Neoadjuvant therapy in non-small cell lung cancer. Prognostic impact of "mediastinal downstaging"]

In the course of a prospective multicenter study, 40 (26 squamous cell and 14 adenocarcinomas) patients with stage IIIA and IIIB non-small cell lung cancer (NSCLC) were submitted to surgery after neoadjuvant radiochemotherapy. Pretherapeutic clinical lymph node status was compared to the lymph node involvement established in the resection specimens. Therapy-induced tumor regression was classified according to a three-step tumor regression grading system. In 29 patients (72.5%) a downward shift in lymph node involvement could be established,whereas in 27.5% ( n=11) pretherapeutic lymph node status was maintained. Of 26 patients with post-therapeutic N0 or N1 status, 21 revealed less than 10% vital tumor tissue in the resection specimens (regression grades IIb or III). Patients with post-therapeutic N0 or N1 lymph node status were found to have a survival benefit compared to patients with N2 lymph node involvement, though this difference was not statistically significant (p=0.27). On the other hand, tumor regression showed a significant correlation to the overall survival period (p=0.02). Thus, therapy-induced tumor regression grading seems to be a more precise method to predict the outcome of the disease.     

Type of lymph node involvement and survival in pathologic N1 stage III non-small cell lung carcinoma.

BACKGROUND: Survival of patients with stage II non-small lung cancer by the 1986 classification depends on the type of lymph node involvement (by direct extension or by metastases in lobar or hilar lymph nodes). The influence of these types of lymph node involvement on survival was investigated in pathologic N1 stage III patients. METHODS: Of 2,009 patients having operation from 1977 through 1993, the cases of 123 patients with pathologic N1 stage III disease (80 T3 N1 and 43 T4 N1) were reviewed. The N1 status was refined by the specific type of lymph node involvement. RESULTS: The cumulative 5-year survival rate of all hospital survivors (n = 111) was 27.2%. A significant difference in mean 5-year survival rate was observed between patients who underwent complete resection and those with incomplete resection (34.4% versus 11.4%; p = 0.0001). Further analysis was performed with hospital survivors having complete resection only (n = 76). The cumulative 5-year survival rate was 34.4%. Type of lymph node involvement did not relate to survival for the group as a whole or for the T3 and T4 subsets. Survival was not related to age, histology, type of resection, or tumor size. CONCLUSIONS: Moderately good results can be obtained with surgical resection for stage III patients with pathologic N1 disease. In contrast with stage II, complete resection of pathologic N1 higher-stage non-small cell lung carcinoma is not influenced by type of lymph node involvement.     

Prognostic factors for survival in patients with T3 laryngeal carcinoma.

In a total of 511 patients with T3,N0-3,M0 laryngeal carcinoma, 24 possible prognostic factors were analyzed retrospectively. The factors were age, sex, mode of treatment, duration of several clinical symptoms, the presence of sore throat, otalgia, dyspnea, and dysphagia, previous tracheotomy, tumor extension, lymph node status (five items), histologic grading, smoking habits, and alcohol intake. For 300 patients in whom surgery was part of the primary treatment, pathologic staging of the primary tumor and of lymph nodes in neck dissection specimens, cartilage invasion, radicality of the operation, differentiation grade, and subglottic extension ware also evaluated. In a univariate analysis for the whole group, tumor extension (limited to the glottic region), lymph node status (clinically palpable lymph nodes, cytologically confirmed positive lymph nodes), level of lymph node metastasis (high and midjugular site), histologic grading (poor differentiation grade), and treatment modality (planned combined therapy) were considered to be prognostic factors of corrected actuarial survival. In the group that underwent surgery, all factors derived from specimens of the larynx and neck dissections had prognostic significance. Multivariate analysis revealed that the glottic site of the tumor, the presence of cyto- and histopathologically proven metastatic lymph nodes, pretreatment tracheotomy, positive resection margins, and planned combined treatment had a significant influence on corrected actuarial survival.     

