Histopathologic Criteria for Local Excision of Colorectal Cancer: Multivariate Analysis

Background: Local treatment of colorectal cancer, including endoscopic removal of colonic polyps and transanal resection of rectal tumors, has become widely accepted. However, risk factors predicting the presence of lymph node metastasis have not been fully investigated. To determine the criteria for local excision of colorectal cancer, histopathologic factors independently predicting the lymph node metastasis were investigated.Methods: We performed a retrospective histopathologic study on 335 patients who underwent resection of colorectal cancer and dissection of regional lymph nodes between 1982 and 1996. Features of node-positive tumors (n = 150) were compared with those of node-negative tumors (n = 185), with special reference to the histopathologic findings of the resected tumor. Multivariate analysis was done using the stepwise logistic regression test.Results: Node-positive tumors, when compared with node-negative tumors, were characterized by tumor larger than 6 cm (42% vs. 22%), serosal invasion (88% vs. 56%), lymphatic invasion (32% vs. 5%), venous invasion (9% vs. 2%), and histology other than well-differentiated (66% vs. 29%). Multivariate analysis showed that factors independently associated with lymph node metastasis were serosal invasion, lymphatic invasion, and histologic type. When these three risk factors were negative, lymph node metastasis was rare (5%). When one, two, or three factors were positive, the frequency of lymph node metastasis was 38%, 66%, and 85%, respectively.Conclusions: In colorectal cancer, factors independently associated with lymph node metastasis are serosal invasion, lymphatic invasion, and histologic type. When these three parameters are favorable, local treatment of colorectal cancer does not require additional lymph node dissection.     

Clinical significance of lymph node micrometastasis in gallbladder carcinoma

BACKGROUND: This retrospective study was intended to define the clinical significance of lymph node micrometastasis in gallbladder carcinoma. METHODS: A total of 1136 regional lymph nodes taken from 63 consecutive patients undergoing radical resection were examined histologically. Micrometastasis was defined as a metastasis missed on routine histologic examination with hematoxylin-and-eosin but detected by immunohistochemical examination with an antibody against cytokeratins 8 and 18. RESULTS: None of 9 patients (0%) with pT1 disease and 19 of 54 patients (35%) with pT2-4 disease had nodal micrometastases. Univariate analysis identified nodal micrometastasis, type of radical resection, M classification, pT classification, perineural invasion, pTNM stage, timing of radical resection, lymphatic vessel invasion, and pN classification as significant variables. Multivariate analysis revealed that nodal micrometastasis (P =.0003) and type of radical resection (P=.0044) were independent prognostic factors. Nodal micrometastasis affected survival adversely, despite the absence (P=.0002) or presence (P <.0001) of overt nodal metastasis. Nodal micrometastasis correlated significantly with invasive characteristics: lymphatic vessel invasion, perineural invasion, and distant metastasis. CONCLUSIONS: Lymph node micrometastasis is the strongest independent predictor of worse survival regardless of the overt nodal status and may indicate aggressive tumor biology among patients undergoing curative resection for gallbladder carcinoma.     

Prediction of lymph node status in patients with superficial esophageal carcinoma: analysis of 160 surgically resected cancers

BACKGROUND: The ability to predict lymph node metastasis in cases of superficial esophageal carcinoma before surgery would allow the identification of specific patients who do not require additional surgical resection after endoscopic local resection. METHODS: From 1980 to 2002 a total of 160 patients with superficial esophageal carcinoma, Tis or T1 tumors, underwent subtotal esophagectomy with lymph node dissection. On the basis of clinicopathologic data the risk factors for lymph node metastases are discussed. RESULTS: Patients with tumors that showed submucosal invasion, a nonflat shape, and lymphatic invasion had a higher risk for lymph node metastasis than the other patients. Multivariate analysis showed that the tumor depth and the macroscopic shape of the tumor were independent risk factors for lymph node metastases. CONCLUSIONS: Esophagectomy with lymph node dissection is recommended for patients with submucosal cancer. Local tumor resection can be recommended for patients with mucosal cancer without lymphatic invasion.     

