node (SLN) biopsy is not usually performed with respect to the internal mammary lymph node chain. However, the SLN may be located in the internal mammary chain, particularly with medial lesions. We carried out this study to investigate whether lymphatic mapping and SLN biopsy can detect internal mammary involvement in patients with breast cancer. METHODS: A dye- and gamma probe-guided SLN biopsy was performed in a consecutive series of 41 patients with tumor in situ or clinical stage I or II breast cancer. After the biopsy, these patients underwent either a modified radical mastectomy or breast-conserving surgery including axillary lymph node dissection. Biopsy of internal mammary lymph nodes was performed in 19 of these patients. RESULTS: No involvement of internal mammary lymph nodes was found histologically in 5 patients in whom lymphatic flow or a "hot nodule" in the internal mammary chain was found using lymphoscintigraphy. Nodal involvement was demonstrated histologically in only 1 of 5 cases where lymphatic vessels showed dye staining or faintly stained nodes. Internal mammary lymph node biopsy also was performed in 14 of 36 patients with neither stained lymphatic vessels or nodes, nor with lymphatic flow or a hot nodule by lymphoscintigraphy. Nodal involvement was found histologically in 1 of these patients. CONCLUSION: SLN biopsy guided by lymphatic mapping is unreliable for identifying metastases to internal mammary lymph nodes.     

Prognostic significance of blood vessel invasion in carcinoma of the breast in women

Prognostic significance of blood vessel invasion in carcinoma of the female breast has been evaluated by study of 242 cases of radical mastectomy done at the Tata Memorial Hospital. The significance of axillary node involvement with the disease has been simultaneously evaluated. In the absence of blood vessel invasion and lymph node metastasis the 5 year survival rate was 98%. Compared with this, 5 year survival rate was reduced to 59% when the blood vessel invasion was present but no lymph node metastasis. Only 12% survived for 5 years when both blood vessels and lymph nodes were involved with the disease. The study indicated that blood vessel invasion in the primary breast carcinoma is more significant than lymph node metastasis.     

淋巴结内淋巴窦血管转化组织病理形态学特征

目的探讨淋巴结内淋巴窦血管转化(VTS)的组织病理形态学特征。方法7例VTS进行组织学观察,组织用福尔马林固定、石蜡包埋、HE染色。结果淋巴结结构弥漫性或局限性消失,血管增生伴泡沫状组织细胞浸润。增生的血管有四种基本类型厚壁型血管、裂隙状血管、海绵状血管、透明血管。结论淋巴结内淋巴窦血管转化为一增生性疾病,非真性肿瘤,主要应与淋巴结病型Kaposi肉瘤鉴别。     

Evaluation of lymphatic flow pattern using indocyanine green fluorescence imaging in a highly metastatic mouse model

Recently, the feasibility of real‐time indocyanine green (ICG) fluorescence imaging–guided complete mesocolic excision in colon cancer surgery has been demonstrated; however, its application to the evaluation of lymphatic flow in widespread lymph node metastasis is uncertain. This study aimed to evaluate lymphatic flow using the real‐time ICG fluorescence imaging. A mouse model of subcutaneous inoculation of BJMC3879Luc2 cells, which have been demonstrated to highly metastasize to the lymph nodes, was used as an evaluation model. Tumor growth and lymphatic flow were monitored weekly by bioluminescent imaging and near‐infrared (NIR) fluorescence imaging, respectively. After sacrificing the mice, lymph node metastases were evaluated by bioluminescent imaging and histopathology. Lymphatic flows in a model of high lymph node metastasis were evaluated using NIR fluorescence imaging. Pathological metastases of bilateral axillary, femoral, and para‐aortic lymph nodes were detected in all inoculated mice (100%: 5/5). Real‐time NIR fluorescence imaging showed the primary lymphatic vessels staining through the metastatic lymph nodes as before the inoculation of the cancer cells. Hitherto, it has been considered that lymphatic flow was changed using the bypass pathway due to occlusion of the primary lymphatic vessels. In this presented study, real‐time ICG fluorescence imaging showed no changes in lymphatic flow after lymph node metastasis. Our results suggest that real‐time ICG fluorescence imaging may have potential for the guidance of colon cancer surgery in cases of widespread lymph node metastasis.     

