中央组淋巴结清扫术治疗甲状腺乳头状癌临床体会

目的在彻底切除肿瘤的前提下,探讨实施中央组淋巴结清扫术治疗甲状腺乳头状癌的临床疗效。方法我院10年期间收治400例甲状腺乳头状癌,采用患侧腺叶切除60例,患侧腺叶和峡部切除加对侧腺叶大部分300例,双侧腺叶和峡部切除40例,均行中央组淋巴结清扫。结果全部患者术后恢复正常,并发一过性喉返神经损伤20例,并发一过性甲状旁腺功能减退20例。患者术后无颈部肿瘤复发。结论实施中央组淋巴结清扫术可达到与目前常规颈侧区淋巴结清扫术相同治疗效果。所以中央组淋巴结清扫对甲状腺乳头状癌治疗尤为重要。     

子宫颈小细胞神经内分泌癌的临床与病理

收集分析了子宫颈神经内分泌癌8例，其中，Ia期1例；Ib期2例；Ⅱa期2例；Ⅱb期1例；Ⅲa期1例；Ⅲb期1例。3例进行了广泛子宫切除及盆腔淋巴结清扫术，5例死亡前分别存活13－38个月，平均19个月。仍存活的3例分别为治疗后3、4、5个月，其中1例已发生肾转移。结果提示，子宫颈小细胞神经内分泌癌是一种罕见的子宫颈恶性程度高的肿瘤，易发生早期转移，预后差；早期病例应采取广泛子宫及盆腔淋巴结清扫术，并进行放疗或化疗。晚期病例只能行化疗或放射治疗。     

甲状腺微小癌的手术方式及减少喉返神经损伤的临床研究

目的 探讨甲状腺微小癌的手术方式及减少喉返神经损伤的方法.方法 回顾性分析解放军309医院普外科2006年1月—2013年12月收治的238例甲状腺微小癌患者的临床资料,总结其术前检查方法、手术方式及喉返神经损伤情况.238例患者均为查体时超声检查发现,超声显示结节直径均≤1.0cm,其中术前行甲状腺结节细针穿刺(FNA)检查84例,明确为微小癌72例,假阴性12例,其余均为术后病理证实.所有病例中单侧单发甲状腺微小癌144例,单侧多发甲状腺微小癌46例,双侧多发甲状腺微小癌48例.结果 238例患者中采用患侧+峡部切除+对侧腺叶次全切除97例,患侧+峡部腺叶切除56例,双侧甲状腺切除23例,双侧甲状腺次全切除62例;行颈部淋巴结清扫132例,未行颈部淋巴结清扫106例;其中术中行喉返神经显露122例,共显露喉返神经182条,未显露喉返神经116例.术后随访1～7年,局部复发6例,无远处转移和死亡病例.238例患者中发生喉返神经损伤6例,其中显露喉返神经组1例,未显露喉返神经组5例,均为单侧损伤.结论 高频超声检查是发现甲状腺微小癌的重要手段,术前FNA检查是及时判定结节性质的可靠方法,手术切除是治疗甲状腺微小癌的有效方式.选择合理的手术方式是提升甲状腺微小癌远期疗效的关键;术中显露并保护喉返神经能最大限度地减少喉返神经损伤.     

肾上腺皮质癌的诊断和治疗

目的:通过对3例肾上腺皮质癌临床资料的分析,对肾上腺皮质癌这种少见恶性肿瘤的诊断和治疗进行探讨.方法.我院从1990年4月～1999年10月共收治肾上腺皮质癌3例,均经手术(或活检)及病理明确诊断,结合文献回顾分析肾上腺皮质癌的临床表现、分期、诊断、治疗和预后.结果:l例属于肿瘤一期,为功能型肿瘤,经手术治疗已存活2年仍存活;2例属于肿瘤四期,均为无功能型肿瘤,手术1例存活2年7个月后死于无关疾病,行穿刺活检1例存活4个月.结论:早期诊断、早期彻底手术是治疗本质的关键,外科手术治疗是肾上腺皮质癌唯一有效的治疗方法.     

