经肌间隙与传统入路行腰椎融合固定术的对比研究

目的　比较肌间隙与传统入路对腰椎内固定术中腰背肌损伤及术后病人短期恢复情况的影响。 方法　采用随机对照临床试验设计,将病人分为肌间隙入路组（A组）和传统入路组（B组）。按照随机数字表进行随机分组。测量基线肌酸激酶（CK）、谷草转氨酶（AST）、VAS和ODI评分。记录手术时间、术中出血量,术后第1和第3天的CK、AST,术后48 h内引流量、术后3 d经B超测定的伤口积液量,术后5 d、3个月的VAS和ODI评分。 结果　共纳入57例病人,其中A组27例,B组30例。两组的年龄、基线CK、AST、VAS和ODI评分无显著差异（P>0.05）。两组的手术时间、术中出血量无显著差异。术后48小时融合侧的引流量无显著差异,但融合对侧有显著差异（P<0.05）。术后第1天的CK、AST有显著差异（P<0.05）,而第3天无显著差异。术后第5天和3个月的VAS和ODI评分有显著差异（P<0.05）。 结论　经肌间隙入路能减轻手术对多裂肌的损伤,有利于病人术后恢复。     

乳腺后间隙神经阻滞麻醉应用于乳腺肿物切除术效果及对免疫功能的影响

目的探讨乳腺肿物切除术中应用乳腺后间隙神经阻滞麻醉的临床价值。方法选取行乳腺肿物切除术82例,随机分为观察组与对照组,每组41例。对照组行喉罩吸入全身麻醉,观察组行乳腺后间隙神经阻滞麻醉。比较两组麻醉效果、免疫功能相关指标及不良反应。结果观察组麻醉起效时间、手术时间及术后恢复时间同对照组比较,均明显较短,差异有统计学意义(P0.05)。两组患者术前免疫功能指标无显著差异(P0.05),观察组患者术后NK细胞、CD_3~+及CD_4~+检测值均显著高于对照组(P0.05)。两组患者恶心、呕吐、头晕、出汗等不良反应发生率分别为12.20%、16.83%,观察组明显较低(P0.05)。结论乳腺后间隙神经阻滞应用于乳腺肿物切除术中,麻醉效果显著,且能减少对免疫功能影响,降低不良反应发生率,值得推广。     

经翼点入路鞍区手术间隙显微解剖研究

目的 对鞍区的显徽解剖研究，进一步掌握和熟悉鞍区内重要结构及其毗邻关系，为临床提供参考．方法 15例(30侧)福尔马林固定的成人头颅标本，模拟翼点入路双侧开颅，对鞍区手术常用的3个手术间隙及其内部结构进行解剖和测量．结果 描述和测量了各间隙内血管和神经的毗邻、走行及直径、长度．间隙I为视交叉间隙，垂体柄的形状呈上粗下细的近似圆锥形，与活体差异较大，翼点入路中通过间隙Ⅱ更能清楚地看见垂体柄；间隙Ⅱ为视神经、颈内动脉(ICA)和大脑前动脉(ACA)问隙，ICA床突上段分为眼段、交通段和脉络膜段；间隙Ⅲ为ICA、小脑幕游离缘间隙．AchA是视束的主要供血动脉之一．结论 在鞍区显微手术中，间隙I、Ⅱ是最常用的间隙，间隙Ⅲ、Ⅳ主要配合间隙I、Ⅱ完成手术．间隙Ⅲ内进行手术操作时，动眼神经的识别和保护比较重要．垂体上动脉分支对视神经血供有非常重要的作用，熟悉这3个间隙的显徽解剖是鞍区手术成功的关键．     

肘前内侧血管神经间隙入路的临床解剖学

目的　对肘前内侧血管神经等相关结构进行解剖研究,为肘关节相关手术提供更佳的手术入路。 方法　 福尔马林防腐动脉灌注红色乳胶成人尸体上肢标本20侧,按层次解剖,从肱桡肌及旋前圆肌间隙进入,通过正中神经与肱、尺动脉之间的血管神经间隙,显露肘前侧解剖结构。观察肱动脉、桡动脉和尺动脉向内、外侧的分支,测量分支到桡、尺动脉分叉处的距离,分支管径;观察正中神经及分支走行情况,测量神经与血管伴行无相互交叉分支距离。 结果　血管神经无互相交叉分支伴行长度平均为6.04 cm,两者之间无重要分支相交叉,易于向两侧分开,能够清楚地提供肘关节相应部位的暴露。动脉向内侧分支较向外侧分支少且细,易于向外侧牵拉。神经肌支,基本上向内侧发出,以极小的锐角从主干发出,几乎与主干平行,易于向内侧牵拉。 结论　肘前内侧血管神经间隙入路,可保护血管神经,能清楚显露肘关节前侧解剖结构,易于操作。     

