年龄≤40岁的乳腺恶性叶状肿瘤患者临床特征及预后影响因素

  目的  探讨年龄≤40岁的乳腺恶性叶状肿瘤（malignant phyllodes tumors,MPTs）患者临床特征及预后因素。  方法  回顾性分析2006年1月至2020年10月188例于天津医科大学肿瘤医院收治的乳腺MPTs患者的临床资料,按照年龄≤40岁和年龄>40岁分为年轻组54例和年长组134例。采用χ2检验或Fisher确切概率法、Kaplan–Meier法、Cox比例风险回归模型进行统计学分析。  结果  年轻组乳腺MPTs患者5年和10年无复发生存（recurrence- free survival, RFS）率分别为55.8%和46.6%。年轻组患者的肿瘤直径>5 cm占59.3%（32/54）、年长组的占35.8%（48/134）,两组比较差异具有统计学意义（P=0.031）;年轻组患者的手术切缘<1 cm和术后化疗的比例分别为50.0%（27/54）和20.4%（11/54）,较年长组的35.8%（48/134）和7.5%（10/134）高（P=0.048,P=0.024）;年轻组中的患者行肿块切除术且保证手术切缘≥1 cm与乳腺全乳切除术相比,RFS差异无统计学意义（P=0.410）。Cox比例风险回归模型多因素分析显示,年龄（P=0.034）和手术切缘（P<0.001）是影响术后RFS的独立预后因素。  结论  年龄和手术切缘影响乳腺MPTs预后,年龄≤40岁患者较>40岁预后更差,对于年龄≤40岁患者在保证手术切缘至少1 cm情况下行肿块切除术可行。      

35例睾丸良性肿瘤的临床病例分析

  目的  探讨睾丸良性肿瘤行保留睾丸手术的治疗效果、预后及其影响因素。  方法  回顾性分析2004年5月至2017年5月中山大学肿瘤防治中心35例睾丸良性肿瘤患者的临床病例资料，分为保留睾丸手术组和根治性睾丸切除术组。  结果  35例患者平均年龄为18.8（0.4~44.0）岁，其中14例（40.0%）行保留睾丸手术、21例（60.0%）行根治性睾丸切除术。两组患者的肿瘤大小分别为1.8（0.4~4.0）cm和2.7（1.0~8.0）cm，围手术期均未见明显并发症，且均治愈出院。术后病理为表皮囊肿18例、成熟型畸胎瘤10例、间质细胞瘤4例和腺瘤样瘤3例。10例患者行术中冰冻快速病理检查，均与石蜡病理结果相符。行保留睾丸手术的患者，随访期间均未发现复发及转移，且性功能和生育能力保存良好。  结论  保留睾丸手术是可靠的，肿瘤的大小影响其实施。对于术前诊断考虑良性或性质不定的睾丸肿瘤，应行术中冰冻快速病理检查，确定为良性者行保留睾丸手术，否则行根治性睾丸切除术。      

胰腺内分泌肿瘤的外科诊断和治疗

  目的  探讨胰腺内分泌肿瘤的诊断及外科治疗方法。  方法  对收治的胰腺内分泌肿瘤16例患者的临床资料进行回顾性分析。  结果  本组16例患者中胰岛素瘤8例,胃泌素瘤4例,无功能性胰岛细胞瘤3例,生长抑素瘤1例。其中14例行根治切除术,2例因肿瘤无法切除而放弃手术治疗。术后发生胰瘘和炎性肠梗阻各2例,16例中3例失访,13例患者平均随访（4.5±2.3）年,2例仅行活检术的患者均在1年内死亡,2例恶性（胰岛素瘤和胃泌素瘤各1例）患者由于肿瘤复发转移在3年内死亡。随访期间良性病例全部生存。  结论  手术切除是胰腺内分泌肿瘤最为理想的治疗方法,选择合适的术式有助于避免术后并发症的发生和改善预后。      

