直肠类癌的诊断与治疗

报告近17年来收治的直肠类癌15例，发现60％病例曾被误诊为直肠息肉、内痔或直肠炎等。因症状缺乏特异性，医生行直肠指检时警惕本病对早期发现有重要意义，确诊仍需病理检查。治疗上，文献多据病变大小确定治疗方式。作者根据本组病例治疗的体会，提出应根据病变大小及浸润深度来确定治疗方案，即病变在2cm以内者行局部切除；如还有肌层浸润时应加作根治术；病变大于2cm者作根治术。     

直肠类癌22例临床分析

本文报道２２例直肠类癌，其中男性１９例，女性３例。按Ｄｕｋｅｓ分期，Ⅰ期１５例，Ⅱ期，Ⅲ期２例、Ⅳ期１例。为提高对本病的诊断率，作者认为，对４０岁以上出现不明原因的直肠肛管症状，应常规指检，对高度怀疑者，应经直肠针吸或活检，取材应有一定深度，以免误诊。直肠类癌的治疗应根据肿瘤的大小结合浸润的深度而定。直径〈１ｃｍ行局部切除，１￣２ｃｍ行局部扩大或广泛切除，〉２ｃｍ或浸及肌层，应行根治性切除。伴肝转     

直肠类癌(附26例报告)

为探讨直肠类癌的病理学特点、诊断及治疗选择,对我院１９８７～１９９７年１０年间收治的２６例直肠类癌病例进行回顾性总结。２６例术前均行直肠镜检查并经病理学检查而确诊,其中１９例分别做了局部切除或局部扩大切除,７例因肿块直径大于２ｃｍ而行根治性手术。术后随访１～１０年,死亡５例。作者认为,直肠镜检查是术前发现直肠类癌的重要手段,对可疑病变行活检时,除常规行ＨＥ染色外,应加做嗜银染色、亲银染色以及免疫组化检查。手术治疗是其最佳的治疗方法,手术切除的范围取决于原发肿瘤的大小、浸润程度、淋巴结受累及肝转移等情况     

肾血管平滑肌脂肪瘤治疗方式探讨：附20例分析

１９８０年以来收治肾血管平滑肌脂肪瘤２０例。其中男７例，女１３例，平均年龄４０岁。肿瘤总数２６个，双肾均有肿瘤者２例，一侧肾有多个肿瘤者２例，直径小于４ｃｍ者５例，大于４ｃｍ者２１例，肿瘤最大者１５ｃｍ×１３ｃｍ×ｌ０ｃｍ。１９８５年前收治７例，全部行肾切除，１９８５年以后的１３例，仅２例行肾切除，２例行肾部分切除，６例行肿瘤剜除，１例行超选择性动脉栓塞，２例保守治疗。建议在处理这种肿瘤时，应根据其大小，位置和具体的技术条件，选择尽可能多的保留功能肾组织的治疗方法，不要轻易作肾切除。     

直肠类癌

为探讨直肠类癌的病理学特点,诊断及治疗选择,对我院１９８７－１９９７年１０年间收治的２６例直肠类癌病例进行回顾性总结。２６例术前均行直肠镜检查并经病理学检查而确诊,其中１９例分别做了局部切除或局部扩大切除,７例因肿块直径大于２ｃｍ而行根治术性手术。术后随访１－１０年,死亡５例,作者认为,直肠镜检查是术前发现直肠类癌的重要手段,对可疑病变行活检时,除常规行ＨＥ染色外,应加做嗜银染色,亲银染色以及免疫     

DNA倍性并非直肠类癌的预后因素

ＤＮＡ倍性并非直肠类癌的预后因素（英）＼＝ＦｉｔｚｇｅｒａｌｄＳ，ｅｔａｌ．ＤｉｓＣｏｌｏｎＲｅｃｔｕｍ，１９９６；３９（６）：６４３￣６４８直肠类癌在直肠肿瘤中不足１％，其处理主要依据肿瘤的大小与浸润深度，但＜１ｃｍ的类癌亦有转移，而＞２ｃｍ或侵袭...     