枕下乙状窦后入路和远外侧入路的比较研究

目的为临床选择合适的手术入路提供解剖依据。方法应用成人头部湿标本10例（20侧），动、静脉系统分别灌注混有红、蓝色染料的乳胶；分别模拟枕下乙状窦后入路和远外侧入路的手术操作。逐层解剖、拍照、测量。结果两种入路涉及的重要解剖结构有：Ⅴ～Ⅻ对脑神经、内耳道、枕髁、颈静脉结节、颈静脉突。结论应根据病变的特点选用合适的手术入路。     

经翼点入路鞍区手术间隙显微解剖研究

目的对鞍区的显微解剖研究,进一步掌握和熟悉鞍区内重要结构及其毗邻关系,为临床提供参考.方法 15例(30侧)福尔马林固定的成人头颅标本,模拟翼点入路双侧开颅,对鞍区手术常用的3个手术间隙及其内部结构进行解剖和测量.结果描述和测量了各间隙内血管和神经的毗邻、走行及直径、长度.间隙Ⅰ为视交叉间隙,垂体柄的形状呈上粗下细的近似圆锥形,与活体差异较大,翼点入路中通过间隙Ⅱ更能清楚地看见垂体柄;间隙Ⅱ为视神经、颈内动脉(ICA)和大脑前动脉(ACA)间隙,ICA床突上段分为眼段、交通段和脉络膜段;间隙Ⅲ为ICA、小脑幕游离缘间隙.AchA是视束的主要供血动脉之一.结论在鞍区显微手术中,间隙Ⅰ、Ⅱ是最常用的间隙,间隙Ⅲ、Ⅳ主要配合间隙Ⅰ、Ⅱ完成手术.间隙Ⅲ内进行手术操作时,动眼神经的识别和保护比较重要.垂体上动脉分支对视神经血供有非常重要的作用,熟悉这3个间隙的显微解剖是鞍区手术成功的关键.     

乳腺纤维腺瘤内癌2例

纤维腺瘤是妇女常见良性乳房肿瘤,而发生于纤维腺瘤的癌数量有限,少于0.5%[1],在外检中容易漏诊.自1931年Cheatle首先报道源自纤维腺瘤的癌以来,文献记载仅200余例,往往是个案报道加文献复习[2～4],但近来出现较大数例报道[5,6],引起人们关注,其命名含义混乱,治疗和预后有所不同,现报道2例.     

经腹膜后间隙入路腹腔镜肾及肾上腺手术的应用解剖

目的 探讨经腹膜后间隙腹腔镜肾上腺肿瘤切除术及肾脏手术的应用解剖及临床价值。方法 对2002年3月今开展的共58例腹腔镜泌尿手术进行分析，其中肾囊肿去顶减压术41例，肾上腺肿瘤切除术16例、肾切除术1例。结果 除1例肾囊肿去顶减压术因后腹膜控腔制备失败开放手术外，其余57例手术均获成功，手术时间肾囊肿30-120min，肾上腺70-140min，1例肾切除210min，失血量20-100ml，平均50ml，术中及术后均未输血，全部患者均无并发症。结论 经腹膜后间隙腹腔镜肾脏及肾上腺手术具有进路直接、解剖简单、易于掌握，对组织损伤小、出血少、对腹腔干扰小、术后恢复快、并发症少等优点。可作为肾上腺良性疾病及部分肾脏疾病手术治疗的首选方法。     