胸大肌皮瓣在喉咽癌修复中的应用

目的探讨运用胸大肌皮瓣修复喉咽癌术后缺损的疗效。方法 26例晚期喉咽癌患者,行肿瘤切除术后以带蒂胸大肌皮瓣修复术后缺损。结果术后21例愈后良好,3例出现咽瘘,1例合并下消化道大出血伴咽瘘者,经第2次手术后痊愈。1例失访。结论胸大肌皮瓣修复喉咽癌切除术后缺损,具有血供丰富,可修复较大面积缺损,术后愈合较好等优点,对延长患者生命,减轻疼痛有重要作用。     

Nd：YAP激光联合平阳霉素治疗喉及喉咽血管瘤的临床分析

目的 探讨Nd:YAP激光联合平阳霉素治疗喉及喉咽部血管瘤的临床疗效.方法 在全麻并支撑喉镜显微镜下用功率3～5 W Nd:YAP激光以非接触式扫描照射喉咽血管瘤至组织苍白萎缩,再按肿瘤大小,分别以不同量的平阳霉素分点均匀注入残留肿瘤组织内至肿瘤组织稍肿胀.结果 本组11例喉及喉咽血管瘤病患者1次治疗治愈3例,2次治疗治愈3例,3次治疗治愈2例,4次治疗基本治愈1例,总有效率81.8%;经4次治疗好转2例.平均治疗次数2.5次.术后瘢痕形成3例,伤口感染1例.结论 Nd:YAP激光联合平阳霉素治疗喉及喉咽血管瘤,手术操作精确、简便、安全,术中无出血,术后患者反应轻,恢复快,治愈率高,并发症发生率低.     

甲状腺肿瘤术后复发患者再手术情况及其病理改变

目的探讨甲状腺肿瘤术后复发患者再次手术情况及其病理改变情况。方法选取中国医科大学肿瘤医院自2013年10月至2018年10月收治的行再次手术的416例甲状腺肿瘤患者为研究对象。记录患者再次手术的原因、再次手术方式、首次与再次手术的病理诊断结果及再次手术术后并发症发生情况。结果 416例患者中,再次手术的原因为首次术式不当125例,甲状腺癌复发53例,甲状腺瘤复发177例,结节性甲状腺肿复发10例,癌残留16例,淋巴结转移8例及其他27例。再次手术方式包括甲状腺全切156例,患侧腺叶加峡部切除143例,患侧腺叶、峡部加对侧次全切除71例,甲状腺癌根治加全喉切除39例,单纯颈淋巴结清扫7例。再次病理诊断结果中桥本式甲状腺炎、乳头状癌、滤泡状癌、髓样癌、未分化癌发生率均高于首次病理诊断。再手术术后并发症发生率为16.11%(67/416)。Kaplan-Meier生存曲线显示,甲状腺肿瘤再次手术患者的3年生存率为96.39%,5年生存率为87.02%。结论甲状腺肿瘤再次手术患者的生存率较高,但风险较大,可出现不同程度的病理改变及并发症。临床上应规范首次手术治疗,降低再次手术概率。     

保留乳腺治疗临床Ⅰ、Ⅱ期乳癌体会

目的:讨论保留乳腺治疗乳癌的可行性.方法:对15例临床Ⅰ、Ⅱ期乳癌患者实施了乳癌区段切除加同侧腋窝淋巴结清扫术;术后辅以化疗,放疗,或抗雌激素(TAM)治疗.结果:13例获随访,2例失随访.4例患者随访10～14年,6例随访8～9年,3例随访5～7年.所有患者随访期内存活,其中1例于术后4年10个月患侧乳癌局部复发,行患乳单纯切除;术后6年7个月发现对侧腋淋巴结转移而行乳癌改良根治术,随访10年仍健在.全组患者无病生存率92.31%,复发率7.69%,治疗效果不低于乳癌改良根治术.结论:保留乳腺治疗临床Ⅰ、Ⅱ期乳癌可作为同期乳癌根治性手术的替代术式.     

喉癌45例远期疗效分析

目的探讨喉癌合理的治疗选择,提高临床疗效和病人生存质量。方法对我院1983年1月—2003年1月诊治的45例喉癌患者的的临床资料,远期治疗结果,进行回顾性分析。45例患者全部接受了外科手术治疗,其中行喉裂开声带切除术3例,垂直部分喉切除术29例,水平部分喉切除术6例,全喉切除术7例,15例做了根治性或功能性颈廓清术,术后均辅以放射治疗。结果随访3年以上,3、5年生存率分别为84.44%、77.78%,部分喉切除患者发音、呼吸和吞咽功能均得到恢复。拔管率100%。结论掌握好手术指征,充分了解肿瘤部位、侵犯范围和淋巴结转移情况,选择正确的术式,术后辅以放射等治疗,可望获得较好的治疗效果。     