腹膜后恶性淋巴结肿大的超声声像图特征及其临床价值

目的 研究腹膜后恶性淋巴结肿大的超声声像图特征及其临床价值.方法对109例癌症患者伴腹膜后恶性淋巴结肿大进行超声检查.结果晚期胃癌、肝癌、胰腺癌、胆囊癌、卵巢癌、食道癌、回盲部及结肠癌均可伴发腹膜后淋巴结肿大,表现淋巴结宽径明显增大、内部回声片状增强、变形、挤压血管、粘连等.结论对恶性淋巴结肿大声像图特征(淋巴结左右径增大,L/S＜2,边界不规则,内部回声片状或云雾状增强,淋巴门消失或变小,周围粘连)及发生部位进行分析,有利于提供肿瘤的定位定性诊断,为临床治疗方案提供依据,具有重要的临床意义.     

Clinical study about endoscopic inguinal lymphadenectomy for patients with vulvar carcinoma

Objective

The aim of this study was to explore the new method of inguinal lymphadenectomy in order to reduce side effects of conventional method for patients with vulvar carcinoma.

Methods

Lipolysis and liposuction were performed to subcutaneous fat on inguinal region. We inserted endoscope and filled with CO₂ gases to this field and then resected inguinal lymph nodes with ultrasonic scalpel. The operative field was placed with the vacuum sealing drainage and pressured with soft saline bag after the operation.

Results

Many lymphatic vessel, small blood vessels and hanging lymph nodes in the subcutaneous tissues of inguinal region were revealed after lipolysis and liposuction and lymph nodes can be easily removed. The follow-up so far showed that healing of the incision was good and there was no lymphedema of patient’s lower limb and inguinal region.

Conclusion

Endoscopic inguinal lymphadenectomy can resect the lymph nodes and keep most of the lymphatic vessels. So this technique has less influence on the lymph backflow of lower limb and inguinal region and can avoid the huge incision of conventional method. This method is worthy of further study.     

脂肪溶解液在乳腺癌腋淋巴结清除术中的应用

目的:探讨脂肪溶解液用于乳腺癌腋淋巴结清除术的可行性。方法:对30例术前扪及腋淋巴结肿大的乳腺癌患者行改良根治术,腋窝注射脂肪溶解液及脂肪抽吸后进行淋巴结清除术,术中均不用结扎血管,完整保留肋间臂神经、胸长神经及胸背神经。结果:平均完成手术时间70.3min,术中出血少,平均每例取出淋巴结16.3个,全部患者病理检查均有淋巴结转移,平均转移4.3个。所有患者术后均未出现明显的并发症,术后平均随访6个月,患者均无腋肿瘤复发、肩关节活动良好、上肢无水肿及麻痹等情况。结论:脂肪溶解液应用于腋淋巴结清除术时可使手术操作简单、省时、淋巴结清除多、神经血管损伤少及术后并发症少等优点,但对远期生存率的影响尚需进一步研究观察。     

Significance of nodal metastatic tumor characteristics in nodal metastasis and prognosis of patients with invasive ductal carcinoma of the breast

There is no study evaluating the significance of nodal metastatic tumor characteristics in tumor progression of invasive ductal carcinomas (IDCs) of the breast. The purpose of this study was to investigate whether nodal metastatic tumor characteristics play an important role in the tumor progression of IDCs. The subjects of this study were 205 IDC patients with nodal metastases. Significant associations with increased numbers of nodal metastases, and patient outcomes were evaluated by multivariate analyses, in comparison with well-known histological parameters. The numbers of lymph nodes with extra-nodal invasion and with extra-nodal blood vessel tumor emboli, the distance of extra-nodal blood vessel tumor emboli from the nodes, and the nodal tumor dimensions significantly increased the number of nodal metastases in the multivariate analysis ( P <0.001). Cox multivariate analyses showed that the parameters which significantly increased hazard rates (HRs) of disease-free survival (DFS), distant organ metastasis (DOM) and overall survival were 6 or more mi-totic figures of nodal metastatic tumors ( P <0.05). Six or more lymph nodes with extra-nodal invasion, and an extra-nodal blood vessel tumor emboli dimension of >0.6 mm significantly increased the HRs of DFS and DOM in multivariate analyses ( P <0.05). The present study demonstrated the important roles of nodal metastatic tumors in the tumor progression of IDCs. (Cancer Sci 2003; 94: 181–187)     

