全直肠系膜切除与直肠癌根治术

目的 探讨直肠癌根治性切除的手术范围。方法 对56例采用全直肠系膜切除术直肠癌患者进行术后病理分析。结果 吻合口瘘发生率为3.6%。56例中有22例直肠系膜内有淋巴结转移,14例直肠系膜内发现癌结节,直系膜转移率50.0%(28/56),5例直肠和纱膜转移位于肿瘤远端2cm以下。结论 直肠癌根治性手术应施行全直系膜切除。     

病理大组织切片对直肠癌系膜环周切缘癌浸润的临床研究

目的：研究中低位直肠癌系膜环周切缘癌浸润的存在规律，为直肠癌的临床治疗提供病理学依据。方法：随机选取2006年11月至2007年7月期间中低位直肠癌患者41例，均以全系膜切除（TME）原则手术治疗，手术标本制作成HE染色病理大组织切片，显微镜观察直肠系膜环周切缘癌浸润的情况。结果：HE染色病理大组织切片检测中下段直肠癌系膜环周切缘癌浸润阳性率为21．95％（9／41）。高、中分化肿瘤系膜环周切缘癌浸润阳性率分别为16．67％（1／6）、8．00％（2／25），低分化肿瘤阳性率高达60．00％（6／10）（P〈0．05）。肿瘤下缘距齿线距离〈5cm的系膜环周切缘癌浸润阳性率46．15％（6／13），高于≥5cm的阳性率10．71％（3／28）（P〈0．05）。患者性别、年龄、肿瘤大体类型、浸润深度、淋巴结转移情况、手术方法（开腹／腹腔镜）均与系膜环周切缘癌浸润阳性率无明显相关性（P〉0．05）。结论：病理大组织切片能客观准确地观察直肠癌术后系膜环周切缘癌浸润情况，术后应常规进行该项检查。肿瘤分化程度低、肿瘤位置低是系膜环周切缘癌浸润存在的高危因素。对于存在系膜环周切缘癌浸润的患者，术后应行规范的放化疗。     

大切片P53免疫组化染色对判断直肠癌远端扩散长度的临床意义

背景与目的:目前直肠癌远端的安全分子切除长度尚无定论。本研究拟探索直肠癌远端肠壁内浸润的分子长度及其对临床的指导意义,阐明根治性直肠癌远端正常肠管应切除的安全长度。方法:收集1996年8月～1997年10月手术切除的P53阳性直肠癌标本61例,应用大切片P53免疫组化染色、对照常规HE染色,在显微镜下测量远端肠壁内浸润长度,并根据组织回缩比率,换算成活体远端浸润的实际长度;长期追踪随访,用寿命表法估计、比较各组浸润长度的生存曲线。结果:用免疫组化染色观察P53阳性直肠癌,82.0%(50/61)病例向远端浸润,肠壁内扩散的分子长度0.11～3.50cm,平均0.59cm,>3cm仅1例;而用常规HE染色观察,29例(47.5%)发生肠壁内扩散,长度为0.10～1.39cm,平均0.13cm,两组均数比较差异有显著性(P<0.0001);随访结果表明,浸润长度>1cm的病例,其生存率明显低于无远端浸润或浸润<0.5cm组(P<0.05)。结论:用免疫组化染色较常规HE染色测量直肠癌远端浸润长度更准确,对指导临床更有意义。P53阳性直肠癌远端浸润多数在1cm以内,根治术切除肿瘤远端正常肠管3cm对95%以上的病例已安全。浸润长度>1cm的病例生存率明显降低。     