经髋关节外侧入路行人工股骨头置换术体会

人工股骨头置换术在我国已普遍开展,由于接受此手术者多为60岁以上年龄偏大的外伤性股骨颈骨折患者,因此尽快地完成手术并尽力减少手术损伤,是治疗能否成功的关键。我院从1991年2月至1997年4月,共行人工股骨头置换术45例,其中27例采用髋关节外侧入路。我们认为此入路损伤小,术中暴露充分,手术时间短。现报道如下。 1 临床资料 1.1 一般资料:27例中男13例,女14例;年龄55～82岁。新鲜股骨颈骨折者15例,陈旧性骨折者8例;骨折后继发股骨头无菌性坏死者4例。 1.2 手术方法:患者取半侧卧位,术侧在上,与手术台呈60°位。髋关节外侧切口Watson-Jones系一弧形切口,从髂前上棘之外下2.5cm处开始,向后下经股骨大转子外侧面及股骨干外侧面,直至股骨大转子基底部     

经眶额颞入路鞍区手术间隙的应用解剖

目的研究眶额颞入路中鞍区4个手术间隙的显微解剖特征,探讨这些间隙在鞍区显微外科手术中的应用。方法在10例(20侧)成人尸头标本上,模拟眶额颞入路开颅,在显微镜下对鞍区手术常用的4个手术间隙及其内部结构进行解剖观察和测量。结果对视交叉前间隙、视神经-颈内动脉间隙、颈内动脉-小脑幕三角间隙及终板间隙的结构构成及其邻近血管神经进行描述测量。结论选择合适的手术入路、熟悉鞍区解剖间隙的显微解剖、保护穿通支是鞍区手术成功的关键。眶额颞入路兼有额下和翼点入路的优点,适合大型鞍区肿瘤的切除。     

远离乳晕的乳腺纤维瘤手术切口的改进

目的了解远离乳晕的乳腺纤维瘤用乳晕边缘切口的可行性。方法收治约220例肿物距乳晕边缘大于3 cm的乳腺纤维瘤手术病人,分为实验组（120例）和对照组（100例）。实验组采用乳晕边缘切口,对照组采用传统开放手术切口。观察两组病人术后疤痕大小、能否哺乳、血肿有无、拆线时间长短、手术时间长短作为检测指标。结果所有切口均甲级愈合,术后6～7 d拆线。对照组传统切口疤痕宽0.2 cm及以下（小于等于0.2 cm）的有20例（20%）,实验组乳晕边缘切口疤痕宽0.2 cm及以下的有90例（75%）,两组之间差异有统计学意义（P〈0.01）。两组的不能哺乳发生率、血肿、拆线时间相似,实验组手术时间较对照组延长。结论乳晕边缘切口应用于远离乳晕的乳腺纤维瘤手术中是安全可行的,能取得治疗及美容双重效果。     

Lobular endocrine neoplasia in fibroadenoma of the breast

Four cases of endocrine neoplasia within fibroadenomas of the breast are described. The tumours are identifiable by light microscopic, silver impregnation and ultrastructural studies. Argyrophilia and the presence of dense-core granules establish the identity of this tumour type. The differential diagnosis from, and possible relation to, lobular carcinoma in situ are discussed.     

Phaeohyphomycosis breast masquerading as fibroadenoma in a young teenage girl

Phaeohyphomycosis is an unusual granulomatous fungal infection, observed in immunocompromised or diabetic patients; however, it is even rarer in immunocompetent patients. Cytological findings of the same have been infrequently reported. The histopathological diagnosis or fungal culture helps in definitive diagnosis to identify the exact fungal species. Hereby, we report a rare case of invasive fungal infection in a breast lump in a young female, presenting as fibroadenoma breast. Fine needle aspiration cytology from the breast lesion showed the presence of septate acute‐angled branching fungal hyphae with focal pigmentation, morphologically suggestive of phaeohyphomycosis which was positive with fungal stains. This was later confirmed on biopsy as histopathology slides showed the presence of prominent pigmented fungal hyphae. The pus culture from needle aspirate also showed phaeohyphomycotic fungal organism delineating the species Exophiala dermatitidis . Aspiration cytology is crucial for the diagnosis of fungal infection in such cases. An appropriate diagnosis will help in early detection and treatment of such infections as these are usually associated with high morbidity and mortality.     

