贲门癌术前肿瘤切除可能性的评估

目的探讨贲门癌尤其是晚期贲门癌的临床特点,术前较正确的估计肿瘤手术切除的可能性,减少不必要的探查手术。方法根据肿瘤是否能被切除,将427例贲门癌患者分为两组,手术切除组:377例,贲门癌完全被切除;手术探查组:50例,均行开胸探查术。两组患者术前均未行化疗、放疗和介入等治疗,对两组患者术前的各项临床资料行单因素和logistic多因素分析。结果logistic多因素分析结果显示当肿瘤有明显的外侵、临床表现有明显的呕吐、上胸背疼痛或腹痛、消化道X线钡餐片表现为胃底广泛增厚、胃小弯肿瘤浸润明显或有巨大软组织阴影、肿瘤>7cm者手术切除率低。分化程度较低的腺癌手术切除率亦低。结论肿瘤外侵、呕吐和疼痛症状、消化道X线钡餐造影表现、肿瘤的大小及病理类型对贲门癌患者术前肿瘤可切除性的评估有意义。     

胸段食管鳞癌的多学科综合治疗

食管癌患者就诊时大多已为中晚期,第七版UICC食管癌新分期Ⅲ期以上肿瘤单纯手术切除往往疗效不满意,系统性的多学科治疗至关重要.越来越多的证据表明术前同期放化疗是最为有效的诱导治疗方式,可使肿瘤降期并提高根治性切除率;针对食管鳞癌中常见的多组、多野淋巴结转移患者,术前诱导化疗不失为可行的选择.对于已根治性手术切除的局部进展期肿瘤,术后辅助放疗或有助于弥补手术清扫范围的不足以加强局控;术后辅助化疗的作用亦有待进一步深入研究.胸段食管鳞癌与西方国家常见的食管下段腺癌有本质的不同,需要积累更多的前瞻性临床研究,以形成适合我国食管癌患者的综合治疗模式.     

X线透视下食管癌活动度检查和胸部CT在评估胸上段食管癌可切除率中的价值北大核心CSCD

目的探讨X线透视下食管癌活动度检查和胸部CT在评估胸上段食管癌可切除率中的价值。方法选取2009~2015年在我科行食管癌根治术的221例胸上段食管癌患者,其中男141例、女80例,中位年龄59(47~79)岁。术前患者均常规行X线透视下食管癌活动度检查及胸部增强CT扫描,判断肿瘤是否发生外侵,分析两种术前判断方法与术中实际结果的符合情况。结果食管癌活动度评分1~6分的患者数分别为70例、85例、32例、29例、2例和3例。食管癌活动度检查预测食管癌外侵的受试者工作特征(ROC)曲线下面积(AUC)为0.897(95%CI 0.85~0.93,P<0.001),最大约登指数处所对应的截断点值为>3。根据ROC曲线活动度评分,将4~6分认为是外侵,1~3分认为是无外侵。与胸部增强CT扫描比较,X线透视下食管癌活动度检查的灵敏度75.0%,特异度89.3%,准确度88.2%,误诊率10.7%。胸部增强CT检查判断外侵的灵敏度75.0%,特异度66.8%,准确度67.4%,误诊率33.2%。两种方法比较,前者的检查特异度更高,误诊率更低。实际侵犯气管与活动度检查符合率86.7%,实际侵犯其它部位患者与活动度检查符合率85.7%。结论X线透视下食管癌活动度检查可提高判断胸上段食管癌可切除率的准确性,是胸部CT检查的有益补充,尤其是在判断病变与气管关系方面有更大优势。     

食管肿瘤行核磁共振检查的临床价值（附31例报告）

对２６例食管癌、３例食管平滑肌瘤，２例食管平滑肌肉瘤病人术前行核磁共振（ＭＲＩ）扫描并与手术及病理对照研究。结果表明ＭＲＩ扫描估价食管肿瘤外侵程度不十分准确，判定肿瘤切除可能性不可靠，对纵隔及食管旁淋巴结检出率低，不能鉴别食管肿瘤的良或恶性。因此，ＭＲＩ检查对食管肿瘤病人选择治疗方案帮助不大。     