Surgical Management of Mesenteric Lymph Node Metastasis in Patients Undergoing Rectosigmoid Colectomy for Locally Advanced Ovarian Carcinoma

Background We sought to determine the incidence of mesenteric lymph node metastases in patients undergoing rectosigmoid resection for epithelial ovarian carcinoma and to evaluate the potential contribution of sigmoid mesocolectomy toward achieving complete surgical cytoreduction. Methods Pathology results for patients undergoing rectosigmoid colectomy for epithelial ovarian carcinoma from August 1998 through September 2005 were retrospectively reviewed. Fifty-three patients with pathological documentation of mesenteric lymph nodes were selected for further review. A focused analysis was performed on cases with an adequate surgical sampling of mesenteric lymph nodes (more than one positive or five total mesenteric lymph nodes) to determine the overall incidence of nodal metastases. χ² analysis was used to identify clinicopathologic factors associated with mesenteric lymphatic spread. Results A total of 39 (73.6%) of 53 patients had an adequate mesenteric resection suitable for nodal analysis. In this subgroup, 32 (82.1%) of 39 patients had one or more mesenteric lymph nodes containing metastatic ovarian carcinoma. Invasion beyond the serosa of the rectosigmoid colon was present in 31 (79.5%) of 39 of cases; however, increasing depth of invasion was not associated with risk of mesenteric nodal disease. In addition to bowel wall involvement, the only clinical factor that correlated with mesenteric lymph node involvement was concurrent tumor spread to retroperitoneal lymph nodes (P = .025). Conclusions Locally advanced ovarian carcinoma involving the rectosigmoid colon is associated with a high incidence of mesenteric nodal metastasis. Standard surgical technique should include a sigmoid mesocolectomy with resection of the associated lymphatic tributaries at the time of rectosigmoid colectomy if the surgical objective is complete cytoreduction of occult nodal disease.     

Distribution of Lymph Node Metastasis Including Micrometastasis in Gastric Cancer with Submucosal Invasion

Abstract The purpose of this retrospective study was to analyze the distribution of lymph node metastases, including micrometastases, according to the location of the gastric cancer with submucosal invasion. A total of 118 patients with submucosal gastric cancer were enrolled in this study. The distribution of lymph node metastases was examined according to tumor location. Immunohistochemical examination using anti-cytokeratin antibody was performed to examine nodal micrometastases in 118 patients. Lymph node metastasis was found in 19.5% (23/118) of the patients. Significant differences were found for tumor size and depth, lymphatic invasion, and venous invasion for patients with and without nodal metastasis. The distribution of lymph node metastasis for tumors at upper or middle portions of the stomach was mainly found along the left gastric artery. The distribution of lymph node metastasis for tumors in the lower and lesser curvature varied. Immunohistochemical analysis found that 15 of 23 patients with lymph node metastasis found by histologic examination had micrometastases. The presence of two or more lymph node micrometastases was found in these 15 patients, and they were distributed in another stations, including distant nodes. The incidence of micrometastasis was 24.2% (23/95) in pN0 patients. Lymph node micrometastases were confined to regional nodes near the primary tumor. When planning minimally invasive treatment for submucosal gastric cancer, it is important to understand the distribution of lymph node metastasis, including micrometastasis, according to tumor location.     

