150例食管癌淋巴结转移规律和清扫方式分析

目的 分析150例食管癌术中淋巴结清扫,分析淋巴结转移的规律,探讨食管癌术中淋巴结清扫方式的依据.方法 150例食管癌根治术,术中常规清扫各部位淋巴结,并分别标记送病理分析,研究淋巴结转移规律和清扫方式.结果本组136例患者有淋巴结转移.本组清扫淋巴结累计1 233枚,平均每例清扫淋巴结8.3枚,517枚淋巴结有转移,转移率为42.6%.胸上段食管癌淋巴结转移多见于中上纵隔,颈部食管旁及锁骨上,胸中段食管癌淋巴结在上纵隔、颈部和腹部均能发现转移,胸下段食管癌淋巴结转移多见于中下纵隔和上腹腔.肿瘤长度,肿瘤浸润深度越深,分化程度与淋巴结转移率相关.结论 胸上段食管癌行颈、胸、腹三野淋巴结清扫,胸中段食管癌行隆突下淋巴结,下胸段食管旁,胃小弯侧淋巴结清扫.胸下段食管癌行隆突下淋巴结,下纵隔淋巴结,胃小弯侧,胃左动脉旁淋巴结清扫.食管癌病灶长度越长,肿瘤分化越低,淋巴结转移率越高.     

近端胃癌191例手术范围的探讨

目的: 探讨近端胃癌合理的切除范围。方法: 分析191例近端胃腺癌根治手术临床资料,评价各组淋巴结清扫效能。结果: 淋巴结清扫效能指数从高至低依次是:贲门旁、胃左动脉旁、脾动脉旁、左肾静脉上旁和腹主动脉旁淋巴结,侵犯食管时,下段食管旁和膈上淋巴结清扫指数较高。结论: 淋巴结清扫范围应根据肿瘤部位来定,进展期近端胃癌应清扫腹主动脉旁淋巴结,肿瘤侵犯食管时应清扫低位食管旁和膈上淋巴结。     

贲门腺癌纵隔淋巴结转移相关因素分析(附118例报告)

目的:探讨贲门腺癌纵隔淋巴结转移相关因素,以明确纵隔淋巴结清扫指征。方法:回顾性分析2011年1月²013年5月118例左胸入路手术治疗贲门腺癌患者临床资料,分析患者临床病理资料与纵隔淋巴结转移的关系。结果:全组病例共清扫纵隔淋巴结362枚,平均清扫每例淋巴结数(3.1±0.4)枚。纵隔淋巴结转移率为25.4%(30/118),转移度为11.6%(42/362)。肿瘤长度、浸润深度、分化程度、肿瘤是否累及食管下段与纵隔淋巴结转移有关,结果有统计学意义(P≤0.05)。结论:贲门腺癌其分化程度越低,肿块越大(最大直径超过3 cm),浸润越深,食管下端累及越容易发生纵隔淋巴结转移。临床工作中对这些患者应该常规行纵隔淋巴结清扫(主要是下纵隔淋巴结)。     

进展期中上部胃癌脾门淋巴结转移与微转移的分析

目的 分析进展期中上部胃癌脾门淋巴结转移与微转移情况。方法 回顾性分析2011年8月至2014年8月82例接受全胃切除D2根治术的进展期中上部胃癌患者临床病理资料,运用免疫组化检测淋巴结微转移,分析脾门淋巴结转移和微转移的临床病理高危因素。结果 82例患者共检及150枚脾门淋巴结,其中18例发生转移(21.9%),常规病理学检测阴性的64例患者中有21例出现微转移(32.8%)。单因素及多因素分析均显示TNM分期、Borrmann分型、肿瘤横向部位是脾门淋巴结转移的高危因素,而T分期、肿瘤横向部位是微转移的独立危险因素。结论 中上部进展期胃癌脾门淋巴结转移及微转移发生率较高,Borrmann分型、TNM分期、肿瘤横向部位、T分期是脾门淋巴结总体转移的高危因素,含有以上临床病理特征者建议常规行脾门淋巴结清扫。     