喉癌的分期:CT与喉造影的准确性比较

对于喉癌进行喉全切除或放疗时,准确划定肿瘤的范围相对不很重要,但随着计划保留发音和吞咽能力的保守外科治疗(声门上或垂直部分喉切除)的发展,精确描划肿瘤就成为至关重要的了。局限于声门上和声门腔的肿瘤适于保守外科治疗,一旦肿物超过这些界限或深入声门旁组织,累及咽软骨或梨状窝尖,则往往指示完全性喉切除。为此作者评价了30例喉癌病人的CT与喉造影,结合手术及病理对比两种方法的准确性和临床用途。结果表明,在确定肿瘤的累及范围(声门上、声门或声门下)方面,CT诊断正确26例,3例假阴性和1例假阳性诊断。喉造影诊断正确19例,6例假阴性     

喉咽癌CT表现及其临床意义

目的　讨论喉咽癌CT表现及其临床意义。方法　分析 18例经手术和病理证实的喉咽癌CT资料。结果　 18例喉咽癌位于梨状窝 11例、环状软骨后区 5例和咽后壁 2例 ,呈等密度或混杂密度软组织肿块 ,增强呈轻度强化 ;肿瘤推移环状、杓状软骨向前移位及甲杓间隙和环甲关节间距增宽为其特征性表现 ,侵犯喉内结构、食管起始部 ,破坏喉软骨及颈部淋巴结转移为间接征象。结论　CT能很好地显示喉咽癌的部位、大小和侵犯范围及有无淋巴结转移 ,对制定治疗计划和评价预后有重要价值。     

以肱骨转移为先发症状的隐匿型甲状腺乳头状癌临床分析一例

以肱骨转移包块为先发症状的甲状腺乳头状癌转移病例在临床中并非罕见,笔者报道的这例病例特殊之处在于行甲状腺全切除及颈部淋巴结清扫手术后,术后病理结果未发现确切的原发病灶,再次行PET/CT检查及131I治疗后的全身碘扫描中发现了左侧髂骨病灶,行髂骨病灶手术切除术后,病理结果证实为另一处甲状腺乳头状癌骨转移灶,再次行131I治疗、规范TSH抑制治疗,诊治过程中不断更新诊断标准,制定出针对性的治疗方案,最终患者得到了有效的治疗。     

Brachytherapy for tongue cancer in the very elderly is an alternative to external beam radiation

Background

The result of curative treatment for very elderly patients with tongue carcinoma has not been reported to date. We retrospectively reviewed the results of brachytherapy in 125 the patients aged over 75 years.

Methods

The results of brachytherapy in 125 patients, 75 years old or older, with Stage I or II squamous cell carcinoma of the oral tongue were reviewed. The 125 cases consisted of 31 Stage I and 94 Stage II cases; 67 patients were under 80 years old and 58 were over 80 years old. All patients were treated using low-dose-rate brachytherapy (¹⁹⁸Au/²²²Rn: 59 cases; ¹⁹²Ir: 38 cases; ²²⁶Ra/¹³⁷Cs: 28 cases).

Results

None of the patients stopped treatment during the course of brachytherapy. The 3 year and 5 year control rates of the primary lesions were both 86%. Post-brachytherapy neck node metastasis was diagnosed in 43 cases and radical neck dissection was performed for 24 cases (21 of the 24 cases were under 80 years old). As a result, the 7 year disease-specific survival (DSS) rate for patients aged under 80 years old was 70% and 41% for those over 80 years old (p = 0.03).

Conclusion

The brachytherapy for elderly patients with tongue cancer was safe, and the control of the primary lesion was almost the same as in younger patients. However, modalities available to treat neck node metastasis are limited. More conservative surgical approaches combined with post-operative irradiation may be advocated for neck node metastasis for elderly patients with tongue cancer.Tongue cancer predominantly occurs in older people, and patients with tongue cancer often have physical and/or psychological complications. Because of such comorbidities, most older patients are not considered candidates for curative surgery. Radiotherapy is now one of the most powerful modalities for the treatment of cancer, and several published studies have demonstrated the feasibility of radiotherapy with curative intent for every type of head and neck cancer [1,2]. Because the use of conventional external beam radiotherapy for head and neck cancer has been reported to cause severe collateral effects, several special techniques have particular relevance to the treatment of the head and neck cancer in the elderly [1,3,4]. Brachytherapy is another modality that may be of relevance to the treatment of elderly patients with tongue cancer.We have already reported our experience of the treatment of tongue cancer with brachytherapy alone or in combination with external beam radiotherapy [5-7]. However, since then no data have been reported concerning the outcome of very elderly patients with squamous cell carcinoma of the head and neck treated by brachytherapy. The aim of this study was to investigate the appropriateness of feasible curative treatment by low-dose-rate brachytherapy for early tongue cancer in patients aged over 75 years. This study was approved by the research ethics board committee.     

