腹腔镜胃上部癌保脾手术的脾门区淋巴结清扫技术

脾门区淋巴结是进展期胃上部癌患者行D2根治术中必须清扫的淋巴结。随着外科技术的进步和治疗理念的更新．保脾的脾门区淋巴结清扫术目前已逐渐被外科医师所接受。由于脾脏位置深在．脾血管解剖变异多,使得腹腔镜保脾的脾门区淋巴结清扫术操作难度大。术者一方面要把握手术适应证：另一方面应采取合理的手术人路和程序化的手术操作步骤．同时必须熟识腹腔镜下脾门区的血管解剖特点．以血管解剖为基础．才能更好地完成腹腔镜下保脾的脾门淋巴结清扫术。     

进展期近端胃癌脾门淋巴结清扫的启示与思考

脾门淋巴结清扫是进展期近端胃癌根治术中胃周淋巴结清扫的难点和焦点。虽然第5版《日本胃癌治疗指南》将脾门淋巴结排除在非大弯侧进展期近端胃癌患者D2淋巴结清扫范围外,但是相关的高级别循证医学证据仍然较少。同时,对于侵犯大弯侧的进展期近端胃癌患者,指南推荐行脾切除术以清扫脾门淋巴结,而在逐渐增多的循证医学证据支持下,保脾脾门淋巴结清扫术越来越多地得到学者的认可。同时,腹腔镜技术的出现为保脾脾门淋巴结清扫术提供一种新的手段,笔者团队在国际上首次报道"黄氏三步法"腹腔镜保脾脾门淋巴结清扫术,不仅降低手术难度,使该技术易于推广,还显示出良好的微创效果。临床实践中脾门区血管后方淋巴结的清扫,也是争议的焦点之一。因此,对于脾门淋巴结清扫这项困难的技术,不仅要求胃肠外科医师进行技术上的探索,对其清扫指征的探索也尤为重要,既要避免不需要清扫患者的扩大手术,但也不能因为技术困难而使高危患者失去根治机会。     

肺鳞癌、腺癌纵隔淋巴结转移的特点

目的 研究原发肺鳞癌及腺癌纵隔淋巴结转移特点,探讨临床意义.方法 对353例原发肺癌施行同侧纵隔淋巴结廓清术,病理检测淋巴结转移频度.结果 清除淋巴结2380组,平均每例6.74组.N2 淋巴结转移率16.2%.T1、T2、T3间淋巴结转移率差异有统计学意义(P<0.01).N2转移率在鳞癌、腺癌分别为30.1%、44.1%.64.2% 鳞癌N2转移为某一组淋巴结,腺癌3组以上转移者46.2%.上叶肺癌跨区域N2转移占15.1%,下叶(包括中叶)肺癌跨区域转移占53.1%.跳跃式转移占N2转移的53.7%.结论 肺鳞癌及腺癌纵隔淋巴结转移具有多发性、跳跃性及跨区域性特点.     

基于膜解剖的腹腔镜脾门淋巴结环周清扫术与前方清扫术的对比研究

目的:探讨基于膜解剖的局部进展期胃上部癌腹腔镜原位保脾脾门淋巴结环周清扫术的安全性、可行性及近期疗效.方法:回顾分析2016年12月至2019年12月为105例局部进展期胃上部癌患者施行基于膜解剖的腹腔镜原位保脾脾门淋巴结清扫术的临床资料,按脾门淋巴结清扫方式分为环周组(n=49,清扫脾叶血管前侧方及后方淋巴结)与前方...     