食管肿瘤行核磁共振检查的临床价值

对２６例食管癌、３例食管平滑肌瘤，２例食用这平滑肌肉瘤病人术前行核磁共振（ＭＲＩ）扫描并与手术及病理对照研究。结果表明ＭＲＩ的扫描估价食管肿瘤外侵程度不十分准确，判定肿瘤切除可能性不可靠，对纵隔及食管旁淋巴结检邮率低，不能鉴别食管肿瘤的良或恶性。因此，ＭＲＩ检查对食管肿瘤病人选择治疗方案帮助不大。     

巨大纵隔肿瘤的外科治疗

目的　回顾性总结 15例巨大纵隔肿瘤的临床经验 ,探讨其外科治疗及预后。　方法　 15例巨大纵隔肿瘤患者中经右胸切口 7例 ,胸骨正中切口 5例 ,左胸切口 3例 ;其中 2例术中运用体外循环 ,2例行血管成形术。结果　患者全部治愈出院 ,辅以放疗、化疗 ,预后良好。　结论巨大纵隔肿瘤的外科治疗困难 ,手术切口、术中操作技术、肿瘤有无外侵对肿瘤切除起主要作用 ,体外循环的运用有助于肿瘤的完整切除。     

食管胃同时眭双原发癌的综合治疗分析（附8例报道）

目的探讨食管胃同时性双原发癌的综合治疗方法。方法对2006年10月至2013年2月期间江苏省中医院消化系肿瘤外科诊治的8例食管胃同时性双原发癌患者的治疗过程进行分析,探讨其综合治疗经验。结果8例食管胃同时性双原发癌患者均经胃镜活检病理学检查明确诊断。根据CT和超声内镜检查结果进行术前分期,T1a期以下的病灶行内镜下黏膜切除6例（食管癌4例,胃癌2例）,行手术切除1例（食管癌）;T2期及以上的病灶行术前新辅助放化疗、手术、术后辅助放化疗等8例（食管癌2例,胃癌6例）,行单纯手术切除1例（食管癌）。8例患者均获随访,随访时间为10～76个月,平均41.3个月。1例在术后7个月死亡,1例在术后20个月发现肿瘤转移,余6例患者随访期间均无复发和转移。结论应根据食管胃同时性双原发癌的不同病情制定个体化治疗方案,包括根治性胃食管癌切除术、内镜下黏膜切除术、术前新辅助放化疗、术后化疗等,过度追求手术治疗并不能取得理想的效果。     

电视胸腔镜在食管疾病诊断与治疗中的应用

电视胸腔镜手术(VATS)作为一种微创技术应用于食管疾病的诊断和治疗已10年左右,其优点为减少术后早期和长期胸痛,减少术后呼吸道并发症,符合美学要求.VATS食管癌分期主要是评估食管癌外侵和转移情况,有助于选择合适的治疗方案.VATS治疗食管癌主要应用于早期食管癌切除,但由于手术部位多,操作较繁杂,应用受到一定的限制;而对食管良性疾病,如平滑肌瘤、贲门失弛缓症等在有条件的医疗中心已成为首选的手术方案.     

右胸单切口食管癌切除食管胃右胸顶吻合术42例

右胸单切口食管癌切除食管胃右胸顶吻合术４２例张世俊孙毅武玉兵１９８９年１０月～１９９６年１２月我们对中段食管癌病变较长，特别是ＣＴ检查发现肿瘤外侵严重，左胸径路难以切除的病例，实行右胸单切口切除食管癌食管胃右胸顶吻合术，提高了切除率，取得了满意疗效。...     

综合治疗食管多原发癌22例

目的 探讨食管多原发癌的治疗策略及疗效。方法回顾性分析2000年3月至2011年3月间北京大学临床肿瘤医院胸外科收治的22例食管多原发癌患者的临床病理资料．并与同期、同一手术组收治的471例单发食管癌患者的预后进行比较。结果22例食管多原发癌手术采用剖胸食管切除者18例,经裂孔食管切除者4例;接受术前化疗者8例,术后化疗者15例,其中手术前、后均予化疗者6例。471例单发食管癌患者手术采用剖胸食管切除者423例,经裂孔食管切除者60例：接受术前化疗者148例,术后化疗者267例,其中手术前后均予化疗者101例。22例多原发癌患者3年生存率为41．9％．中位生存期为29．2个月：471例单发食管癌患者的3年生存率为54．7％,中位生存期46．8个月;两组比较差异无统计学意义（P=0．051）。结论食管多原发癌治疗效果较差：广泛的食管切除在此类患者中有重要的意义．同时辅以积极的全身综合治疗．     