Early cancer of the stomach: pattern of lymphatic metastasizing and its influence on surgical approach

Results of surgical treatment of 156 patients were analyzed. There were no metastases to the lymph nodes in patients with invasion of mucous membrane only. In patients with invasion of the tumor into a submucous layer regional metastases were revealed in 18 (19%) cases. Number of affected lymph nodes varied from 1 to 7 (2.7, on the average). Metastases to 1 lymph node were revealed in 9 (50%) patients, to 2-3 nodes -- in 5 patients, to 5-7 nodes -- in 4 patients. In 14.78% patients metastases were only to perigastric lymph nodes, in 4 cases -- to nodes of the second level (N2). Invasion of the tumor into submucous layer, location and size of the tumor were the main factor of risk of lymphatic cancer spread. Frequency of lymphatic cancer spread does not exceed 10% in any variant. In patients with proximal tumor, infiltrative growth and size more than 4 cm, tumor lymphatic metastases are diagnosed in each third person. It is concluded that gastrectomy or distal subtotal resection of the stomach with modified D2 lymphatic dissection is the method of choice in treatment of patients with invasion of stomach cancer into submucous layer.     

Optimal lymph node dissection for carcinoma of the biliary tract]

To clarify the optimal lymph node dissection for carcinoma of the biliary tract, we analyzed the mode of lymphatic spread in 86 resected cases with carcinoma of the gallbladder and 139 with carcinoma of the extrahepatic bile duct, and investigated long-term results after resection based on the degree of lymph node metastasis. Of the 86 patients with carcinoma of the gallbladder, 62 (72.1%) had lymph node metastasis. Patients with m and mp tumors (n = 9) had no lymph node metastasis, whereas ss tumors (n = 13) had 23.1% lymph node metastasis. Those with se, si tumors (n = 64) had greater lymph node involvement (92.2%). In 4 patients with advanced carcinomas (ss or more) who survived more than 5 years, only one (limited to periportal lymph nodes) of them had lymph node metastasis. Of the 139 patients with carcinoma of the extrahepatic bile duct, 58 (41.7%) had lymph node metastasis. There was no lymph node metastasis in 15 patients with m or fm tumors. The frequency of metastasis in the ss (n = 39) and se, si (n = 85) tumors was 17.9% and 60.0%, respectively. Twenty-four patients with advanced tumors survived more than 5 years. Curative resection was achieved in all 24 and lymph node metastasis was n0 in 19, n1 in 4 and n2 in 1 patients. Satisfactory long-term result can be achieved in carcinoma of the biliary tract after resection when lymph node metastasis is limited to nodes in the hepatoduodenal ligament. In view of our surgical results and the lymphatic drainage system of the biliary tract, systemic dissection of the regional lymph nodes, including periportal, posterior pancreato-duodenal, and celiac nodes, is necessary in patients with N0-N2 (limited to lymph nodes in the hapatoduodenal ligament) tumors in whom it contributes to good prognosis.     

VEGF-C和MMP-7的表达与胃癌侵袭转移的关系

目的 探讨胃癌中血管内皮生长因子C（VEGF-C）和基质金属蛋白酶7（MMP-7）的表达及两者与胃癌侵袭和淋巴结转移的关系。方法 采用SP免疫组化技术，分别检测60例胃癌组织、癌旁组织及30例癌周区域淋巴结中VEGF-C及MMP-7的表达水平。结果 VEGF-C和MMP-7在胃癌组织中的阳性表达率明显高于正常胃黏膜及癌旁组织；在区域淋巴结癌转移组中的阳性表达率明显高于无癌转移组（P〈0．01）；伴有淋巴结转移的胃癌组织中VEGF-C，MMP-7的阳性表达率明显高于无淋巴结转移组（P〈0．05）；VEGF-C，MMP-7表达与淋巴结转移、淋巴管侵犯、浸润深度、TNM分期有密切关系（P〈0．05）。结论 VEGF-C和MMP-7在胃癌中的高表达与胃癌浸润侵袭程度、淋巴结转移有密切关系。     

Clinicopathological features and medical management of early gastric cancer

BACKGROUND: The detection of early gastric carcinoma (EGC) has increased worldwide due to advances in endoscopic techniques and equipment. The aim of the current study was to compare the clinicopathological findings of patients with and without lymph node metastasis. METHODS: A total of 440 cases of early gastric carcinoma in patients who underwent surgical procedures between 1981 and 2002 at Kochi Medical School were studied. RESULTS: Lymph node metastasis was observed in 38 patients (8.6%) with EGC. Multivariate analysis identified 4 independent risk factors of lymph node metastasis: (1) submucosal invasion; (2) tumor diameter greater than 3.5 cm; (3) the presence of vascular invasion; and (4) the presence of lymphatic permeation. CONCLUSION: For patients with tumor size between 1 cm and 3.5 cm we would recommend endoscopic resection initially, with a consideration for additional surgical resection if microscopic vascular invasion or lymphatic permeation is demonstrated.     

