Noncurative resection for advanced gastric cancer.

Between 1965 and 1985, 489 patients with advanced gastric cancer who were treated with gastric resection and in whom tumor cells remained after the operation were defined as cases of a "noncurative resection." The clinicopathological features and prognosis of these patients were examined and two groups were prepared: locally advanced cancer and cancer with a distant metastasis. In locally advanced cancer cases, tumor cells remained in the neighboring organs, lymph nodes, and/or resected margins; in those with distant metastasis, peritoneal dissemination and/or liver metastasis were present regardless of whether or not the metastasis was removed, with or without locally noncurative factors. Serosal invasion was prominent and high rates of lymph node metastasis and lymphatic involvement were evident in both groups. The survival rate for patients with locally advanced gastric cancer was better than that of patients with distant metastasis (P < 0.01). Survival time in patients with locally advanced cancer can be lengthened by resecting all of the primary tumor and as much of the metastatic lesions as possible, even if the surgical management is "noncurative." Aggressive postoperative chemotherapy for patients with distant metastasis from a gastric cancer is to be recommended.     

Time trends of surgical treatment and the prognosis for Japanese patients with gastric cancer

The incidence of gastric cancer is much higher in Japan than in other countries even though diagnostics and treatments of such patients have improved. The objective of this study was to present an overview of the past, present and future of surgical treatment for our patients with gastric cancer. We analysed data on 2152 Japanese men and women with gastric cancer who underwent surgical resection from 1965 to 1995 at Kyushu University in Fukuoka, Japan, based on a univariate and the multivariate analysis. We focused on time trends of surgical treatment and the postoperative outcome. Over the years, there have been favourable changes in the numbers of patients with early gastric cancer. In all cases of gastric cancer, the rate of 18% in the first six year period (group 1) was 57% in the last 5 year period (group 6). Size of the tumour was smaller, well-differentiated tumour tissue was more common, and lymphatic involvement was less frequent. Lymph node metastasis, liver metastasis and peritoneal dissemination all decreased. Extensive lymph node dissection was more frequently done and the rate of curative resection (curability A and B) increased. With increases in identifying the early stage of cancer and better perioperative care, mortality rates 30 days after the surgery greatly decreased. Multivariate analysis revealed that the 10 factors of depth of invasion, lymph node metastasis, lymph node dissection, tumour size, liver metastasis, peritoneal dissemination, lymphatic invasion, vascular invasion, lesion in the whole stomach and lesion in the middle stomach were independent factors for determining the prognosis. Detection of the tumour in an early stage, standardized surgical treatment, including routine lymph node dissection, close follow-up schedules and better perioperative management are expected to increase survival time for patients with this malignancy.     

分化型甲状腺癌患者血清TNF-α、IL-6和VEGF表达与侵袭转移的相关性分析

目的:探讨分化型甲状腺癌患者血清TNF-α、IL-6和VEGF的浓度变化与甲状腺癌分期及侵袭转移的相关性。方法:采用双抗体夹心酶联免疫吸附法（ELISA）测定64例分化型甲状腺癌患者（甲状腺癌组）和42例甲状腺腺瘤患者（甲状腺腺瘤组）的血清TNF-α、IL-6和VEGF浓度,并与40例健康成年人（对照组）作为对照。结果:甲状腺癌组血清TNF-α、IL-6和VEGF水平均高于甲状腺腺瘤组和对照组（P均<0.01）;甲状腺癌患者其水平Ⅳ期组>Ⅲ期组>Ⅰ、Ⅱ期组（P均<0.01）;且伴有颈部淋巴转移的甲状腺癌患者其水平显著高于无颈部淋巴转移的患者（P＜0.01）;在甲状腺癌患者不同性别之间和不同年龄组之间差异均无统计学意义（P＞0.05）。结论:外周血TNF-α、IL-6和VEGF水平与甲状腺癌的侵袭、转移密切相关,检测其表达水平对判断甲状腺癌患者病情进展有重要意义。     

Histopathologic findings predicting lymph node metastasis and prognosis of patients with superficial esophageal carcinoma: analysis of 240 surgically resected tumors

