胸段食管癌淋巴结转移特点的临床研究

目的 探讨胸段食管癌淋巴结转移的规律和特点,从而为其手术入路和淋巴结清扫范围提供参考.方法 回顾性分析2009年1月至2012年12月间中南大学湘雅医学院附属肿瘤医院胸外科收治的72例胸段食管癌患者的临床资料,所有病例均行右胸入路手术. 记录各组淋巴结的清扫及转移情况,并分析淋巴结转移的影响因素.结果 72例患者中,有48例出现淋巴结转移,淋巴结转移率为66.7％;清扫淋巴结总数为1495枚,转移181枚,淋巴结转移度为12.1％,平均每例清扫淋巴结20.8枚.在各组淋巴结中,右喉返神经旁（1R组）淋巴结转移率最高,达30.6％（22/72）.左喉返神经旁淋巴结（2L组、4L组和5组） 转移率为12.5％（9/72）.淋巴结转移率与肿瘤大小和浸润深度有关（均P＜0.05）,而与病变部位和分化程度无关（P＞0.05）.结论 胸段食管癌淋巴结转移以右喉返神经旁淋巴结转移为主,故其手术最佳入路应是右胸入路,淋巴结清扫则应以右、左喉返神经旁淋巴结为重点的系统纵隔、腹野淋巴结清扫.     

Non-invasive and minimally invasive staging of regional lymph nodes in penile cancer

Introduction  The management of the regional lymph nodes in penile cancer patients, particularly when these lymph nodes are impalpable, remains controversial. Prophylactic bilateral inguinal lymphadenectomy is associated with high morbidity and is often unnecessary. However, there is no non-invasive or minimally invasive staging technique that can determine the lymph node status of penile cancer patients with 100% accuracy. Methods  We reviewed the current literature to examine the role of non-invasive and minimally invasive techniques for staging regional lymph nodes in penile cancer with particular reference to clinically impalpable disease. Results  Cross-sectional imaging (un-enhanced CT and MRI) modalities have a role in the assessment of patients with palpable inguinal basins and in locating distant metastases, but are unreliable in staging impalpable regional lymph nodes. The spatial resolution of lymphotropic nanoparticle enhanced MRI (LNMRI) and positron emission tomography (PET)/CT are limited to several millimetres and so these modalities cannot reliably detect micro-metastases (<2 mm). Ultrasound (US) and fine-needle aspiration cytology (FNAC) are indicated in staging palpable inguinal basins but are unreliable in isolation in the assessment of impalpable lymph nodes. They are, however, useful as an adjunct to dynamic sentinel lymph node biopsy (DSLNB) in lowering false-negative rates. Conclusions  While we await staging modalities that can equal the results of DSLNB with fewer disadvantages, histological staging in the form of DSLNB remains the best minimally invasive staging modality we can offer at risk patients presenting with clinically node negative groins.     

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目的 分析进展期胃癌胃周淋巴结转移及淋巴结清除与病人预后的关系。方法 对1982－1992年间收治并行手术治疗的进展期胃癌299例进行统计分析。结果 肿瘤进展与淋巴结转移的程度显著相关（P＜0.05）。淋巴结转移有无、淋巴结清扫与术后生存直接相关，对于侵及浆膜下或侵出浆膜并伴有远处淋巴结转移的病例，淋巴结清扫仍能提高术后生存率（P＜0.05）。结论 严格的淋巴结清扫可以提高胃癌病人术后生存率。     

食管癌淋巴结转移特点及其危险因素

目的 探讨食管癌淋巴结转移情况及其危险因素,为外科手术行淋巴结清扫提供参考。方法回顾总结2006年1月至2010年12月在复旦大学附属肿瘤医院胸外科行三野淋巴结清扫食管癌根治术308例患者的临床资料．分析淋巴结的转移规律及特点。结果308例患者平均清扫淋巴结（35．6±14．5）枚,197例（64％）患者出现淋巴结转移。Logistic单因素分析结果显示,脉管（淋巴管及血管）侵犯（P=0．019）及肿瘤浸润深度（P〈0．001）是发生淋巴结转移的危险因素。各站淋巴结中,胸部气管旁淋巴结转移率最高（25．0％）。上段食管癌腹部淋巴结转移率显著低于中段或下段食管癌（P=0．001）,而各段食管癌颈胸部淋巴结转移率比较,差异无统计学意义（P〉0．05）。颈胸部和颈胸腹部淋巴结转移率分别为14．6％和11．0％,而颈腹部和胸腹部则分别为3．6％和4．9％。脉管侵犯（P〈0．001）和胸部气管旁淋巴结转移（P=0．014）是食管癌发生颈部淋巴结转移的危险因素。结论食管癌淋巴结转移具有上、下双向和跳跃性的特点．胸部气管旁淋巴结转移可作为行颈部淋巴结清扫的指征。     