Results of resection in non-oat cell carcinoma of the lung with mediastinal lymph node metastases.

From 1974 to 1981, 1598 patients with non-oat cell carcinoma of the lung were seen and treated. All were staged according to the AJC staging system. Of these, 706 patients had evidence of mediastinal lymph node metastases (N2). There were 151 patients (21%) who had complete, potentially curative resection of their primary tumor and all accessible mediastinal lymph nodes. The histologic type of tumor was adenocarcinoma in 94 patients, epidermoid carcinoma in 46 patients, and large-cell carcinoma in 11 patients. The extent of pulmonary resection consisted of a lobectomy in 119 patients, pneumonectomy in 26 patients, and wedge resection or segmentectomy in six patients. Almost all patients also received radiation therapy to the mediastinum. Clinical staging of the primary tumor and the mediastinum was based on the radiographic presentation of the chest and on bronchoscopy. Before treatment, 104 of 151 patients (69%) were believed to have had stage I (90 patients) or II (14 patients) disease, and 47 patients had stage III disease, of whom only 33 had evidence of mediastinal lymph node involvement. Excluding deaths from unrelated causes, the overall survival rate was 74% at 1 year, 43% at 3 years and 29% at 5 years. Survival in patients with clinical stage I or II disease treated by resection was favorable despite the presence of N2 nodes (50% at 3 years). Survival in obvious clinical N2 disease was poor (8% at 3 years). There was no difference in survival between patients with adenocarcinoma and those with epidermoid carcinoma. However, survival was poorer in patients with N2 nodes in the inferior mediastinum compared to those without lymph node involvement at that level.     

Pathomorphological and histological prognostic factors in curatively resected ductal adenocarcinoma of the pancreas

The fate of patients with potentially resectable carcinomas is not only determined by the pTNM tumor stage, but also possibly by tumor-biological factors. The aim of this study was to identify these prognostic factors in patients undergoing primary curative (R0) resection. The study retrospectively analyzed 113 patients with ductal adenocarcinoma who were operated on between 1986 and 1995. R0 resection was able to be performed in 93 patients. Lymph node metastases were found in 73%. The rates of lymph vessel and perineural invasion were 83.5% and 45%, respectively. Among the 25 carcinomas without lymph node metastases, 64% already had lymph vessel invasion and 48% had perineural invasion. The cumulative 5-year survival rate of the 91 surviving patients analyzed was 10.5%. Depending on the tumor stage we found a significant difference in 5-year survival rates between patients without lymph node metastases (26.5%) and those with lymph node involvement (5%) (P = 0.008). A multivariate analysis only identified lymph vessel invasion (L0/1), tumor size (≦/≦2 cm), and tumor grading (G) to have significant and independent prognostic value. Lymph vessel invasion, tumor size, and tumor grading proved to be independent factors determining long-term prognosis. Received: May 12, 1999 / Accepted: January 7, 2000     

Prognostic value of deoxyribonucleic acid aneuploidy in primary non-small-cell lung carcinomas and their metastases.

The ploidy status of the deoxyribonucleic acid of a malignant lung tumor provides additional information besides histologic grading and tumor staging according to lymph node infiltration and tumor metastasis. Ninety-nine surgical specimens from patients with non-small-cell lung carcinoma were investigated by flow cytometry. Deoxyribonucleic acid aneuploidy was found in 48% of the primary tumors. Patients with deoxyribonucleic acid-euploid tumors showed better survival (p < 0.01) than those with deoxyribonucleic acid-aneuploid carcinomas independent of tumor stage. Deoxyribonucleic acid ploidy status of the primary tumor was compared with that of N2 lymph node metastases in 29 cases. Seven samples showed a change from deoxyribonucleic acid aneuploidy in the primary tumor to deoxyribonucleic acid euploidy in the lymph node metastases. Survival was significantly better for patients with euploid primary tumors and lymph node metastases, followed by patients with deoxyribonucleic acid-aneuploid primary tumors and euploid lymph node metastases. Survival was poorest in patients with deoxyribonucleic acid-aneuploid primary tumors and lymph node metastases. It was observed that only the simultaneous determination of deoxyribonucleic acid ploidy of primary tumors and lymph node metastases permits accurate prognostic evaluation in case of lymph node infiltration.     