Predictive factors for lymph node metastasis in early gastric cancer with submucosal invasion: analysis of a single institutional experience

OBJECTIVE: An accurate assessment of a potential lymph node metastasis is an important issue for the appropriate treatment of early gastric cancer. Minimizing the amount of invasive procedures used in cancer treatment is critical for improving the patient's quality of life. Therefore, this study analyzed the predictive risk factors for a lymph node metastasis in early gastric cancer with a submucosal invasion. METHODS: The data from 1043 patients surgically treated for early gastric cancer with submucosal invasion between 2002 and 2005 were reviewed retrospectively. The patients were divided into 3 layers according to their depth: SM1, SM2, and SM3. The clinicopathological variables predicting a lymph node metastasis were evaluated. RESULTS: A lymph node metastasis was observed in 19.4% of patients. The tumor size, histologic type, Lauren classification, tumor depth, and perineural invasion showed a positive correlation with the rate of lymph node metastasis and N category by univariate analysis. Multivariate analyses revealed the tumor size (>or=2 cm) and lymphatic involvement to be significantly and independently related to lymph node metastasis. The presence of lymphatic involvement was the strongest predictive factor for a lymph node metastasis, being observed in 43.8% of cases in which a lymph node metastasis had been revealed. No lymph node metastasis was observed in the 12 cases with no lymphatic involvement, SM1 invasion, and tumor size <1 cm. CONCLUSIONS: Lymphatic involvement and tumor size are independent risk factors for a lymph node metastasis in early gastric cancer with submucosal invasion. Minimal invasive treatment, such as endoscopic mucosal resection, may be possible in highly selective submucosal cancers with no lymphatic involvement, SM1 invasion, and tumor size <1 cm.     

Pattern of lymph node involvement and prognosis in pancreatic adenocarcinoma: direct lymph node invasion has similar survival to node-negative disease

Lymph node status is one of the most important predictors of survival in pancreatic ductal adenocarcinoma. Surgically resected pancreatic adenocarcinoma is often locally invasive and may invade directly into peripancreatic lymph nodes. The significance of direct invasion into lymph nodes in the absence of true lymphatic metastases is unclear. The purpose of this study was to retrospectively compare clinical outcome in patients with pancreatic ductal adenocarcinoma with direct invasion into peripancreatic lymph nodes with patients with node-negative adenocarcinomas and patients with true lymphatic lymph node metastasis. A total of 380 patients with invasive pancreatic ductal adenocarcinoma classified as pT3, were evaluated: ductal adenocarcinoma with true lymphatic metastasis to regional lymph nodes (248 cases), ductal adenocarcinoma without lymph node involvement (97 cases), and ductal adenocarcinoma with regional lymph nodes involved only by direct invasion from the main tumor mass (35 cases). Isolated lymph node involvement by direct invasion occurred in 35 of 380 (9%) patients. Overall survival for patients with direct invasion of lymph nodes (median survival, 21 mo; 5-year overall survival, 36%) was not statistically different from patients with node-negative adenocarcinomas (median survival, 30 mo; 5-year overall survival, 31%) (P=0.609). Patients with node-negative adenocarcinomas had an improved survival compared with patients with lymph node involvement by true lymphatic metastasis (median survival, 15 mo; 5-year overall survival, 8%) (P<0.001) regardless of the number of lymph nodes involved by adenocarcinoma. There was a trend toward decreased overall survival for patients with 1 or 2 lymph nodes involved by true lymphatic metastasis compared with patients with direct invasion of tumor into lymph nodes (P=0.056). However, this did not reach statistical significance. Our results indicate that patients with isolated direct lymph node invasion have a comparable overall survival with patients with node-negative adenocarcinomas as opposed to true lymphatic lymph node metastasis.     