开放性锁骨上入路在甲状腺肿瘤切除术中的临床应用

  目的  分析开放性锁骨上入路在甲状腺肿瘤切除术中的临床应用。  方法  通过比较传统颈前低位弧形切口入路甲状腺切除术同开放性锁骨上入路甲状腺切除术，术后患者美观满意度、手术效果、手术时间等，探讨开放性锁骨上入路甲状腺肿瘤切除术的临床实用性。  结果  22例行开放性锁骨入路甲状腺切除术（B组）较29例行传统切口入路甲状腺切除术（A组）具有良好的美观满意度（P < 0.05），与传统切口具有同样手术疗效。开放性锁骨上入路甲状腺切除术具有良好的美观满意度，与传统切口持有同样手术疗效。  结论  开放性锁骨上入路甲状腺肿瘤切除术对于需单侧叶切除的甲状腺良性肿瘤以及部分恶性肿瘤具有良好的临床推广价值，甚至对于大于切口直径的肿瘤仍适用，其在保证手术治疗疗效同时具有较佳的美观度。      

83例淋巴结阴性直肠神经内分泌肿瘤的临床病理特征

  目的  探讨淋巴结阴性直肠神经内分泌肿瘤（rectal neuroendocrine neoplasms，R-NENs）的临床病理特征。  方法  回顾性分析2012年12月至2019年12月中日友好医院83例淋巴结阴性R-NENs患者的临床病理资料，并定期随访。  结果  83例患者中男性49例（59.0%）、女性34例（41.0%）；平均年龄（43.3±11.4）岁；61例（75.5%）患者主要因非特异性症状就诊；肿瘤单发75例（90.4%）；肿瘤平均直径为（0.8±0.7）cm；主要浸润黏膜层及黏膜下层80例（96.4%）；病理分级以G1为主，共65例（78.3%），Ki-67指数平均值为（2.1±1.7）%；肿瘤分期Ⅰ期78例（94.0%）。免疫组织化学法检测CgA阳性29例（34.9%）。治疗方式使用内镜下切除67例（80.7%），手术16例（19.3%）。中位随访时间24（3~90）个月，5年生存率100%，2例（2.4%）复发。肿瘤复发与Ki-67阳性指数具有显著相关性（P=0.025）；肿瘤浸润深度与肿瘤直径具有相关性（P=0.030）。Kaplan-Meier法分析得出治疗方式、肿瘤分级对预后复发的差异具有统计学意义（P=0.031、0.001）。  结论  淋巴结阴性R-NENs直径>1.0 cm相对容易浸及固有肌层，直径≤ 1.0 cm也有浸及固有肌层的可能，建议此类患者行超声内镜（EUS）检查以决定治疗方式。内镜下切除为淋巴结阴性R-NENs的主要治疗方式，Ki-67指数较高患者治疗后相对容易复发。      

后腹腔镜肾上腺节细胞神经瘤切除六例

 目的　分析后腹腔镜肾上腺节细胞神经瘤切除术的手术方法及疗效。方法　回顾性分析行后腹腔镜肾上腺细胞神经瘤切除6例患者的临床资料,其中男性4例,女性2例。年龄32～59岁,平均41.3岁。左侧2例,右侧4例。结果　6例手术均在腹腔镜下完成,无中转开放。术中血压无剧烈波动,术后病理均证实为肾上腺节细胞神经瘤。肿瘤直径3.6～11.2 cm,平均（5.9±2.1）cm;手术时间90～210 min,平均120 min;出血50～700 ml,平均160 ml。术后7～9 d出院,术后均无严重并发症。随访4～32个月无复发。结论　后腹腔镜肾上腺节细胞神经瘤切除术手术创伤小、出血少、术野清晰、对肠道干扰少、恢复快、并发症少,是肾上腺节细胞神经瘤理想的治疗方式。     