FLOW CYTOMETRIC DETERMINATION OF THE DNA CONTENT IN TRANSITIONAL CELL CARCINOMA OF THE BLADDER: PREDICTABILITY OF PLOIDYWITH REGARD TO PELVIC LYMPH NODE METASTASIS

Flow cytometry was used to evaluate 93 deparaffinized transurethral resection or cystectomy specimens to investigate the predictability of DNA profiles with regard to pelvic lymph node metastasis. The pathological stage and grade were also compared with the status of the pelvic lymph node. The incidence of aneuploidy in the total specimen group was 55 out of 93 (59%). Aneuploidy and pathologic stage were significant risk factors for pelvic lymph node metastasis (p = 0.0091, 0.0008 respectively) but histologic grade was not correlated with pelvic lymph node status (p = 0.7418). Aneuploidy was noted in all of the 11 specimens exhibiting lymph node involvement compared with 44 of the 82 (54%) without lymph node involvement (p=0.0091). There was no positive pelvic lymph node involvement in patients with diploid tumor compared with 11 of the 55 (20%) patients with aneuploid tumors. In conclusion, the recognition of a DNA aneuploid stemline in a primary transitional cell carcinoma of the bladder is statistically correlated with a greater likelihood of pelvic lymph node metastasis. This suggests that preoperative DNA flow cytometry for primary tumor might be helpful in selecting patients who should be offered additional treatment such as neoadjuvant chemotherapy before definitive treatment or a more conservative approach such as transurethral resection.     

Detailed Pathologic Characteristics of the Primary Colorectal Tumor Independently Predict Outcome after Hepatectomy for Metastases

Introduction

Outcome after hepatic resection for colorectal cancer liver metastases (CRLM) is heterogeneous and accurate predictors of survival are lacking. This study analyzes the prognostic relevance of pathologic details of the primary colorectal tumor in patients undergoing hepatic resection for CRLM.

Methods

Retrospective review of a prospective database identified patients who underwent resection for CRLM. Clinicopathological variables were investigated and their association with outcome was analyzed.

Results

From 1997–2007, 1,004 patients underwent hepatic resection for CRLM. The median follow-up was 59 months with a 5-year survival of 47 %. Univariate analysis identified nine factors associated with poor survival; three of these related to the primary tumor: lymphovascular invasion (LVI, p < 0.0001), perineural invasion (p = 0.005), and degree of regional lymph node involvement (N0 vs. N1 vs. N2, p < 0.0001). Multivariate analysis identified seven factors associated with poor survival, two of which related to the primary tumor: LVI (hazard ratio (HR) 1.3, 95 % confidence interval (CI) 1.06–1.64, p = 0.01) and degree of regional lymph node involvement [N1 (HR 1.3, 95 % CI 1.04–1.69, p = 0.02) vs. N2 (HR 1.7, 95 % CI 1.27–2.21, p < 0.0005)]. A significant decrease in survival along the spectrum of patients ranging from LVI negative/N0 to LVI positive/N2 was present. Patients who were LVI-positive/N2 had a median survival of 40 months compared with 74 months for patients who were LVI-negative/NO (p < 0.0001).

Conclusions

Histopathologic details of the primary colorectal tumor, particularly LVI and the detailed assessment of the degree of lymph node involvement, are strong predictors of survival. Future biomarker studies should consider exploring factors related to the primary colorectal tumor.     

Prognosis of completely resected pN2 non-small cell lung carcinomas: What is the significant node that affects survival?