Histopathological study of stromal smooth muscle cells in fibroadenoma of the breast

Smooth muscle cells are extremely rare stromal components of flbroadenoma. Eighty-five cases of flbroadenoma were reviewed In order to investigate the frequency of smooth muscle cells and to discuss its origin. Of the 85 cases, four (4.7%) cases showed smooth muscle cells in the stroma. Distribution In terms of age and tumor size did not show any difference from other cases. Three cases were classified as an intracanallcular subtype, and one was a mastopathic subtype. The cells possessed most of the ultrastructural characteristics of smooth muscle cells, but poor indentation of nuclear contours suggested the last remnant of fibro-blasts. It was therefore easy to recognize the cells derived from fibroblasts. In two of four cases, smooth muscle cells were observed in the stroma, which had marked hyaliniza-Uon and calcification. Therefore, it was supposed that smooth muscle cells could appear in the stroma of long-standing tumors.     

Cytological features of myxomatous fibroadenoma of the breast

Fibroadenoma (FA) is a benign tumor that must be differentiated from carcinomas. FAs often exhibit myxedematous changes (myxomatous FA, M-FA). We previously reported on the clinical significance of M-FA. M-FA and (mucinous) carcinoma share clinical findings, rapid growth and a relatively large size, a high-depth/width (D/W) ratio, a relatively round shape, and posterior echo enhancement with internal hyperechogenicity on ultrasonography (US). Next, a biopsy is required for differential diagnosis. In this study, we evaluated the diagnostic significance of the cytological findings of M-FA with US findings. Among 13 FAs that were diagnosed by cytology, we compared (i) a group of six mucinous carcinomas with acellular mucin and a D/W ratio ≥ 0.7 (a suspicious factor for malignancy) with a group with a D/W ratio of <0.7, and (ii) the frequency of metachromasia on Giemsa stain between M-FAs and non-M-FAs among eight FA cases confirmed by histology. (i) FA lesions (7 of 13) showed metachromasia with Giemsa staining significantly more frequently than did mucinous carcinoma (0/6) (Fisher's exact test, P < 0.044). FA lesions with a D/W ratio ≥ 0.7 (6/7) showed metachromasia significantly more frequently than did FA with a D/W ratio <0.7 (1/6) (Fisher's exact test, P < 0.029). Among eight FA cases confirmed by histology, M-FA cases (6/6) demonstrated metachromasia significantly more frequently than non-M-FA cases (0/2) (P < 0.036). M-FA cytologically exhibits marked metachromasia on Giemsa staining. Combining cytological examination and understanding the clinical features of M-FA may allow us to choose cytological examination as a first-line diagnostic method for tumor-forming lesions.     

Infarction of breast fibroadenoma in a postmenopausal woman

Infarction of a breast fibroadenorna usually occurs in young females during pregnancy or lactation. This report describes a rare case of the total infarction of a fibroadenoma in a 58 year old postmenopausal woman. The chief complaint was a rapidly enlarged, slightly painful lump. Medullary carcinoma was suspected on palpation and mammography. Microscopically, the tumor was composed of a coarsely lobulated necrotic mass invaginated into an epithelial lined cyst. This was interpreted as an infarcted intracanalicular flbroadenoma, although the possibility of an infarcted phyllodes tumor cannot be entirely excluded. The significance of this rare event is the possible confusion with carcinoma. Extensive search for viable tissue is essential for the confirmation of the diagnosis.     

Invasive ductal carcinoma with a predominant intraductal component arising in a fibroadenoma of the breast

A rare case of invasive ductal carcinoma with a predominant intraductal component arising within a fibroadenoma of the breast in a 42 year old Japanese female was investigated by light microscopy. The patient, who had a well-defined, rubbery breast tumor measuring 2.0 X 3.0 cm, had undergone a tumorectomy 21 months after she noticed the tumor. Histologically, the fundamental architecture of the tumor showed an intracanalicular-type of fibroadenoma, but extensive proliferation of atypical cells was noticed in the lumen of the ducts. Tumor cells in the canaliculi had characteristics of ductal carcinoma, such as solid, comedo and cribriform patterns. As most of the ducts were occupied by carcinoma cells with several foci of microinvasion in the stroma of the fibroadenoma, it was diagnosed as invasive ductal carcinoma with a predominant intraductal component arising within a fibroadenoma. This coexistence of in situ proliferation and invasive lesions of carcinoma within a fibroadenoma suggest the origin of the carcinoma to have been in the epithelial component of the fibroadenoma. In addition, this study clarifies the fact that carcinoma cells may proliferate and spread along the lumen of pre-existing ducts of the fibroadenoma and speculates that the duct system of the fibroadenoma has complete continuity.     

