卵巢癌肿瘤细胞减灭术中脾脏切除的手术探究

目的探讨晚期和复发的上皮性卵巢癌减瘤术中脾脏切除术的必要性和可行性。方法回顾分析首次（5例）或再次细胞减灭术（7例）中施行脾脏切除术的12例晚期卵巢癌患者的临床资料。结果12例患者的平均总生存期为37．75个月（15个月-65个月）,3年总生存率为58．33％（7／12）;7例生存至今的患者中2例无瘤生存,分别生存3年和3．5年,三年无瘤生存率为16．67％（2／12）。手术并发症发生率25％（3／12）,与脾切除直接相关的手术并发症发生率为8．33％（1／12）。获得满意减瘤术的9例患者和不满意减瘤术的3例患者的平均总生存期分别为43．33个月和21个月（t=3．215,P〈0.05）,有显著性差异。结论晚期或复发的卵巢癌肿瘤细胞减灭术时为达到满意的手术对脾脏转移者施行脾脏切除是必要和可行的。     

新辅助化疗158例晚期卵巢癌治疗应用

[目的]探讨术前新辅助化疗在晚期卵巢癌治疗中的应用价值。[方法]1987—1998年初次治疗的Ⅲ期、Ⅳ期卵巢癌患者303例，Ⅲ期251例，Ⅳ期52例。145例直接手术减瘤（直接手术组），其中Ⅲ期136例，Ⅳ期9例；158例术前行新辅助化疗（新辅助化疗组），其中Ⅲ期115例，Ⅳ期43例。[结果]无残存肿瘤、残存肿瘤≤2cm、2．1～5cm、〉5cm中位生存时间，Ⅲ期分别为54、33、24、16个月，Ⅳ期为42、30、17、16个月（P〈0．05）。5年生存率：Ⅲa期、Ⅲb期为36．7％，Ⅲc期20．8％，Ⅳ期为22．4％。有、无新辅助化疗总的中位生存时间21.3个月比27．0个月，两组之间无统计学差异（P=-0．062）。术后化疗疗程数〈6个疗程与≥6个疗程相比中位生存时间17个月与39个月（P〈0．001）。术前新辅助化疗疗程数对生存率无影响，增加疗程数并不能提高生存率。[结论]术前新辅助化疗手术满意减瘤率高，总的生存期与常规手术组无差异。     

三维适形放射治疗局部晚期胰腺癌12例疗效观察

[目的]探讨三维适形放射治疗对局部晚期胰腺癌的疗效：[方法]26例局部晚期胰腺癌随机分成治疗组12例，对照组14例。治疗组使用三维适形放射治疗，Dv50Gy-60Gy／25～30f．35～42d：对照组使用常规放射治疗，两组总剂量及分割剂量相同，分割剂量2Gv。[结果]治疗组和对照组放射治疗后1个月疼痛缓解率分别为100％（12／12）和64．29（9／14）（x^2=5．31，P〈0．05）；治疗组和对照组肿瘤退缩率分别为83．33％（10／121和35．71％（5／14）（x^2=6．00，P〈0．01）；中位生存期13．5个月，治疗组和对照组2年生存率分别为41．67％（5／12）和7．14％（1／14）（x^2=4．34，P〈0．05）。[结论]三维适形放射治疗局部晚期胰腺癌，能提高患者的生存质量，延长生存期。     

24例直肠间质瘤的临床特点与外科治疗分析

[目的]探讨直肠间质瘤的临床特点及外科治疗。[方法]回顾性分析1986～2007年间收治的24例直肠间质瘤患者的临床资料。[结果]24例患者中男性14例，女性10例。中位年龄50岁。手术切除23例，其中局部切除16例，根治性切除7例，9例术后复发（39．1％），两种术式的术后复发率差异无显著性（X^2=1．371，P〉0．05）。5年生存率为92．0％，3年、5年无病生存率分别为72．0％和57．6％，中位无病生存时间为61个月。[结论]对于最大径〈5cm的低位直肠间质瘤，局部切除是一种安全可行的手术方式。     

