The value of surgical staging in the early stages of ovarian carcinoma

The value of surgery in early ovarian cancer was assessed in a retrospective analysis of prognostic factors in all 222 patients with primary stage I epithelial ovarian carcinoma treated in this department between 1975 and 1987. Only cellular differentiation grade (p less than 0.03) and surgical procedure - total abdominal hysterectomy, bilateral salpingo-oophorectomy +/- omentectomy vs. unilateral salpingo-oophorectomy - (p less than 0.02) were of significant influence on estimated survival (Cox model). All other factors (age, FIGO stage, integrity of the capsule, uni-vs. bilaterality, histology) were of no prognostic importance. Unilateral salpingo-oophorectomy without any additional staging reduces the 5-year survival probability (62% vs. 84%). Future prospective studies on adjuvant therapy must be based on exact staging during surgical management before randomisation. Determination of cellular differentiation is also essential.     

Potential for cure in ovarian cancer

There has been steady progress in improving the survival stage by stage for women with ovarian carcinoma. Part of this is the "Will Rogers" phenomenon: the improvement in results among two groups by movement of a subset of patients from one stage to the other stage. For those stage I patients at low risk (stage I-A1, I-B1, well or moderately differentiated) for recurrence, the exceeding of 90% survival rates in these carefully staged patients without postoperative radiation or chemotherapy represents significant progress in comparison to results a decade ago. Moreover, those patients thought to be stage I or II but found to have upper abdominal metastasis by careful surgical staging will now receive the best therapy for stage III ovarian cancer. The combination of the small volume of upper abdominal tumor discovered in these latter patients and the effects of receiving the best therapy for stage III disease should result in improved survival for this subset of patients. The impact of cisplatin-based chemotherapy has already impacted positively on improved survival for women with stage III and IV ovarian carcinoma. With more surgeons now trained in the techniques of debulking surgery in advanced ovarian carcinoma, the recent survival rates for patients receiving cisplatin-based chemotherapy should improve significantly in the next decade.     

Lymph node staging

Cancers of the head and neck (HNC) include cancers of the larynx, nasal passages/nose, oral cavity, pharynx, salivary glands, buccal regions, and thyroid. In these cancers, lymph node staging and localization of pathological lymph nodes are necessary to decide on either (neo) adjuvant or surgical therapy and are a major factor for the prognosis in HNC patients. Cervical node metastases have different incidence, and their presence is associated with a decrease in global survival to roughly half and with higher recurrence rates. The node metastases can be categorized in the following 2 groups: overt (clinical) or nonovert (occult). The latter can be subcategorized as metastases detectable by traditional methods (eg, staining) or "submicroscopic" metastases, only evident with immunohistochemical or molecular analysis. Compared with clinical invasive and laboratory examinations, which may have complications and are expensive, radiology plays an important role in lymph node staging. Mainly, the overt node metastases are the field of radiological imaging, and second, the detection of nonovert metastases is important and holds promise for the future because many patients of those initially classified as cN0 have, in fact, occult metastatic disease (pN1). Vice versa, radiological imaging has to avoid false-positive results that can lead to an elective or radical neck dissection, which are associated with increased morbidity and mortality and thus overshadow the improvement in survival. Radiological imaging plays a role not only as an initial staging of N+ but also in the case of N0 due to the continuing controversy for the treatment of N0 patients. A close observation of the patient may reveal a positive node in the follow-up. The imaging modalities used for the node staging in HNC patients include ultrasound, contrast-enhanced computed tomography, contrast-enhanced magnetic resonance imaging (MRI), and positron emission tomography scans. None of the above-mentioned methods reaches a 100% sensitivity or specificity, and the accuracy of the exact number of metastases or levels involved has not been studied; thus, neck dissection with subsequent pathological examination remains the gold standard for node staging. Among the described cross-sectional imaging modalities, MRI presents a lot of advantages mainly due to the increased soft tissue contrast and the ability to obtain tissue characteristics in different sequences, including diffusion- and perfusion-weighted sequences and proton spectroscopy imaging. The lack of the radiation burden makes MRI suitable for a close follow-up of the patient, and the imaging with the use of new intravenous contrast material (such as ultrasmall iron oxide particles) seems superior to the conventional. In this article, we will focus on the lymph node MRI staging in HNC patients and the MR anatomy of the nodes, the necessary diagnostic workup, and the advantages of the method over computed tomography. The possibilities of the new imaging sequences and the treatment implications will be addressed as well.     