OBJECTIVE: We analyzed the effect of the station of mediastinal metastasis with regard to the location of the primary tumor on the prognosis in patients with non-small cell lung cancer. METHODS: Of 956 consecutive patients who underwent operation for primary lung carcinoma between 1986 and 1996, 760 patients (79.5%) were diagnosed as having non- small cell carcinoma and were subjected to complete removal of hilar and mediastinal lymph nodes together with the primary tumor. RESULTS: The status of lymph node involvement was N0 in 480 patients (63.2%), N1 in 139 patients (18.3%), and N2 in 141 patients (18.6%). The 5- and 10-year survival of patients with N2 disease were 26% and 17%, respectively. Neither cell type nor the extent of procedure was a significant survival determinant. Patients having involvement of subcarinal nodes from upper-lobe tumors had a significantly worse prognosis than those patients with metastases only to the upper mediastinal or aortic nodes (P =.003). Patients with nodal involvement of the upper mediastinum from lower-lobe tumors had a significantly worse survival than those patients with metastases limited to the lower mediastinum (P =.039). Furthermore, patients with involvement of the aortic nodes alone from left upper-lobe tumors had a significantly better survival than those patients with metastasis to the upper or lower mediastinum beyond the aortic region (P =.044). CONCLUSIONS: When mediastinal metastasis is limited to upper nodes from upper-lobe tumor, to lower nodes from lower-lobe tumor, or to aortic nodes from left upper-lobe tumor, acceptable survival could be expected after radical resection.     

Evaluation of regional lymph node dissection in patients with upper urinary tract urothelial cancer

OBJECTIVE: The role of the lymph node dissection (LND) in conjunction with nephroureterectomy (NU) in upper tract urothelial cell carcinoma (UT-UCC) remains undefined. We evaluated the manner in which the LND was applied at NU, the patterns of lymph node (LN) involvement and the preoperative variables that could identify patients at high risk for lymph node metastasis (LNM). METHODS: We examined clinical, radiological and pathological records of patients who underwent NU for UT-UCC between 1985 and 2004. The central pathology laboratory reviewed all specimens and graded tumors using the 2002 World Health Organization/International Society of Urologic Pathologists grading system. RESULTS: Of the NU performed in 252 patients for UT-UCC, 105 (42%) were N0, 28 (11%) N+ and 119 (47%) Nx. Some form of LN resection was performed with NU in 53% of patients, with a median of four LN sampled (interquartile range, 2-10). After adjustment for tumor and patient characteristics, surgeon remained a significant predictor of LN resection (P < 0.0005). Of the evaluated variables, suspicious LN on preoperative computed tomography, present in 60% of N+ patients, was the only preoperative variable associated with the pathological finding of LNM (P < 0.0005). CONCLUSIONS: LND in patients with UT-UCC is surgeon-dependent. Given the prognostic importance of LN status and the limited accuracy of preoperative staging of the regional LN, surgeons should perform a regional LND at the time of NU.     

Pathologic N1 non-small cell lung cancer: correlation between pattern of lymphatic spread and prognosis

OBJECTIVES: Patients with N1 non-small cell lung cancer represent a heterogeneous population with varying long-term survivals. Prognosis and pattern of recurrence seem to be particularly affected by the level of lymph node involvement. METHODS: From 1990 to 1995, a total of 1954 consecutive patients underwent surgical resection for non-small cell lung cancer: 549 (28%) had ipsilateral pulmonary lymph node metastases (N1). The hospital survivors (n = 535) were reviewed. Three levels of lymph node metastases (hilar, interlobar, and lobar) were identified according to the new Regional Lymph Node Classification for Lung Cancer Staging and differentiated from lymph node involvement on the basis of direct invasion. RESULTS: 1 The overall 5-year survival of patients with N1 disease was 40%. Survival was related in the univariate analysis to T classification, level-type of N1 involvement, number of involved nodes, multilevel involvement, Karnofsky Index, R status, and adjuvant therapy. In the multivariate analysis, only T classification and level-type of N1 involvement clearly showed statistical power (P =.000 and P =.001, respectively). The pattern of cancer relapse according to level-type of N1 involvement differed significantly: hilar N1 disease recurred at distant sites in 41% of patients and locoregionally in 12% of patients, whereas N1 disease by direct invasion occurred in 24% and 17% of patients, respectively (P =.030). CONCLUSIONS: Metastases to ipsilateral hilar, interlobar, or both, lymph nodes are associated with a poorer prognosis compared with metastases in intralobar lymph nodes or with lymph node involvement by means of direct invasion. Although surgical resection remains the mainstay of treatment, the high rate of tumor recurrence in both groups mandates further randomized studies with multimodality therapy approaches.     