食管癌贲门癌浸润与切除长度的关系（附38例报告）

对８３例中晚期食管癌贲门癌病人行手术切除治疗，于术中、术后对标本进行测量及病理学检查。４４例食管癌中浸润最远达９．８ｃｍ，浸润近侧超过６．０ｃｍ的有４例（９％），远侧超过６．０ｃｍ的有７例（１６％）。３９例贲门癌浸润最远达１３ｃｍ，浸润范围超过９．５ｃｍ者有４例（１０％）。我们认为：食管、贲门癌外科治疗切除范围距肿瘤５．０ｃｍ可适宜于９０％左右的病例；其余的切除应在８．０ｃｍ甚至１０．０ｃｍ以上；     

阑尾类癌的诊断和治疗：（附6例报告）

阑尾类癌少见，报告手术治疗６例，５例生存５年以上，１例生存１年零４个月，死于肿瘤腹腔内广泛转移。结合文献对阑尾类癌的发病率、症状，好发部位，治疗、预后进行了讨论。本文认为对直径＜１．０ｃｍ的阑尾类癌行单纯阑尾切除，尽量切除阑尾系膜；对直径在１．０～２．０ｃｍ的癌肿，可行单纯阑尾切除，彻底切除阑尾系膜，直径＞１．５ｃｍ或已有浸润者，行回盲部或右半结肠切除；直径＞２．０ｃｍ或已有转移和类癌综合征者，行右半结肠切除。     

经括约肌或尾骨入路的直肠肿瘤局部切除术

本文报道９例低恶性或良性的直肠肿瘤行局部切除术的结果。其中广基无蒂绒毛状腺瘤６例，距肛缘４～９ｃｍ，肿瘤直径２．０～３．５ｃｍ；类癌２例．肿瘤距肛缘７ｃｍ，直径０．５～０．８ｃｍ；血管瘤１例，肿瘤距肛缘４ｃｍ，大小为２．５ｃｍ×５ｃｍ。经肛门前括约肌局部切除４例，经尾骨局部切除４例，经尾骨及括约肌局部切除１例。术后无肛门失禁及复发。作者认为经肛门括约肌或尾骨入路的肿瘤局部切除术对于距肛缘１０ｃｍ以下的直肠低恶性或良性肿瘤是较理想的手术方式。     

肾上腺偶发瘤的手术治疗(附47例报告)

目的：探讨肾上腺偶发瘤的手术治疗方式。方法：采用开放手术治疗肾上腺偶发瘤４４例，经腹腔镜手术治疗３例。结果：所有病例均完整切除肿瘤，肿瘤最大直径１．２￣１７．０ｃｍ，疗效满意。结论：对肾上腺偶发瘤，术前应常规行内分泌检查；对肿瘤直径〈６ｃｍ而影像学检查无粘连者，可作腹腔镜探查；对肿瘤直径〉６ｃｍ或术前怀疑为嗜铬细胞瘤者，或肿瘤与周围脏器有粘连者，以行开放手术为宜。     

Rectal carcinoid tumors--treatment and prognosis

Because of their location, rectal carcinoid tumors present a special therapeutic challenge for the surgeon. Only about 15% of these tumors manifest metastases and the others can be cured by complete local excision; hence performing a low anterior resection or an abdominoperineal resection for all patients would result in excessive rates of morbidity and death. Present-day treatment programs call for radical cancer resections only for lesions 2 cm in diameter or larger and local resection for all others. However, in a review of 595 patients, including 29 from the University of Chicago Hospitals, it was determined that this practice results in undertreatment of 24% (19/78) of all rectal carcinoid tumors that were associated with metastases, for 5% of all lesions smaller than 2 cm also had metastases. Invasion of the muscularis propria, we found, was an excellent additional prognostic sign for tumor progression. If the criteria for radical cancer resection included both size (all tumors 2 cm or larger and invasion of the muscularis propria in all smaller lesions, only 6% (5/78) of all aggressive tumors would have been missed and only 1.2% of all individuals with rectal carcinoid tumors would have received too limited an operation. It is hoped that the use of these new criteria will improve present-day survival statistics for patients with rectal carcinoid tumors.     

Treatment of rectal carcinoid tumors

We investigated the treatment of 24 rectal carcinoid tumors from both the clinicopathologic and prognostic viewpoints. All tumors less than 2 cm in diameter had neither muscle layer invasion nor lymph node metastasis, except for an atypical carcinoid tumor that had both lymphatic permeation and intramural metastasis. One typical carcinoid tumor larger than 2 cm had both several lymphatic permeations and urinary bladder invasion. All cases had a good prognosis with no recurrence and no new metastases. For rectal carcinoid tumors less than 2 cm in diameter, local resection is sufficient, whereas radical operation is required for tumors larger than 2 cm in diameter. For atypical rectal carcinoid tumors, radical operation should be considered even if the diameter is less than 2 cm.     