肾颗粒细胞癌的诊断与治疗(附20报告)

目的总结对肾颗粒细胞癌的诊治经验,提高对此类型肾癌的认识。方法对20例肾颗粒细胞癌的临床资料回顾分析。男13例,女7例,其中合并肾静脉、下腔静脉瘤栓3例,合并肺转移1例,肝、骨转移2例,年龄20～74岁,平均(53.7±5.4)岁,15例行根治性肾切除术+系统性淋巴清扫术,1例在深低温停循环技术行根治性肾癌切除+腔静脉瘤栓取除术,1例行肿瘤剜除术。3例远处转移者均为外院手术后患者,入院后给予行生物治疗。结果 20例术后病理证实为肾颗粒细胞癌。病理分期:pT1aN0M0 2例,pT1bN0M0 4例,pT2N0M0 5例,pT3aN0M0 1例,pT3aN1M0 2例,pT3bN1M0 2例,pT3cN1M0 1例,pT4NxM1 3例,Fuhrman病理分级:G17,例,G2,10例;G3～4,3例。15例获随访,随访6～40月,平均24个月,1例术后7个月死于脑血管意外,4例死于肿瘤复发或转移,10例无瘤生存超过3年。结论肾颗粒细胞癌临床表现与透明细胞相似,CT及MRI特殊表现可与透明细胞癌相鉴别;免疫组化染色Vimentin阳性,CK8及CK18同时阳性,光镜表现为癌细胞胞浆含大量嗜酸性细颗粒,电镜下为丰富的线粒体;根治性肾切除术+腹膜后系统性淋巴结清扫术是治愈和延长生命的首选方法。     

Neoadjuvant Radiochemotherapy and Radical Resection for Advanced Squamous Cell Carcinoma of the Oral Cavity

BACKGROUND AND PURPOSE: Several multimodal strategies have been developed to treat patients with squamous cell carcinoma of the oral cavity. The advantages of preoperative radiochemotherapy are downstaging of the primary tumor, an increased resectability rate, and the elimination of micrometastases. After successful phase II trials, the following therapy regimen for resectable advanced oral carcinoma was applied. PATIENTS AND METHODS: 134 patients with resectable squamous cell carcinoma of the oral cavity stage II-IV received neoadjuvant radiochemotherapy consisting of 39.6 Gy in daily fractions of 1.8 Gy and concomitant carboplatin (70 mg/m(2) days 1-5). Radical resection and neck dissection were carried out afterwards. RESULTS: After a median follow-up of 73 months, 82 patients (61%) had died. 54 patients (40%) experienced locoregional relapses or distant metastases. The overall survival was 65% +/- 4% after 2 years and 45% +/- 4% after 5 years. Cox regression survival analysis identified tumor regression, extracapsular lymph node spread and resection state as prognostic factors. Side effects of grade 3-4 were rare. CONCLUSION: Neoadjuvant radiochemotherapy with subsequent radical surgery can be recommended as an effective and safe treatment for primary resectable advanced tumors of the oral cavity. Acute and long-term toxicities appear to be moderate.     

Late results of radiotherapy of soft tissue sarcoma

PURPOSE: To evaluate the effect of radiation therapy in the treatment of soft-tissue sarcomas. MATERIALS AND METHODS: Between March 1970 and January 1990, 58 patients with soft-tissue sarcoma were referred for radiation therapy. The most frequent histologic diagnoses included fibrosarcoma (n = 15), neurofibrosarcoma (n = 5) and rhabdomyosarcoma (n = 5). Central tumor sites in the trunk (n = 31) were much more frequent than in the head and neck region (n = 14) or the extremities (n = 13). Thirty-nine of 58 primary tumors were bigger than 5 centimeters. Forty-five patients were irradiated after surgery, 5 patients prior to surgery; in 8 cases only radiation therapy was used. Radiation therapy was performed with Co-60 photons and an average total dose of 58 Gy, fractionated in single doses of 2 Gy. The treatment results were obtained by actual follow-up examinations. RESULTS: Twenty-three of 58 patients survived at least 5 years (39.9%). Of 15 patients with R0 resection 11 were alive after 5 years (73.3%). Local tumor control was achieved in 34 of 58 patients (58.6%). Low 5-year-survival rates were associated with dedifferentiation of the primary tumor (three survivors in 10 patients with G3 tumor), tumor diameters over 5 cm (13 survivors of 39), R2 resection (3 survivors of 16) and tumor sites in the body trunk (11 survivors of 31). CONCLUSIONS: (1) The best results of radiation therapy were achieved after R0 resection of the primary tumor. (2) Tumors in the trunk are prognostically worse because of bigger tumor diameters due to later diagnosis.     