Small carcinoma of the pancreas. Factors of prognostic relevance

Tumor size seems to be one of the primary prognostic factors that influence outcome in pancreatic cancer patients. This finding is reflected in both the Japanese and the International Union against Cancer (UICC) staging systems, in which T categories have a major influence on stage grouping. To investigate whether small tumor size is a prognostic indicator in patients with pancreatic carcinoma, we evaluated (in a prospective study) patients with a small pancreatic cancer, categorized as T1a (<2 cm) or T1b (<4 cm) tumors according to the UICC (1997). Patients and Results: Of 670 treated patients with pan-creatic malignancies, 26 (3.8%) had a small pancreatic tumor (20 T1b; 6 T1a), Twenty-one patients were treated by pylorus-preserving duodenopancreatectomy, 4 patients re-ceived a left pancreatic resection, and 1 patient underwent a total pancreatectomy. All procedures included extensive soft tissue clearance. Local growth pattern was analyzed according to the Japan Pancreas Society (JPS) criteria for pancreatic cancer, i.e., lymph node involvement — N1 (limited to group 1 nodes) was found in 6/26 patients. Serosal infiltration — S1 (single area) was found in 6/26 and S2 (multiple areas) in 6/26; S3 (infiltration to adjacent organs) was found in 1/26. Retroperitoneal infiltration — Rp1 (adjacent to the pancreas) was found in 7/26 and Rp2 (not limited to adjacent tissues, but no other organs involved) was found in 3/26. Venous involvement (Pv2) was found in 1/26. The 5- and 10-year survival rate for the 26 patients was 46%. Interestingly, the T1a tumor patients had a significantly lower 5 year survival rate than the T1b patients (32% vs 58%; P < 0.05). Of prognostic relevance was lymph node metastasis, and retroperitoneal and serosal involvement and these patients had a significantly lower 5-year survival rate than those without such involvement regardless of tumor size (P < 0.01). Conclusions: An overall 5-year survival rate of 46% is exceptionally good. Unfortunately, among pancreatic cancer patients those with a small carcinoma represent a highly selected group, representing less than 5% in our series. Interestingly tumor size is of less prognostic relevance than lymph node, retroperitoneal, and serosal involvement. Radical resection with extensive soft tissue clearance therefore seems essential to achieve such a high survival rate. Received for publication on July 27, 1998; accepted on Aug. 31, 1998     

Histomorphologic tumor regression and lymph node metastases determine prognosis following neoadjuvant radiochemotherapy for esophageal cancer: implications for response classification