术前核磁共振检查对胸段食管癌切除可能性的估计

１９９３年６月～１２月对２６例胸段食管癌病人进行了核磁共振（ＭＲＩ）检查。将ＭＲＩ检查结果、手术及病理进行对比分析，结果表明ＭＲＩ对肿瘤浸润深度及肿瘤是否侵犯胸主动脉、气管、支气管及左心房等重要脏器判断有较大帮助，对于术前切除可能性的准确判断率较高，而对淋巴结转移的准确判断帮助不大。对于早期局限于粘膜及粘膜下层的食管癌不能作出准确的判断。作者认为对术前食管造影长度大于４ｃｍ的胸段食管癌病人可进行ＭＲＩ检查，以了解肿瘤浸润情况，判断切除率。     

Evaluation of noninvasive tests for the preoperative staging of carcinoma of the esophagus: a prospective study

A prospective study was undertaken to define the usefulness of conventional full-lung linear tomography, radionuclide liver plus spleen and bone scans, and thoracic and abdominal computed tomography for the preoperative staging of carcinoma of the esophagus. Thirty-three patients with carcinoma of the esophagus were studied. The computed tomographic (CT) scan of the thorax and upper abdomen was the single most accurate noninvasive study. With computed tomography, the relationship of the tumor to the tracheobronchial tree was the feature most useful in predicting local resectability. In all patients with the finding of tracheobronchial compression by the tumor, the tumor could not be resected completely. The predictive value of this CT finding in patients with locally unresectable tumor was high (0.83), indicating its usefulness in assessing unresectability. The CT finding of visible separation between tumor mass and tracheobronchial tree was present in 10 of 14 patients with locally resectable tumor (predictive value, 0.63). However, tumor abutting the tracheobronchial tree without compression was a poor predictor of unresectability (predictive value, 0.36). The radionuclide bone scan was the only other noninvasive study to demonstrate a metastasis not evident by CT scan. The combination of chest and abdominal CT scan, bone scan, and bronchoscopy before operation will accurately stage the majority of patients with esophageal cancer but no noninvasive test is of sufficient reliability to exclude patients from operative resection if otherwise indicated.     

Low impact of staging EUS for determining surgical resectability in esophageal cancer

Background

Although studies have shown that EUS has a high sensitivity and specificity for T and N staging, the value of EUS for staging tumors as resectable or nonresectable after CT of the chest and abdomen and US neck assessment, is largely unknown. This study was designed to assess the diagnostic value of EUS for determining resectability of esophageal cancer.

Methods

A retrospective analysis of all consecutive patients with esophageal carcinoma who underwent staging EUS, CT, and US. Tumors were considered resectable when there was no evidence of metastases or ingrowth in adjacent structures. Sensitivity, specificity, positive (PPV), and negative (NPV) predictive value of CT/US neck and CT/US neck?+?EUS for predicting surgical resectability were calculated. PPVs of CT/US alone and CT/US?+?EUS together were compared for assessing the diagnostic value of EUS.

Results

In total, 211 patients (155 men; mean age of 64?±?9.4?years) were included, of which 176 (83?%) underwent all three staging investigations. Based on preoperative staging, 173 (82?%) patients were considered resectable and 38 (18?%) nonresectable. Of all 173 initially resectable patients, 145 were operated on. Of these patients, five (3.4?%) tumors were found nonresectable during surgery. Postoperative sensitivity, specificity, PPV, and NPV of CT/US and CT/US?+?EUS for predicting surgical resectability were 88 versus 87?%, 20 versus 40?%, 97 versus 98?%, and 6 versus 10?%, respectively.

Conclusions

Although EUS adds to the specificity of preoperative esophageal cancer staging after CT chest and abdomen, and US of the neck have been performed, the overall added value of EUS is limited.     