Alpha-fetoprotein-producing early gastric cancer: report of two cases

We have experienced two cases of alpha-fetoprotein (AFP)-producing early gastric cancer. One patient was a 73-year-old man diagnosed as having an early gastric cancer type 0 I + IIa at 40 x 40 mm on the greater curvature of the lower body of the stomach. The histological findings showed that proliferation of a well-differentiated tubular adenocarcinoma with hepatoid pattern was massively invading to the middle layer of the submucosa, with positive lymph vessel, and lymph node metastasis. The other patient was a 76-year-old man diagnosed as having an early gastric cancer type 0 IIa + IIc at 25 x 25 mm on the anterior wall on the greater curvature of the antrum. The histological findings showed that proliferation of a small cell carcinoma was massively invading to the deep layer of the submucosa, with positive lymph vessel, and lymph node metastasis. AFP was immunohistochemically found in the tumor cells of these two cases. Both patients died from liver metastasis. AFP-producing early gastric cancer was concluded to be at high risk of liver metastasis.     

胃贲门及部分胃小弯整块切除在食管中下段癌手术中的临床意义

目的探讨贲门及部分胃小弯整块切除在食管中下段癌手术中的临床意义。方法对我院2007年1月～2009年12月期间的110例食管中下段癌患者行根治术,骨骼化胃左动脉,并整块切除胃贲门及部分胃小弯组织,常规送病检。结果全组无围术期死亡。术后病检证实均为食管鳞状细胞癌。28例发生胃左动脉旁淋巴结癌转移,阳性率25.5%。其中胸中段食管癌5例,阳性率15.6%;中下及下段食管癌23例,阳性率29.5%。pTNM分期：0～Ⅱ期46例,发生胃左动脉旁淋巴结癌转移7例（15.2%）;Ⅲ～Ⅳ期54例,发生胃左动脉旁淋巴结癌转移21例（38.9%）。有3例患者病变呈食管壁内跳跃性转移,均发生胃左动脉旁淋巴结转移。结论胃贲门及部分胃小弯整块切除在食管中下段癌手术治疗中具有重要的临床意义,与手术疗效密切相关,应作为食管中下段癌手术的常规步骤。     

Gastric stromal tumor with CD34 immunoreactivity--a case report

Gastric stromal tumors are the most common mesenchymal tumors, and such submucosal mass lesions of the upper gastrointestinal tract occur frequently. A 54-year-old woman with no major complaint was admitted to our hospital for evaluation of a mass located between the stomach and the pancreas. Abdominal ultrasonography, computed tomography and endoscopic ultrasonography demonstrated a mass lesion which was located near the lesser curvature of the stomach. Selective left gastric arterial angiography revealed a hypervascular mass, and we diagnosed it as a leiomyosarcoma of the stomach. At laparotomy, there was a large solid mass 5 cm in diameter along the minor curvature of the stomach. Tumor resection with partial gastrectomy was performed, and the histological diagnosis was a gastric stromal tumor with CD34 immunoreactivity. We report a case of stromal tumor of the stomach with extramural growth and review the literature.     

Extent of mediastinal lymph node dissection for clinical T1 non-small cell lung cancer

The present study was designed to determine the extent of lymph node dissection for clinical T1 non-small cell lung cancer without negatively influencing curability. The study included 192 cases with clinical T1 non-small cell lung cancers who underwent lobectomy with mediastinal lymphadenectomy. Among 69 cases with right upper lobe tumors, metastasis was found in subcarinal lymph node in one case only. No metastasis was found in subcarinal node in cases free of metastasis in hilar and/or superior mediastinal nodes. Among 33 cases with right lower lobe tumors, metastasis was detected in the superior mediastinal node only in cases with metastasis in hilar and/or subcarinal nodes. Among 51 cases with left upper lobe tumors, no metastasis was found in the subcarinal node. Among 22 cases with left lower lobe tumors, metastasis was found in the superior mediastinal nodes only in cases with metastasis in hilar and/or subcarinal nodes. We propose the following scheme for the extent of mediastinal node dissection. Dissection of mediastinal node for clinical T1 non-small cell lung cancer cannot be omitted. But, 1) for upper lobe tumors, subcarinal lymphadenectomy could be omitted if no metastasis is found in hilar and superior mediastinal nodes based on gross and microscopic examination of frozen sections. 2) Similarly, for lower lobe tumors, superior mediastinal lymphadenectomy could be omitted if no metastasis is detected in the hilar and subcarinal nodes.     

