低位直肠癌选择性侧方淋巴结清扫研究进展

盆腔侧方淋巴结(Lateral pelvic lymph node,LPLN)是低位直肠癌患者常见的局部转移部位,同时也是术后局部复发的主要部位,然而目前对于LPLN转移的治疗方案仍没有明确的定论.同时LPLN的转移应被看作是局部而不是全身,新辅助放化疗(Chemoradiotherapy,CRT)并不能替代手术清扫,...     

低位直肠癌侧方淋巴结清扫的进展与争论

直肠癌是最常见的消化道恶性肿瘤之一,近年来发病率呈上升趋势,目前是我国第4位高发的恶性肿瘤,上海市的第3位高发的恶性肿瘤[1],其中低位直肠癌约占所有直肠癌的70%[2]。低位直肠癌病死率较高,原因是多方面的,如血道播散、淋巴结转移及局部复发等,其中淋巴结转移是主要的原因。对于直肠癌的治疗,外科手术切除仍然是最有效的手段。     

低位直肠癌侧方淋巴结清扫术的价值综述

直肠癌是常见的下消化道恶性肿瘤之一，外科手术是目前主要的治疗方法。但局部复发及转移又是术后残废的主要原因。低位直肠癌病死率较高，其原因是多方面的（如血道播散、淋巴转移及局部复发），其中淋巴结转移是主要的原因。目前学术界对低位直肠癌行全直肠系膜切除（total mesorectal exeision，TME）以求根治达成共识，但对其侧方淋巴结的清扫能否降低患者复发率及提高术后的生存率存在分歧。     

国外低位直肠癌侧方转移淋巴结的清扫

目前国外对腹膜反折下低位进展期直肠癌的外科治疗研究集中在手术方式的合理选择、切除肿瘤远端肠管范围和保留肛门括约肌手术。有关清扫区域淋巴结转移范围 ,特别是侧方（平行）淋巴结转移的清扫不断增加。为了深入了解对局部复发率高的低位直肠癌术后复发的控制程度及提高５年生存率 ,本文对国外的有关进展作一概述。１直肠癌侧方淋巴结的转移率腹膜反折下（Ｒｂ）直肠的淋巴引流 ,虽主要向上方但也向下方和两侧髂内血管淋巴结输出 ,因而直肠癌发生部位的划分 ,应以腹膜反折为界（距肛缘约７ｃｍ左右）较为合理、实用。从局部解剖学角度而…     

全直肠系膜切除术联合侧方淋巴结清扫术治疗中低位直肠癌侧方淋巴结转移的疗效

目的:探讨侧方淋巴结清扫术(lateral lymph node dissection, LLND)对侧方淋巴结(lateral lymph node, LLN)转移直肠癌患者的治疗价值和LLN转移位置对生存预后的影响。方法:自2015年01月至2020年01月,回顾性收集分析在中国医学科学院肿瘤医院行全直肠系膜切除术(total mesorectal excision, TME)+LLND的临床怀疑LLN转移的中低位直肠癌患者与同时期行TME根治性切除的直肠癌患者的资料。根据手术方式,分为TME+LLND组(n=129)与TME组(n=362)。倾向得分匹配后,两组各有125例患者成功匹配。本研究的长期随访终点是3年局部复发率(local recurrence, LR)和3年无复发生存率(recurrence-free survival, RFS)。结果:TME+LLND组手术时间明显长于TME组(356.1 vs 244.8 min,P<0.001),而术后并发症并无明显增加(16.0 vs 12.0,P=0.362)。预后方面,TME+LLND与TME两组间3年LR率无明显...     

侧方淋巴结清扫在低位直肠癌治疗中的临床意义

外科手术仍是治疗直肠癌最主要的手段.直肠癌根治术的失败原因多为血道播散、淋巴转移和局部复发,这些因素都是危及直肠癌患者术后生活质量的问题.我院自1997年起开始对低位直肠癌淋巴结转移规律进行研究,现就侧方淋巴结清扫(侧方清扫)在低位直肠癌治疗的临床意义加以总结.     