前哨淋巴结阳性乳腺癌非前哨淋巴结转移的情况分析

目的探讨前哨淋巴结（SLN）阳性乳腺癌患者的临床病理特征与非前哨淋巴结（NSLN）转移的关系。 方法回顾性分析2010年1月至2016年1月中山大学附属第一医院500例行前哨淋巴结活检（SLNB）的临床分期为T_1-2N₀M₀期乳腺癌患者资料,其中病理检查确诊SLN阳性、随后行腋窝淋巴结清扫（ALND）的乳腺癌患者共89例,总结其临床、病理因素的特征及其对腋窝NSLN转移的影响因素进行单因素及多因素Logistic分析。 结果SLN阳性率为17.8%（89/500）,49.4%（44/89）出现NSLN转移。单因素分析显示,NSLN转移与原发肿瘤分期、脉管浸润、SLN阳性数、SLN阳性率相关（χ²=4.062、36.084、7.003、10.889,P=0.044、<0.001、0.030、0.004）。进一步多因素Logistic回归分析显示,脉管浸润、SLN阳性率是NSLN转移的独立预测因子（OR=46.142,95%CI：11.821~258.472,P<0.000 1;OR=10.482,95%CI：2.564~51.312,P=0.002）。 结论SLN阳性的乳腺癌患者,其原发肿瘤分期、肿瘤是否多发、脉管浸润、SLN阳性数、SLN转移率与腋窝NSLN转移相关。其中,脉管浸润及SLN阳性率≥0.5是SLN阳性乳腺癌患者腋窝NSLN转移的独立预测因子。     

Florid, papillary endosalpingiosis of the axillary lymph nodes

A 55-year-old woman underwent radical mastectomy and axillary node dissection because of an invasive ductal carcinoma with neuroendocrine features. Histologically, all 22 sampled lymph nodes had widespread cystic inclusions lined by a regular, serous-type epithelium positive for cytokeratin-7, WT-1, CA125, and estrogen receptors. Papillary projections were found in the lumen of some cysts. The lesions were consistent with florid, papillary endosalpingiosis (FPE), a hitherto unreported condition in a supradiaphragmatic location. Metastases from papillary carcinomas of ovary, breast, or thyroid were excluded considering the lesion's immunophenotype (negative for mammaglobin and TTF-1) and the absence of both atypical features and a concurrent abdominal serous tumor. In only one node, lesions co-existed with a metastasis of breast carcinoma. Supradiaphragmatic FPE represents a pitfall in the differential diagnosis of metastases, especially in sentinel nodes, since it may increase their size and reveal an unusual ultrasonographic image. Clinicopathologic findings and a focused immunohistochemical study led to the correct diagnosis of this benign lesion.     

Clinical importance of micrometastasis in sentinel lymph nodes

Introduction

We evaluated the incidence of micrometastasis and nonsentinel lymph node metastasis as well as local and axillary recurrence rates after level I-II axillary lymph node dissection.

Materials and methods

Patients (n = 760) with early-stage breast cancer underwent sentinel lymph node biopsy, and 45 patients (6.0%) with micrometastasis (0.2-2.0 mm) were included in this study. Data concerning tumor, patients’ characteristics and adjuvant treatments were recorded.

Results

The median age was 46 (26-67) years, median breast tumor size was 20 (1-50) mm, and median number of excised sentinel lymph nodes were 2 (1-5). All patients with micrometastasis underwent further level I-II axillary lymph node dissection. Eleven of 45 (24.4%) patients with micrometastasis in their sentinel lymph node biopsy had nonsentinel lymph node metastasis after an axillary lymph node dissection. There was no factor related to nonsentinel lymph node metastasis. Stage migration occurred in 4 of 45 patients (8.8%) due to the detection of micrometastases or macrometastases in nonsentinel lymph nodes.

Discussion

The classical treatment after detection of micrometastasis in sentinel lymph nodes is further axillary dissection. However, nonrandomized, nonprospective studies with 4-5 years follow up showed 0.6% axillary recurrence without further axillary lymph node dissection, although we still need the results of randomized controlled studies.     