Preoperative radiotherapy improves survival for patients undergoing total mesorectal excision for stage T3 low rectal cancers

OBJECTIVE: To examine the effect of preoperative radiotherapy (PRT) on patients who undergo rectal resection with total mesorectal excision (TME) for stage T3 low rectal cancers. SUMMARY BACKGROUND DATA: Evidence for the value of PRT before rectal cancer surgery is weakened by variability in the use of TME. Many surgeons have concluded that PRT is unnecessary for small rectal tumors if TME is performed, but there are no prospective data to support this opinion. METHODS: Since 1980, 2,200 patients with rectal cancer have been enrolled in a prospective database. Of these, 259 underwent curative anterior or abdominoperineal resection with TME for pathologically confirmed T3 lesions within 8 cm of the anal verge. Patients were grouped by receiving PRT (n = 92) or not receiving PRT (n = 167). Five-year overall survival and 5-year local recurrence rates were evaluated. RESULTS: Overall survival was increased from 52% in patients not receiving PRT to 63% in those receiving PRT. PRT increased overall survival for node-negative patients from 58% to 82%, with no benefit for node-positive patients. There was no significant difference in local recurrence rates. When categorized by tumor size, there was no difference in overall survival or local recurrence for 0- to 2-cm tumors or those larger than 5 cm, but PRT increased overall survival from 50% to 72% for patients with 2- to 5-cm tumors. Similar results were observed for patients with tumors staged as T3 on preoperative endoluminal ultrasound. CONCLUSIONS: Patients with pT3 low rectal cancers undergoing resection with TME have an improved survival with PRT. The effect is most beneficial for patients with node-negative and 2- to 5-cm tumors, although this group may include larger and node-positive tumors that have been downstaged by PRT. PRT should be advocated for all patients with T3 rectal cancers less than 8 cm from the anal verge, even if the surgery includes a properly performed TME.     

Radical resections for T4 lung cancer

T4 lung cancers are a heterogeneous group of locally advanced lung cancers. Treatment is palliative for the majority of patients, ranging from supportive care to chemoradiotherapy. In certain patients, however, surgery is beneficial and may be curative. Patients with T4N0M0 cancers invading the distal trachea, carina, left atrium, aorta, superior vena cava, or vertebral bodies may be surgical candidates. Radical resections of these T4 lung cancers have potential for cure if no mediastinal lymph node metastases (N2 or N3) occur and if resection is complete. Increased postoperative mortality exists and extends beyond 30 days, as evidenced by a 30-day mortality of 8% and a 90-day mortality of 18%. Improved palliation (median survival of 19 months) and cure (31% five-year survival) are possible in patients who meet the criteria, who undergo radical resection, and who are followed by physicians in facilities with special interests in extended resections. The use of induction therapy and surgery in T4 patients may further increase survival and the number of T4 patients in whom radical resection is possible. Radical resections are contraindicated in patients with T4 lung cancers associated with malignant pleural effusions. Unfortunately, these patients have the worst prognosis. If surgical palliation is an option, only pulmonary resection with pleurectomy and not pleuropneumonectomy should be considered. In contrast, lung cancers with the best prognosis are those T4 tumors diagnosed because of a satellite tumor nodule within the same lobe. Because radical resections are usually not required, operative mortality is not increased. Five-year survival in patients with satellite intralobar tumor nodules without mediastinal nodal metastases is comparable to survival of highly selected T4N0M0 patients who undergo radical resection. These two extremes of T4 lung cancers, malignant pleural effusion and satellite intralobar tumor nodules, generally are not considered for or do not require radical resections. It is debatable that the definition of T4 should include these entities.     

Adenomas of the Ampulla of Vater: A comparison of Outcomes of Operative and Endoscopic Resections

Background

Data comparing operative and endoscopic resection of adenomas of the ampulla of Vater are limited. Our aims were to evaluate and compare the long-term results and outcomes of endoscopic and operative resections of benign tumors of the ampulla of Vater as well as to determine which features of benign periampullary neoplasms would predict recurrence or failure of endoscopic therapy and therefore need for operative treatment.