The International Sepsis Forum's controversies in sepsis: how will sepsis be treated in 2051?

Sepsis, the life-threatening illness that arises from innate immunity to overwhelming infection, is treated symptomatically at the start of the 21st century. Looking ahead 50 years, one can perhaps foresee profound changes in the way we manage this disorder. A shift from a focus on eradicating micro-organisms as universally inimical to one on supporting optimal host–microbial homeostasis will have a profound impact on how we treat infection, and will relegate antibiotics to a small, adjuvant role. Probiotic therapy may well be as important as antibiotic therapy. Resuscitation strategies will support microvascular flow rather than systemic pressure. Rapid genetic profiling will permit pre-emptive gene therapy for some, and titration of specific therapies directed against fundamental intracellular processes in others. We will treat diseases, not syndromes, and guide therapy by molecular staging. A fanciful victim of sepsis in 2051 illustrates how future treatments might transform sepsis from a prolonged and morbid illness to a rapidly reversed acute disease.     

卵巢癌患者外周血细胞粘附分子水平测定的临床意义

目的：探讨卵巢癌患者外周血可溶性细胞粘附分子CD29和CD44变化及其意义。方法：采用流式细胞仪技术检测40例卵巢癌患者外周血可溶性细胞粘附分子CD29和CD44表达。结果：卵巢癌患者外周血可溶性细胞粘附分子CD29和CD44表达显著增加。结论：卵巢癌患者外周血可溶性细胞粘附分子CD29和CD44的水平对卵巢癌的临床分期具有一定的临床价值。     

Laparoscopic surgical staging of stage I primary squamous cell carcinoma of the vagina

Vaginal carcinoma is an uncommon malignancy and one of the few gynecologic malignancies that is still clinically staged. Clinical staging, which can be difficult in some instances, is potentially inaccurate, as it has been shown to be in early endometrial and ovarian carcinoma. In addition, clinical staging can result in over- or undertreatment of the disease. The lack of standardization of treatment further compounds the issue, particularly for patients with small-volume disease. We report three patients with grade 2 or 3 small-volume primary squamous cell carcinoma of the vagina who underwent pelvic lymph node sampling for staging purposes. Each patient had lesions small enough to be considered for brachytherapy only. An average of 12 lymph nodes were removed with an average operative time of 72 minutes. All procedures were performed on an outpatient basis, and there were no intraoperative or postoperative complications. In one patient, teletherapy was added to the brachytherapy because a microscopic focus of squamous cell carcinoma was discovered in an obturator lymph node. Our initial experience indicates that laparoscopic sampling of lymph nodes in patients with early vaginal carcinoma may be helpful in preventing undertreatment of these women. Individualization of treatment can be accomplished quickly and safely on an outpatient basis, and initiation of treatment is not delayed. We believe further evaluation of laparoscopic staging of primary vaginal carcinoma is indicated.     

食管鳞状细胞癌患者根治术后生存预测模型的建立与验证:一项多中心真实世界队列研究

  目的  建立并验证食管鳞状细胞癌患者根治术后生存预后预测模型与风险分级标准,为术后最优辅助治疗方案的确定提供真实世界证据。  方法  分别收集2011年5月31日至2018年7月31日在河南省安阳市肿瘤医院(安阳中心)和2009年8月1日至2018年12月31日在广东省汕头大学医学院附属肿瘤医院(汕头中心)连续就诊的食管鳞状细胞癌患者的临床数据和生存随访数据。以安阳中心数据集为建模集,采用基于多因素Cox比例风险回归逐步后退法和AIC准则(Akaike information criterion)的“两步法”构建总生存预测模型。通过Bootstrap重抽样1 000次对模型进行内部统计验证,在汕头中心数据集进行外部验证。根据列线图得分构建预后风险分级标准。  结果  建模队列和验证队列分别纳入4 171例和1 895例食管鳞状细胞癌患者。模型由年龄、性别、肿瘤原发位置、T分期、N分期、淋巴结清扫数、肿瘤大小、辅助治疗方案和术前血红蛋白水平9个变量组成。其中,N分期与辅助治疗方案存在显著交互作用(P＜0.001),即与单纯手术相比,N+期患者可能从辅助治疗中获益,但辅助治疗无法改善N0期患者的预后。建模队列的模型一致性指数(C-index)为0.728 (95% CI: 0.713~0.742),经Bootstrap内部验证后为0.722 (95% CI: 0.711~0.739),验证队列的模型C-index为0.679 (95% CI: 0.662~0.697)。校准图提示模型预测生存率与观测生存率一致性良好。在两个队列中模型准确性均显著高于第7版AJCC(American Joint Committee on Cancer)TNM分期系统(P＜0.05)。此外,在各TNM分期内部,该模型仍可实现理想的预后风险分层效果。  结论  本研究为我国食管鳞状细胞癌患者根治术后总生存提供了个体化预测模型,并揭示N分期可能是制订食管鳞状细胞癌患者术后辅助治疗方案的重要决定因素。     