Surgery and clinicopathological features of gastric adenocarcinoma involving the esophago-gastric junction

To clarify the optimal operative procedure for gastric adenocarcinoma involving the esophago-gastric junction (EGJ), we investigated 49 cases with an upper gastric cancer invading the esophagus who underwent surgical treatment in our department during the period from 1991 to 2000. According to Siewert's classification, there were 21 cases with a type II tumor, and 28 cases with a type III tumor. Twenty-five cases underwent surgery through an abdominal approach only. The remaining 24 cases were operated on via a left thoraco-abdominal approach. Eight (33%) of 24 cases who underwent extended lymphadenectomy through a left thoraco-abdominal approach had lower mediastinal lymph node metastasis. Metastasis was observed in cases with cancer invasion more than 2 cm from the EGJ. There were 6 cases with a T1 tumor, 6 with a T2 tumor, 27 with a T3 tumor, and 10 with a T4 tumor. Incidences of lymph node metastasis were 0% for T1, 67% for T2, 81% for T3, and 80% for T4. Proximal gastrectomy was performed in 6 cases at the early stage and in 10 cases at the advanced stage with distant metastasis (M1). Total gastrectomy was done in 33 cases at the advanced stage, and 3 of these 33 cases had metastasis to the parapyloric lymph nodes. We performed combined resection of the body and tail of the pancreas and the spleen in 7 cases. One of these 7 cases had direct invasion to the pancreas and 6 cases had remarkable metastasis to the lymph nodes along the splenic artery. Splenectomy preserving the pancreas was done in 24 cases. The incidences of metastasis of the lymph nodes along the splenic artery and the splenic hilum were 25% and 17%, respectively. We performed partial resection of the diaphragm surrounding the esophageal hiatus in 15 cases through a left thoraco-abdominal approach. Six cases had metastasis to the diaphragm and nine cases had direct invasion to the diaphragm. Tumors were stage I in 8 cases, II in 5 cases, III in 13 cases and IV in 23 cases, and the curability was categorized as A in 8 cases, B in 20 and C in 21. The overall 5-year-survival rate was 25%, and the rates according to cancer stage were 86% for stage I, 40% for stage II , 21% for stage III and 0% for stage IV. The 5-year survival rates of cases at stage II and III were 33% for cases using the left thoraco-abdominal approach and 28% for cases with the abdominal approach. Based on these results, we recommend distal esophagectomy with total gastrectomy, and occasional combined resection of the spleen and the diaphragm through a left thoraco-abdominal approach for advanced gastric adenocarcinoma involving the EGJ.     

不同分型食管胃交界部腺癌的淋巴结转移规律及手术方式的选择研究

目的：探究不同分型食管癌交界部腺癌（AEG）患者术后淋巴结转移规律以及手术方式的选择。方法：以我院2007年4月至2013年6月收治的158例食管癌胃交界部腺癌患者作为研究对象,所有患者均行经上腹、左胸入路淋巴清扫术,术后对各分型淋巴结转移的规律进行比较分析,并对手术方式的选择予以探讨。结果：158例患者术中共清扫淋巴结2449枚,平均每例清扫15.5枚,其中证实有105例患者伴有淋巴结转移,阳性淋巴结总数转移度711枚,转移度为29.0%,其中胸下段食管旁及下纵隔淋巴结转移以SiewertⅠ型患者为主。AEG患者淋巴结转移与否在肿瘤大小和病理分期方面具有显著差异性（P〈0.01）,具有统计学意义。结论：AEG患者淋巴结转移与肿瘤大小和病理分期有着密切的关系,根据Siewert分型,Ⅰ型、Ⅱ型的AEG患者均可选择经上腹左胸两切口,而Ⅲ型AEG患者则可选择单一经腹切口进行手术。     