中低位直肠癌伴盆壁淋巴结肿大的处置争议与思考

目的 对中低位直肠癌盆壁淋巴结肿大的流行病学、诊断及治疗进行综述。方法 检索2020-01-01-2023-03-01中国知网和PubMed中低位直肠癌盆壁淋巴结或侧方淋巴结相关文献。中文检索词为“直肠癌、盆壁淋巴结、侧方淋巴结”,英文检索词为“rectal cancer, pelvic lymph node, lateral lymph node”。共检索到相关文献151篇。纳入标准：(1)盆壁淋巴结的解剖、引流和影像学研究;(2)盆壁淋巴结或侧方淋巴结的相关临床研究及综述。排除标准：低质量文献。根据纳入和排除标准,最终纳入46篇文献(中文7篇,英文39篇)。结果 中低位直肠癌常伴有盆壁淋巴结肿大。盆壁淋巴结作为侧方淋巴结的一部分,影像学检查中根据其直径、形态和信号判断其转移的风险。但其灵敏度和特异度较差,故目前临床上尚无统一的诊断标准。盆壁肿大淋巴结的治疗有新辅助放化疗、侧方淋巴结清扫(LLND)以及新辅助放化疗+LLND 3种策略。对于无高危因素的直肠癌患者不推荐行预防性LLND。针对新辅助放化疗后淋巴结的变化情况,采取个体化治疗,行全直肠系膜切除术(TME)+LLND或单纯行T...     

与腹膜返折以下直肠癌侧方淋巴结清扫的几个相关问题探讨

淋巴转移是直肠癌主要的扩散途径之一,如不进行合理的淋巴结清扫将会造成局部复发的危险,影响生存率。但是近20年来国内的同道们针对淋巴结清扫范围问题一直在不停地争论,焦点主要是扩大淋巴结清扫,尤其是侧方淋巴结清扫是否必要。尤其近年来腹腔镜应用于癌症的治疗逐渐开展,这     

102例直肠癌侧方淋巴结转移患者临床病理特点及生存预后分析

Objective To investigate the therapeutic effect and prognostic significance of lateral lymph node dissection (LPLND) in patients with lateral lymph node (LPLN) metastasis. Methods The clinicopathological data of rectal cancer patients who underwent total mesorectal excision (TME) combined with LPLND and pathologically confirmed as LPLN metastasis after operation were retrospectively analyzed. The clinicopathological characteristics and metastasis rules of patients with LPLN metastasis were discussed, and the survival prognosis after LPLND was analyzed. Results A total of 102 rectal cancer patients with pathologically confirmed LPLN metastasis were included. The common sites of LPLN metastasis were internal iliac vessels lymph nodes (n=68, 66.7%), followed by obturator lymph nodes (n=44, 43.1%), and common iliac vessels or external iliac vessels lymph nodes (n=12, 11.8%). There were 10 patients (9.8%) with bilateral LPLN metastases, and the mean number of LPLN metastases was 2.2±2.4, among which 16 patients (15.7%) had LPLN metastases number≥2. The 3-year OS (66.8% vs. 7.7%, P<0.001) and DFS (39.1% vs. 10.5%, P=0.012) of patients with LPLN metastases to the external iliac or common iliac lymph node were significantly lower than those with metastases to the internal iliac or obturator lymph node. The multivariate analysis showed that LPLN metastasis to external iliac or common iliac lymph node was an independent risk factor both for OS (HR=3.53; 95%CI: 1.50-8.31; P=0.004) and DFS (HR=2.40; 95%CI: 1.05-5.47; P=0.037). Conclusion LPLN mainly metastasizes to the internal iliac or obturator lymph node areas. The survival of patients with metastasis to the external iliac or common iliac lymph node cannot be improved by LPLND, and thus systemic comprehensive treatment is often the optimal treatment option. © 2023, CHINA RESEARCH ON PREVENTION AND TREATMENT. All rights reserved.     