Kidney metastasis from gallbladder cancer

A case of kidney metastasis from primary gallbladder cancer is presented. Five years after operation for gallbladder cancer, a 73-year-old woman exhibited hematuria. Imaging disclosed a 5×4cm solid mass in the right kidney and enlarged lymph nodes behind the inferior vena cava adjacent to the right renal vein. The right kidney and adjacent tissues, including retroperitoneum and regional lymph nodes, were resected en bloc. The renal tumor was diagnosed as a metastasis from the primary adenocarcinoma of the gallbladder, based on histological similarities, absence of other primary adenocarcinoma, and fluctuations in CA19-9 levels during the progress and after the resection of the metastatic tumor. The initial operation had been an extended cholecystectomy with wedge resection of the liver bed, plus regional lymphadenectomy. The excised gallbladder had a 2.3 ×1.2cm nodular tumor in the fundus. Histological examination indicated the gallbladder tumor to be a moderately differentiated tubular adenocarcinoma invading the subserosal layer. Mild lymphatic invasion was recognized in the gallbladder wall, although lymph node metastasis was negative. We believe this patient represents the first case of kidney metastasis from gallbladder cancer. The mode of spread of the gallbladder cancer to the kidney appeared to be lymphogenous.     

趋化因子受体CCR7在胃癌中的表达及其与淋巴结转移的关系

目的探讨趋化因子受体CCR7的表达对预测胃癌淋巴结转移的临床价值。方法对132例行胃癌根治术和30例内镜活检的胃癌组织标本采用免疫组化法检测CCR7的表达。结果CCR7在56.8%的病例中呈阳性表达。CCR7在伴有淋巴结转移病例中的表达显著高于无淋巴结转移者(P<0.001);其与肿瘤大小(P<0.01)、浸润深度(P<0.001)、淋巴管浸润(P<0.001)和TNM分期(P<0.001)相关,并与多层螺旋CT(MSCT)和病理检查判断的淋巴结转移密切相关(P<0.05,P<0.01);但与年龄、性别、肿瘤位置、Lauren分类和血管浸润无关。在回顾性研究中,CCR7表达对胃癌淋巴结转移判断的敏感性、特异性、阳性预测值(PPV)、阴性预测值(NPV)和准确率分别为83.1%、73.8%、78.7%、78.9%和78.8%;在前瞻性研究中,CCR7表达对胃癌淋巴结转移判断的敏感性、特异性、PPV、NPV和准确率分别达85.0%、60.0%、80.9%、66.7%和76.7%。结论CCR7表达与胃癌淋巴结转移密切相关,对内镜活检组织检测CCR7的表达有助于预测胃癌淋巴结转移及决定淋巴结清扫的手术范围。CCR7可能成为胃癌治疗的新靶点。     

肝细胞癌临床病理学特征与手术后长期存活的多因素相关分析

目的评估肝细胞癌（hepatocellular carcinoma，HCC）病理学特征对于长期存活的影响。方法选取1991年1月至2002年6月西南医院实施根治性肝切除，具有完整随访资料和临床资料234例HCC，应用COX比例风险模型单因素和多因素分析影响预后的病理因素，寿命表法计算生存率，Kaplan-Meier乘积极限法绘制生存曲线，log-rank Χ^2检验比较生存时间差异。结果单因素分析提示影响HCC预后的病理因素包括肿瘤大小、微血管侵犯、大血管侵犯、淋巴结侵犯、邻近器官侵犯和Edmonson-Steiner分级，多因素分析发现大血管侵犯（RR：1．728，P〈0．05）、微血管侵犯（RR：1．476，P〈0．05）、淋巴结侵犯（RR：5．010，P〈0．01）、邻近器官侵犯（RR：1．695，P〈0．05）是独立影响HCC预后的重要病理因素。结论大血管侵犯、微血管侵犯、淋巴结侵犯、邻近器官侵犯是影响HCC预后的重要病理学因素。     