Lymph node classification of esophageal squamous cell carcinoma and adenocarcinoma

The lymphatic channels of the esophagus run vertically along the axis of the esophagus and some of them drain into the cervical lymph glands upwards and into the abdominal glands downwards, and the pattern of lymph node metastasis of esophageal carcinoma is widespread. In various classifications of pattern of lymphatic spread, four classifications were proposed; location, number, ratio, and size. No definite survival advantage of aggressive lymph node dissection during esophagectomy has been proved compared with less dissection. Stage migration, micrometastasis, and sentinel lymph node concept all make it possible to individualize surgical management of esophageal carcinoma as a part of various multimodal treatments. Early diagnosis, standardization of surgery including routine lymph node dissection, and perioperative management of patients have all led to better survival rates of esophageal carcinoma.     

转移淋巴结的数量和范围对食管癌预后的影响

目的探讨转移淋巴结枚数、组数及野数对食管癌患者预后的影响,为更加合理的淋巴结转移分级提供参考。方法回顾性分析2001年6月至2009年12月间在上海市胸科医院进行手术治疗的204例食管癌患者的临床资料,并按照2009年第七版国际食管癌TNM分期对所有患者进行重新分期。采用Log-rank检验和Cox比例风险模型来评估转...     

Minimally invasive retroperitoneal lymph node dissection for testicular cancer

Testicular cancer is the most common solid organ malignancy in young men between the ages of 15 and 35. Although much of this increase in survival can be attributed to improvements in systemic chemotherapy, surgery retains a critical role in the diagnostic and therapeutic management of testicular cancer. Laparoscopic retroperitoneal lymph node dissection is an effective staging and therapeutic procedure in patients with low-stage testicular cancer. It is an attractive alternative to the open approach, with faster recovery, improved cosmesis, and reduced post-operative morbidity driving its application. In experienced hands, it can be used in postchemotherapy patients.     

肝内胆管癌肝外淋巴转移特点的初探

目的探讨肝内胆管癌肝外淋巴转移的特点。方法回顾性分析我院2006年1月至2006年8月间67例肝内胆管癌术后病理资料。结果22例患者发生淋巴结转移，阳性率为32．8％。其中原发肿瘤位于肝左叶者16例，位于肝右叶者6例。原发肿瘤位于肝左叶者淋巴结转移的发生率（47％，16／34）显著高于肝右叶（18．2％，6／33）（X^2=6．332，P=0．012）。肝十二指肠韧带组淋巴结转移发生率最高（95．45％，21／22）。肝左叶肿瘤淋巴结转移可累及胃小弯侧和胃左动脉旁淋巴结，且存在跳跃性淋巴结转移。结论肝内胆管癌淋巴结转移途径因原发肿瘤位置的差异而有所不同。     

Survival benefits of pancreatoduodenectomy for gastric cancer: relationship to the number of lymph node metastases

Background and aims Pancreatoduodenectomy (PD) for advanced gastric cancer is rarely performed because of the high frequency of associated morbidity and mortality. The aim of this study was to determine the limited indication of PD for advanced gastric cancer. Materials and methods From January 1984 and December 2005 patient’s charts were reviewed and outcomes after PD for gastric cancer were compared between two subgroups; those with a ‘high’ number (7≤ group) of lymph node metastases and those with ‘low’ numbers (6≥ group). Results PD was intraoperatively selected because of direct tumor invasion into the pancreas (52.2% of the 7≤ group vs 12.5% of the 6≥ group) or pancreatic lymph node infiltration (47.8% of the 7≤ group vs 87.5% of the 6≥ group; P = 0.058). The postoperative histological analysis showed 22 cases from 23 (95.7%) in 7≤ group with T3 or T4 tumor, compared with only 4 cases (50%) in 6≥ group (P = 0.014). The 5-year survival rates were significantly better in the 6≥ group compared with the 7≤ group (P = 0.014). Conclusions The indication for PD in advanced gastric cancer should consider the degree of extensive lymph node metastases and incurable factors.     