老年直肠癌局部切除33例分析

[目的]探讨直肠癌局部切除术在老年患者中应用的疗效。[方法]回顾性分析33例65岁以上老年直肠癌患者局部切除术,经肛门局部切除29例,经骶骨局部切除4例。术后病理Tis8例,T1 14例,T2a 5例,T2b 2例,T3 4例。其中3例T3患者行术前放疗,13例患者行术后放疗。[结果]全组无手术并发症和手术死亡发生。局部复发率15．2％（5／33）,其中1例伴有远处转移。远处转移率9．1％（3／33）。3年和5年生存率分别为96．4％和86．6％。[结论]老年直肠癌患者行局部切除术有一定疗效,辅助放化疗能够降低局部复发、延长生存期。     

三蛇汤治疗晚期非小细胞肺癌44例

[目的]观察三蛇汤辨证论治配合化疗治疗晚期肺癌的近期疗效。[方法]186例晚期非小细胞肺癌患者随机分为治疗组和对照组，其中治疗组44例，对照组42例：两组均予TP或GP，或NP小剂量静脉化疗，对照组单纯化疗，治疗组采用化疗合并中药三蛇汤治疗。[结果]治疗组和对照组中位生存期分别是12个月和10．5个月，平均生存期分别是13．61个月和12．14个月；1年生存率分别为47．73％和30．95％，2年生存率分别为13．64％和7．14％；治疗组和对照组的生活质量提高＋稳定例数分别为41例和26例。[结论]三蛇汤对提高晚期非小细胞肺癌患者的生存质量具有重要意义，可能对延长晚期非小细胞肺癌患者生存期有一定作用。     

18例原发性腹膜癌诊治分析

目的探讨原发性腹膜癌的临床特点、诊断标准、治疗方法及预后。方法对本院收治的18例原发性腹膜癌的临床资料进行回顾性分析，以腹胀、腹水、食欲差、消瘦为首发症状16例（88．89％）。18例均行肿瘤减灭术，病理为浆液性乳头状腺癌。术后给予铂类为主方案化疗6～8个疗程。结果随访＜2年2例，均无瘤生存；＞2年16例。总2年、3年、5年生存率分别为75％（12／16）、43．75％（7／16）、25％（4／16）。14例Ⅲ期患者2年、3年、5年生存率分别为78．57％（11／14）、50％（7／14）、28．57％（4／14），Ⅳ期2例，1例生存13个月，1例生存25个月；残存肿瘤＜2．0em和＞2．0em，2年生存率各为100％（9／9）和42．86％（3／7），3年生存率各为87．5％（7／9））和0，5年生存率各为44．45％（4／9）和0；腹腔化疗＋全身化疗与单纯全身化疗2年生存率各为90％（9／10）和50％（3／6），3年生存率各为70％（7／10）和0，5年生存率各为40％（4／10）和0。结论临床警惕腹胀、腹水患者原发腹膜癌的可能。积极减瘤术和以DDP为主腹腔化疗目前是原发性腹膜癌的最好方法。术前化疗有利于减瘤术。     

晚期上皮性卵巢癌肠肿瘤切除的作用

目的：分析晚期上皮性卵巢癌行肿瘤细胞减灭术时肠道转移瘤行肠道肿瘤切除的临床应用。方法：回顾性分析1998～2003年52例晚期上皮性卵巢癌行肿瘤细胞减灭术时肠道转移瘤行肠道肿瘤切除的患者,与同期未行肠道肿瘤切除的仅行姑息性手术的16例患者进行比较,采用统计学方法进行处理。结果：68例手术治疗患者中,52例完成肠道肿瘤切除手术,其中34例无肉眼呵见残余肿瘤,8例残余肿瘤〈1cm,10例残余肿瘤〉1cm,其中位生存期分别为28个月、23个月和13个月,16例因肿瘤广泛转移未行肠道肿瘤切除仅行姑息性手术的患者中位生存期为7．66个月,肠道肿瘤广泛转移及肠系膜根部广泛种植是手术失败的关键。结论：晚期上皮性卵巢癌行肿瘤细胞减灭术时行肠道转移瘤切除,达到满意手术效果时对生存期提高足有帮助的,而选择恰当的患者是手术治疗的关键。     