Strategies for surgical treatment of gallbladder carcinoma based on information available before resection

HYPOTHESIS: Precise preoperative staging for gallbladder carcinoma is difficult, despite recent advances in hepatobiliary imaging. However, the most accurate preoperative staging may be possible by integrating preoperative key data. OBJECTIVE: To establish useful strategies for the surgical treatment of gallbladder cancer based on information available before resection. DESIGN: Retrospective review. SETTING: University hospital and tertiary referral cancer center.Patients and METHODS: From January 1, 1978, through March 31, 2001, 152 patients with gallbladder cancer underwent surgical resection with curative intent. Preoperative diagnoses of the T factor (image-T) and N factor (image-N) in the TNM classification were determined by evaluating all findings of diagnostic imaging, including ultrasonography, enhanced computed tomography, endoscopic ultrasonography, and angiography. The distribution of lymph node metastasis and prognostic factors were also analyzed. RESULTS: The overall diagnostic accuracy for image-T was 52.6% (95% confidence interval, 44.7%-60.6%) and was lower in patients with pT1 and pT2 disease (37.2% and 33.9%, respectively). However, image-T was a significant predictor of lymph node metastasis and patient outcome. Preoperative staging for N was more difficult, with only 24.5% (95% confidence interval, 12.4%-36.5%) of the node-positive patients being correctly diagnosed. An analysis of harvested lymph nodes showed that the cystic, pericholedochal, and posterosuperior peripancreatic nodes were the most prevalent sites of metastasis, and these were considered key nodes for the lymphatic spread of gallbladder cancer. By combining data on image-T and positivity of these key nodes, more accurate TNM staging was possible. Although an extended lymph node dissection provided significantly better survival in patients with pN2 disease, there was no survival advantage to more radical operations, including bile duct resection or pancreaticoduodenectomy. CONCLUSIONS: Although precise preoperative TNM staging for gallbladder carcinoma was difficult, the most accurate staging before resection was possible by integrating image-T classification and data from the intraoperative histopathologic examination of key lymph nodes. Based on this staging, we propose algorithms for the surgical treatment of gallbladder carcinoma.     

A case of mucosal esophageal carcinoma with a large intramural metastasis in the stomach

The prognosis of mucosal carcinoma of the esophagus is extremely good because of low frequency of lymphatic invasion compared with submucosal carcinoma. A 64-year-old male was admitted presented with dysphagia and weight loss. Roentgenogram and esophagoscopy revealed erosive lesions in the lower portion of the esophagus and a huge submucosal tumor that looked like the myosarcoma in the cardial portion. After total resection of thoracic esophagus and partial gastrectomy, esophagogastrostomy was done through the anterior thoracic route. During the operation, we found a few disseminative foci in the thoracic cavity (pl1) and direct invasion of cardial tumor to the celiac portion. Therefore, the operation was absolute by palliative. Histological examination of the resected specimen showed that the IIc-like lesion of the lower portion of the esophagus was a moderately differentiated squamous cell carcinoma invading the mucosa (mm), which was 2.0 x 1.6 cm in size, with marked lymphatic invasion, and intra-mural metastatic foci (7.0 x 5.0 cm) at the cardial portion. The patient died 3 months after the operation with mediastinal lymph node metastasis. In our 19 cases of resected mucosal carcinoma of the esophagus, lymphatic invasion was positive in 16%, and lymph node metastasis was positive in 16%, and intramural metastasis was in only one case. Frequency of intramural metastasis in esophageal carcinoma is about 10% in sm -a3 lesion, 5% in mm. In our experience, the prognosis of curatively resected mucosal carcinoma of the esophagus is generally good. We get long survivals, when curative operation is undergone, even if the lymphatic invasion is positive.     