Feasibility of laparoscopic D3 lymphadenectomy for male rectosigmoid cancer with clinically positive lymph nodes

Background  Laparoscopic D3 lymphadenectomy is a challenging surgical procedure and has not been reported before. The present study aimed to test the technical feasibility of this procedure. Methods  Fifty-four consecutive male patients with clinically staged III rectosigmoid cancer were recruited to undergo laparoscopic D3 lymph node dissection. The extent of the D3 lymphadenectomy of rectosigmoid cancer included skeletonization of bilateral common iliac arteries and veins and abdominal aorta upwards to the level of the duodenal third portion and left renal vein, in addition to the mesenteric dissection in the standard anterior resection. The patients were prospectively followed for surgical feasibility, efficiency, and outcomes. Results  Laparoscopic D3 lymphadenectomy for rectosigmoid cancer was performed with acceptable operation time (303.4 ± 35.8 min, mean ± standard deviation) and moderate blood loss (344.8 ± 50.6 ml) through small wounds. There was no mortality within 30 days after operation and the complication rate was acceptable (20.4%). The patients has quick functional recovery, as evaluated by the restoration of flatus passage (60.4 ± 12.4 h), hospitalization (11.0 ± 1.5 days), and the degree of postoperative pain (3.5 ± 0.6, visual analogue scale). D3 lymphadenectomy resulted in the harvest of ample lymph nodes (24.6 ± 4.5) for histopathological examinations and facilitated the upstaging of three (5.6%) patients. Conclusion  D3 lymph node dissection by the laparoscopic approach can be safely and efficiently performed for male rectosigmoid cancer with quick convalescence. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

肝移植术后淋巴结结核1例报告并文献复习

目的探讨肝移植术后淋巴结结核的临床特点、诊断及治疗方法。方法回顾性分析武警总医院移植研究所1例肝移植术后淋巴结结核患者的诊治过程,并进行文献复习。结果于患者左颌下扪及肿大淋巴结2个;红细胞沉降率增快,c反应蛋白水平增加;腹部CT示腹腔内多发淋巴结肿大,增强后表现为环形强化;颌下淋巴结内液体涂片见到抗酸杆菌,组织病理学检查结果为淋巴结坏死性肉芽肿。抗痨治疗33d后患者临床表现逐渐消失。继续治疗16个月,未见复发。结论肝移植术后淋巴结结核罕见,主要通过淋巴结坏死物涂片镜检和病理学检查诊断;采用对氨基水杨酸异烟肼片＋利福喷丁＋链霉素＋乙胺丁醇＋莫西沙星联合用药抗痨方案治疗有效。     

淋巴结切除对肝癌合并淋巴结转移患者预后影响分析

目的探讨淋巴结清扫对原发性肝癌伴淋巴结转移患者的疗效。方法回顾性分析60例原发性肝癌伴淋巴结患者的病历资料,按是否行淋巴结清扫分为2组:对照组(未行淋巴结清扫组)30例,治疗组(行淋巴结清扫组)30例。结果处理组患者的半年、1年及2年生存率分别为80.0%、63.3%和56.7%;对照组患者的半年、1年及2年生存率分别为80.0%、60.0%和26.7%。处理组的2年生存率显著高于对照组(P=0.039)。两组患者的术后并发症发生率都很低,且两组间发生率无明显差异。结论对肝癌伴淋巴结转移患者进行淋巴结清扫有益于提高患者的长期生存率。     