Demonstration of polyclonal origin of giant fibroadenoma of the breast

We have shown that fibroadenoma of the breast is polyclonal and that phyllodes tumour is monoclonal in origin. It is not known whether a giant fibroadenoma which is histologically identical to the more usual type of fibroadenoma but grows to be a huge mass, like a phyllodes tumour, is polyclonal or monoclona. Clonal analysis was conducted on the DNA samples extracted from the paraffin sections of a giant fibroadenoma resected from a 21-year-old woman. The method used was based on trinucleotide repeat polymorphism of the X-chromosome-linked androgen receptor gene and on random inactivation of the gene by methylation. Clonal analysis showed that the giant fibroadenoma and the adjacent normal breast tissue are polyclonal in origin. Although the term giant fibroadenoma has often been used interchangeably with the term benign phyllodes tumour, because of their similarity in clinical appearance, our present results demonstrate that a giant fibroadenoma is a polyclonal fibroadenoma that has attained an immense size and is different from the monoclonal phyllodes tumour.     

Histological features useful in the distinction of phyllodes tumour and fibroadenoma on needle core biopsy of the breast

AIM: To identify features useful in distinguishing phyllodes tumours from fibroadenomas on core biopsy. METHODS AND RESULTS: Starting from the diagnosis made on the surgical specimen, 12 features in the previous core biopsy specimens were analysed. Thirty-six phyllodes tumours had 44 previous core biopsy specimens, which were reported as fibroadenoma in 11 and spindle cell lesion of uncertain nature in one, and included phyllodes tumour in the differential diagnosis in 32. The lesions with a core diagnosis of fibroadenoma were excised largely because they were growing or exceeded 30 mm; review of the corresponding surgical specimen showed heterogeneous stromal cellularity. Thirty-eight fibroadenomas had previous core biopsy specimens reported as fibroadenoma in 37, and one of which included phyllodes tumour in the differential diagnosis. The following four features were significantly more common in cores from phyllodes tumours and had a kappa statistic of > 0.6 in a reproducibility study: stromal cellularity increased in at least 50% compared with typical fibroadenoma, stromal overgrowth (x10 field with no epithelium), fragmentation and adipose tissue within stroma. CONCLUSIONS: This study describes features useful in the diagnosis of phyllodes tumour on core biopsy. Some core biopsy specimens from phyllodes tumours show features of fibroadenoma on core biopsy because of tumour heterogeneity.     

Analysis of histological features in needle core biopsy of breast useful in preoperative distinction between fibroadenoma and phyllodes tumour

Morgan J M, Douglas‐Jones A G & Gupta S K
(2010) Histopathology 56 , 489–500 Analysis of histological features in needle core biopsy of breast useful in preoperative distinction between fibroadenoma and phyllodes tumour Aims: Fine Needle Aspiration Cytology (FNAC) has been replaced by Needle core biopsy (NCB) as the pathological investigation of choice in pre‐operative diagnosis of breast lesions. Despite the greater yield of material with spatial information, the distinction between fibroepithelial lesions of the breast, fibroadenoma (FA) and benign phyllodes tumour (PT), remains problematic. The aim of this study was to confirm a set of histological features which may assist in the pre‐operative distinction between FA and PT on NCB and to explore novel strategies to refine the analysis of the data. Methods: Previously defined histological criteria were applied to 112 NCBs of fibroepithelial lesions of the breast. Contingency tables for frequency analysis, logistic regression, receiver operating characteristic (ROC) and linear discriminant analysis were used. Results: Frequency analysis identifying significant differences agreed with published data. Correct categorisation was possible in 95% of cases using logistic regression analysis (age and mitotic index) and in 94% using discriminant analysis (age, mitoses and %stroma). ROC analysis identified cut off values (between FA and PT) for age (50–55 years), %stroma (85–90) and mitoses (≥1/2.2 mm²). Conclusion: The results confirm previously published observations and provide novel putative predictive tools, to be tested prospectively.