胸段食管鳞癌根治术后淋巴结转移特点及对预后的影响

目的 研究胸段食管鳞癌根治术后淋巴结转移特点及对预后的影响,探讨合理的术后辅助治疗方案.方法 应用Spearman相关分析、Cox模型及Kaplan-Meier法等对204例患者的临床及随访资料进行多因素分析.结果 204例患者中淋巴结转移率为40.2%(82/204),转移度为7.57%(166/2193).相关因素分析显示:肿瘤浸润深度、肿瘤长度及细胞分化程度与淋巴结转移有关(χ2=17.466,11.494.6.767,P<0.05);患者年龄、肿瘤部位与淋巴结转移无关(χ2=1.086,3.897,P>0.05).生存分析显示:淋巴结转移个数<4枚组与≥4枚组1、3、5年生存率比较差异有统计学意义(χ2=4.493,4.494,4.450,P<0.05);有淋巴结转移较无淋巴结转移者易发生复发及转移(r=-2.060,-4.296,P<0.05).多因素分析显示:病理分期、分化程度、术后辅助治疗是独立的预后因素.结论 肿瘤长度、浸润深度及细胞分化程度与胸段食管鳞癌术后淋巴结转移有关,淋巴结转移状态及转移个数可影响预后.术后口服化疗药物对无淋巴结转移者生存有益.     

Mode of lymph node metastases in esophageal cancer induced in rabbits with Vx2 carcinoma

We carried out experimental studies in which Vx2 carcinoma was inoculated submucosally into the esophagi of 57 rabbits. The purpose was to clarify the mode of tumor growth and lymph node metastasis of esophageal cancer. The inoculation was given into five different segments of the esophagus and the cardia in six different groups of rabbits: the cervical (Ce), the cervicothoracic junction (Ce=Iu), the upper thoracic (Iu), the middle and lower thoracic (ImEi) and the abdominal (Ea) segments and the cardia (C). The lymph node metastatic pattern of the Vx2 carcinoma was then observed. The Ce and Ce=Iu located carcinomas metastasized mainly above the tracheal bifurcation; the ImEi located carcinomas metastasized equally above and below the tracheal bifurcation. In cases of the Ea and C located carcinomas, the lymph node metastasis was restricted to the abdomen when serosal invasion was excluded but it spread widely from the abdomen to the neck when serosal invasion was positive. Thus, in experimentally-induced carcinoma, tracheal lymph node metastasis occurred with a high frequency. As intraoperative assessment is closely related to anatomical factors and operative risk, care should be taken that such assessments are thoroughly carried out.     

食管癌淋巴结转移规律及预测模型研究进展

食管的淋巴管网丰富,引流范围广泛,涉及颈、胸和腹等处20余组淋巴结。淋巴结转移状态也是确定食管癌分期的重要指标,是判断患者预后的独立因子。手术依然是食管癌治疗最重要的方式之一。然而,目前关于食管癌淋巴结转移规律和食管癌淋巴结清扫范围依然缺乏统一的认识。选择性三野淋巴结清扫似乎更符合个性化医疗和精准医疗的时代潮流,但由于影像学诊断颈部淋巴结转移的灵敏性和特异性不足,选择性三野淋巴结清扫仍需高质量的临床证据验证。基于大数据的数学建模和影像组学已辅助用于疾病的临床诊断、治疗和预后的临床抉择,对其深入的研究及发展将有助于食管癌相关的诊断和治疗。     

Laparoscopic lymph node dissection after endoscopic submucosal dissection: a novel and minimally invasive approach to treating early-stage gastric cancer