Surgical management of adenocarcinoma in the gastric cardia

From 1979 to 1988, a total of 1083 patients with gastric cancer underwent resection at Kurume University Hospital. Among these cancers, 183 (16.8%) were located in the upper third of the stomach. Of these, 56 (5.2%) were adenocarcinomas in the esophagogastric (E-G) junction. Cancer in this area was designated as cardia cancer when the focus of the cancer was macroscopically located within 2 cm of the E-G junction line and the tumor was less than 8 cm in diameter. The incidence of early gastric cancer in the cardia was only 13%, while the incidence for stage III advanced cancer was high at 46%, and the positive lymph node metastasis rate was 59%. Thirty-nine (70%) were cured by resection with a 5-year-survival rate of 64%, while for non-curative resection, this was only 10%. Twenty-two cases of either advanced cardia or advanced CE cancer underwent combined resection of the diaphragm. The rate of invisible metastasis to the diaphragm was 20% in our experimental study. The two year-survival rate for a combined resection of the diaphragm was 64%, while the rate for those who did not undergo a required combined resection was 42%.     

中段食管癌根治术扩大二野清扫淋巴结的临床体会

目的探讨胸中段食管癌扩大二野清扫的淋巴结转移规律。方法从2008年9月至2012年9月对52例胸中段食管癌患者以Ivor-Lewis术式为基础进行扩大二野清扫,并对淋巴结转移规律进行分析。结果 52例患者并发症发生率为36.5%(19/52),死亡1例。淋巴结转移发生率为50%(26/52)。共清扫淋巴结1 426枚,其中99枚淋巴结发生转移,淋巴结转移度为6.9%;主要集中在颈深组、食管旁、喉返神经旁、隆突下、贲门区和胃左动脉旁,淋巴结转移率分别为17.3%、19.2%、7.6%、13.4%、25%和5.7%;转移度分别为15.2%、17.2%、6.1%、19.2%、24.2%和3.0%。早期食管癌和进展期食管癌淋巴结转移率分别为25%和52.1%,转移度分别为1.9%和7.1%,两者转移率和转移度之间差异均有统计学意义(χ2=2.178、1.083,P<0.05)。结论胸中段食管癌有广泛转移的倾向,颈深区及上纵隔区域是胸段食管癌淋巴结转移的重要区域。Ivor-Lewi术式更方便胸中段食管癌切除和现代二野淋巴结的清扫,并且以此为基础经右胸顶对颈深区淋巴结清扫也是安全可行的。     

术前超声造影对乳腺癌前哨淋巴结转移的预测价值

目的：分析术前超声造影对乳腺癌前哨淋巴结转移的预测价值。方法：选择乳腺癌病人276例,术前均行超声造影检查寻找前哨淋巴结,将病理学检查结果和超声造影结果进行对比,计算超声造影敏感性、特异性、阳性预测值、阴性预测值及准确率。结果：276例病人中,124例肿瘤位于左乳,152例位于右乳;100例肿瘤部位在外上象限,47例在外下象限,60例在内上象限,69例在内下象限;所有病人均经病理证实为原发性乳腺癌,其中183例为浸润性导管癌,65例为导管内原位癌,16例为黏液癌,12例为其他;原发肿瘤直径0.6～4.9 cm,前哨淋巴结直径0.3～3.2 cm。术前超声造影共检出497枚前哨淋巴结,手术共切除518枚前哨淋巴结,术前超声造影对前哨淋巴结的检出率为95.95%(497/518);病理学检查确认存在120枚转移前哨淋巴结。术前超声造影预测前哨淋巴结阳性病人73例,阴性病人203例,其对有无前哨淋巴结的预测灵敏性76.12%,特异性89.47%,阳性预测值69.86%,阴性预测值92.12%,准确率86.23%。结论：术前超声造影还需联合其他示踪方式对乳腺癌前哨淋巴结转移情况进行预测,才能获...     