BACKGROUND: If it were possible to elucidate the histopathologic findings predicting lymph node metastasis and prognosis in superficial squamous cell carcinoma of the esophagus (SSCCE), they could be used as markers to identify patients who do not require additional surgical resection after endoscopic mucosal resection (EMR). METHODS: Two hundred forty surgically resected SSCCEs were examined histopathologically. Histopathologic factors including vertical tumor invasion depth in the submucosal layer (VTIDsm), degree of nuclear atypia (low, one point; high, two points), growth pattern (expansive, one point; infiltrative, two points), and histologic grade (calculated by adding the latter two scores to obtain Grade 1, two points; Grade 2, three points; and Grade 3, four points) were evaluated to investigate the associations among these factors, lymph node metastasis, and prognosis. RESULTS: No lymph node metastasis was found in 54 patients with carcinoma limited to the lamina propria. Their 5-year survival rate was 100%. Multivariate analysis of 186 carcinomas invading beyond the lamina propria showed that lymphatic permeation correlated with lymph node metastasis (P<0.0001) and the presence of lymph node metastasis and a high histologic grade were independent factors indicating a poor prognosis (P = 0.0061 and 0.023, respectively). In 53 patients whose tumors had invaded the lamina muscularis or slightly invaded the submucosa (VTIDsm <500 microm), no lymph node metastasis was found in the lymphatic permeation negative and blood vessel permeation negative patients with VTIDsm values <200 microm and histologic Grades 1 or 2. CONCLUSIONS: Lymphatic permeation is a good predictor of lymph node metastasis in patients with SSCCE. Lymph node metastasis and the histologic grade are independent prognostic factors. Vessel permeation, VTIDsm, and histologic grade were found to be important factors for identifying patients who did not require additional surgical treatment after EMR.     

Rare case of early mucosal gastric cancer presenting with metastasis to the bulbar conjunctiva

Early gastric cancer has an excellent outcome following surgical treatment. In particular, mucosal gastric cancer (m-cancer) very rarely results in metastatic dissemination and may be successfully treated by local surgical resection. We report a 64-year-old Japanese woman who presented with a recurrent cystic lesion on the left bulbar conjunctiva, with a biopsy specimen revealing metastatic signet-ring cell carcinoma. Gastrointestinal investigations revealed an early gastric cancer in the lesser curvature of the stomach. Biopsy specimen of the gastric lesion indicated poorly differentiated adenocarcinoma, which was identical to findings in the lesion in the bulbar conjunctiva. She underwent a distal gastrectomy and made an uneventful recovery. Histopathological analysis indicated a gastric signet-ring cell carcinoma that was limited to the mucosal layer, without evidence of lymphatic spread. Although the exact mechanism of metastatic dissemination to the bulbar conjunctiva is unclear, this case is very unusual, because ocular metastases almost invariably occur in the context of documented and established malignant disease. This is, to our knowledge, the first reported case of a patient with gastric mucosal cancer who presented with a conjunctival metastatic deposit and who subsequently received curative surgical treatment for both conditions. Received: November 5, 2001 / Accepted: February 5, 2002     

甲状腺乳头状癌颈淋巴结转移规律与手术方式的选择

目的:从甲状腺乳头状癌颈部淋巴结转移规律探讨其最佳手术方式.方法:回顾性分析我院近三年367例甲状腺乳头状癌(papillary thyriod carcinoma,PTC)根治术患者的临床及病理资料.结果:颈淋巴结总转移率为77.11%(283/367),中央区(VI区)转移率为 70.30%(258/367),颈侧区(Ⅱ、Ⅲ、Ⅳ、Ⅴ区)转移率为 62.67%(230/367),颈侧区中的Ⅱ区转移率最高60.49%(222/367).发病年龄、原发灶个数、肿瘤是否累及被膜、癌灶直径、肿瘤边界是否清晰、癌灶位置、超声血流信号分级、癌症是否合并桥本氏甲状腺炎或结节性甲状腺肿对颈部淋巴结转移的影响差异均有统计学意义(P<0.05);性别因素及癌灶是否钙化对颈部淋巴结转移的影响差异无统计学意义(P>0.10),经logistic回归分析发现,肿瘤是否累及被膜对颈部淋巴结转移的影响因素最大.结论:VI区是甲状腺乳头状癌最常见的转移部位,术中应常规清除,其次依次为Ⅱ、Ⅲ、Ⅳ、Ⅴ区.对于患者原发肿瘤若累及包膜、或多发病灶、或癌灶直径>1 cm及患者发病年龄<45岁等应同时做颈侧区清扫.     

Extent of surgical resection for esophageal and gastroesophageal junction adenocarcinomas

The early-stage lymphatic dissemination in esophageal cancer poses challenges for adequate surgical treatment. The role of extensive lymph node dissections remains a matter of debate. Results of the only available large randomized controlled trial suggest that fit patients who have esophageal cancer are treated best by a transthoracic esophagectomy with extended en bloc (two-field) lymphadenectomy. For less fit patients or patients who have junctional or cardiac tumors, transhiatal esophageal resection could suffice. In patients who have truly "early" adenocarcinoma (ie, with high-grade dysplasia or intramucosal carcinoma) endoscopic resectional or ablative treatments may be suitable. When the tumor invades the submucosal layer, the high risk for lymph node involvement and tumor recurrence probably necessitates more extensive treatment schedules for definitive cure.     