BACKGROUND AND OBJECTIVE: Endoscopic submucosal dissection (ESD), a newly developed endoscopic mucosal resection (EMR) technique, can completely cure a differentiated mucosal gastric cancer smaller than 2 cm. For early-stage gastric cancers (EGCs) deviating from the above-mentioned criterion, gastrectomy with lymph node dissection is performed for potential risk of lymph node metastasis (LNM). However, many of surgical EGC cases actually do not have LNM, indicating this surgery may not be necessary for many cases of EGC. To avoid this unnecessary surgery, we have introduced laparoscopic lymph node dissection (LLND) after ESD. Standard gastrectomy with extended lymph node dissection is indicated for patients if LLND reveals LNM. We present our novel approach and the preliminary results of EGC patients having potential risk of LNM. METHODS: Five patients with EGC deviating from the EMR criterion underwent the combination of ESD and LLND. ESD was performed using a newly developed insulation-tipped diathermic knife. Lymph nodes, which were determined on the basis of the location of the primary tumor and lymphatic drainage of the stomach, were removed laparoscopically. The lymphatic drainage was visualized by submucosally injecting indocyanine green (ICG) around the post-ESD ulcerative scars during intraoperative gastroscopy. RESULTS: The ESD enabled en bloc resection without any complications. The resected margins of all the lesions were free of cancer cells vertically and horizontally. LLND was successfully performed without any complications. The mean number of the dissected lymph nodes was 15 (range 6 to 22). In 4 of the 5 patients, the dissected lymph nodes were free of cancer cells, and therefore, the combination of ESD and LLND was considered a definitive treatment. The remaining patient was found to have LNM but chose not to undergo any surgery. During follow-ups, the patients' previous quality of life was restored without any tumor recurrence. CONCLUSIONS: The combination of ESD and LLND enables the complete resection of the primary tumor and the histologic determination of lymph node status. This combination treatment is a potential, minimally invasive method, and may obviate unnecessary gastrectomy without compromising curability for EGC patients having the potential risk of LNM.     

肺癌淋巴结转移规律的临床研究

目的 探讨原发性肺癌淋巴结转移频率,分布范围及特点,为广泛廓清提供依据。方法 按Ｎａｒｕｋｅ肺癌淋巴结分布图对３８６例肺癌病人施行了手术切除及广泛肺门、叶间及纵隔淋巴结廓清术。结果 清除淋巴结２６０３组,Ｎ１淋巴结转移率２０．１％,Ｎ２淋巴结转移率１６．２％。Ｔ１,Ｔ２,Ｔ３间淋巴结经差异非常显著。     

The relationship of p53 Protein and lymph node metastases in invasive breast cancer

The p53 expression in invasive breast cancers from 106 patients was correlated with clinicopathological variables to ascertain its usefulness for estimating prognosis. The p53 expression was significantly associated with the number of axillary lymph node metastases and the presence of internal mammary lymph node metastases; however, it was not associated with age, menopausal status, histologic type, or tumor size. Although p53 expression was a significant prognostic factor according to univariate analysis, it did not appear to be an independent prognostic factor according to multivariate analysis. Thus, the prognostic power of p53 expression is likely to be weak and therefore probably of limited clinical value. Nevertheless, the number of patients in our study was small, and we believe that an investigation of a larger series of patients is indicated.     

微创食管癌切除术后淋巴结转移规律及预后分析

目的淋巴结转移是食管癌转移的主要方式,对食管癌患者预后有重要影响,本文探讨食管癌胸腹二区淋巴结的转移规律。 方法选取2010年1月至2016年10月于山东大学齐鲁医院经微创食管癌切除术(minimally invasive esophagectomy, MIE)治疗的食管癌患者613例,参照日本食管肿瘤研究会(JEOG)淋巴结分区标准清扫淋巴结,统计各组淋巴结的转移率。对2010年1月至2013年10月行MIE治疗的203例食管癌患者进行生存分析。另外410例患者由于术后时间较短,随访数据未列入统计。 结果胸上段食管癌较多发生上纵隔淋巴结转移,其左、右喉返神经旁淋巴结转移率分别高达35.9%、40.7%,均显著高于胸中段和胸下段食管癌;胸中段食管癌既向上发生上纵隔淋巴结转移,又向下发生腹腔淋巴结转移;胸下段食管癌主要向胃周淋巴结转移,其中胃左动脉旁淋巴结转移率最高。单因素分析结果显示,病变长度、肿瘤分化程度、肿瘤浸润深度、淋巴结转移程度是影响食管癌患者预后的相关因素(P< 0.05)。COX多因素回归分析结果显示,肿瘤低分化和淋巴结转移是影响食管癌患者预后不良的独立危险因素(P< 0.05)。 结论手术治疗食管癌应重点清扫双侧喉返神经旁淋巴结和胃左动脉旁淋巴结。     