腹膜后腹腔镜手术治疗肾上腺肿瘤38例

目的：评估腹膜后腹腔镜治疗肾上腺肿瘤的临床疗效。方法2010年1月至2013年3月38例患者均施行腹膜后腹腔镜肾上腺肿瘤切除术,其中肾上腺皮质腺瘤24例,嗜铬细胞瘤8例,节细胞神经纤维瘤2例,肾上腺囊肿3例,髓样脂肪瘤1例。所有患者均行肾上腺超声、CT平扫加增强以及磁共振成像（MRI）平扫加增强,证实为肾上腺肿瘤。病变位于左侧18例,右侧19例,双侧1例。肿瘤直径约2.0～11.0 cm。结果38例手术均成功,未中转开放手术;手术时间33～178 min,平均（97.5±35.1）min;出血量5～150 ml,均未输血,术后未出现严重并发症;术后住院时间为5～13 d,平均（7.5±1.8）d。结论腹膜后腹腔镜肾上腺肿瘤切除术安全、有效,创伤小,恢复快,应为肾上腺肿瘤的首选治疗方法。     

肾上腺偶发瘤的临床对策

目的:探讨肾上腺偶发瘤的临床对策.方法:回顾总结2002年1月～2004年5月收治的50例肾上腺偶发瘤病例资料.结果:50例经腰切除31例,经腹切除10例,腹腔镜切除9例,效果满意.病理检查皮质腺瘤31例,皮质增生3例,皮质腺癌2例,嗜铬细胞瘤8例,肾上腺囊肿3例,髓质脂肪瘤l例,节细胞瘤1例,肾上腺转移癌1例.结论:所有肾上腺偶发瘤均应行内分泌功能检查,肾上腺B超、CT、MRI对确诊肾上腺占位病变有较高价值.除诊断明确的＜3.0cm的肾上腺囊肿和肾上腺髓样脂肪瘤外均应早期手术治疗.腹腔镜手术创伤小,恢复快,为首选术式,肿瘤较大或与周围脏器有粘连者宜经腹手术.     

泌尿、生殖系统（060395～060423）

嗜铬素A和突触素在肾上腺肿癌中的表达及其临床意义；肾上腺偶发瘤的临床对策；腹腔镜在肾上腺肿瘤切除术中的应用；肾上腺偶发瘤52例临床分析；合并肾囊肿的肾细胞癌临床特点（附64例报道）；不同亚型囊肿相关性肾细胞癌的临床特点；青少年肾细胞癌14例报告；[编者按]     

360°直肠腔内超声对直肠少见肿瘤的诊断及术前分期价值

  目的  分析直肠少见肿瘤的360°直肠腔内超声图像特征,以提高其诊断正确率。  方法  选取2012年9月至2018年9月于陕西省人民医院在360°直肠腔内超声检查下行外科手术及化疗的直肠少见肿瘤患者14例,根据超声及病理结果等资料,分析各种病变的特征性表现。  结果  14例患者共检出病灶16个,术前超声诊断准确者8例,诊断符合率为57.1%,准确分期率78.5%。其中直肠神经内分泌肿瘤4例（28.6%）,准确分期3例（75.0%）;直肠肛管黑色素瘤3例（21.4%）,准确分期2例（66.7%）;直肠间质瘤6例（42.9%）,准确分期6例（100.0%）;直肠淋巴瘤1例（7.1%）,超声误诊为直肠癌。其中13例行手术治疗,1例淋巴瘤行化疗。  结论  直肠肛管少见肿瘤种类较多,360°直肠腔内超声对直肠肛管少见肿瘤的临床诊断及术前分期具有较大价值。      

电视腹腔镜下肾上腺肿瘤切除的临床研究(附87例)

目的：探讨电视腹腔镜下肾上腺肿瘤切除的临床应用。方法：回顾性分析了自2001年1月-2007年6月底我院行电视腹腔镜下肾上腺肿瘤切除术87例的临床资料。结果：87例肾上腺肿瘤中，经后腹腔途径81例，经腹途径6例；6例中转开放。结论：腹腔镜肾上腺肿瘤切除术经后腹腔途径优于经腹腔途径。后腹腔入路虽然技术难度较大，但手术效果优于经腹入路。肿瘤小于6cm，肿瘤无转移、无局部重要脏器及大血管浸润和黏连均适合行腹腔镜手术切除。     