咽旁肿瘤切除术(附29例)

目的探讨如何根据术前诊断选择最佳的手术进路,提高疗效,减少并发症和后遗症。方法本组29例,男性16例,女性13例,年龄18~57岁,中位年龄45。均采用手术治疗及术后化疗或放疗。手术进路:口腔入路、颌颈入路、颈侧高位切开下颌骨外旋入路、颌咽入路、上颌骨掀翻入路、上颌骨加咽旁肿瘤切除。结果病理类型:良性21例,恶性8例,随访5年,良性肿瘤均未见复发,骨肉瘤1例术后2个月复发,上颌窦癌1例术后2年复发,口咽侧壁粘液表皮样癌1例术后6年复发,再次术后2年复发,颌下腺腺样囊性癌术后4年复发并肺转移,未继续治疗,恶性淋巴瘤2例化疗后5年无复发。手术均未出现并发症,术后有暂时性的神经功能障碍,均在半年内恢复。结论口腔入路仅适用于紧邻咽粘膜下小肿瘤、颌颈入路适用于咽旁混合瘤、神经鞘瘤和颈动脉体瘤、颈侧高位切开下颌骨外旋入路适用于腮腺深叶肿瘤及高位神经鞘瘤、颌咽入路适用于恶性肿瘤连同下颌升枝一并切除、上颌骨掀翻入路及上颌骨适用于晚期的上颌窦癌及颅底肿瘤侵入咽旁。     

淋巴结切除术对子宫内膜癌的临床意义

手术治疗是子宫内膜癌的主要治疗方式,通过手术治疗可以明确诊断、病理分级、临床分期,并为术后的辅助治疗提供充分的临床资料。对于子宫内膜癌患者是否常规进行淋巴结切除仍存在较大争议,特别是对于低危的子宫内膜癌患者而言,因为低危患者淋巴结转移发生率非常低,且不影响患者的预后,但目前没有全面的划分淋巴结转移危险因素及其危险程度的统一标准。本文就子宫内膜癌的淋巴结转移特点,影响淋巴结转移的因素,淋巴结切除的并发症,淋巴结切除术对预后的影响,淋巴结切除的临床意义及淋巴结切除的发展方向等方面加以综述,我们认为对于内膜癌患者应选择个体化的治疗方案,注重术前的全面评估,对于G3,透明细胞,浸润肌层≥1/2,病灶>2cm,宫颈受累等应进行包括腹主动脉旁淋巴结在内的系统淋巴结切除术。     

Pathology of early invasive adenocarcinoma of the esophagus or esophagogastric junction: implications for therapeutic decision making

BACKGROUND: As an alternative to surgical resection, endoscopic treatment modalities are being explored for the treatment of patients with early esophageal carcinoma. This study aimed to evaluate patterns of local growth and regional dissemination of early adenocarcinoma of the esophagus or esophagogastric junction, as these pathologic features may contribute to rational therapeutic decision making. METHODS: Among 173 patients who underwent esophageal resection for invasive adenocarcinoma (1993-1998), 32 (19%) had early stage cancer (pT1). Clinical records, pathology reports, and original slides of the surgically resected esophagus were reviewed in each case. RESULTS: In 12 patients tumor invasion was limited to the mucosa, whereas in 20 patients the tumor showed infiltration of the submucosa. All cancers were associated with intestinal metaplasia. Areas of high grade dysplasia accompanied 27 of the 32 cancers (84%). Intramucosal cancer had no lymph node metastasis but presented as multifocal disease in 42% of cases and extended under preexisting squamous mucosa in 17% of cases. In submucosal cancer, lymph node metastases were present in 30% of cases. Disease specific 3-year survival for patients with intramucosal cancer was 100% and for those with submucosal cancer 82% (P = not significant). CONCLUSIONS: Based on the local growth pattern of intramucosal adenocarcinoma of the esophagus or esophagogastric junction, endoscopic treatment of patients with this disease should be applied with caution. For submucosal carcinoma, surgery is the mainstay of treatment, as lymph node metastasis is frequently present. Both subclassifications of early cancer show a favorable outcome after esophagectomy.     