OBJECTIVE: We sought to quantitatively and objectively evaluate histomorphologic tumor regression and establish a relevant prognostic regression classification system for esophageal cancer patients receiving neoadjuvant radiochemotherapy. PATIENTS AND METHODS: Eighty-five consecutive patients with localized esophageal cancers (cT2-4, Nx, M0) received standardized neoadjuvant radiochemotherapy (cisplatin, 5-fluorouracil, 36 Gy). Seventy-four (87%) patients were resected by transthoracic en bloc esophagectomy and 2-field lymphadenectomy. The entire tumor beds of the resected specimens were evaluated histomorphologically, and regression was categorized into grades I to IV based on the percentage of vital residual tumor cells (VRTCs). A major response was achieved when specimens contained either less than 10% VRTCs (grade III) or a pathologic complete remission (grade IV). RESULTS: Complete resections (R0) were performed in 66 of 74 (89%) patients with 3-year survival rates of 54% +/- 7.05% for R0-resected cases and 0% for patients with incomplete resections or tumor progression during neoadjuvant therapy (P < 0.01). Minor histopathologic response was present in 44 (59.5%) and major histopathologic response in 30 (40.5%) tumors. Significantly different 3-year survival rates (38.8% +/- 8.1% for minor versus 70.7 +/- 10.1% for major response) were observed. Univariate survival analysis identified histomorphologic tumor regression (P < 0.004) and lymph node category (P < 0.01) as significant prognostic factors. Pathologic T category (P < 0.08), histologic type (P = 0.15), or grading (P = 0.33) had no significant impact on survival. Cox regression analysis identified dichotomized regression grades (minor and major histomorphologic regression, P < 0.028) and lymph node status (ypN0 and ypN1, P < 0.036) as significant independent prognostic parameters. A 2-parameter regression classification system that includes histomorphologic regression (major versus minor) and nodal status (ypN0 versus ypN1) was established (P < 0.001). CONCLUSIONS: Histomorphologic tumor regression and lymph node status (ypN) were significant prognostic parameters for patients with complete resections (R0) following neoadjuvant radiochemotherapy for esophageal cancer. A regression classification based on 2 parameters could lead to improved objective evaluation of the effectiveness of treatment protocols, accuracy of staging and restaging modalities, and molecular response prediction.     

Results of surgical intervention for p-stage IIIA (N2) non-small cell lung cancer: acceptable prognosis predicted by complete resection in patients with single N2 disease with primary tumor in the upper lobe

OBJECTIVES: Non-small cell lung cancer with mediastinal lymph node involvement is a heterogeneous entity different from single mediastinal lymph node metastasis to multiple nodes or extranodal disease. The objective of this study was to identify the subpopulation of patients with N2 disease who can benefit from surgical intervention. METHODS: We reviewed 219 consecutive patients with N2 non-small cell lung cancer treated with a thoracotomy between November 1980 and June 2002 and retrospectively analyzed 154 of those who had p-stage IIIA disease and underwent a complete resection. Age, sex, side (right or left), histology, location (upper or middle-lower lobe), tumor size, c-N factor, and N2 level (single or multiple) were used as prognostic variables. RESULTS: The 3- and 5-year survivals were 45.3% and 28.1%, respectively, in patients with p-stage IIIA (N2) disease. Survival for those with single N2 non-small cell lung cancer was significantly better than in those with multiple N2 disease (P =.0001), and patients with a tumor in the upper lobe showed a significantly longer survival than those with middle-lower lobe involvement (P =.0467). The 3- and 5-year survivals for patients with single N2 disease with a primary tumor in the upper lobe were 74.9% and 53.5%, respectively. A multivariate analysis with Cox regression identified 5 predictors of better prognosis: younger age, squamous cell carcinoma as determined by histology, primary tumor location in the upper lobe, c-N0 status, and a single station of mediastinal node metastasis. CONCLUSION: Our results suggest that of the heterogeneity of N2 diseases, patients with single N2 disease with non-small cell lung cancer in the upper lobe are good candidates for pulmonary resection.     

