结直肠癌病检淋巴结数目与TNM分期及预后的关系

目的 探讨病检淋巴结数目与结直肠癌分期及预后的关系.方法 将567例结直肠癌患者根据术后病检的淋巴结数目分为3个组:≤6枚、7～11枚、≥12枚组,比较各组5年生存率的差别.TNM分期(Ⅰ～Ⅳ期)分别以病检淋巴结数目分为<12枚和≥12枚两组,比较各分期中两组的5年生存率的差别,分析预后相关因素.5年生存率的比较采用Kaplan-Meier法并经Log-rank检验,预后多因素分析采用Cox比例风险模型.结果 567例平均病检淋巴结数目为(16.75±9.88)枚,病检淋巴结数目分别为≤6枚,7～11枚,≥12枚时,结直肠癌5年生存率各为32.3%(21/65),43.8%(53/121),57.7%(220/381),单因素分析表明,病检淋巴结数目≥12枚的结直肠癌5年生存率明显高于其他两组(≤6枚,7～11枚)(P<0.05).<12枚、≥12枚淋巴结两组在Ⅰ期或Ⅳ期的结直肠癌5年生存率无明显差别(89.5%vs.89.1%,8.0%vs.18.2%,P>0.05),而≥12枚淋巴结的Ⅱ期和Ⅲ期5年生存率明显高于<12枚(71.1%vs.32.6%,48.8%vs.30.0%,P<0.05),多因素COX回归模型分析表明,病检淋巴结数目是Ⅱ、Ⅲ期结直肠癌独立的预后因素.结论 病检的淋巴结数目主要通过影响Ⅱ、Ⅲ期的预后与结直肠癌总5年生存率明显相关,是Ⅱ、Ⅲ期结直肠癌独立的预后因素.

Abstract：

Objective To study the relationship between the number of examined lymph nodes and the prognosis of colorectal cancer by TNM stage. Methods According to the number of examined lymph nodes, 567 patients of colorectal carcinoma who underwent resection were divided into three groups: ≤ 6,7-11 and ≥ 12, the 5-year overall survival rates of three groups were compared. For each TNM stage ( stage Ⅰ -Ⅳ ) , patients were substratified into two groups basing on the number of examined lymph nodes:<12 group and ≥12 group, the 5-year survival rates of two groups in each TNM stage were assessed, and prognostic factors of stage Ⅱ and Ⅲ stage were analyzed. 5-year survival curves were estimated with the Kaplan-Meier method and compared by the log-rank test. Cox proportional models were used to conduct multivariate analyses of prognostic factors. Results The average number of examined lymph nodes was 16. 75 ±9. 88. With the patients grouped by the number of lymph nodes ( ≤6,7 -11 and ≥12 nodes) , the 5-year survival rate was 32. 3% , 43. 8% , and 57. 7% , the univariable analysis indicated that the 5-year survival rate of ≥ 12 examined nodes were significantly higher than the other groups (P<0. 05). There was no difference between two groups in the 5-year survival rates of stage Ⅰ or Ⅳ colorectal cancer (89. 5% vs.89. 1% ,8. 0% vs. 18. 2% , P>0. 05 ) , however, the 5-year survival rates of stage Ⅱ and Ⅲ colorectal cancer in ≥12 group were significantly higher than<12 group(71. 1% vs. 32. 6% ,48. 8% vs. 30. 0% ,P<0. 05) , multivariable analysis revealed that the number of lymph nodes examined was an independent factor of prognosis of stage Ⅱ and Ⅲ colorectal cancer. Conclusions The number of examined lymph nodes significantly influenced the 5-year overall survival rate of TNM stage Ⅱ and Ⅲ colorectal cancer.     

小淋巴结转移与结直肠癌分期和预后的关系

淋巴结转移是影响结直肠癌预后的重要因素。目前临床上对结直肠癌标本淋巴结检查没有统一的规范，对直径〈5mm的小淋巴结的检出和转移状况不重视。而传统的淋巴结检查方法，对小淋巴结漏检的可能性极大。多个研究表明：小淋巴结中不仅存在转移，且其占阳性淋巴结总数的50％以上。小淋巴结的检出精确了结直肠癌患者的病理分期，有利于术后正确辅助治疗方案的选择。临床上应改进结直肠癌标本淋巴结检查方法，提高小淋巴结的检出率。     

循环肿瘤细胞的检测及其在结直肠癌中的研究进展

结直肠癌发病率逐年上升,转移和复发是结直肠癌死亡的主要原因。循环肿瘤细胞(CTCs) 的存在是肿瘤复发和远处转移的关键,与肿瘤患者的预后密切相关。CTCs 来源于肿瘤组织,主要存在于癌症患者的外周血中,已成为近年来研究的热点生物标志物。CTCs 检测在结直肠癌的早期诊断、评估结直肠癌术后预后、预测转移性结直肠癌的化疗反应、评估晚期结直肠癌的治疗反应和预后、筛选结直肠癌靶向治疗可能获益的患者方面具有重要意义。     