β-catenin在胃癌及其淋巴结转移癌中的表达及意义

目的探讨β-连接素（β-catenin,β-cat）在胃癌原发灶及相应淋巴结转移癌中的表达及意义。方法采用免疫组织化学（S-P）法检测28例远癌正常胃组织,70例胃癌（48例有淋巴结转移）及相应淋巴结转移癌中β—cat的表达。结果70例胃癌组织中β-cat表达率为68．6％,远低于正常胃组织的阳性率（92．9％）（P〈0．05）。β-catenin在48例胃癌原发灶和淋巴结转移癌中的表达率有较高的一致性（两者均表达占41．1％,两者均不表达占25％）。β—cat的阳性表达与胃癌的分化程度、浸润深度及淋巴结转移密切相关（P〈0．05）,且在胃癌原发灶与其淋巴结转移癌中显著相关（列联系数R=0．317,P〈0．05）。结论β—cat可作为判断胃癌生物学行为的指标,为预测胃癌的转移及预后评估提供依据。     

弥漫型胃癌组织中增殖细胞核抗原的表达

目的：研究弥漫型胃癌增殖细胞核抗原（PCNA）的表达与肿瘤浸润，淋巴结转移的关系。方法：采用免疫组化法，对11例弥漫型胃癌组织中PCNA的表达水平进行检测，结果：112例弥漫型胃癌中96例（85．7％）PCNA阳性，粘膜及粘膜下肿瘤PCNA阳性率（28．6％）明显低于浆浆膜外肿瘤（93．0％），（P＜0．05），淋巴结转移组PCNA阳性率（82．0％）明显高于无淋巴结转移组（34．8％），淋巴结转移≥10枚淋巴结组PCNA阳性率（94．1％）明显高于＜10枚淋巴结组（42．9％）（P＜0．05）。结论L对胃癌组织进行PCNA蛋白的检测，有助于预测胃癌进展程度和诊断淋巴结转移，以及评估胃癌的预后。     

胃低分化神经内分泌癌的病理学特征与早期诊断相关性研究

目的分析胃低分化神经内分泌癌临床病理特征,为疾病的早期诊断和评估提供帮助。方法分析1993年1月~2011年5月我院收治的经手术切除、病理证实为胃神经内分泌癌患者51例的临床资料。结果 51例患者术前诊断为胃低分化神经内分泌癌31例,鳞癌11例,腺癌9例。术后病理诊断显示,贲门部位发生肿瘤32例,胃窦10例,胃体9例;以近端肿瘤居多（32例,62.7%）;诊断时多为进展期（33例,64.7%）,伴有局部淋巴结和远处转移;镜下肿瘤细胞体积较小,胞质稀少,排列呈巢状,多伴有坏死。结论胃低分化神经内分泌癌术前诊断误诊率高,应提高对其独特生物学特征的认识,术前合理选择辅助检查,有助于提高早期诊断水平。     

434例肺癌淋巴结转移及其廓清的临床研究

目的：研究肺癌淋巴结转移的方式与规律，以探讨肺癌淋巴结合理的手术廓清范围。方法：对434例肺癌患者施行手术并予淋巴结廓清，回顾性分析病理证实的转移淋巴结的分布情况。结果：手术共清除2198组淋巴结，病理证实有癌细胞转移的749组。淋巴结转移率T1期为16．5％，T2期33．5％，T3期35．6％，T4期52．3％，T1期和T4期的组间有显著性差异（P＜0．01）。上叶肺癌上纵膈与下纵膈淋巴结转移有显著差异。左上叶肺癌第5组淋巴结有30．6％转移，左下叶和右中、下叶肺癌第7组淋巴结有26．5％转移。结论：除T1期肺癌淋巴结转移仅限于区域性上纵膈或下纵膈外，总体上，上叶肺癌以上纵膈淋巴结转移居多，而中、下叶肺癌则上、下纵膈均可发生淋巴结转移。左上叶肺癌第5组淋巴结转移和中、下叶肺癌第7组淋巴结转移是上、下纵膈之间淋巴结扩大转移的信号。原发肺癌除T1期可仅行区域性上纵膈或下纵膈淋巴结清扫外，均应行系统性肺门和上下纵膈淋巴结廓清。     