同侧小体积肾及肾上腺肿瘤一期手术16例体会

目的 总结同侧小体积肾及肾上腺肿瘤患者一期行后腹腔镜肾部分及肾上腺部分切除术的临床经验。方法 回顾性分析2010年9月至2021年11月南京医科大学第一附属医院收治的16例同侧小体积肾及肾上腺肿瘤一期后腹腔镜手术患者的临床资料。结果 所有患者均在后腹腔镜下完成肾部分及肾上腺部分切除手术,其中机器人辅助手术3例,无中转开放手术者。肾肿瘤直径0.9～4.0(2.4±1.0) cm;肾上极肿瘤7例,肾中极4例,肾下极4例,1例多发;肾上腺肿瘤直径1.0～4.0(2.0±1.0) cm。术后病理示肾透明细胞癌12例,嫌色细胞癌1例,极性倒置的乳头状肾肿瘤1例,肾错构瘤2例;肾上腺皮质腺瘤15例,嗜铬细胞瘤1例。肾透明细胞癌合并肾上腺皮质腺瘤最常见,占比68.75%。术后随访1～90个月（中位随访时间24个月）,均无复发或转移。结论 小体积肾肿瘤合并的同侧肾上腺肿瘤多为良性,此类患者一期行后腹腔镜肾部分及肾上腺部分切除术安全有效,术后需长期随访。     

肾上腺肿瘤的诊断及微创治疗

随着内分泌学检查和影像学的进步,肾上腺肿瘤的检出率增加,诊治标准逐步完善。诊断方面,高血压人群的影像学筛查指征、亚临床内分泌腺瘤的治疗策略、影像学检查对肿瘤性质的鉴别是下一步的研究热点。治疗方面,腹腔镜已成为肾上腺良性肿瘤治疗的“金标准”,而恶性肿瘤和嗜铬细胞瘤的微创治疗的适应证不断拓宽,主要体现于腹腔镜在体积6～10cm的肾上腺皮质癌和体积> 6 cm的嗜铬细胞瘤患者中应用。肾上腺部分切除的手术范围和适应证主要依靠医师临床经验。另外微创治疗围手术期的处理亦应得到充分重视。本文针对以上内容做一综述。      

后腹腔镜下切除巨大肾上腺肿瘤的临床观察

目的 总结后腹腔镜下切除巨大肾上腺肿瘤（≥6cm）的临床经验。方法 自2007年6月至2013年3月对32例巨大肾上腺肿瘤（直径≥6cm）的患者行后腹腔镜下切除术,回顾性分析其临床资料。结果 患者均顺利完成手术。平均手术时间80min（45～110min）,术中出血量平均80ml（30～180ml）。术后随访时间3～50个月,平均19.5个月,仅1例患者复发转移。结论 后腹腔镜下切除巨大肾上腺肿瘤安全可行,肿瘤大小不是腹腔镜下切除巨大肾上腺肿瘤的决定因素。优先阻断肾上腺中央静脉可以有效地减少出血和功能性肿瘤术中突发症状。     

原发性无功能肾上腺皮质癌的诊断治疗

目的:探讨原发性无功能肾上腺皮质癌的诊断治疗。方法:回顾性分析16例经影像学检查、手术及病理证实的原发性无功能肾上腺皮质癌临床资料。结果:本组16例患者,男6例,女10例,年龄平均47岁,肿瘤直径平均9.5cm。16例患者相关内分泌检查均提示无异常。B超显示肿瘤内回声和形态多不规则,MRI,CT总体表现为肿瘤形状不规则,边界不清晰,肿瘤内部密度不均匀,增强后周边明显强化。临床分期Ⅰ期1例;Ⅱ期6例;Ⅲ期6例;Ⅳ期3例。16例患者均行手术治疗。术后病理均证实为肾上腺皮质腺癌。术后随访4例至今存活。结论:B超、CT、MRI可帮助诊断原发性无功能肾上腺皮质癌。积极手术是确切的治疗手段。50岁以上人群应以B超等影像检查监测肾上腺,以便早期发现。     