结直肠癌患者手术前后循环DNA 水平的变化及其意义

目的：探讨结直肠癌患者手术前后循环DNA水平的变化及其临床意义。方法：检测42例结直肠癌患者术前、术后3,14,30 d循环DNA水平,并检测同期14例健康体检者循环DNA水平作为对照。结果：结直肠癌患者术前循环DNA水平明显高于健康人[（92.25±46.88）ng/mL vs.（22.14± 16.16）ng/mL]（P<0.01）;结直肠癌术前循环DNA水平在不同年龄、性别、肿瘤部位分组间差异无统计学意义（P=0.293,P=0.244,P=0.135）。结直肠癌患者术后3 d循环DNA水平达（114.95±62.41）ng/mL,较术前明显升高（P<0.01）,但在术后14,30 d分别为（38.50± 37.71）ng/mL与（31.69±41.48）ng/mL,明显低于术前（均P<0.01）。结论：循环DNA水平在结直肠癌患者中升高,且术后早期一过性进一步升高,随后明显下降。循环DNA水平有望成为结直肠癌术后监测肿瘤状态和评价疗效的标志物。

     

第七版《AJCC肿瘤分期手册》结直肠癌内容的更新与解读

2009年10月14日,美国肿瘤研究联合会（American Joint Committee on Cancer,AJCC）和国际抗癌联盟（International Union Against Cancer,UICC）共同制定的《AJCC肿瘤分期手册》公布了更新的第七版,引发肿瘤医生极大关注.今天,AJCC肿瘤TNM分期系统已广泛地被各个国家的研究者以及肿瘤登记机构所采纳,成为适用于各个学科肿瘤分期的全球性语言.     

结直肠癌局部淋巴结浸出液癌胚抗原含量与淋巴结分期的关系

目的 探讨结直肠癌局部淋巴结浸出液癌胚抗原(CEA)含量与该淋巴结分期的关系.方法 2006年1月至2009年12月结直肠癌根治性切除术病例共92例.每例整块切除的新鲜标本中分别摘取原发灶肠管旁淋巴结和顶端淋巴结各2枚,分别测定CEA浓度,并送组织学检查,其余标本全数取出淋巴结送组织学检查.结果 pN 0期48例,CEA浓度30.16 ng/mg;pN 1期22例,CEA浓度93.26 ng/mg;pN 2期22例,CEA浓度359.74 ng/mg,3组比较差异有统计学意义(P＜0.01).结论 结直肠癌局部淋巴结浸出液CEA浓度与pN分期显著相关,可用于指导术后辅助化疗.

Abstract：

Objective To study the relationship between carcinoembryonic antigen (CEA) level of the regional nodes extract and pN staging in patients with colorectal cancer. Methods From Jan. 2006 to dex. 2009 radical resection was performed in 92 patients with colorectal cancer. Intraoperatively, two paracolonal regional lymph nodes and two predominate nodes were bisected, preserved in normal saline,and the extracts were sent for CEA assay. The same bisected node was fixed in Formalin for histopathologic examination. Results In the pN0, pN1 and pN2 stages, the mean CEA concentrations were 30. 16,93.26 and 359.74 ng/mg respectively ( P ＜ 0.01). Conclusion The concentration of CEA in the node extract is significantly correlated with pN stageing in patients with colorectal cancer, and it can be used to guide the adjuvant chemotherapy postoperatively before the final pN result obtained.     

CD44s表达与结直肠癌病理分期及预后的关系

目的 探讨标准型CD44(CD44s)在结直肠癌及癌旁黏膜中表达的临床应用价值.方法 对74例结直肠癌及癌旁黏膜进行免疫组织化学检测,应用Log-rank检验和COX比例风险模型分析CD44s表达与患者预后的关系.结果 CD44s在结直肠癌及癌旁黏膜巾表达的阳性率分别为42%、16%.按TNM系统肿瘤分期,Ⅲ～Ⅳ期结直肠癌CD44s强阳性染色为39%,显著高于Ⅰ～Ⅱ期的6%(X2=8.46,P＜0.01).全组中位随访时间58个月,CD44s表达阳性与阴性患者术后生存率比较差异有统计学意义(x~2=17.82,P＜0.01).在Ⅲ～Ⅳ期结直肠癌患者中,CD44s表达阳性者的术后总生存期显著短于CD44s表达阴性者(x~2=16.23,P＜0.01);而在Ⅰ～Ⅱ期结直肠癌患者中,CD44s表达阳性和阴性者的预后相比差异无统计学意义(x~2=1.34,P＞0.05).COX多因素分析表明,TNM分期和CD44s表达是反映结直肠癌预后的独立指标. 结论 CD44s过表达与结直肠癌病期进展和预后相关.     