Long-term survival after gastric cancer with liver metastasis: a report of two cases

We have experienced two cases of long-term survival after surgery for gastric cancer case with liver metastasis. One case was of a 66-year-old male patient diagnosed as having type 1 advanced gastric cancer located in the posterior wall of the lower body with liver metastasis. The stage of this case was P0H1N1T2M0 stage IV. This patient underwent distal gastrectomy with D2 lymph node resection, partial hepatectomy of the S3 region including the metastatic liver tumor and coagulation of metastatic liver tumors in the S6 and S7 regions. This patient was treated by intra-hepatic arterial infusion of 5-FU, CDDP and peroral administration of UFT after surgery. This patient has died at 3 years and 7 months after surgery. The other case was of a 55-year-old male patient diagnosed as having type 2 advanced gastric cancer located in the lesser curvature of the cardia with liver metastasis. The stage of this case was P0H1N1T3 M0 stage IV. This patient underwent total gastrectomy with D2 lymph node dissection, wedge resection of the S8 region including the metastatic liver tumor and coagulation of a metastatic liver tumor in the S4 region. This patient was treated by obstruction of the hepatic artery using coils, peroral administration of UFT, lentinan, MMC, and continuous low-dosage 5-FU and CDDP after surgery. This patient has died at 3 years and 6 months after surgery. These results suggest that for long-term survival in cases of gastric cancer with liver metastasis, hepatectomy or coagulation of the metastatic tumor with postoperative chemotherapy are indicated in cases that have no non-curative factors and only a few metastatic tumors.     

直肠间质瘤的MRI表现及临床分析

目的 探讨直肠间质瘤的MRI表现及临床特征。方法 回顾性分析9例经病理学证实直肠间质瘤的MRI及临床资料。结果 临床8例出现下腹部胀痛不适，1例无明显症状。肿瘤位于直肠上段1例、中段及下段5例、下段3例，最大直径约2.7~8.3cm，平均(6.3±1.6)cm。7例肿瘤肠腔外生长、2例腔内、外生长。MR平扫9例T1WI为等及较低信号，T2WI上8例稍高信号、1例高信号；DWI均为高信号；动态增强扫描9例均持续明显强化，内部均见无强化坏死区，8例见强化假包膜；5例见直肠缘滋养血管，1例导致直肠不全梗阻，3例出现肝脏单发转移，9例均未见腹、盆腔积液及淋巴结转移。9例均经手术根治性切除，其中8例中、高度危险性肿瘤术后行伊马替尼辅助治疗。术后随访6~71个月，3例因肿瘤广泛转移死亡，其余6例未见复发及转移。结论 直肠间质瘤缺乏特殊临床症状；MRI对其诊断具有较大价值，多表现为肠壁外生性肿块，平扫T2WI呈高或稍高信号，DWI高信号，动态增强扫描持续中度以上明显强化，呈“快进慢出”的强化模式，假包膜常见，较大肿瘤可见坏死、囊变，容易发生种植转移和血行转移，但淋巴结转移少见；早期根治性切除可以改善预后。     

胸段食管癌手术胃左动脉旁淋巴结清扫178例分析

目的:通过分析胸段食管癌胃左动脉旁淋巴结转移与相关病理因素的关系,探讨胃左动脉旁淋巴结清扫的意义。方法:对178例胸段食管癌切除术的患者,全部行胃左动脉旁淋巴结清扫,根据术后病理分为胃左动脉旁淋巴结转移阳性组和阴性组,分析胃左动脉旁淋巴结转移与临床病理因素之间的关系。结果:178例食管癌中发生胃左动脉旁淋巴结转移的阳性率21.91%。胸段食管癌病变部位越低、病理分期越晚,贲门旁淋巴结转移越多,胃左动脉旁.淋巴结转移的可能性越大。同时,本资料还显示食管旁、隆突下和贲门旁淋巴结转移阴性的患者其胃左动脉旁淋巴结转移率也均在18%以上。结论:食管中下段癌需常规进行胃左动脉旁淋巴结清扫,这对于有效的控制癌肿术后复发转移,改善预后,都有重要意义。