CT和B超对卵巢肿瘤定性的诊断价值比较

目的探讨卵巢肿瘤的CT、B超表现,并就两种检查方法对卵巢肿瘤定性诊断作对照分析。方法对78例(102个病灶)经病理证实的卵巢肿块的临床及影像学资料作回顾性分析。经CT检查55例,经B超检查62例,同时经CT和B超检查者39例,间隔时间为0～3d。结果CT、B超对卵巢良、恶性肿瘤判断的敏感性、特异性和准确性分别为94.7%对89.9%,87.5%对81%,93.2%对88%,经χ2检验无显著差异(P>0.05)。但CT对卵巢肿瘤腹腔、腹膜种植、淋巴结肿大等有助卵巢肿瘤定性诊断及临床分期的征象检出率均高于B超,χ2检验有显著差异(P<0.05)。结论CT与B超对卵巢肿瘤具有重要诊断价值,CT在卵巢肿瘤定性诊断及辅助恶性肿瘤临床分期方面优于B超。     

Sphincter preservation therapy for rectal cancer

Rectal cancer presents a unique challenge to oncologists and patients due to the location and anatomy of the rectum and the difficulties inherent in pre-operative staging. These issues are especially important with distal rectal tumors when patients may face the decision of tumor control without sphincter preservation or more limited surgical procedures that may potentially compromise tumor control and thus survival. Current options for sphincter preservation for low-lying rectal tumors are preoperative radiotherapy with or without chemotherapy for tumor downstaging, local excision with or without adjuvant chemoradiation and low anterior resection with coloanal anastomosis. Pretreatment evaluation, by radiologic studies and pathologic predictors of lymph node involvement, is an integral part of determining which patients are suitable candidates for treatment with local excision. Preoperative chemoradiotherapy is a treatment option for some patients who are not initially considered to be candidates for sphincter preservation. Many investigators have suggested that the rate of sphincter preservation in patients with rectal cancer may be improved following preoperative chemotherapy and radiation. For properly selected patients, local excision holds promise as a means of achieving sphincter preservation.     

The potential of ovarian tissue transplant to preserve fertility

Laboratory research on ovarian cryopreservation and transplantation began in the 1950s leading to clinical studies in the 2000s. The research that was performed during this half a century indicated that cryopreserved ovarian tissue has the potential to restore fertility in women who face premature ovarian failure due to chemotherapy, radiotherapy or surgery. Until today, ovarian function has been restored in at least four women. Even though no pregnancies have been reported to date from these clinical studies, animal studies indicate that this is a valid prospect for humans. Future clinical trials will determine in a larger number of patients the longevity of ovarian grafts, normalcy of hormone production and ovarian follicle development, possibility and safety of pregnancy and the safety of auto-transplantation in cancer patients. In addition, further basic research may be needed to develop better cryoprotectants and cryopreservation techniques. However, the major improvement in the efficiency of ovarian transplantation is anticipated to come from research exploring the revascularisation process.     