内镜超声在结直肠癌术前分期中的应用价值

目的 探讨内镜超声（EUS）在结直肠癌术前TNM分期中的应用价值。方法 对60例手术切除的结直肠癌患术前行内镜超声检查,术后进行病理检查,将两对肿瘤侵犯深度的诊断结果进行比较。结果 经EUS检查,发现正常结直肠壁表现为5层结构,第1、3、5民支表现为高回声,第2、4层表现为低回声。第1、2层为黏膜层,第3层为黏膜下层,第4层为固有肌层,第5层为浆膜下和浆膜层。EUS下结直肠癌表现为低回声肿块,其回声强度介于第3层高回声和第4层低回声之间。根据EUS下结直肠壁5层结构和邻近器官的改变判断肿瘤侵犯的深度,进行TNM分期诊断。肿瘤旁直径大于或等于5mm圆形的低回声病灶诊断为转移性淋巴结。EUS对本组结直肠癌TNM分期诊断总的准确率为85．0％;周围淋巴结转移诊断的敏感性和特异性为54．8％和66．7％。结论有EUS对结直肠癌侵犯深度的判断有较高的准确率,对术前TNM分期诊断有一定价值。术前EUS检查可以结直肠癌治疗选择合适的方案提供指导。     

结直肠癌的分子生物学研究进展

结直肠癌的发生、发展是一个多步骤、多阶段及多基因参与的细胞遗传性疾病。笔者就肿瘤标志物的检测对于结直肠癌的诊断和治疗方面的意义进行综述。     

消化系统肿瘤的TNM分期

分类规则 包括下列部位：食管、胃、小肠、结肠与直肠肛管、肝脏、胆囊、肝外胆道、Vater壶腹、胰腺。每一部分按下列标题分述：（1）通过评估TNM分类进行分类的规则以及可以提高治疗前评估准确性的其他方法。（2）解剖学分区。（3）区域淋巴结的限定。（4）TNM临床分期。（5）pTNM病理学分期。（6）G组织病理学分级。（7）分期。（8）小结。     

胃癌第7版TNM分期的临床应用

目的:分析胃癌第7版与第6版TNM分期之间的差别.方法:回顾性分析316例胃癌患者的临床病理资料,按第6版及第7版TNM分期标准分别进行分期,并分析各期5年生存率.结果:两版TNM分期在同一期之间生存差异无统计学意义(P>0.05);第7版Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期5年生存率分别为64.2%、49.9%、17.8%、0.0%,4个分期5年生存率差异有统计学意义(P<0.05);ⅢA期、ⅢB期、ⅢC期5年生存率分别为32.2%、28.2%、5.0%,3个亚期5年生存率差异具有统计学意义(P ＜0.05).结论:第7版TNM分期更加细化,并对患者预后做出科学的评估.对不同分期的患者进行个体化综合治疗,具有临床应用价值.     

胃、大肠癌循环癌细胞的检测

目的胃大肠癌循环癌细胞的检测。方法用常规细胞学(HE)和免疫细胞化学(ICC)方法对23例进展期胃、大肠癌切除患者门静脉系血及外周血进行癌细胞的检测。结果 23例患者中常规 HE 染色,阳性2例(8.7%),可疑3例(13%);免疫细胞化学方法,阳性4例(17.4%)。4例阳性患者血中癌细胞浓度在40-1000个/ml 范围内。结论循环癌细胞的检测可能有助于预测肝内微转移灶的发生,判断患者预后,为术后选择辅助治疗提供依据。     

140例结肠癌术前CT TNM分期与术后病理分期的相关性

目的:探讨结肠癌CT TNM分期与病理分期的相关性。方法:行CT检查结肠癌140例,其中平扫104例,平扫加增强36例,将其结果进行TNM分期,并与术后临床病理分期进行对照。结果:104例平扫CT患者术前的T、N、M及TNM分期诊断准确率与术后病理相比分别为84.62%(88/104)、71.15%(74/104)、85.58%(89/104)、81.73%(85/104),均具有中度一致性(均P0.001)。36例平扫加增强CT患者的诊断准确率分别为91.67%(33/36)、75%(27/36)、100%(36/36)、83.33%(30/36),均具有中度、完全、中度一致性(均P0.001)。结论:CT与病理无论T、N、M分期还是TNM综合分期,都具有中度以上的一致性,可作为结肠癌术前分期的有效的评估方法。     