Adrenal incidentaloma: report of 33 cases

BACKGROUND AND OBJECTIVES: The aim of our study was to review the imaging characteristics, endocrinologic screening and histologic diagnoses of adrenal incidentaloma cases encountered in our institute. METHODS: Thirty-three adrenal incidentaloma cases that had been evaluated in Hacettepe University Hospital between 1985 and 1995 were reviewed retrospectively. Adrenal masses were discovered incidentally by abdominal ultrasonography (USG) and/or computed tomography (CT). Detailed endocrine evaluation was carried out to rule out a possible functioning mass. RESULTS: Among these incidentaloma cases, 2 silent Cushing syndrome (6.06%) cases, 6 silent pheochromocytoma (18.18%) cases, 2 adrenocortical carcinoma (6.06%) cases, and 2 metastatic masses (6.06%) were diagnosed. CONCLUSIONS: An optimal diagnostic approach to an adrenal incidentaloma would consider the results of the biochemical tests and a review of anatomical qualities depicted on CT or magnetic resonance imaging (MRI) while taking into account the previous clinical epidemiologic data.     

Surgical management of metastatic adrenal tumors: Decision-making factors in imaging

The present study aimed to clarify decision-making factors based on imaging for laparoscopic adrenalectomy (LA) or open adrenalectomy (OA) for adrenal metastasis (AM) based on our previous experience. From November 2003 to November 2006, 11 adrenalectomies were performed for AM for malignancies such as lung cancer, renal cell carcinoma (RCC) and breast cancer at Tokai University Hospital. A diagnosis of AM for these malignancies was suspected whenever a newly diagnosed adrenal mass was located, characterized by a basal computed tomography (CT) density superior to 10 Hounsfield units, strong or heterogeneous vascular enhancement following contrast injection and/or increasing size in sequential imaging studies. There was no evidence of extra-AM. The approach to surgical management using LA or OA was determined on the basis of CT and/or magnetic resonance imaging. The patients were reviewed every 2 or 3 months by physical examination and systemic CT. We analyzed the decision-making factors based on imaging for surgical management with LA or OA from the results of oncological outcome, imaging, intraoperative and pathohistological findings. In this study, 9 patients underwent 11 adrenalectomies (9 laparoscopic and 2 open procedures). Non-small cell lung cancer was the most common primary malignancy (5 adrenalectomies of 4 patients), followed by RCC (4 adrenalectomies of 4 patients) and breast cancer (2 adrenalectomies of 1 patient). The median tumor size for the LA group was 3.1±0.7 cm (range 2.1-4.3) and for the OA group, 6.1±0.8 cm (5.5 and 6.7 cm) (p=0.001). The operative time for the LA group was 127±42 min (range 90-215) and for the OA group, 224±47 min (190 and 257 min) (p=0.018). Blood loss for the LA group was 49±63 g (range 3-207) and for the OA group, 340±10 g (333 and 347 g) (p<0.001). No complications were noted and no conversion of LA to OA occurred. All 9 adrenal tumors selected for LA were removed safely without strong adhesion to the surrounding tissue. Two adrenal tumors removed by OA had a strong adhesion to the surrounding tissue. All 9 patients had complete resection, without capsular disruption and a negative margin in the pathological findings. No port-site and local recurrences occurred. No patients presented with local relapse or port-site metastasis. Disease-free survival rate for the LA group was 57% and for the OA group, 50% (p=0.661). LA is a less invasive treatment than OA for AM. However, for complete resection, OA should be selected for cases where resection by LA is difficult. Therefore, in the decision making towards the appropriate surgical management with LA or OA, it is important to closely assess pre-operative imaging. Imaging features supporting OA include no detection of fatty tissue between the tumor and proximal organs, tumors with an irregular contour, large tumors and tumors with a cystic component.     