Fully robotic total gastrectomy with D2 lymphadenectomy for gastric cancer

PurposeRobotic surgery with technical advantages was shown to make complex maneuvers easier and more precise for gastric surgery [1]. This video demonstrates our technique on robotic total gastrectomy with the da Vinci Xi platform for gastric cancer.Methods68-year-old female was presented with persistent epigastric abdominal pain and underwent upper endoscopy showed ulcerated mass extended from the cardia to the lesser curvature. Histopathology showed gastric adenocarcinoma. After patient received neoadjuvant chemotherapy, decision was made to proceed with surgery.ResultsInitially, greater curvature dissection was started by division of the gastrocolic ligament with entering the lesser sac with monopolar scissors and bipolar forceps. The right gastroomental vessels were identified and divided at their root along with lymph nodes. After ligation of the right gastric vessels, dissection was extended to retrieve lymph nodes around the left gastric vessels. Duodenum was circumferentially dissected and transected 2 cm distal to the pylorus. Subsequently, extended lymphadenectomy was started with suprapancreatic lymph node dissection to retrieve lymph nodes around the common hepatic artery and celiac axis. Spleen-preserving dissection of the lymphatic tissue of the distal splenic artery and the splenic hilum was performed. The distal esophagus was divided with robotic stapler. Fully robotic end-to-side esophagojejunal anastomosis was constructed. For the reconstruction of gastrointestinal continuity after total gastrectomy, side-to-side jejuno-jejunal anastomosis was performed. Total operative time was 5 hours and estimated blood loss was 20 cc.DiscussionTotally robotic gastrectomy with D2-lymphadenectomy is a safe technique for gastric cancer and provides intracorporeal suturing in reconstructing the anatomy.     

Lung cancer and lymph drainage]

Lung cancer is lymphophile and may involve lymph nodes (LN) belonging to lung lymph drainage. LN metastases are figured within stations numbered 1 to 14. These stations are located along lymph vessels. The lymph vessels and the LN are forming together anatomical chains. Lymph vessels are valved and pulsatile and travel to the cervical venous confluence where they pour the lung lymph into the blood circulation. They may be totally or partly nodeless along their travel, anastomose with each other around the trachea, and connect with the thoracic duct within the mediastinum. Within the anatomical LN chains, LN are variable in number and in size from one individual to another. They may be absent from one or several stations of the international mapping. Stations are located along the anatomical chains: pulmonary ligament (9), tracheal bifurcation(8 and 7), right paratracheal (4R, 2R and 1), preaortic (5 and 6), left paratracheal (4L, 2L and 1). Station 3 is located on 2 differents chains (phrenic and right esophagotracheal). Station 10 are located at the beginning of the mediastinal lymph nodes chains. Each chain connects with the blood circulation, anastomoses with he neighbouring chains and behave as an own entity whatever the number of its LN. International station mapping misknowns this anatomy and occults the true pronostic value of lung lymph drainage.     