低位直肠癌直肠系膜区域微转移的病理形态学观察

目的 研究低位直肠癌在直肠系膜各区域微转移的分布规律,为直肠癌最佳手术方案的制定提供病理学依据。方法62例经低前切除和全直肠系膜切除术的患者,其手术标本经取材、包埋后,以2．5mm的间隔行大组织切片,切片行HE染色。在大组织切片上直肠系膜被分为3个区域：直肠系膜外侧区、直肠系膜中间区、直肠系膜内侧区。通过显微镜在切片上观察直肠癌微转移灶的区域分布、发生频率、类型、是否淋巴转移以及与肿瘤原发灶的关系。结果直肠癌微转移灶发生在直肠系膜和直肠系膜外侧区的频率分别为38．7％（24／62）和25．8％（16／62）。微转移灶侵犯标本环周切缘和远端直肠系膜的频率均为6．5％（4／62）,远端直肠系膜的转移不超过肿瘤下缘以远3cm。大多数直肠系膜内有微转移的患者（20／24）,其临床病理分期为Dukes C。结论低位直肠癌手术时,完整地切除直肠系膜而不破坏其外侧区至关重要;本研究的结果支持远端直肠系膜的切除长度不能〈4cm的临床原则。     

直肠癌淋巴结转移规律及其根治术中的合理切除

背景与目的：直肠癌是消化道最为常见的恶性肿瘤之一，淋巴转移是常见的转移途径，也是导致复发而致死亡的重要原因。本研宄探讨直肠癌淋巴结转移规律与直肠癌根治术的合理切除范围。方法：2004年9月-2005年9月于本院普外科胃肠专业组的接受直肠癌根治术27例患者，系膜淋巴结及侧方淋巴结分为10组，送检。结果：共取出淋巴结555个，癌浸润99个，其中肿瘤旁267个，癌浸润72个；肿瘤近端165个，癌浸润21个；肿瘤远端75个，无癌浸润；侧方48个，癌浸润6个。44％有淋巴结转移，11％发生侧方淋巴结转移，直肠癌淋巴结转移肿瘤旁为主，癌浸润淋巴结肿瘤旁占72．7％，近端为21．2％，侧方6．06％，肿瘤远端未见癌浸润淋巴结。结论：直肠癌的淋巴转移以肿瘤旁为主，为保肛低位直肠癌远端切除1～2cm是可行的。     

食管癌手术适宜切除长度的研究

目的　探讨食管癌手术的适宜切除长度。方法　将 70例食管鳞癌手术标本制成病理大切片 ,于显微镜下观察壁内浸润、多中心起源、跳跃式转移等情况。根据等比回缩法将镜下长度推算为术中实际长度。结果　本组 70例中 ,发现食管癌壁内浸润 5 1例 (72 .9% ) ,其中单纯近端浸润 15例 ,单纯远端浸润 12例 ,两端均有浸润 2 4例。食管癌近端壁内浸润长度均数为 0 .9± 0 .8cm ,最大值为 4 .0cm ;食管癌远端壁内浸润长度均数为 0 .5± 0 .3cm ,最大值为 2 .0cm。发现多中心起源 11例(15 .7% ) ,其中单纯近端 3例 ,单纯远端 6例 ,两端均有 2例。近端多中心起源病灶与主瘤距离加多中心起源病灶长度均数为 3.2± 1.5cm ,最大值为 4 .7cm ;远端多中心起源病灶与主瘤距离加多中心起源病灶长度均数为 3.6± 2 .4cm ,最大值为 9.1cm。9例 (12 .9% )患者发现有跳跃式转移灶 ,其中单纯近端转移 5例 ,单纯远端转移 2例 ,两端均有转移 2例。近端跳跃式转移灶与主瘤的距离加跳跃式转移灶的长度均数为 1.9± 0 .6cm ,最大值为 2 .9cm ;远端跳跃式转移灶与主瘤的距离加跳跃式转移灶的长度均数为 1.4± 1.0cm ,最大值为 2 .7cm。 70例患者中无残端癌发生。结论　对于食管癌手术的适宜切除长度 ,近端切缘距离肿瘤上缘应不少于 5cm     

直肠癌组织类型与根治术术式的选择

目的 提出直肠癌根治术术式选择与组织类型间的关系。方法 直肠癌标本以显微镜测量瘤体沿肠壁间向远侧端浸润距离。结果 直肠癌恶性程度与远端直接浸润距离成正相关系。结论 本文提出了距齿线6.0cm以内的直肠癌中,绒毛状腺瘤恶变可行保肛根治术,乳头状腺癌、高、中分化腺癌在距齿线4.0cm以上方可行保肛根治术;距齿线6.0cm以内的低分化腺癌、粘液腺癌、印戒细胞癌均应行Miles术。     