Indications for pancreatoduodenectomy in patients undergoing lymphadenectomy for advanced gallbladder carcinoma

Background/Purpose Carcinoma of the gallbladder shows diverse patterns of spread. The most appropriate surgical procedures according to the depth and extent of the spread of the tumor are still controversial.Methods We investigated this surgical problem clinicopathologically, especially regarding the indications for pancreatoduodenectomy (PD), by retrospectively reviewing the clinical records of 216 patients who were surgically treated for advanced gallbladder carcinoma. Detailed studies of resected specimens, in our department, showed that preservation of the pancreas head carried an increased risk of residual microscopic metastases in small peripancreatic lymphatic nodes and ducts. Some patients with curative operations had shown recurrence in lymph nodes around the head of the pancreas within a few years after PD. Therefore, we performed hepatopancreatoduodenectomy (HPD) in 93 patients, some of whom underwent the HPD as a prophylactic dissection of peripancreatic lymph nodes and some of whom underwent the HPD as a curative resection due to invasion to the peripancreatic lymph nodes, duodenum, and pancreas, observed macroscopically. The surgical outcome after PD was compared with that obtained after other curative resections (non-HPD).Results In patients with microscopically negative lymph node metastasis without hepatoduodenal ligament invasion, PD was not necessary for a complete resection of lymphatic metastases around the pancreas head. The 5-year survival rate of these patients who had HPD was not significantly higher than that for non-HPD resections with curative intent (73% vs 63%), and lymphatic recurrence was not marked. On the other hand, in patients with positive lymph node metastases without hepatoduodenal ligament invasion, PD was necessary for a complete resection. The 5-year survival rate after HPD in these patients was significantly improved compared to that after non-HPD resections with curative intent (87% vs 17%), because lymphatic recurrence was reduced (0% vs 80%).Conclusions In advanced carcinomas with positive hepatoduodenal ligament invasion, although the basic operative strategy, which inevitably includes right lobectomy, should be curative, PD should not be performed for prophylactic lymphatic resection, because local recurrence in the hepatoduodenal ligament cannot be controlled by PD, and the 5-year survival rate of curative HPD was only 4% (non-HPD resection with curative intent, 18%); moreover, frequent, lethal, major postoperative complications (hepatic failure) occurred after combined right lobectomy.     

Pattern of lymph node metastases in patients with squamous cell carcinoma of the thoracic esophagus who underwent three-field lymphadenectomy

BACKGROUND/AIMS: Lymph nodes in patients with squamous cell carcinoma of the thoracic esophagus might be involved with metastases at cervical, mediastinal, and abdominal sites. The range of lymph node dissection is still controversial. The pattern of lymph node metastasis and factors that are correlated with lymph node metastasis affect the surgical procedure of lymph node dissection. The purpose of the present study was to explore the pattern of lymph node metastasis and factors that are correlated with lymph node metastasis in patients with esophageal cancer who underwent three-field lymphadenectomy. METHODS: Lymph node metastases in 230 patients who underwent radical esophagectomy with three-field lymphadenectomy were analyzed. The metastatic sites of lymph nodes were correlated with tumor location by chi-square test. Logistic regression was used to analyze clinicopathological factors related to lymph node metastasis. RESULTS: Lymph node metastases were found in 133 of the 230 patients (57.8%). The average number of resected lymph nodes was 25.3 +/- 11.4 (range 11-71). The proportions of lymph node metastases were 41.6, 19.44, and 8.3% in neck, thoracic mediastinum, and abdominal cavity, respectively, for patients with upper thoracic esophageal carcinomas, 33.3, 34.7, and 14%, respectively, in those with middle thoracic esophageal carcinomas, and 36.4, 34.1, and 43.2%, respectively, for patients with lower thoracic esophageal carcinomas. We did not observe any significant difference in lymph node metastatic rates among upper, middle, and lower thoracic carcinomas for cervical or thoracic nodes. The difference in lymph node metastatic rates for nodes in the abdominal cavity was significant among upper, middle, and lower thoracic carcinomas. The lower thoracic esophageal cancers were more likely to metastasize to the abdominal cavity than tumors at other thoracic sites. A logistic regression model showed that depth of tumor invasion and lymphatic vessel invasion were factors influencing lymph node metastases. CONCLUSIONS: Based on our data, cervical and mediastinal node dissection should be performed independent of the tumor location. Abdominal node dissection should be conducted more vigorously for lower thoracic esophageal cancers than for cancers at other locations. Patients with deeper tumor invasion or lymphatic vessel invasion were more likely to develop lymph node metastases.     