长春瑞滨+顺铂方案同期放化疗治疗晚期鼻咽癌35例

[目的]评价长春瑞滨＋顺铂方案（NP）联合同期放化疗治疗鼻咽癌的疗效。[方法]35例晚期（Ⅲ、Ⅳ期）鼻咽癌患者随机进入本研究,给予鼻咽及颈部淋巴引流区照射,放射治疗总剂量7000cGy／35次,同期给予NP方案化疗2个周期,测量病灶大小变化,观察疗效及毒副反应。随访34-64个月,统计生存期。[结果]35例晚期（Ⅲ、Ⅳ期）鼻咽癌患者经治疗后有效率为77．14％,其中T晚期者有效率为94.29％,N晚期者为81．82％,3年无进展生存率为71．43％,3年总生存率为85．71％。毒副反应主要表现为中性粒细胞缺乏的血液系统反应,恶心、呕吐等消化道反应和静脉炎。[结论]同期放、化疗和／或联合辅助化疗可以降低鼻咽癌的远处转移率．提高患者生存期。     

胆囊鳞癌和腺鳞癌9例临床分析

[目的]探讨原发性胆囊鳞癌和腺鳞癌的临床病理特征及手术治疗疗效。[方法]回顾性分析9例胆囊鳞癌（5例）和腺鳞癌（4例），采用Kaplan-Meier法计算生存率。[结果]T1和T4病变8例（88．9％），B病变1例（11．1％）。7例（77．8％）累及肝脏，淋巴结转移5例（55．6％）。凡切除5例，R1切除1例，R2切除3例。全组1年、3年及5年生存率分别为55．6％、29．6％和29．6％。R0切除的1年生存率为100％，R1／R2切除的1年生存率为0。[结论]胆囊鳞癌和腺鳞癌恶性程度高，易侵犯肝脏。即使局部晚期患者，R0切除可延长生存期。     

肝动脉栓塞结合无水酒精注射治疗复发性肝癌

〔目的〕应用肝动脉栓塞（TACE）结合无水酒精注射（PEI）治疗25例肝癌根治性切除术后肝内复发的患者，与同期接受单一治疗的37例肝内复发患者进行疗效比较。［方法］1991年3月～1993年12月，98例原发性肝癌患者接受根治性肝切除术，临床跟踪62例发生肝内复发。其中25例（第1组）行TACE＋PEI治疗，每2～3个月重复一次，同时行B超，碘油（Lipidol）－CT（LP－CT）检查。37例（第2组）接受单一治疗（TAC／TACE／PEI）。［结果］第1组中，B超检测复发病灶数72个，最小直径1．1cm，LP－CT检测复发病灶数为84个，最小直径为0.8cm。第1组的病灶坏死率，再次手术率，3年、5年累积生存率分别为68％，24％，55％及36％，明显高于第2组（48％，13．5％，42％及25％，P＜0.05），而治疗后第1组肝癌再复发率（30％）明显低于第2组（45％，P＜0．05）。［结论］原发性肝癌根治性切除术后定期跟踪，对复发病灶早期行TACE＋PEI治疗，不仅可以早期诊断肝内复发灶，显示隐蔽病灶，而且能明显提高肝内复发病灶的疗效，延长生存期，可能是肝切除术后肝内复发病灶的首选治疗模式。     

The utility of computed tomography scans in predicting suboptimal cytoreductive surgery in women with advanced ovarian carcinoma