Methods

Retrospective review of all patients treated for adenomas of ampulla of Vater at our institution from 1994 to 2009.

Results

Over a 15-year span, 180 patients (mean age 59 years) were treated for benign adenomas of the ampulla of Vater with a mean follow-up of 4.4 years. Obstructive jaundice was more common in the operative resection group (p?=?0.006). The adenomas were tubular in 83 patients (44 %), tubulovillous in 77 (45 %) and villous in 20 (11 %). Endoscopic resection alone was performed in 130 patients (78 %). Operative resection was performed in 50 patients (28 %), with pancreatoduodenectomy in 40, transduodenal local resection in 9, and pancreas-sparing total duodenectomy in 1. Nine patients who underwent endoscopic resection initially were endoscopic treatment failures. Fifty-eight percent of endoscopically treated patients required one endoscopic resection, while 58 (42 %) required two or more endoscopic resections (range 2–8). Patients who underwent operative resection had larger tumors with a mean size of 3.7?±?2.8 versus 1.8?±?1.5 cm in those treated by endoscopic resection (p?p?=?0.02). Intraductal extension and ulceration had no effect on recurrence if completely resected endoscopically (p?=?0.41 and p?=?0.98, respectively). Postoperative complications occurred in 58 % of patients, and post-endoscopic complications in 29 % (p?p?=?0.006); 4 % of recurrences had invasive carcinomas. When comparing patients who underwent local resections only (endoscopic and operative), there was no difference in the recurrence rate between endoscopic resection and operative transduodenal resection (32 versus 33 %; p?=?0.49). The need for two or more endoscopic resections for complete tumor removal was associated with 13-fold greater risk of recurrence (p?Conclusion There is no significant difference between endoscopic and local operative resections of benign adenomas of ampulla of Vater; recurrences are more common when two or more endoscopic resections are required for complete tumor removal. Appropriate adenomas for endoscopic resection included tumors <3.6 cm that do not extend far enough intraductally (on EUS) to preclude an endoscopic snare ampullectomy.     

An analysis of survival and treatment failure following abdominoperineal and sphincter-saving resection in Dukes' B and C rectal carcinoma. A report of the NSABP clinical trials. National Surgical Adjuvant Breast and Bowel Project

Abdominoperineal resections for rectal carcinoma are being performed with decreasing frequency in favor of sphincter-saving resections. It remains, however, to be unequivocally demonstrated that sphincter preservation has not resulted in compromised local disease control, disease-free survival, and survival. Accordingly, it is the specific aim of this endeavor to compare local recurrence, disease-free survival, and survival in patients with Dukes' B and C rectal cancer undergoing curative abdominoperineal resection or sphincter-saving resection. For the purpose of this study, 232 patients undergoing abdominoperineal resection and 181 subjected to sphincter-saving resections were available for analysis from an NSABP randomized prospective clinical trial designed to ascertain the efficacy of adjuvant therapy in rectal carcinoma (protocol R-01). The mean time on study was 48 months. Analyses were carried out comparing the two operations according to Dukes' class, the number of positive nodes, and tumor size. The only significant differences in disease-free survival and survival were observed for the cohort characterized by greater than 4 positive nodes and were in favor of patients treated with sphincter-saving resections. A patient undergoing sphincter-saving resection was 0.62 times as likely to sustain a treatment failure as a similar patient undergoing abdominoperineal resection (p = 0.07) and 0.49 times as likely to die (p = 0.02). The inability to demonstrate an attenuated disease-free survival and survival for patients treated with sphincter-saving resection was in spite of an increased incidence of local recurrence (anastomotic and pelvic) observed for the latter operation when compared to abdominoperineal resection (13% vs. 5%). A similar analysis evaluating the length of margins of resection in patients undergoing sphincter-preserving operations indicated that treatment failure and survival were not significantly different in patients whose distal resection margins were less than 2 cm, 2-2.9 cm, or greater than or equal to 3 cm. If any trend was observed, it appeared that patients with smaller resection margins had a slightly prolonged survival (p = 0.10). This observation was present in spite of the fact that local recurrence as a first site of treatment failure was greater in the group with less than 2 cm that it was in the greater than or equal to 3 cm category, 22% versus 12%. This increased local recurrence rate in the population with smaller margins was not translated into an in crease in overall treatment failure and had absolutely no influence on survival. It is suggested that local recurrence serves as a marker of distant disease.(ABSTRACT TRUNCATED AT 400 WORDS)     

Anorectal carcinoid tumors. Is aggressive surgery warranted?