甲状腺癌的再次手术治疗

目的：探讨甲状腺癌再次手术的必要性及其手术方式，分析再次手术的原因。方法：回顾性分析我科于1999年2月～2002年10月，45例甲状腺癌再次手术的临床资料。结果：首次行甲状腺肿块切除术的有43例，行甲状腺患叶 峡部切除术的2例。首次手术后的病理类型：乳头状腺癌32例，滤泡性腺癌12例，髓质样癌l例。根据外院手术治疗资料及我院术前彩色多普勒超声检查或CT检查结果，均再次行手术治疗，其中再次行甲状腺残叶 峡部切除术的28例，行甲状腺残叶 峡部 同侧功能性颈清扫的17例。再次手术后病理检查证实癌残留的29例(67．4％)，颈部淋巴结有转移癌的有12例(70．6％)，随访至今均生存。结论：甲状腺癌行局部切除术，残癌率高，再次手术是必要的。     

Treatment of gastric cancer based on the pathological and biophysiological aspects of cancer

Spread of the gastric cancer is multifarious according to its pathological and biophysiological characteristics. The therapeutic strategy was reviewed by the analysis of more than 8.000 cases of gastric cancer treated at Cancer Institute Hospital. Main type of recurrence in early stage cancer was, though seldom, the hematogenous metastasis to the liver. On the other hand, in the advanced cases, macroscopically localized, and histologically well differentiated tumor type easily adhered and invaded to the adjacent organs and structures, and infiltrating and undifferentiated tumor type tended to cause peritoneal dissemination. Lymph node spread was observed in any tumor type, but frequently observed in intermediate type. Invasion to the adjacent organs and limited lymphatic spread can be controlled by wide combined resection of adjacent organs, and extended lymphadenectomy. However, hematogenous metastasis and peritoneal dissemination are difficult to be controlled by surgical intervention. Thus, minor surgery can be directed for small early stage cancer under strict criteria, and wide and extended resection for localized type, and combination of surgery and adjuvant chemotherapy for intermediate and infiltrating tumor types advancing more than stage II.     

Regularities of relapse and metastasis of signet ring cell carcinoma of the stomach following combined and surgical treatment

Characteristics of recurrence and metastatic development of signet ring cell carcinoma of the stomach were studied in 59 cases after combined and surgical treatment. Peritoneal dissemination appeared to be the most frequent pattern of tumor progression. It accounted for 55% of all relapses and occurred in 27% of patients even without extension through serous membrane (pT2). Metastasizing through the lymphatic viae was fairly frequent mostly in cases of peritoneal carcinomatosis while blood flow-related dissemination was not. Subtotal resection in patients with early-stage signet ring cell carcinoma (pT1) was justified because local recurrences are extremely rare in that pathology. Since (pT2-4) stump relapse is fairly frequent (14-16%), the operation of choice was gastrectomy, whatever site of tumor. Regional metastasis recurrence was 20% among patients with relapsing tumor. It usually co-occurred with distant metastases and, therefore, was less clinically significant. However, when concomitant with local recurrence, it ruled out radical treatment. Preoperative radiotherapy was followed by a significant drop in regional metastasis recurrence rate (4.5 and 13.3%, p = 0.04).     

Lymphatic dissemination of hepatic metastases. Implications for the follow-up and treatment of patients with colorectal cancer

Hepatic spread of colorectal cancer is a prominent cause of treatment failure, but selected patients with liver metastases may attain long-term palliation or cure with liver resection. A review of the records of 81 patients seen at the National Cancer Institute for treatment of colorectal hepatic metastases revealed 7 instances of metastases discovered at operation within the hepatic lymphatic drainage in the absence of other extrahepatic tumor. These patients were studied with reference to location and stage of the primary colon cancer and location of metastases at the time of planned liver resection. All seven patients had their extrahepatic lymphatic disease limited to nodes draining the liver, implicating lymphatic dissemination from hepatic metastases as the mechanism of tumor spread. This pattern of spread rendered these patients unresectable for cure. If lymphatic metastases occur from hepatic tumor this implies a need for frequent and thorough follow-up of patients following resection of a primary colon cancer, and indicates urgency in treatment of liver metastases.     

Management and prognosis of patients with early colorectal cancer

The controversy remains as to the management of patients with early colorectal cancer, especially criteria for subsequent surgical resection. However, all authors agree that residual carcinoma and lymph node metastasis closely affect survival of the patients. In this paper, we estimated the risk factor for local residual carcinoma or lymph node metastasis in early cancer, and wish to report the experience with particular reference to the management and prognosis of patients with invasive carcinoma. Subsequent surgery was indicated when the removed material showed at least one of the following findings: carcinoma near the surgical margin, massive invasion, vessel invasion and poorly differentiated adenocarcinoma. Patients without risk factors were adequately treated by polypectomy alone. Thirty-three percent of the patients with risk factors had residual carcinoma. We decided that massive invasion and carcinoma near the surgical margin were true risk factors for residual carcinoma. Only one patient with risk factors had lymph node metastasis. It is difficult to estimate the true risk of lymph node metastasis and further study is needed.     