内镜粘膜下剥离术或挖除术治疗上消化道疾病的体会

目的探讨内镜粘膜下剥离术（endoscopicsubmucosaldissection,ESD）或挖除术治疗上消化道疾病的疗效、安全性及并发症。方法分析2012年1月。2013年3月在我院行内镜粘膜下剥离术或挖除术治疗的33例上消化道病变的病例资料。结果本组33例患者包括食管病变8例（其中1例合并有食管胃结合部病变）,食管胃结合部病变3例（其中1例合并有胃底病变）,胃病变19例（其中2例病变多发）,十二指肠病变3例。术后病理分别为炎性或增生性息肉11例,腺瘤样息肉3例,囊肿1例,异位胰腺1例,平滑肌瘤2例,间质瘤7例,轻到重度非典型增生7例,早期癌1例。病灶直径0．5～3．5cm。所有患者均顺利完成了内镜下切除手术（1例穿孔较大者联合腹腔镜下修补）,手术时间20～120（中位数45）min,出血量2—50（中位数5）ml。其中术中穿孔2例,术中出血2例,术后迟发性出血2例（通过保守治疗痊愈）。33例患者均接受了随访,随访时间2～12个月,无复发或转移病例。结论内镜粘膜下剥离术（ESD）或挖除术治疗上消化道息肉、癌前病变、早期癌及间质瘤的疗效确切,创伤小,恢复快,但有一定的并发症,需由有经验的内镜医生开展。     

External and interstitial radiation therapy of carcinoma of the oral tongue. A review of 32 years' experience.

In 204 patients with squamous cell carcinoma of the oral tongue treated with radiation therapy, the most significant prognostic factors appeared to be the presence of neck lymph node metastasis on presentation and the status of the disease three months after treatment. The most common site of failure was the primary lesion, either alone or with neck disease. External irradiation alone was seldom successful. Use of peroral cone irradiation or interstitial implants, either alone or in combination with external irradiation, achieved good local control in early lesions. When the primary tumor was uncontrolled by radiation therapy, salvage with surgery was rare. When failure occurred in the neck alone, radical neck dissection was successful in the majority of cases.     

支气管成形术治疗肺癌20例

目的探讨支气管成形术治疗肺癌的适应证、手术方法及注意事项。方法 2000年1月—2010年12月应用支气管成形术治疗肺癌20例,其中男15例,女5例;年龄48～75岁,平均62岁;左肺上叶支气管袖状切除5例;右肺上叶支气管袖状切除8例;右肺上中叶支气管袖状切除3例;左肺上叶支气管及左肺动脉双袖状切除2例;右肺上叶支气管袖状及右肺动脉侧壁切除成形2例。术后病理诊断:鳞癌14例,腺癌3例,小细胞癌2例,腺样囊性癌1例。结果无手术死亡,未发生支气管胸膜瘘、大咯血、脓胸等其他严重并发症。结论支气管成形术已成为治疗中心型肺癌的首选术式,但必须严格掌握其适应证、熟练掌握操作方法及注重术后处理。     

巨块型肝细胞癌的双介入治疗探讨（附30例报告）

目的：评价肝动脉灌注栓塞（ＴＡＥ）和ＣＴ引导下经皮穿刺注入无水乙醇（ＰＥＩ）联合治疗巨块型肝细胞癌的疗效。材料与方法：３０例无转移的巨块型肝细胞癌患者先经ＴＡＥ治疗２周后再行５次左右的ＰＥＩ。结果：本组病例全部随访，随访时间为１个月至３年，有效率为９４％，副作用为发热、疼痛。结论：ＴＡＥ和ＰＥＩ联合治疗巨块型肝细胞，先用ＴＡＥ，后用ＰＥＩ，效果较好