弥漫大B细胞淋巴瘤化疗后残余淋巴结性质分析

目的探讨弥漫大B细胞淋巴瘤（DLBCL）化疗后残余淋巴结的血流动力学状态、病理、影像及超声学改变,评价淋巴结性质及其与临床治疗的关系。方法分析50例经足疗程（R-CHOP方案6-8个疗程）化疗后有残余淋巴结存在的DLBCL患者,对其进行彩色多普勒超声检查,行超声引导下的淋巴结穿刺活组织检查,部分患者残余淋巴结与PET—CT结合,分析残余淋巴结性质。结果50例DLBCL的患者足疗程化疗后,彩色超声共发现64枚淋巴结。其中42例患者53枚残余淋巴结未见动脉血流,病理活组织检查HE染色符合临床完全缓解标准。另8例患者11枚淋巴结超声提示淋巴结周边型血流;同时PET-CT显示这些淋巴结的标准摄取值较高,提示组织处于高代谢状态,与超声动力学状态相符合;选取残余淋巴结再行活组织检查HE染色,可见淋巴结残余病灶组织,未见肿瘤组织。42例治疗有效的患者治疗后残余淋巴结为治疗后炎性反应或是纤维组织增生。结论经足疗程化疗后的患者淋巴结可持续存在,超声与PET．CT检查对恶性淋巴瘤残余病变的诊断有较好的准确性,化疗后4周复查彩色超声示淋巴结长径〉1．5om、血流信号呈中心型血流或者周边型,可行PET,CT检查作为评价肿瘤残余性质的参考指标。     

降低乳腺癌术后淋巴水肿新技术——腋窝反向淋巴制图的研究进展

腋窝反向淋巴制图(axillary reverse mapping, ARM)技术是指在腋窝淋巴结切除术(axillary lymph node dissection, ALND)和/或前哨淋巴结切除术(sentinel lymph node dissection, SLND)中显示上肢淋巴管道并对其予以保护, 从而降低术后上肢淋巴水肿发生率, 是针对乳腺癌手术治疗的一项新兴技术, 目前仍处于临床试验阶段。本文回顾了近年来国外相关临床试验, 分析ARM淋巴结和淋巴管的显示方法, 评估保留ARM淋巴结和淋巴管的可行性, 评价ARM技术对降低乳腺癌术后上肢淋巴水肿发生率的临床意义。      

The subperitoneal space, mechanisms of tumour spread in the peritoneal cavity, mesentary, and omentum.

The subperitoneal space consists of fatty tissue, blood vessels, lymphatics, and lymph nodes enveloped by a serosal lining. This provides a complex interconnecting space which is an important conduit for pathology within the peritoneal cavity. The anatomy and pathology of the subperitoneal space and the surrounding cavity is discussed in its relationship to tumor spread.     

Flt-4-positive vessel density correlates with vascular endothelial growth factor-d expression, nodal status, and prognosis in breast cancer.

PURPOSE: Metastasis to the regional lymph nodes through the lymphatic vessels is a common step in the progression of cancer and an important prognostic factor in many types of cancer. Recent evidence suggests that tumor lymphangiogenesis promotes lymphatic metastasis, and that the presence of Flt-4 on tumor blood and lymphatic vessels may play a important role in mediating lymphangiogenic factor-induced neovascularization. We assessed flt-4-positive vessel density (FVD) in breast cancer, and examined whether FVD associates with lymph node metastasis, VEGF-D expression, or prognosis. EXPERIMENTAL DESIGN: One hundred three invasive breast carcinomas with long-term follow-up were included in our study. Flt-4 was assessed using immunohistochemistry, then we analyzed the relationship between FVD and lymph node status, as well as VEGF-D expression and other established clinicopathological parameters. The relationship between FVD and prognosis was also investigated. RESULTS: Mean FVD of "hot spot" was 29.3 +/- 22.5 for each case. FVD was correlated significantly with lymph node metastasis (P < 0.0001), VEGF-D expression (P = 0.0019), tumor size (P = 0.0015), estrogen receptor (P = 0.0211), progesterone receptor (P = 0.0462), and c-erbB-2 (P = 0.0326). Survival curves determined by the Kaplan-Meier method and univariate analysis demonstrated that high FVD was associated with both worse disease-free survival (P = 0.0035) and overall survival (P = 0.0336). CONCLUSIONS: Increased FVD was correlated with lymph node metastasis and VEGF-D expression. High FVD may be a significant unfavorable prognostic factor for long-term survival in breast cancer. It is possible that Flt-4 becomes a target for antiangiogenic therapy to breast cancer.