直肠癌远端肠管、直肠系膜内DNA含量的检测及其临床意义

目的检测直肠癌组织中DNA含量、细胞增殖活性并以此探讨直肠癌远端肠管及直肠系膜的切除范围.方法应用流式细胞术对38例直肠癌手术标本的癌组织、远端3 cm、5 cm处肠管及相应的3～5 cm、＞5 cm处直肠系膜和正常组织中DNA指数(DI)增殖指数(PI)和S期细胞百分比(SPF)进行检测,并比较各组织间差异.结果癌组织、癌远端3 cm肠管中异倍体率显著高于癌远端5 cm肠管及正常组织(P＜0.05),癌远端3 cm肠管与癌组织、癌远端5 cm肠管与正常组织间异倍体率无显著差异.癌组织中PI及SPF显著高于癌远端3 cm、5 cm肠管及相应直肠系膜和正常组织(P＜0.05).癌远端3cm、5 cm肠管中PI及SPF高于正常组织,但差异无显著性(P＞0.05).癌组织、癌远端3～5 cm、＞5 cm处直肠系膜中异倍体率及PI、SPF值均显著高于正常组织(P＜0.05);远端直肠系膜中异倍体率高于癌组织,但无显著差异;不同范围内的远端系膜中异倍体率、PI及SPF无显著差异(P＞0.05).结论直肠癌远端3 cm肠管中存在着DNA含量及细胞增殖活性的异常改变,具有恶变倾向,手术时应予以切除.直肠癌远端3～5 cm、＞5 cm处直肠系膜中也存在着DNA含量及细胞增殖活性的异常改变,呈现出恶性肿瘤生物学特性,直肠癌外科治疗时有必要切除癌远端5 cm以上的直肠系膜.     

结直肠癌肝转移相关的病理组织学评价

 目的　探讨结直肠癌肝转移的病理组织学特性。方法　对 335例行结直肠癌切除的患者行回顾性病理组织学研究 ,将有肝转移者的病理组织学参数与无肝转移者对比。结果　本组 4 1例 (12 % )有肝转移 ,有肝转移者与无肝转移者诸因素的百分率比较为 :肿瘤大小超过 6cm(5 1%υs 2 8% ;P <0 .0 1) ,肠系膜浸润 (98%υs 6 6 % ;P <0 .0 1) ,淋巴结浸润 (34%υs 15 % ;P <0 .0 1) ,静脉浸润 (2 4 %υs 3% ;P <0 .0 1) ,和淋巴结转移 (85 %υs 39% ;P <0 .0 1)。多元回归分析显示 :与肝转移有关的独立因素是肠系膜浸润、静脉浸润和淋巴结转移。诊断肝转移的精确度最高的是静脉浸润 (88% ) ,最低的是肠系膜浸润(41% )。在 98例有肠系膜和淋巴结转移者中 ,有肝转移者与无肝转移者静脉浸润差异非常显著 (2 6 %υs 6 % ;P <0 .0 1) ,其肠外淋巴结转移差异显著 (6 8%υs 4 7% ;P <0 .0 5 )。结论　结直肠癌肝转移的重要因素是肠系膜浸润 ,静脉浸润和淋巴结转移。其决定因素是静脉...     

直肠癌扩大根治术中几个原则问题的探讨

目的探讨在低位直肠癌治疗中直肠系膜全切除(TME)原则和侧方淋巴结清扫的意义.方法回顾分析哈尔滨医科大学附属肿瘤医院1981年9月～1995年10月782例经扩大根治术的大肠癌病人的资料.术中遵循TME原则及扩大淋巴结清除的方法清除直肠癌上方、侧方及部分下方淋巴结.应用常规病理学的方法观察其侧方淋巴转移的规律并以直接方法统计侧方转移阳性病例的生存率.结果(1)侧方淋巴转移是腹膜返折以下直肠癌的转移途径,约占该部位直肠癌的12.5%;(2)侧方淋巴转移易发生在低分化腺癌及粘液腺癌.肉眼类型中的有浸润倾向者,侧方淋巴转移与浸润深度有关;(3)侧方转移者的五年生存率为42.2%.结论腹膜返折以下的进展期直肠癌应该在TME的同时行侧方淋巴清除,如此可以避免转移淋巴结及系膜组织的残留,提高生存率.     