Preoperative CT scan for esophageal tumor]

Thoracic CT scans were performed preoperatively in 19 patients with carcinoma of the esophagus and one patient with esophageal leiomyoma. CT findings were compared with surgical and pathological findings before and after operation. CT was shown to be inaccurate in the preoperative assessment of the involvement of esophageal carcinoma and of little value in judging potential resectability (69%). Its accuracy was low in staging the tumor, usually understaging (37.5% staging II) or overstaging tumor (45.4% staging III), without information about suitable treatment of esophageal cancer. With low accuracy in visualizing lymph nodes of the mediastinum and periesophagus (30%), it is not helpful in distinguishing benign from malignant tumor of the esophagus.     

The questionable role of computed tomography in preoperative staging of esophageal cancer

The findings of computed tomography (CT) in 18 patients with histologically proven esophageal carcinoma were compared with operative and pathological findings. Computed tomography delineated esophageal lesions in 14 of the 18 patients. In 11 patients, CT scanning was found to be inaccurate in assessing tumor involvement of esophageal lymphatic drainage. Nine patients had no abdominal nodal metastasis demonstrated by CT scan. Operative exploration revealed tumor involvement of celiac or left gastric lymph nodes in all of these patients. Two patients' CT scans demonstrated tumor involvement of celiac and left gastric lymph nodes; at operative exploration, these nodes were enlarged, but they were histologically negative for esophageal carcinoma. Operative exploration changed the preoperative TNM classification in 8 of the 11 patients. Review of these data indicates that surgical exploration continues to be the only reliable method of determining the actual extent and often the resectability of esophageal carcinoma.     

The feasibility of three-dimensional displays of the thorax for preoperative planning in the surgical treatment of lung cancer.

OBJECTIVE: Three-dimensional (3D) displays of anatomic structures have become feasible for preoperative planning in some surgical procedures. There have been no reports, however, on the use of 3D displays for surgical treatment of lung cancer. We hypothesized that 3D displays of the thorax are useful for preoperative planning for lung cancer. METHODS: Based on virtual reality technologies, we rendered 3D displays of the thorax from two-dimensional (2D) computed tomographic (CT) images of six anonymous patients, some of whom underwent surgical removal of lung cancer. For determining the resectability of lung cancer, we tested 17 participants with varying degrees of surgical skills to view 3D displays and read 2D CT images of these thoracic cavities in a randomized order. We measured their performance in terms of the accuracy of predicted resectability, the confidence of their prediction, planning time used, and workload experienced. RESULTS: The results demonstrated that viewing 3D displays of thoracic cavities has significant advantages over reading 2D CT images in determining the resectability of lung cancer: increasing the accuracy of predicted resectability by about 20%, enhancing the confidence of the prediction by about 20%, decreasing planning time by about 30%, and reducing workload by about 50%. All participants preferred viewing 3D displays to reading 2D CT images for preoperative planning. Junior residents found 3D displays of thoraces more useful than senior residents. CONCLUSIONS: It is feasible to use 3D displays of the thorax for preoperative planning in treating lung cancer. Using 3D displays in surgical treatment of lung cancer has potential benefits, once the technique is perfected.     

The role of computed tomography in assessing the operability of oesophageal carcinoma

The reliability of CT scanning in assessing resectability in carcinoma of the oesophagus was investigated prospectively by direct comparison with the operative findings. Over 11 months, 38 patients judged potentially operable following conventional investigation underwent CT scanning from the thoracic inlet to the level of the adrenal glands. These patients were then explored surgically with a view to resection. The CT findings were assessed by two radiologists without access to clinical information. Operative findings were recorded by the surgeon. Comparison was made between the tomographic and surgical findings specifically assessing: longitudinal tumour extent, direct mediastinal infiltration, invasion of other mediastinal structures, lymph node involvement and the presence of hepatic and pulmonary metastases. The sensitivity and specificity of the scan for each feature was then calculated. Scan sensitivity was poor, ranging from 0%-66.7%. Specificity was better with a range of 70.8%-100% according to the criterion studied. We conclude that the poor sensitivity means that CT scanning is of little value in the preoperative assessment of resectability in oesophageal carcinoma.     