The potential of ovarian tissue transplant to preserve fertility

Laboratory research on ovarian cryopreservation and transplantation began in the 1950s leading to clinical studies in the 2000s. The research that was performed during this half a century indicated that cryopreserved ovarian tissue has the potential to restore fertility in women who face premature ovarian failure due to chemotherapy, radiotherapy or surgery. Until today, ovarian function has been restored in at least four women. Even though no pregnancies have been reported to date from these clinical studies, animal studies indicate that this is a valid prospect for humans. Future clinical trials will determine in a larger number of patients the longevity of ovarian grafts, normalcy of hormone production and ovarian follicle development, possibility and safety of pregnancy and the safety of auto-transplantation in cancer patients. In addition, further basic research may be needed to develop better cryoprotectants and cryopreservation techniques. However, the major improvement in the efficiency of ovarian transplantation is anticipated to come from research exploring the revascularisation process.     

卵巢癌与宫颈癌放射治疗中CT诊断的临床应用价值研究

目的:探讨CT诊断在卵巢癌与宫颈癌放射治疗中的的应用价值;方法:选择卵巢癌患者40例、宫颈癌患者60例,分别进行CT诊断,比较CT检查分期与手术病例分期的差异;结果:卵巢癌患者CT检查结果显示,浆液性囊腺癌25例,卵巢未成熟畸胎瘤与库肯勃瘤各2例,粘液性囊腺癌9例,1例未检出,1例交界性囊腺癌。FIGO分期中I、Ⅱ、Ⅲ、IV期分别为1、11、21、6例。宫颈癌CT检查结果显示,鳞癌、腺癌、腺鳞癌分别34、15、11例,FIGO分期中I、Ⅱ、Ⅲ、IV期分别为2、15、20、21例。放射治疗前后患者CT分期结果与手术病理分期结果无明显差异(P>0.05);结论:CT检查能够有效的诊断卵巢癌与宫颈癌,并准确FIGO分期,为临床治疗方案的制定提供了依据。     

CT和MRI在卵巢癌定性、分期、侵袭和转移诊断中的价值以及临床应用

目的探讨卵巢癌的CT及MRI在诊断定性、分期及其对周围器官侵袭和转移的诊断价值及临床意义。方法对68例卵巢癌患者术前同时行CT和MRI检查,结合手术结果、病理诊断与临床分期对照分析。结果 (1)CT对卵巢癌的诊断符合率为80.9%(55/68),MRI为92.6%(63/68),MRI优于CT(χ2=3.0235,P<0.05)。(2)MRI对卵巢癌的定性诊断优于CT(χ2=4.2531,P<0.05),分期诊断优于CT(χ2=5.7129,P<0.05)。(3)MRI对转移至肠道、子宫及输卵管、肝脏等远处及淋巴结的诊断敏感度显著高于CT(P<0.05);对转移至腹膜、网膜的诊断敏感度略低于CT(P<0.05)。CT诊断卵巢癌转移的诊断总符合率为75.4%(46/61),MRI为88.5%(54/61),MRI显著高于CT(χ2=10.1723,P<0.05)。结论 MRI对于卵巢癌定性、分期及肿瘤侵犯周围器官和转移的诊断显著优于CT,二者联合应用,可以提高卵巢癌的诊断率。     

保留卵巢功能的卵巢肿瘤手术的临床研究

目的探讨对卵巢肿瘤患者行保留卵巢功能手术的可行性及其意义.方法回顾分析我院接受保留卵巢功能手术的71例卵巢肿瘤患者的临床资料.对双侧良性肿瘤行剜除术,肿瘤较大者行全肿瘤切除,保留卵巢皮质部分健康组织;对恶性肿瘤根据患者年龄、生育要求、肿瘤临床分期、病理类型及随访条件等确定选择保留卵巢功能手术,术后均加用化疗.结果术后90%患者按月行经,72%患者妊娠分娩,97%的良性肿瘤临床完全治愈,90%的恶性肿瘤临床完全缓解.结论对于卵巢肿瘤施行保留卵巢功能的手术是可行,且有效,但要严格掌握手术指征.     