Regional micrometastasis of low rectal cancer in mesorectum: a study utilizing HE stain on whole-mount section and ISH analyses on tissue microarray

Aim: To investigate the regional spread of microscopic tumor nodules in the mesorectum of patients with low rectal cancer, and to provide further pathological evidence for optimal procedure selection of radical resection for rectal cancer. Methods: Sixty-two patients with low rectal cancer underwent low anterior resection and total mesorectal excision (TME). Surgical specimens were sliced transversely on serial embedded blocks at 2.5-mm intervals, and stained with hematoxylin and eosin (HE). On whole-mount sections the mesorectum was divided into 3 regions: the outer region of the mesorectum (ORM), the middle region of the mesorectum (MRM), and the inner region of the mesorectum (IRM). Microscopic metastatic foci were investigated for metastatic mesorectal region, frequency, types, involvement of the lymphatic system, and correlation with the primary tumor. Tumor-suspect nodules previously considered disease free by HE stain on whole-mount section were examined by in situ hybridization (ISH) on tissue microarray (TMA) through detecting mRNAs of CEA and CK20 with non radioactive biotin-tagged oligonucleotide probes. Results: Microscopic spread of the tumor was observed in 50.0 percent of patients (31 out of 62, 24 by HE stain on whole-mount section and 7 by ISH on TMA) and that in the ORM was observed in 38.7 percent of the patients (24 out of 62, 16 observed by HE stain on whole-mount section and 8 by ISH on TMA). Microscopic tumor foci spread in the circumferential resection margin (CRM) occurred in 8.1 percent of the patients (5 out of 62, 4 observed by HE stain on whole-mount section and one by ISH on TMA), and distal mesorectum (DMR) involvement was detected in 6.5 percent (4 out of 62, all observed by HE stain on whole-mount section), with the spread extending to within 3 cm from the lower margin of the tumor. Most (26 of 31) of the patients with microscopic spread in mesorectum had TNM Stage III diseases. Conclusions: The results of the present study support the theory that complete excision of the mesorectum without destruction of the ORM is essential for surgical management of low rectal cancer, and an optimal DMR clearance resection margin of no less than 4 cm was referenced. Five patients with microscopic tumor nodule spread in the CRM observed in the study suggested that microscopic metastases exist in pelvic lateral areas and in the mesorectum simultaneously, indicating the significance of preoperative and/or postoperative radiochemotherapy.     

大切片上直肠癌远端壁内扩散的研究

目的 研究直肠癌远端壁内扩散的规律,为临床保肛手术提供依据。方法 收集广州中山医科大学肿瘤医院1996年8月－1997年10月间直肠癌手术标本98例,制成大切片,在显微镜下观察直肠癌的远端壁内扩散,运用等比回缩规律,得出活体情况下的远端壁内扩散长度。结果 98例标本中,48例发生远端壁内扩散,最短0．1cm,最长2．5cm,其中＜0．5cm者37例,≥0.5cm且＜1.0cm者6例,≥1.0cm者5例。从大切片上可以观察到肿瘤发生直接侵袭、神经侵袭、淋巴侵袭和血管侵袭。远端壁内扩散可同时或分别沿黏膜层、黏膜下层、内环肌层、外纵肌层和浆膜层进行。结论 直肠癌远壁内扩散范围大多在0．5cm以内,扩散≥1cm的很少。临床保肛手术远切缘≥3cm比较安全。     

Distribution and patterns of lymph nodes metastases and micrometastases in the mesorectum of rectal cancer