肺癌TNM分期的新进展

目前临床上广泛使用的肺癌分期法是1997年正式提出的,在过去的10年中对规范肺癌的诊治及临床研究起到了重要的作用,但也渐渐显示出其不足之处。2007年国际肺癌研究联合会（IASLC）通过收集100869例肺癌患者的临床资料,就TNM分期与预后之间的相关性做了深入分析,提出了对第7版肺癌TNM分期的修改建议：（1）根据肿瘤大小不同,将原来的T分期分为T1a（肿瘤最大直径≤2cm）、T1b（3cm≥肿瘤最大直径〉2cm）、T2a（5cm≥肿瘤最大直径〉3cm）、T2b（7cm≥肿瘤最大直径〉5cm）;（2）将T2c（肿瘤最大直径〉7cm）和原发肺叶内出现转移灶归为T3,将同侧其他肺叶内出现转移灶归为T4;（3）把癌性胸水、心包积液及对侧肺结节转移归为M1a,肺外转移归为M1b。新的版本在国际上将具有更高的权威性和认同度,在今后肺癌的治疗及判断预后上将起到更细致、更精确的指导作用;同时,也为肺癌的研究提供了一个新的起点。     

血清肿瘤标志物联合检验诊断结直肠癌的价值

为探究血清肿瘤标志物联合检验诊断结直肠癌的价值,选取2017-2018年在我院治疗的67例结直肠癌患者为观察组,并以同期健康体检者67名为对照组,观察2组癌胚抗原(CEA)、糖类抗原(CA19-9、CA72-4)、细胞角蛋白19的可溶性片段(CYFRA211)的表达水平、不同分期血清肿瘤标志物水平以及检测灵敏度与特异性...     

Persistent Problems in Colorectal Cancer Reporting

Tumor stage, as determined by the Tumor, Node, Metastasis (TNM) staging system, is the single most influential factor determining treatment decisions and outcome among patients with colorectal cancer. Several stage-related elements in pathology reports consistently pose diagnostic challenges: recognition of serosal penetration by tumor (ie, pT3 vs pT4a), evaluation of regional lymph nodes, distinction between tumor deposits and effaced lymph nodes, and assessment of tumor stage in the neoadjuvant setting. This article discusses each of these issues in detail and provides practical tips regarding colorectal cancer staging.     

Lymph Node Retrieval and Assessment in Stage II Colorectal Cancer: A Population-Based Study

Background: Adjuvant chemotherapy for patients with stage III (node-positive) colorectal cancer (CRC) reduces mortality by one third. Retrieval of an inadequate number of lymph nodes in the surgical specimen may result in incorrectly designating some patients as stage II (node negative), and consequently, such patients may not be offered appropriate chemotherapy. Recent National Cancer Institute guidelines suggest that a minimum of 12 nodes should be examined to ensure accurate staging.Methods: This population-based study identified stage II (T3N0 and T4N0) CRC cases by using CRC pathology reports (1997–2000) from the Ontario Cancer Registry. Patients aged 19 to 75 years were identified, and demographic, surgical, pathologic, and hospital data were extracted. Factors relating to the number of lymph nodes assessed were examined.Results: A total of 8848 CRC cases were reviewed, and 1789 stage II cases were identified. Seventy-three percent of cases were designated as node negative on the basis of assessment of <12 lymph nodes. Multivariate analysis showed that age, tumor size, specimen length, use of a pathology template, and academic status of the hospital were significant predictors of the number of lymph nodes assessed.Conclusions: A subset of patients with CRC in Ontario were assigned stage II disease on the basis of examination of relatively few lymph nodes.     

应用分支DNA技术及SqRT-PCR方法检测结直肠癌患者腹腔冲洗液中游离癌细胞

目的探讨分支DNA(b-DNA)及半定量RT-PCR(SqRT-PCR)在结直肠癌术中腹腔冲洗液中游离癌细胞检测中的应用。方法分别采用基于b-DNA信号放大的基因表达定量检测技术及SqRT-PCR方法检测48例结直肠癌患者术中腹腔冲洗液中CEA mRNA的表达,同时行腹腔冲洗液细胞学检查(peritoneal lavage cytolo-gy,PLC),收集12例结直肠良性病变患者的腹腔冲洗液为阴性对照,GAPDH mRNA为内参对照。结果b-DNA技术和SqRT-PCR方法检测游离癌细胞的阳性率(43.8%,31.3%)较PLC的检出率(4.2%)高(P0.01)。结直肠癌患者腹腔冲洗液中CEA mRNA的相对表达量均与肿瘤分化程度、浆膜侵犯程度和Dukes分期有关(P0.05),而与肿瘤大小、患者性别、年龄无关(P0.05)。结论b-DNA技术和SqRT-PCR方法检测游离癌细胞各有优缺点;腹腔内游离癌细胞的存在与结直肠癌临床病理因素有关。