Role of Surgery for Gallbladder Carcinoma with Special Reference to Lymph Node Metastasis and Stage Using Western and Japanese Classification Systems

The role of radical resection in the treatment of gallbladder carcinoma was examined with special reference to lymph node metastasis using two classifications: one proposed by the American Joint Committee on Cancer (AJCC) and the other by the Japanese Society of Biliary Surgery (JSBS). Histologic evaluations for the depth of tumor invasion (T), lymph node metastasis (N), stage, and follow-up for a mean period of 38 months (range 4-185 months) were completed in 52 patients with gallbladder carcinoma who underwent surgical resection from 1982 to 1997. The definition of T was similar in the two classifications. The extent of nodal involvement (N, AJCC; n, JSBS), stage, and survival were examined. In the absence of lymph node metastasis, the 5-year survival rate reached 71%. The 5-year survival rate in patients with involved nodes confined to the hepatoduodenal ligament, posterosuperior pancreaticoduodenal region, or along the common hepatic artery (N1 and part of N2 by AJCC; nl and n2 by JSBS) approximated 28%. In contrast, postoperative survival was poor in the presence of more extensive nodal involvement (rest of N2 by AJCC; n3 and n4 by JSBS), with no 2-year survivors. The definition of stage I was the same in both classifications, and all patients in this stage are alive. The 5-year survival rates in stages II and III by the AJCC were 70.7% and 22.4%, respectively, and those by JSBS 61.9% and 23.1%, respectively. Thus the survival rates in stages I to III were essentially similar irrespective of the staging system. Stage IV showed significantly worse survival than stage III by the JSBS classification. In contrast, the differentiation of stage IV from III by the AJCC was not significant because of the better survival in stage IV that contained any T with nodal involvement in the posterosuperior pancreaticoduodenal region and along the common hepatic artery. Radical resection should be considered for patients with stage I to III disease defined by either classification and applied to the tumor invasion up to T3 with nodal involvement confined to the hepatoduodenal ligament, posterosuperior pancreaticoduodenal region, and along the common hepatic artery. The role of radical surgery seems to be limited in patients with more extensive tumor invasion or lymph node metastasis.     

胃底贲门癌根治术中保留脾脏对预后的影响

目的探讨胃底贲门癌根治术中保留脾脏对预后的影响。方法回顾性分析1994年7月至2003年12月间108例经根治性手术治疗的胃底贲门癌患者的临床病理资料,比较保脾与切脾两组患者的并发症发生情况和预后。结果切脾组38例,保脾组70例,最后随访日期2004年12月。本组淋巴结转移率68.5%(74/108),第10组淋巴结转移率16.7%。切脾组与保脾组术后并发症发生率(18.4%vs14%,χ2=0.318,P=0.573)、肿瘤复发率和肿瘤病理特征差异均无统计学意义。保脾组5年生存率明显高于切脾组(38.7%vs16.9%,P=0.008)。多因素分析显示,保留脾脏不是影响预后的独立因素(P=0.085),只有肿瘤浸润程度(P=0.009)和淋巴结转移(P=0.001)是独立的预后因素。结论除脾脏受侵犯者外,贲门癌根治术中应尽可能保留脾脏。     

The Importance of Surgery to Non-Small Cell Carcinoma of Lung with Mediastinal Lymph Node Metastasis

In the past 25 years, 1,654 patients with non-small cell cancer underwent resection at National Cancer Center Hospital, Tokyo. A comparative study has been made of 5-year survival of patients who had pulmonary resection with and without mediastinal lymph node dissection.There were 426 patients (25.8% of the total) with N2 M0 disease. Of these, 345 underwent pulmonary resection with mediastinal lymph node dissection. The 5-year survival in this group was 15.9% (T1 N2 M0, 30.0%; T2 N2 M0, 14.5%; and T3 N2 M0, 12.9%). In the remaining 81 patients, who did not have mediastinal lymph node dissection, 5-year survival was 6.7%.Of the 426 patients with N2 M0 disease, 242 were select patients who underwent a curative operation with an overall 5-year survival of 19.2%. Sixty-six of them had squamous cell carcinoma and a 5-year survival of 30.8%; 153 had adenocarcinoma and a survival of 16.0%; 14 had large cell carcinoma and a survival of 12.8%; and 9 had adeno-squamous cell carcinoma, and none survived 5 years.To improve the end results, it is important to perform as many curative operations with mediastinal lymph node dissection as possible. Histological cell type and tumor status must be taken into consideration.     