Evaluation of 118 Thyroid Cancer Patients Who Underwent a Re-operation after Local Resection

OBJECTIVE To evaluate the incidence of residual thyroid cancer and cervical lymph node metastasis following a previous local resection for thyroid cancer, and to discuss methods of a reoperation.METHODS From 1994～2005, 118 patients with thyroid cancer who had previously been treated with a nodule-resection or subtotal Iobectomy in other hospitals underwent a surgical re-operation.RESULTS The incidence of residual cancer at the primary site was 38.1%. The lymph node metastasis rate at the central area was 39.8%.The rate of lymph node metastasis in patients with enlarged lymph nodes in the ipsilateral internal jugular chain was 37.5%. The rate of laryngeal recurrent nerve injury was 15.2% in other hospitals while that of the second operation in our hospital was 1.6%.CONCLUSION Nodule-resection or subtotal Iobectomy alone is not indicated for patients with thyroid cancer because of the high rate of local residual cancer. It is important to be familiar with the anatomy of the laryngeal recurrent nerve for thyroid surgery. Exploration to the central area is necessary for differentiated thyroid cancer.     

A case of metastatic lung carcinoma in the thyroid gland presenting as a goiter

This report concerns a patient with primary lung cancer that had metastasized to the thyroid, and who was treated with a single-stage surgical operation. The thyroid gland has generally been considered to be an infrequent site for metastasis of primary carcinomas of other organs, but metastatic thyroid disease has been found with moderate frequency in postmortem studies. Although there is no clear consensus regarding the role of surgery in the treatment of metastatic disease of the thyroid, the postoperative course of our patient prompts us not to advocate thyroidectomy in cases of advanced and aggressive tumors such as carcinoma of the lung. Adequate diagnosis and treatment of thyroid metastasis should be considered, after which an aggressive surgical approach may be recommended for selected patients. Received: August 6, 1998 / Accepted: May 31, 1999     

食管粘膜下癌淋巴结转移12例

 探讨食管粘膜下癌发生淋巴结转移的有关因素及特点,制定治疗早期食管癌的最佳方案.方法:手术切除食管粘膜下癌52例,常规清扫区域淋巴结,分组病理检查,术后进行长期随诊.结果:本组食管粘膜下癌淋巴结转移率为23.1%(12/52),发生淋巴结转移主要与肿瘤的分化程度有关,分化越差,转移率越高,其次与肿瘤的大小、病理形态类型等因素有关.跳跃式转移发生率高,转移淋巴结大部分≤1cm,可能是食管粘膜下癌发生淋巴结转移的特点.结论:对早期食管癌应行食管次全切除术,并常规清扫区域淋巴结.     

Results of a surgical resection for patients with stage IV non--small-cell lung cancer

PurposeThis study retrospectively investigated the clinical significance of surgical treatment for stage IV non–small-cell lung cancer (NSCLC).SubjectsThere were 36 patients who underwent surgical resection for stage IV NSCLC between 1999 and 2008.ResultsThe patients included 22 males and 14 females. All patients had either synchronous distant metastasis or pleural dissemination. The mean age of the patients was 65.8 years (range, 18 to 90 years). The histological types included 29 adenocarcinomas, 5 squamous-cell carcinomas and 2 large-cell carcinomas. The organs of metastasis were bone in 5 patients, brain in 4, adrenal gland in 4, axillary lymph nodes in 3, liver in 2, and 1 patient had a contralateral pulmonary metastasis. The number of metastases was one site in 13, two sites in 3, three sites in 1, and five sites in 2 patients. The patients with bone metastasis were treated with radiation, and the patients with brain metastasis underwent stereotaxic radiosurgery. The patients with either adrenal metastasis, axillary lymph node metastasis, or contralateral lung metastasis underwent surgical resection. Among the patients with distant metastasis, the 5-year survival rate was 30.1 %. There were 17 patients with pleural dissemination. The 5-year survival rate in these patients was 25.3%. The overall 5-year survival rate after surgery in the patients with stage IV disease was 26.8%.ConclusionSelected patients who can undergo surgical resection for the primary tumor and effective local therapy for metastatic lesions still have a chance to obtain long-term survival. Surgical treatment for NSCLC with oligometastatic disease can be considered as one arm of multidisciplinary treatment.