Factors related to improved clinical outcomes associated with adrenalectomy for metachronous adrenal metastases from solid primary carcinomas

Background

Surgery for metachronous adrenal metastases from solid primary carcinoma has increased with the development of technical skills. Here we analyzed the postoperative clinical outcomes of patients who underwent adrenalectomy for metachronous adrenal metastases from solid primary carcinomas.

Adrenal incidentaloma

Adrenal incidentalomas are incidentally discovered adrenal masses greater than 1 cm in diameter that appear to be clinically nonfunctioning. They are detected during imaging procedures of the abdomen and chest (CT, MRI, and ultrasonography) for an unrelated condition or symptom complex. With the widespread escalation in the use of these imaging modalities and marked improvements in image resolution, the probability of finding an incidentaloma on cross-section imaging is rapidly approaching the 6% prevalence of previously reported autopsy studies. All incidentalomas greater than 1 cm should be evaluated for hormonal activity, including a 1-mg overnight dexamethasone suppression test, total 24-hour urinary metanephrines and fractionated catecholamines, and, in the hypertensive patient, a serum potassium level and plasma aldosterone concentration to plasma renin activity ratio. All hormonally active tumors should be removed. Hormonally inactive tumors are resected based on size, imaging phenotype, and interval growth. Percutaneous biopsies are generally unwarranted and are potentially dangerous. Laparoscopic adrenalectomy has become the surgical procedure of choice for most benign functioning and nonfunctioning tumors of the adrenal gland. Subclinical metabolic abnormalities associated with adrenal incidentalomas remain an area of intense clinical research.     

High risk of malignancy in patients with incidentally discovered adrenal masses: accuracy of adrenal imaging and image-guided fine-needle aspiration cytology

AIMS AND BACKGROUND: The incidental finding of nonfunctioning adrenal masses (incidentalomas) is common, but no reliable criteria in differentiating between benign and malignant adrenal masses have been defined. The aim of this preliminary study was to assess the usefulness of adrenal imaging and image-guided fine-needle aspiration cytology in patients with nonfunctioning adrenal incidentalomas with the aim of excluding or confirming malignancy before surgery. METHODS: Forty-two consecutive patients (18 men and 24 women; median age, 54 years; range, 25-75 years) with incidentally discovered adrenal masses of 3 cm or more in the greatest diameter were prospectively enrolled in the study. All patients underwent helical computerized tomography scan and image-guided fine-needle aspiration cytology, 33 (78.6%) underwent magnetic resonance imaging, and 26 (61.9%) underwent norcholesterol scintigraphy before adrenalectomy. RESULTS: The revised final pathology showed 30 (71.4%) benign (26 adrenocortical adenomas, of which 3 were atypical, 2 ganglioneuromas, and 2 nonfunctioning benign pheochromocytomas) and 12 (28.6%, 95% CI = 15-42) adrenal malignancies (8 adrenocortical carcinomas and 4 unsuspected adrenal metastases). The definitive diagnosis of adrenocortical carcinoma was made according to Weiss criteria and confirmed on the basis of local invasion at surgery or metastases. The sensitivity, specificity and accuracy were 75%, 67% and 83% for computerized tomography scan, 92%, 95% and 94% for magnetic resonance imaging, 89%, 94% and 92% for norcholesterol scintigraphy, and 92%, 100% and 98% for fine-needle aspiration cytology. The sensitivity and accuracy of image-guided fine-needle aspiration cytology and magnetic resonance imaging together reached 100%. Immediate periprocedural complications of fine-needle aspiration cytology occurred in 2 (4.7%) patients: self-limited pneumothorax (n = 1), and severe pain (n = 1) requiring analgesic therapy. No postprocedural or late complications were observed. CONCLUSIONS: With the aim of selecting for surgery patients with a non-functioning adrenal incidentaloma of 3 cm or more in diameter, the combination of magnetic resonance imaging and fine-needle aspiration cytology should be considered the strategy of choice.