BACKGROUND: Computed tomography (CT) scans of the abdomen and pelvis may predict which patients with ovarian carcinoma can undergo optimal cytoreduction at primary surgery. Previous studies have demonstrated that patients with ovarian carcinoma had optimal cytoreduction rates ranging from 50-60%. The authors sought to determine whether these findings applied to a surgical practice with a higher rate of optimal debulking. A predictive model using CT scanning and CA 125 values would allow the authors to determine which patients would be more appropriately treated with neoadjuvant chemotherapy. METHODS: Preoperative CT scans for patients with Stage III/IV ovarian carcinoma (according to the staging system of the International Federation of Gynecology and Obstetrics) who were treated between 1996 and 2001 were evaluated retrospectively by 2 radiologists for 17 criteria evaluating the extent of disease. Clinical data were extracted from medical records. Residual tumors measuring > or = 1 cm were considered suboptimal. Logistic regression was used to evaluate which criteria correlated with optimal cytoreduction. RESULTS: Eighty-seven patients were identified retrospectively who met entry criteria and had preoperative CT scans of sufficient diagnostic quality. Sixty-two patients (71%) received optimal cytoreductive surgery and 45 (52%) required aggressive surgical procedures. In a multivariate model, only diffuse peritoneal thickening (DPT) independently predicted suboptimal surgical resection (P = 0.016). However, a model using both DPT and ascites on most CT scans had a positive predictive value of 68% and a sensitivity of 52% for predicting suboptimal cytoreduction. CONCLUSIONS: The presence of DPT and large-volume ascites was associated with a very low rate of optimal cytoreduction (32%) in a surgical practice. These patients may be more appropriately treated with neoadjuvant chemotherapy followed by surgical cytoreduction.     

卵巢转移瘤109例临床分析

:[目的]了解卵巢转移瘤的临床特征 ,探讨其治疗和预后。[方法]对1985年～1996年109例卵巢转移瘤病人进行回顾性分析。[结果]109例卵巢转移瘤占同期收治的卵巢恶性肿瘤的9 7% ,双侧卵巢转移占62 4% ,单侧卵巢转移占37 6% ,伴腹腔转移占71 6%。1年生存率5 0% ,平均生存时间13个月。来源于乳腺癌、淋巴瘤和生殖道癌的卵巢转移瘤平均生存时间为27个月、32个月和22个月 ,来源于结肠癌、胃癌和肺癌的平均生存时间为9个月、8个月和3个月。肿瘤局限在盆腔内的平均生存时间比腹盆腔广泛转移的明显延长(21个月比9个月) ,有显著的统计学意义(P<0 01)。胃肠道和生殖道癌卵巢转移术后残存肿瘤的直径<2cm(理想肿瘤细胞减灭术)的平均生存时间明显长于>2cm者 ,亦有显著的统计学意义(P<0 01)。[结论]卵巢转移瘤常合并腹盆腔广泛转移 ,预后差 ,但手术达理想减瘤者可以明显延长生存     

Recurrent micropapillary serous ovarian carcinoma

BACKGROUND: The objectives of the current study were to: 1) characterize the clinical outcome of patients with recurrent micropapillary serous ovarian carcinoma (MPSC) and 2) evaluate the survival impact of secondary cytoreductive surgery and other prognostic variables. METHODS: Twenty-six patients with recurrent MPSC were identified retrospectively from hospital and tumor registry databases. Survival curves were generated from the time of tumor recurrence using the Kaplan-Meier method and statistical comparisons were performed using the log-rank test, logistic regression analysis, and the Cox proportional hazards regression model. RESULTS: The median age of the patients at the time of recurrence was 46 years. The mean progression-free interval was 31.6 months, and 92% of patients had advanced stage disease at the time of the initial diagnosis. Twenty-one patients underwent secondary cytoreductive surgery; tumor debulking was performed in 90.5% of cases and 52.4% of patients required an intestinal resection. Optimal resection (residual disease < or = 1 cm) was achieved in 15 patients (71.4%). Patients undergoing optimal secondary cytoreduction had a median survival time of 61.2 months from the date of disease recurrence, compared with 25.5 months for those patients in whom suboptimal residual disease remained (P < 0.02) and 29.9 months for nonsurgical patients (P < 0.01). On multivariate analysis, optimal secondary cytoreduction was found to be the only independent predictor of survival. Salvage chemotherapy produced an objective response in 25% of patients with measurable disease. The administration of chemotherapy prior to surgical intervention was associated with a trend toward worse survival and a lower likelihood of optimal secondary cytoreduction. CONCLUSIONS: Optimal secondary cytoreductive surgery is feasible in the majority of patients with recurrent MPSC and is an independent predictor of subsequent survival. Surgical intervention should be considered for those patients with recurrent MPSC. [See editorials on pages 675-6 and 677-80, this issue.]     