Morphological characteristics of lateral pelvic lymph nodes in rectal carcinoma

Aim Macroscopic and imaging indicators for lymph node metastasis have been documented not in lateral pelvic lymph nodes but in mesorectal lymph nodes in patients with rectal carcinoma. We conducted this study to uncover morphological characteristics of lateral pelvic lymph nodes in patients with rectal carcinoma. Materials and methods Fifty-eight patients with locally advanced rectal carcinoma who had total mesorectal excision and lateral pelvic lymph node dissection were studied. Total number of lateral pelvic lymph nodes evaluated was 462, with 538 mesorectal lymph nodes being used for comparison. Factors of lymph nodes evaluated were size (long- and short-axes diameters), shape (ovoid and irregular), and heterogeneity of internal structure. Receiver operating characteristic (ROC) curve analysis was used to compare the diagnostic accuracy of each factor. Results Lateral pelvic lymph node at non-metastatic status appeared to be longer (4.5 vs 3.5 mm) and thinner (2.2 vs 2.6 mm) than mesorectal lymph nodes. ROC curve analysis, for discriminating non-metastatic and metastatic lateral pelvic lymph nodes, revealed that a short-axis diameter appeared to be the most prominent factor with highest area under curve (0.907) and was more reliable than either long-axis diameter (0.811) or shape (0.527) other than internal structure (1.00). A short-axis diameter was an independent risk factor for metastasis by multivariate analysis with an odds ratio of 1.29 (p < 0.0001, 95% confident interval, 1.22–1.36). The most reliable cut-off value was 4 mm with 96% of sensitivity, 68% of specificity, and 82% of overall accuracy. Conclusion Lateral pelvic lymph nodes tended to be longer and thinner than mesorectal lymph nodes at non-metastatic status. A short-axis diameter of 4 mm or larger was the prominent indicator of metastasis in lateral pelvic lymph nodes.     

Metastases to the regional lymph nodes,lymph node recurrence,and distant metastases in nonadvanced papillary thyroid carcinoma

To investigate the biological characteristics of papillary thyroid carcinoma from the perspectives of lymph node metastasis, lymph node recurrence, and distant metastasis, 746 patients with nonadvanced papillary thyroid carcinoma were retrospectively studied. There were 76 men and 670 women with a mean age of 42.7 years. The rate of lymph node metastasis was significantly higher in young patients (aged less than 30 years). Lymph node recurrence was observed in 80 patients and distant metastasis in 13, being seen with significant frequency in the young and elderly (aged over 50 years) patients and in the men. The frequency of distant metastasis was significantly greater in the elderly patients and in those with lymph node recurrence. These findings indicate that the role of regional lymph nodes and the clinical meaning of lymph node recurrence differ between young and elderly patients.     

A detailed histological study on occult metastasis of the lymph nodes

One representative microsection from each lymph node was carefully surveyed for metastasis in a routine examination. To scrutinize the existence of occult metastasis, three additional sections were then made from half of the remaining lymph node. A total of 1,698 lymph nodes taken from 55 patients with carcinoma of the esophagus, stomach, colon, thyroid or breast were thus reexamined histologically. The initial examination was not able to prove any metastasis in these lymph nodes. Upon reexamination, however, involvement by cancer cells was detected in 10 nodes of 7 patients. The maximum diameter of the metastatic foci varied from 0.2 mm to 1.3 mm and was less than 0.5 mm in more than half of the nodes. The metastatic patterns in the nodes were classified into three types, i.e., marginal sinus type, medullary sinus type and mixed type. The marginal sinus type was the most frequent, with the mixed type being next and the medullary sinus type being found in only one node. Accordingly, surgeons should keep the possibility of occult metastasis in mind and the marginal sinus of the lymph node should be carefully examined in order to detect any small foci of metastasis.     

肺内淋巴结的临床和影像学特点

目的 探讨经术后病理证实的肺内淋巴结病例的临床、影像特点,以提高临床诊断率.方法 回顾性分析2008年5月至2011年9月,16例手术、病理确诊的肺内淋巴结患者中男9例,女7例;年龄39～73岁,平均58.2岁.术前均行胸部X线平片及高分辨CT检查,单发者11例,多发者3例,另有2例肺癌合并不同肺叶内单发或多发淋巴结的临床、影像学资料.结果 全组6例有粉尘接触史或吸烟史,3例来自同一油田区;术前诊断包括肺良性结节、肺癌、肺转移瘤、肺癌肺内转移及性质不明,误诊率56.3％.术前X线胸片发现率50％(8/16例).肺内淋巴结CT扫描下最大径4～11 mm,平均7.1mm,全部位于隆凸以下水平;87.50％(14/16例)为实性结节;68.75％(11/16例)为边界清楚的类圆或卵圆形结节;87.5％(14/16例)距离胸膜1 cm以内;87.5％(14/16例)可见线状密度影;2例可见毛刺征;全组末见钙化及纵隔淋巴结病变.术后病理全部淋巴结均可见炭末沉着,8例可见淋巴结增生.结论 肺内淋巴结足较为少见的肺内良性结节,临床、影像学表现具有一定特点.对于隆凸以下水平的胸膜下结节,应考虑该诊断可能.     