癌结节对结直肠癌肝转移同期切除术预后的影响

目的探讨癌结节对初始可切除同时性结直肠癌肝转移患者同期切除术预后的影响。 方法回顾性分析2003年7月至2015年7月复旦大学附属中山医院行同期切除的212例同时性结直肠癌肝转移患者资料,分析癌结节和临床病理因素的相关性,采用Kaplan-Meier生存分析和Cox回归模型分析癌结节对预后的影响。 结果癌结节的阳性率为43.9%（93/212）,癌结节和肿瘤分化、淋巴结转移、血管浸润和神经浸润显著相关（P=0.044、0.001、0.035、<0.001）,是低DFS的独立预后因素。癌结节阳性患者的OS和DFS明显低于癌结节阴性患者,差异有统计学意义（P=0.003、<0.001）。淋巴结阳性的135例患者中,癌结节阳性和阴性患者的OS比较,差异无统计学意义（P=0.608）,癌结节阳性患者DFS更低（P=0.003）;在淋巴结阴性的77例患者中,癌结节阳性患者的OS和DFS均显著低于癌结节阴性患者（P<0.001、0.010）。 结论对于结直肠癌肝转移同期切除术后患者,癌结节和肿瘤分化、淋巴结转移以及神经浸润显著相关,且预示不良预后。     

Multimodal treatment of non small cell lung cancer

The primary treatment of lung cancer depends on tumor stage. Chest CT scan and bronchoscopy are used to define the TNM stage and resectability. In case of lung cancer without mediastinal lymph node enlargement or direct mediastinal involvement (clinical stage I-IIb + T3N1) surgical treatment is recommended. The use of adjuvant chemotherapy has to be defined, but will be indicated in stage II and IIIa. Expected 5-year survival achieves 40 to 80 % depending on tumor stage. Exceeds the shorter diameter of mediastinal lymph nodes in chest CT scan more than 1 cm (or in case of positive PET scan) mediastinoscopy is indicated. In case of N2-disease and after tumor response to preoperative chemotherapy (about 60 %) secondary resection of the tumor leads to higher 5-year survival rates (20-40 %) compared to patients without induction therapy (5-20 %). In these patients and after unexpected detection of solitary lymph node metastasis by primary resection adjuvant mediastinal radiotherapy should be added. If the tumor has infiltrated the mediastinum or the upper sulcus (T3/4) and/or mediastinal lymph nodes are obviously tumor burden (e. g. > 3 cm, N2 bulky, N3) radical primary resection may not be possible. In these patients combined radio- and chemotherapy induces a high percentage of tumor regression and can be used before secondary resection (5-year survival 5-20 %). Locally advanced tumors infiltrating the main bronchus close to the carina or the carina itself and tumors with metastases in the same lobe, both without mediastinal lymph node metastases (T3/4N0-1), can be resected by sleeve pneumonectomy and lobectomy with satisfactory results respectively. In patients with resectable lung cancer and no clinical sign of tumor disease (f. e. anemia, weight loss, pain) limited staging procedure with chest CT scan including upper abdomen and bronchoscopy is reasonable. In the remaining patients complete staging is necessary. We recommend an interdisciplinary approach to patients with lung cancer.     

结肠癌根治术后复发的多因素分析

目的探讨结肠癌根治术后复发的因素。方法对2000年1月～2005年1月收治的135例结肠癌患者的临床资料进行回顾性分析。选择对结肠癌术后复发可能产生影响的临床因素,通过Cox比例风险模型进行多因素分析。结果全组患者复发率为16.3％。单因素分析显示,淋巴结转移、肿瘤大小、Dukes’分期和肿瘤细胞分化程度与结肠癌根治术后肿瘤复发有关。多因素分析显示,淋巴结转移和肿瘤细胞分化程度与结肠癌根治术后肿瘤复发有关。结论淋巴结转移和肿瘤细胞分化程度是影响结肠癌术后复发的独立危险因素。