早期结直肠癌淋巴结转移的基础和临床研究

目的探索早期结直肠癌淋巴结转移的规律和相关因素,探讨其治疗方法以及“高级别上皮内瘤变”这一新概念在临床应用中的一些注意事项。方法对复旦大学附属肿瘤医院1985年1月至2000年12月手术治疗的61例黏膜肌层浸润和黏膜下层浸润的早期结直肠癌病例的临床资料进行回顾性分析,并对其中48例行根治性手术的病例选用细胞角蛋白(CK)的单抗、经免疫组化法进行淋巴结微转移的检测。结果黏膜肌层癌变时25%(4/16)的病例可出现区域淋巴结微转移,黏膜下层癌变时则有31.3%(10/32)的病例可出现淋巴结微转移和转移。在黏膜肌层和黏膜下层浸润的早期结直肠癌中,淋巴结微转移的发生和肿瘤大小相关,当肿瘤最大径≥3cm时微转移多见(P=0.031)。黏膜下层浸润时,淋巴结微转移的发生还和癌变的腺瘤类型(绒毛状腺瘤)、浸润深度(sm3)密切相关(P值分别为0.039和0.018)。随访发现11.5%(3/26)的黏膜肌层癌变病例,有局部复发、血道转移等恶性生物学行为表现。结论黏膜肌层浸润的早期结直肠癌病例中已可以出现区域淋巴结的微转移,当癌变浸润至黏膜下层时淋巴结微转移和转移的发生率更高。在早期结直肠癌的治疗中,选择局部切除手术需要慎重。当肿瘤最大径≥3cm、癌变腺瘤为绒毛状腺瘤或有证据提示黏膜下层浸润已达sm3时,建议选择根治性     

Patterns and Predictors of Failure after Curative Resections of Carcinoma of the Ampulla of Vater

Background:Curative resection does not always equate with long-term survival. The aim was to identify patterns and predictors of failure and independent factors of prognosis after curative resection.Methods:Sixty-six patients with ampullary carcinoma who underwent surgical intervention were reviewed. Fifty-nine patients underwent pancreaticoduodenectomy. Cox regression analysis, log-rank test, Fisher exact test, or ² test was used.Results:No patient died as a result of surgery; major complications occurred in three, and the 5-year survival rate after curative resection (n = 55) was 52.6%. Significant survival predictors were preoperative serum carcinoembryonic antigen level; gross tumor appearance; tumor, node, and tumor node metastasis stage; and microscopic lymphatic vessel and venous invasion in the primary tumor. Multivariate analysis demonstrated that lymphatic vessel invasion, tumor, and tumor node metastasis stage were significant independent prognostic factors. No patient experienced locoregional failure alone; all 24 relapsed patients had distant failure, and six of them had both. The liver was the most frequent metastatic organ, followed by nodes, peritoneum, lung, and bone. The carcinoembryonic antigen and carbohydrate antigen levels and lymphatic vessel and venous invasion were significant predictors of distant failure, and the mean time to relapse was 13 (range, 0.7–33) months.Conclusions:Curative resection is associated with significant survival; however, effective systemic adjuvant therapy is needed to prevent distant failure for patients with elevated carcinoembryonic antigen and carbohydrate antigen levels or positive lymphatic vessel or venous invasion. A 3-year follow-up period would be necessary to document relapses.