三维适形放射治疗在非小细胞肺癌综合治疗中的价值

[目的]探讨三维立体定向放射治疗在非小细胞肺癌综合治疗中的价值。[方法]研究组52例采用前胸后背相对野常规放射治疗,剂量36Gy,18次,2Gy/次,3.6周完成;然后进行三维适形放射治疗,剂量30～42Gy,3Gy/次,10～14次。对照组52例采用常规放射治疗,剂量60～62Gy,2Gy/次,30～31次。两组患者放射治疗结束后,均进行化疗。[结果]研究组放射性食管炎和放射性肺炎发生率显著低于对照组(P<0.05,P<0.01)。研究组近期有效率(CR PR)(86.5%,45/52)显著高于对照组(51.9%,27/52)(P<0.05)。研究组1、2年局部控制率(78.8%,51.9%)显著高于对照组(46.2%,15.4%)(P<0.01)。研究组1、2年生存率(63.46%,38.46%)显著高于对照组(53.85%,17.31%)(P<0.01)。[结论]三维适形放射治疗可用于非小细胞肺癌的综合治疗,其毒副反应轻,有较好的近期疗效。     

原发性输卵管癌手术治疗64例分析

[目的]探讨手术治疗在输卵管癌治疗中的重要性。[方法]回顾分析1990年1月至2006年6月浙江省肿瘤医院收治的原发性输卵管癌64例临床资料。[结果]64例输卵管癌的5年生存率56．25％。52例分期手术患者和12例无分期手术患者的3年、5年生存率差异有显著性（84．61％vs58．32％，P=0．0429；65．38％vs33．32％，P=0．043）；23例满意肿瘤细胞减灭术和14例不满意细胞减灭术患者的的3年、5年生存率差异有显著性（89．47％vs66．67％，P=0．0466；68．42％vs35．67％，P=0．04441。41例盆腔淋巴结清扫术和23例无盆腔淋巴结清扫术患者的3年、5年生存率之间无显著性差异（84．21％vs69．23％，P=0．4667；63．16％vs53．84％，P=0．459）。[结论]分期手术、满意的肿瘤细胞减灭术是影响输卵管癌预后的重要因素。盆腔淋巴结清扫术在输卵管癌分期手术和细胞减灭中是必要和可行的。     

The role of bowel surgery with cytoreduction for epithelial ovarian cancer

AimsTo assess the efficiency and morbidity associated with bowel resection with the initial cytoreduction procedure for advanced ovarian cancer.Materials and methodsA review was carried of 95 patients with ovarian cancer who underwent cytoreductive surgery between 2000 and 2003. The relationship between dichotomised preoperative, intra-operative and postoperative outcome variables were tested using SPSS software. Kaplan–Meier curves were generated to compare survival. Cox proportional hazards regression was used to determine the independent significance of factors after cytoreductive surgery.ResultsIn patients in whom bowel resection was carried out, the largest residual tumour mass was <1 cm in 66.67% of patients, compared with 45.28% of patients undergoing surgery without bowel resection (P = 0.038). The median survival in the optimally debulked patients was 50.38 months compared with 37.15 months in the patients who had suboptimal cytoreduction (P = 0.0021). The median survival in patients undergoing bowel resection was 50.70 months compared with 44.62 months in the patients who had cytoreduction without bowel resection (P = 0.2176). Multivariate analysis showed that optimal cytoreduction (P = 0.005) was found to be independently prognostic for overall survival. Major adverse events, such as ileus, intestinal fistulae, urinary tract fistulae, were not significantly different between groups.ConclusionBowel resection is a worthwhile endeavour in selected patients with advanced ovarian cancer to increase therapeutic efficiency. The surgical morbidity rate from these procedures is not serious and seems acceptable.     