前列腺癌的MRI诊断

目的：研究MRI对前列腺癌的定性诊断及分期诊断的能力,讨论对诊断准确性有影响的因素。方法：回顾性分析265例、328人次行前列腺MRI检查的影像资料及临床资料,着重研究了其中178例病理证实的前列腺癌患者的MRI表现及分期,并与临床病理分期对照。结果：MRI能显示83．1％的前列腺癌,分期的准确率为82．0％。前列腺活检后3周内、内分泌治疗后,既往患前列腺炎的患者定性诊断准确率稍低,注意观察前列腺尖部,神经血管束及包膜轻度不规则的情况可提高定性和分期诊断的准确性,对中央带病灶MRI诊断效果不好,结论：MRI是评价前列腺癌的一种很好的影像学方法。对病史资料全面了解。根据情况运用多种MRI检查方法及不断总结提高诊断者的经验会提高MRI对前列腺癌的定性诊断和分期诊断的准确率。     

上皮性卵巢癌P53、Livin和PARP表达检测及其对卵巢癌化疗耐药、临床预后的影响研究

目的探讨P53、Livin和多聚二磷酸腺苷核糖聚合酶(PARP)在上皮性卵巢癌中的表达,以及与卵巢癌化疗耐药和临床预后间的相关性。方法选取2011年1月至2015年6月北京首都国际机场医院妇科经手术病理检查证实的上皮性癌卵巢患者74例为研究对象。对患者进行随访,根据复发情况分为化疗敏感组与化疗耐药组,对比两组间的耐药基因表达情况及生存率,并对生存时间的影响因素进行分析。结果 P53、Livin和PARP在化疗敏感组的阳性率分别为47.1%、56.9%、52.9%,在化疗耐药组的阳性率分别为73.9%、95.7%、95.7%,组间比较各项在化疗敏感组的阳性率均低于化疗耐药组,差异具有统计学意义(P0.05)。化疗敏感组中位生存时间52.0个月,其3年、5年累计生存率分别为68.63%和41.18%,化疗耐药组中位生存时间31.5个月,3年、5年生存率分别为47.83%与26.10%,组间比较化疗敏感组的各期生存率均高于化疗耐药组,差异有统计学意义(P0.05)。将年龄、病理分化程度、临床分期、化疗敏感程度引入Cox回归模型,临床分期、化疗敏感程度对生存时间有显著影响(P0.05)。结论 P53、Livin和PARP的表达均与上皮性卵巢癌患者的化疗耐药性相关,因此可用来预测患者的化疗疗效,对于耐药基因高表达的患者,可给予个性化的治疗方案,以改善患者预后。     

Intraperitoneal radioactive chromic phosphate P 32 in the treatment of ovarian cancer

The use of intraperitoneal radioisotopes in the management of women with ovarian cancer is controversial. We analyzed the experience with intraperitoneal chromic phosphate P 32 at our institution, from October 1979 to February 1983, in 22 patients with various stages and grades of ovarian malignancy. Survival in stage I is 87.5% and in stage II, 50%. Survival is 88.9% among patients with grade 1 tumors and 33.3% for those with grade 3 lesions. Morbidity related to chromic phosphate P 32 was minimal; small bowel obstruction occurred in only one patient who had also received external pelvic irradiation. Our results suggest that chromic phosphate P 32 is a safe, well tolerated, inexpensive, and effective adjuvant to surgery in the management of selected patients with ovarian malignancy.     

螺旋CT检查在卵巢癌术前分期中的价值

卵巢癌起病隐匿,早期多无临床症状,近2/3的病人初次发现时已经是晚期。现在对于卵巢癌的治疗主要采用包括手术切除及联合化疗在内的治疗方法。螺旋CT检查在术前能比较准确地对原发灶和转移灶的表现加以判断,并对癌肿的转移情况进行了解,为手术治疗方案提供帮助。笔者搜集1996~2     

Operative technique for the laparoscopic staging of pancreatic malignancy

Summary

Special technique and equipment is required for staging and pre-operative assessment of patients with pancreatic cancer. The operative steps to explore the pancreas through an infragastric route used in 21 consecutive patients with pancreatic neoplasms are described in this paper. This entails the use of distally curved coaxial instruments and of endosurgical staplers to open the gastro-colic ligament. A wide exposure of the pancreatic body and tail allows laparoscopic contact ultrasonography of the whole gland. Both longitudinal and transversal sections of the pancreas are obtained for the purpose of defining tumour limits, lymph nodal involvement and possible spread to regional vessels. Analysis of preliminary results supports the view that laparoscopic assessment of pancreatic cancer is safe and effective in achieving the goal of an accurate staging. Laparoscopic related information in this series led to a change in diagnosis or surgical strategy in 9.5% and 38% of patients, respectively. This approach obviates exploratory laparotomy in patients not suitable for resection and carries a potential value in the selection of patients for future adjuvant treatments.