低位直肠癌淋巴结转移的分析

目的:探讨腹膜返折以下直肠癌淋巴结转移的规律及其临床价值.方法:对行侧方淋巴结清扫的182例低位直肠癌病人进行回顾性分析.结果:腹膜返折以下直肠癌存在侧方淋巴结转移,转移率为16%,低分化腺癌及粘液腺癌侧方淋巴结转移率高.结论:侧方淋巴结转移是腹膜返折以下直肠癌淋巴转移的重要途径,低位进展期直肠癌应在上方淋巴结清扫的同时行侧方淋巴结清扫.     

胃癌行腹主动脉旁淋巴结清扫的研究进展

手术治疗是治疗胃癌的主要方式之一,标准的术中淋巴结清扫尤为重要。关于胃癌患者是否行腹主动脉旁淋巴结清扫（para-aortic lymph node dissection,PAND）仍存在争议。预防性PAND的意义被否定,但治疗性PAND的效果还有待进一步的研究去证实。术前化疗联合规范的手术治疗可能是未来进展期胃癌伴腹主动脉旁淋巴结转移的标准治疗模式。本文就胃癌行PAND的研究进行综述,以期为临床实践提供指导。      

直肠癌侧方淋巴结清扫和全直肠系膜切除

目前全直肠系膜切除（TME）原则已经是直肠癌手术的基本原则之一。很多学者把TME作为金标准,但不可将TME和侧方淋巴结清扫混为一谈。不可以因为TME而废除淋巴结清扫,也不可以因行淋巴结清扫而不行TME,只有二者同时进行才可达到根治肿瘤的目的。     

经“Ｈｏｌｙｐｌａｎｅ”间隙保留盆腔自主神经侧方淋巴结清扫术的临床观察

目的　探讨经“Ｈｏｌｙｐｌａｎｅ”间隙保留盆腔自主神经（ＨＰＡＮＰ）侧方淋巴结清扫术在男性直肠癌低位保肛术中的临床应用价值。方法　比较传统手术与ＨＰＡＮＰ侧方淋巴结清扫术在男性直肠癌低位保肛术中的应用情况,对各组患者的排尿功能、性功能、局部复发率和３年生存率等指标进行分析、评价。结果　ＨＰＡＮＰ侧方淋巴结清扫术组肿瘤下缘距肛门距离较传统手术组明显缩短（Ｐ＜０.０５）;术后排尿障碍、勃起障碍、射精障碍的发生率均低于传统手术组,组间比较差异有统计学意义（Ｐ＜０.０５）;ＨＰＡＮＰ手术术式分型与排尿障碍、勃起障碍、射精障碍分级之间呈正相关（Ｐ＜０.０５）;两组３年生存率无明显差异;局部复发率ＨＰＡＮＰ组明显低于传统手术组（Ｐ＜０.０５）。结论　ＨＰＡＮＰ侧方淋巴结清扫术对降低局部复发率、预防术后排尿障碍、勃起障碍、射精障碍等有较好的临床价值。     

微粒子炭在直肠癌手术中对淋巴结清除的指导作用

目的:探讨微粒子炭在指导直肠癌手术中淋巴结清除的临床意义。方法:采用前瞻性病例对照研究,患者随机分组:40 例直肠癌患者术前经肠镜局部注射微粒子炭后行直肠癌根治术,40例仅行常规直肠癌根治术作为对照组。所有病例记录清除的淋巴结数并做病理检查。结果:术中被黑染的淋巴结清晰可辨;注墨组平均每例清除淋巴结数为(24. 6±4. 2)个,对照组为(15. 1±2. 6)个,P=0. 003 7;淋巴结转移病例中,注墨组平均每例清除转移淋巴结(7 .8±1 .7)个,对照组(4. 2±2. 0)个,P=0. 004 5;注墨组总的淋巴结黑染率62 .0%, 转移淋巴结黑染率66. 4%。结论:局部应用微粒子炭对指导直肠癌手术中的淋巴结清除具有统计学意义。     