BACKGROUND AND OBJECTIVES: Facts buried in the mesorectum remain to be unveiled. This study investigated the number, size, and detailed distribution of lymph nodes metastases and micrometastases within the mesorectum of rectal cancer. METHODS: Thirty-one patients who underwent total mesorectal excision (TME) were treated with lymph node revealing solution to retrieve lymph nodes, which were submitted to hematoxylin and eosin (HE) examination and immunohistochemical (IHC) staining. RESULTS: The mean number of mesorectal nodes per case was 17.7. The mean size of metastatic, micrometastatic, and isolated tumor cells (ITC) harbored nodes was 5.2 mm, 4.5 mm, and 3.3 mm, respectively. Most of the metastatic (92.1%), micrometastatic and ITC-involved nodes (69.2%) were located along the superior rectal artery (SRA). Posterior-wall located tumor might spread along both sides of the mesorectum simultaneously (P = 0.34), while lateral-wall located tumor spread preferably to ipsolateral side versus contralateral side (P = 0.012). CONCLUSION: Most of the metastases and micrometastases positive lymph nodes were smaller than 5 mm and distributed along the SRA. The patterns of lymph nodes spread were related to the circumferential situation of tumor in the rectal wall. Surgical excision of the rectal cancer should completely remove the whole mesorectum, especially to avoid any damage of the mesorectum on tumor side.     

Mesorectal spread and micrometastasis of rectal cancer studied with large slice technique and tissue microarray

BACKGROUND AND OBJECTIVES: Mesorectal tissue seems to be an ideal substrate for the spreading of tumors. The aim was to study the distribution of mesorectal neoplastic foci, examine occurrence of circumferential margin involvement and investigate micrometastasis of the lymph nodes. METHODS: A large slice technique, combined with tissue microarray, was used in the pathologic study of 31 specimens operated on following the principles of total mesorectal excision (TME). RESULTS: Three hundred and forty-nine mesorectal neoplastic foci were examined from 18 specimens. Almost one third of them were in the outer layer of mesorectum. Concerning position of primary tumor, ipsolateral neoplastic foci were significantly more than contralateral neoplstic foci. Twelve specimens were diagnosed to have circumferential margin involved. Nine hundred and ninety-two lymph nodes were harvested with 148 involved by tumor. No significant difference in occurrence of micrometastasis was observed among tumors of different stage. CONCLUSION: Combination of large slice and tissue microarray provided a more detailed method in studying the spread of rectal cancer. Complete excision of the mesorectum with fascia propria circumferentially intact is essential since there is an outer scattering and lateral discrepancy for neoplastic foci distribution. Circumferential margin involvement and micrometastasis observed suggested adoption of preoperative and/or postoperative radiochemotherapy.     

Location of pelvic recurrence after «curative» low anterior resection for rectal cancer

AIMS: It has been emphasized that the mesorectum is the key to local recurrence after resection for rectal cancer. In view of this we studied the location of recurrences, relative to the bed of the primary tumour, the neorectum and the level of anastomoses, in patients referred for recurrences after low anterior resection (LAR) in the . METHODS: The relative level above the anal verge of the primary cancer, the anastomosis and the recurrence was registered by proctoscopy in 46 patients operated on for recurrent cancer after low anterior resection. The origin of the recurrence was determined from the operative specimen. RESULTS: The median level of the primary cancers was 10 cm above the anal verge, with the anastomoses 2 cm lower, the majority being within 2 cm. Most recurrences were within 1 cm of the anastomosis. No rectal cancer occurred more than 3 cm distal to the anastomosis. Seventy to 80% of recurrences started peri-rectally, most invading the anastomosis. CONCLUSIONS: The tumour bed is most often the origin of the recurrence. Recurrences were mostly due to inadequate radial, and in a few cases longitudinal, dissection of the mesorectum. Virtually all recurrences were within reach of the examining finger. At follow-up of rectal cancers most local recurrences can therefore be identified earlier by digital examination than by proctoscopy.     

SAFETY MARGIN IN ANUS-SAVING RESECTION FOR LOW RECTAL CANCER

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