Prognostic significance of the number of positive lymph nodes in gallbladder cancer

The aim of this study was to assess the prognostic impact of the number of lymph node metastases. The medical records of 33 patients with node-positive gallbladder cancer (GBC) treated at our institution from January 1985 through December 2002 were reviewed. There were 10 cases with a single node metastasis. The sites were as follows: the cystic duct node, the pericholedochal node, the retroportal node, the hilar node, the lymph node around the common hepatic artery, and the paraaortic node. According to the International Union Against Cancer (UICC) 5th edition, 5-year survival rates for the patients with pN1, pN2, and greater than pN2 were 19.2%, 10%, and 0%, respectively (not significant). Patients with a single node metastasis had a higher 5-year survival rate (33%) than patients with two or more lymph node metastases (0%; P<0.05). There were no lymph node recurrences in patients with a single node metastasis. Number of positive nodes and liver metastasis were factors predictive of significantly worse survival. Rather than using the topographic classification, or even simply classifying whether nodal involvement is positive or negative, classification according to the number of positive nodes will contribute to establishing a more practically useful staging system.     

Accuracy of intraoperative imprint cytology of sentinel lymph nodes in breast cancer

BACKGROUND: In breast cancer treatment, immediate completion of axillary lymph node dissection (ALND) can be performed if the intraoperative sentinel lymph node (SLN) examination is positive. This study evaluates the accuracy of intraoperative imprint cytology (IC) for detecting SLN metastases. METHODS: Pathology reports from 385 SLN biopsy examinations were reviewed retrospectively. The SLNs were serially sectioned perpendicular to the long axis and IC was performed intraoperatively. The SLNs then were formalin-fixed for permanent sections. Final pathology was compared with the intraoperative IC results. RESULTS: The sensitivities for IC detection of N0(i+) (n = 36), N1mi (n = 24), and N1a-3a (n = 65) metastases were 0%, 4%, and 74%, respectively. The specificity was 100%. CONCLUSIONS: Final pathology identified 89 (23%) patients with N1 or greater disease. IC allowed 49 (55%) of these patients to undergo synchronous completion of ALND. No unnecessary completion ALNDs were performed. The sensitivity of IC decreased with decreasing size of the metastasis.     

胃癌根治术中肿大淋巴结的分析

目的　研究胃癌根治手术中肿大淋巴结实际转移状况并分析淋巴结切除范围与预后的关系。方法　查阅手术记录和术后病理报告并进行 5年随访。记录肿大淋巴结数 ,比较近端胃、远端胃和全胃切除术的淋巴结切除数目并分析其与预后的关系。结果　本组 15 5例胃癌标本中 ,共摘取淋巴结 3 3 0 5枚 (平均 2 1.3 2枚 /例 ) ;肿大淋巴结 10 3 7枚 (平均 6.69枚 /例 ) ;转移淋巴结 42 3枚 (平均 2 .73枚 /例 )。在 15 5例获 5年随访的患者中 ,行D2式手术 10 9例 ,D3式 46例 ,5年生存分别是 3 7例和 11例。结论　手术中肿大淋巴结不一定是转移淋巴结 ;胃癌根治术中淋巴结清扫范围不应盲目扩大 ,而应根据术中冰冻病检结果判断。