进展期胃癌术前CT与手术结果的对比研究

目的探讨CT检查对进展期胃癌手术可切除性的术前评估价值。方法回顾性分析对比93例进展期胃癌的CT表现及手术治疗的相关资料。结果胃底贲门癌23例,胃体部癌59例,胃窦部癌11例。肿瘤肿块最大者直径1.5～11cm。93例胃癌均显示胃壁有不同程度的增厚,部分胃壁有软组织肿块形成,黏膜面有溃疡形成,胃腔及贲门狭窄,贲门管壁增厚,食道下段受累以及周围组织器官侵犯等。CT对进展期胃癌的定位、定性诊断与胃镜活检和/或手术病理符合率高,肿瘤检出率可达100%。手术前判断为可切除组的手术切除率达93.3%;不宜手术切除组病例的不能切除率为75.0%。结论胃癌术前CT诊断具有重要临床意义,CT对肿瘤的可切除性评估有较高的参考价值,值得推广应用。     

Laparoscopy Predicts Metastatic Disease and Spares Laparotomy in Selected Patients With Pancreatic Nonfunctioning Islet Cell Tumors

Introduction: Our objective was to compare the efficacy of CT alone to CT followed by laparoscopy in determining resectability of pancreatic nonfunctioning islet (NFI) cell tumors.Methods: A retrospective analysis from 1993 to 1999 revealed 48 patients who underwent surgical evaluation for NFI cell tumors. Of these, 34 (71%) patients underwent laparoscopy and CT for either diagnostic purposes or tumor staging. CT and laparoscopic criteria for curative resectability were defined and the sensitivity, specificity, and predictive value of both modalities in determining resectability were calculated.Results: The most frequent tumor location and presenting symptoms were pancreatic head (n = 27, 56%) and abdominal pain (n = 31, 65%), respectively. Median tumor size was 4.0 cm. In the laparoscopy group, curative resection was performed in 20 cases (59%). CT followed by laparoscopy was more sensitive than CT alone in predicting resectability (93% vs. 50%, P = 0.03) with similar specificity (both 100%). The predictive value for tumor resectability was 74% for CT alone and 95% for CT followed by laparoscopy. Reasons for unresectability identified at laparoscopy but not indicated by CT were liver metastases (n = 6) or nodal disease (n = 1). Four of these patients were spared a laparotomy while the other three patients underwent surgical palliation and all are alive with disease (AWD). In those not undergoing laparoscopy (n = 14), curative resection was performed in 64% (n = 9). Four of these patients underwent resection, despite having metastases, and three are AWD.Conclusions: NFI cell tumors of the pancreas present as large masses with frequent metastases. Despite metastatic disease, prolonged survival is often achieved with or without open surgical treatment. Laparoscopy can be used in diagnosis and accurately identifies metastases not seen on CT, thus sparing laparotomy in some patients.     

Endosonography of upper gastrointestinal tract cancer on demand using miniprobes or endoscopic ultrasound

BACKGROUND: The aim of this study was to investigate whether endosonography on demand with miniprobes and conventional endoscopic ultrasound improves the accuracy of endosonographic staging of upper gastrointestinal tract cancer. METHODS: Altogether, 173 patients underwent endoscopic ultrasonography for preoperative staging of esophageal (n = 63) or gastric cancer (n = 110). Depending on the endoscopic appearance (i.e., size and growth pattern), tumors were examined with a linear-array echoendoscope (7.5 MHz) or with high-resolution miniprobes (12.5 MHz). The results of preoperative staging were correlated with histopathology of the resection specimen. RESULTS: The overall accuracy of miniprobe ultrasonography and endoscopic ultrasound in assessing the infiltration depth of upper gastrointestinal cancer was 87% and 81%, respectively. Miniprobe ultrasonography was superior to conventional endoscopic ultrasound in the staging of early cancers, particularly T1 tumors (accuracy, 81% vs 56%). The combined accuracy of both techniques for all tumor stages was 82%. Correct diagnosis of lymph node involvement was obtained with miniprobe ultrasonography or endoscopic ultrasound in 76% and 71% of the cases, respectively. The combined accuracy in assessing the lymph node status was 73% (sensitivity, 68%; specificity, 81%). CONCLUSIONS: Endosonography on demand using either miniprobes or conventional endoscopic ultrasound may result in more effective and less invasive staging of esophageal and gastric cancer. Selective use of high-resolution miniprobes and conventional endoscopic ultrasound offers accurate staging of all tumor stages.