A case of lateral lymph node metastasis of submucosal rectal cancer

We report a case of lateral lymph node metastasis of submucosal rectal cancer. A 54-year-old man was pointed out with stool occult blood reaction positive. Screening colonoscopy revealed an 18 mm 0-Is rectal cancer in Rb 6 cm from anal verge. Endoscopic mucosal resection (EMR) was performed. Tumor appeared to be well treated, but pathological findings demonstrated the tumor invasion into submucosally (1,300 μm) with lymphovascular invasion ie ly (+) and v (+). Laparoscopic low anterior resection was then performed and no metastasis of lymph nodes (pSM, N0/stage I) was found. But he suddenly had an elevation of CEA (4 ng/mL to 26 ng/mL) after 14 months and following MRI and PET-CT revealed a recurrence in a right lateral lymph node (#283). Chemoradiation therapy (CRT) with CPT-11, UFT and LV was performed. After CRT, lateral lymph nodes and para aortic lymph nodes dissection were performed. Despite of the chemotherapy, he died after 13 months from a recurrence of lateral lymph node metastasis.     

Extent of lymph node dissection in rectal carcinoma

Basing on 170 specimens of advanced rectal cancers radically resected, metastatic rule and extent of lymph node dissection were studied in order to guide future surgical treatment. In 170 cases, 77 had lymph node metastases. The lymph node metastatic rate was 45.3% and metastatic degree was 8.9% (527/5 912). Metastasis of the rectal cancer, according to the lymphatic anatomy, can be divided into upward, lateral and downward drain. Because the rectal cancer at any site can lead to the upward metastasis, the upward lymph node dissection, up to the base of inferior mesenteric artery (the third line of lymph nodes), must be done in all rectal cases, otherwise, 10% of patients would have residual cancer. In view of the lateral metastasis occurring only in rectal cancers under the peritoneal reflection, for which lateral lymph node dissection is necessary or one eighth of patients would have residual lesion. Generally, no lateral lymph node dissection is needed in cancers above the peritoneal reflection. Pathologic factor influencing the lymphatic metastasis is the form of tumor growth, such as poorly differentiated and mucoid adenocarcinomas aggressively growing deeply and extensively resulting in a higher lymph node metastatic rate, for which lymph node dissection must be performed.     

Lateral lymph node dissection in rectal cancer: State of the art review

Half of the local regional recurrences from rectal cancer are nowadays located in the lateral compartments, most likely due to lateral lymph node (LLN) metastases. There is evidence that a lateral lymph node dissection (LLND) can lower the lateral local recurrence rate. An LLND without neoadjuvant (chemo)radiotherapy in patients with or without suspected LLN metastases has been the standard of care in the East, while Western surgeons believed LLN metastases to be cured by neoadjuvant treatment and total mesorectal excision (TME) only. An LLND in patients without enlarged LLNs might result in overtreatment with low rates of pathological LLNs, but in patients with enlarged LLNs who are treated with (C)RT and TME only, the risk of a lateral local recurrence significantly increases to 20%. Certain Eastern and Western centers are increasingly performing a selective LLND after neoadjuvant treatment in the presence of suspicious LLNs due to new scientific insights, but (inter)national consensus on the indication and surgical approach of LLND is lacking. An LLND is an anatomically challenging procedure with intraoperative risks such as bleeding and postoperative morbidity. It is therefore essential to carefully select the patients who will benefit from this procedure and where possible to perform the LLND in a minimally invasive manner to limit these risks. This review gives an overview of the current evidence of the assessment of LLNs, the indications for LLND, the surgical technique, pitfalls in performing this procedure and the future studies are discussed, aiming to contribute to more (inter)national consensus.     

Role of lymph node dissection in management of bladder cancer

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) is the gold standard for treatment of muscle-invasive bladder cancer. Recent retrospective series suggest that extended PLND provides a survival benefit, probably by removing undetected micrometastases. There have been several studies suggesting the survival benefit of extended PLND, not only for patients with node-negative disease but also for those who are node positive. The optimal boundaries of PLND seem to be at least up to the level of aortic bifurcation, including Marcille’s fossa, under the present circumstances. Because retrieval of more lymph nodes may help to improve the prognosis of patients, careful approaches should be considered both surgically and pathologically. PLND should be performed for all patients who undergo RC. Prospective randomized studies will give us the answer to the question of whether extended PLND should be performed routinely.