The role of secondary cytoreductive surgery for recurrent mucinous epithelial ovarian cancer (mEOC)

Background

Mucinous epithelial ovarian cancer (mEOC) may exhibit a distinct biological behavior in epithelial ovarian cancer (EOC). The role of secondary cytoreductive surgery was evaluated in patients with recurrent mEOC, and the prognosis was assessed.

Methods

Twenty-one patients with stages IIc to IV mEOC who experienced disease recurrence and received secondary cytoreductive surgery at Fudan University Cancer Hospital between Jan. 1997 and Dec. 2005 were retrospectively reviewed. Survival curves were generated using the Kaplan–Meier method and the significant comparison of survival rate was estimated by the log-rank test.

Results

The median progression-free interval (PFI) was 14 months (range, 5–46 months) after the first cytoreduction. Seven patients (33%) who received secondary cytoreductive surgery were optimally cytoreduced with residual disease less than or equal 1 cm, and the other 14 patients (67%) underwent suboptimal surgical cytoreduction. The overall median survival time was 27 months (range, 8–64 months). The median survival time after recurrence was 10 months (range, 3–32 months). There was no significant statistical difference in median survival between patients with optimal and suboptimal secondary surgical cytoreduction, with an estimated survival of 10 months and 9.8 months, respectively (P > 0.05).

Conclusion

Optimal primary cytoreductive surgery for advanced mEOC was very important. Once it recurs, the prognosis is very poor. Patients with recurrent mEOC should be carefully assessed before performing secondary cytoreductive surgery, as this may have limited impact on the overall survival rates.     

Minilaparotomy,Cyfra21-1, and Other Predicting Factors for Suboptimal Cytoreductive Surgery in Advanced Epithelial Ovarian Cancer: A Pilot Study

Background: Currently, there is no reliable method to predict the result of the primary cytoreduction to decide whether to go on primary cytoreductive surgery or receive neoadjuvant chemotherapy. This study aimed to identify candidate predicting factors from clinical data, serum biomarkers, CT/MRI imaging, and minilaparotomy for suboptimal cytoreduction in women with advanced epithelial ovarian cancer. Methods: Women who were clinically suspicious of advanced-stage epithelial ovarian, fallopian tube, and peritoneal cancer undergoing primary cytoreductive surgery were recruited. Clinical data, abdominopelvic CT/MRI, and serum biomarkers, including CA125, HE4, and Cyfra21-1, were collected preoperatively. At the start of the surgery, a minilaparotomy incision was made, the peritoneal cavity was assessed, and the operating surgeons gave the impression of whether the optimal cytoreductive surgery would be attainable. Subsequently, the incision was extended as necessary, and the standard cytoreductive surgery was attempted. After the procedure completion, the surgical outcome (optimal vs. suboptimal cytoreduction) and other operative outcomes were recorded. The association between the potential predicting factors and the surgical outcome was examined. Results: Fourteen patients were included in this pilot study. Twelve patients were diagnosed with primary ovarian or fallopian tube cancer, while two had ovarian metastasis from colorectal cancer. The optimal cytoreduction was achieved in eight women. After minilaparotomy, the surgeons could predict suboptimal surgery correctly in five out of six cases (OR: 24.12, 95%CI: 2.34-Inf., p<0.01). Moreover, no patient with the finding of rectosigmoid invasion from CT had optimal surgery (OR: 12.96, 95%CI: 1.26-Inf., p=0.03). Lastly, increased serum cyfra21-1(>8 ng/mL) and HE4 (>83 pmol/L) were significantly associated with suboptimal cytoreduction, with OR: 35.00, 95%CI: 1.74-702.99, p=0.02 and OR: 15.00, 95%CI: 1.03-218.30, p=0.05, respectively. Conclusion: The finding of rectosigmoid invasion from abdominal CT, increased serum cyfra21-1 and HE4, and the initial minilaparotomy impression were potentially associated with suboptimal cytoreduction.