早期胃癌淋巴结转移的危险因素分析

目的探讨早期胃癌病人淋巴结转移的危险因素,以期为临床治疗方案的选择提供依据。方法回顾性分析我院2010年1月至2013年12月期间收治的早期胃癌病人的临床病理特征与淋巴结转移规律关系。结果共89例早期胃癌病人纳入研究分析,所有病人淋巴结转移率为14.6%(13/89)。肿瘤大体类型分为隆起型、表浅型、凹陷型,其淋巴结转移率分别为10.0%、5.6%及22.0%,各型间淋巴结转移率差异有统计学意义(P =0.000);黏膜内癌与黏膜下癌淋巴结转移率分别为4.9%(2/41)及22.9%(11/48),二者间差异有统计学意义(P =0.016);高分化良好型早期胃癌无淋巴结转移,中分化及低分化早期胃癌淋巴结转移分别为10.3%(3/29)、18.5%(10/54),差异有统计学意义(P =0.000);6例病人伴有脉管癌栓,其中4例发生淋巴结转移。Logistic 回归多因素分析结果显示：肿瘤大体类型、分化程度、浸润深度及脉管癌栓对淋巴结转移具有显著性影响(P <0.05),其比值比(OR)值分别为4.7、3.2、15.1和5.7。病人性别、年龄、肿瘤部位等与淋巴结转移无相关性。结论早期胃癌病人淋巴结转移率低,其转移与否同肿瘤大体类型、浸润深度、分化程度以及脉管癌栓密切相关。     

放射免疫显像在食管癌分期中的应用

目的 探讨放射免疫显像（RII）在食管癌分期的应用。方法 （1）LSAB法测定组织切片和抗人食管鳞癌单抗G9的反应;（2）^125I标记G9,在荷食管癌裸鼠腹腔注射^125I-G9后的连续3d内,测定各主要组织、器官的放射性;（3）食管鳞癌术前经纤维食管镜在原发灶周围黏膜下注射^131I-G9后行RII;（4）对清扫淋巴结行放射性测定。结果 （1）LSAB显示癌原发灶和转移淋巴结呈阳性,正常食管和淋巴结阴性;（2）^125I-G9在裸鼠体内分布显示,肿瘤组织的放射性计数均明显高于其它器官／组织;（3）镜下注药48h时RII在食管旁纵隔、贲门旁、胃小弯旁出现散在的细点状放射性浓集,浓集区域所清扫的淋巴结中,包含有转移淋巴结;无浓集区域,未发现转移淋巴结;（4）全部有转移淋巴结的放射性比活度均比无转移高,且均数高出两倍多。结论 （1）单抗G9能选择性定位于食管鳞癌细胞膜;（2）^125I-G9在荷食管癌裸鼠有肿瘤组织导向作用,显像效果良好;（3）用^131I-G9在食管鳞癌行RII,对转移淋巴结有定位作用,可作为cTNM分期的选择手段。     

结直肠癌淋巴结转移的多因素分析

目的探讨结直肠癌淋巴结转移的相关临床病理因素。方法回顾分析广西医科大学第一附属医院结直肠肛门外科2008年4月至2009年12月手术治疗的291例结直肠癌病例资料,采用单因素和Logistic多因素回归分析方法,研究结直肠癌淋巴结转移与临床病理因素之间的关系。结果单因素分析显示,性别、年龄、肿瘤部位、肿瘤占肠腔周径、肿瘤大小、大体类型、组织类型与结直肠癌淋巴结转移无关,而肿瘤分化程度、肠壁浸润深度、术前血癌胚抗原（CEA）水平与淋巴结转移有关。Logistic多因素回归分析显示,肿瘤分化程度和肠壁浸润深度与淋巴结转移有关。结论肿瘤分化程度和肠壁浸润深度是影响结直肠癌淋巴结转移的重要危险因素。     

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目的 探讨胃癌临床病理特征与淋巴结转移的关系,为临床进行合理的淋巴结清扫范围提供依据。方法 统计1200例胃癌标本,术后常规解剖原发灶及各组淋巴结,并标记和计数,计算肿瘤部位、浸润深度、Borrmann分型及分化程度与淋巴结转移率的关系。结果 胃癌的淋巴结转移率为73％,转移度为35．6％;C、M、A区及全胃癌淋巴结转移率为60．3％、55．4％、63．1％和88．4％;早期胃癌、浆膜内和浆膜外浸润的淋巴结转移率依此呈递增趋势（P＜0．05）;Borramnn Ⅲ、Ⅳ型胃癌淋巴结转移率明显高于BorrmannⅠ、Ⅱ型（P＜0．05）;分化差者明显高于分化好者（P＜0．05）。结论 术中淋巴结清扫应按胃癌的临床病理分期、部位、大小、大体分型和分化程度作出判断,并结合不同分区淋巴结分组、分站转移特点,合理选择淋巴结清扫范围。