The management of large carcinoid tumors of the anorectum is controversial. Most carcinoid tumors of the rectum and anus are early lesions, adequately treated by local excision. However, because of their relative rarity, the number of advanced cases seen at most institutions is small. Forty-three patients with anorectal carcinoid tumors were treated at our institution between 1960 and 1988 with complete follow-up. The median age of onset was 56 years. Eleven patients had no symptoms and the tumor was detected incidentally in eight additional patients with other diseases. Twenty tumors were larger than 2 cm in diameter and all patients had symptoms. Eight patients had another malignancy and three patients had ulcerative colitis. An association between ulcerative colitis and rectal carcinoid tumors is not widely appreciated. Eighteen tumors were treated by local excision, 16 by radical surgery, and nine underwent only biopsy. With complete resection of the primary lesion, local recurrence was never a problem. The median survival from diagnosis was 38 months in this series and 23 patients died of disease. After detection of metastases, the median survival time was 10 months. Tumors more advanced that T2 or larger than 2 cm in diameter were always fatal. All 13 patients with involved lymph nodes died of metastatic disease, with a median survival of 10 months, although one lived 9 years. Advanced rectal carcinoid tumors are aggressive malignancies. Adequate local excision controls regional disease but rectal carcinoid tumors are cured only when they are discovered before the T3 stage, measure less than 2 cm in diameter, and when lymph nodes are not involved. Consequently if a local excision permits complete resection, radical extirpative surgery will provide little benefit.     

Indications for and limitations of low anterior resection

The indications for low anterior resection are based mainly on tumor location, penetration depth, histology, macroscopic appearance, etc. Patients with tumors located 2 cm above the puborectal muscle by digital examination can undergo low anterior resection. Distal surgical margins should be at least 1 cm from the tumor in cases of differentiated cancer and localized tumors of stage T2 or less and more than 2 cm in poorly differentiated cancer and tumors of stage T3 or greater with total mesorectal excision (TME). Longer distal surgical margins should be provided in patients with unlocalized tumors and extensive node metastasis. The final decision on whether low anterior resection is appropriate should be made after mesorectal preparation down to the levator muscles with adequate surgical margins. Low anterior resection is contraindicated in patients with poor anorectal function and high age. A rectal stump 1 to 2 cm from the dentate line should be maintained for better postoperative anorectal function if radical excision can still be performed.     

Intraoperative ultrasonography in surgery for liver tumors

Intraoperative ultrasonography was used in 37 patients during surgery for suspected liver tumors. The size, number, and site of the lesions were determined together with the relationship of the tumor to the intrahepatic vessel, as well as possible small daughter lesions within the liver. Final diagnosis in these patients was hepatocellular carcinoma in 19 cases, metastases from colorectal cancers in 15 cases, and benign lesions in three cases. Previously undetected small tumors were revealed in one patient with sigmoid cancer and in five patients with liver cell carcinoma who had cirrhosis. Vascular tumoral infiltrations were easily displayed and the surgical approach modified accordingly: a more extended resection was performed in two cases of huge central hepatic metastases. Intraoperative ultrasonography revealed seven cases of small (2 to 3 cm) hepatocellular carcinomas in cirrhotic livers that were not visible or palpable, thus allowing a subsegmentary resection. Finally, in three cases of atypical tumors, an intraoperative echo-guided biopsy specimen was required to establish the benign nature of lesions and resection was avoided. Intraoperative ultrasonography facilitates the diagnosis of small liver tumors and can also aid the surgeon in his choice of technique, especially in cases of cirrhosis of the liver. A resection can be avoided altogether when multiple lesions are involved, or echo-guided subsegmentary resections can be performed in cirrhotic livers when a less extended resection is required. This technique makes it possible to establish the relationship between the tumor and intrahepatic vessels, thus preventing vascular injury and making radical hepatic resection safer.     

Surgical resection of pulmonary metastases from colorectal adenocarcinoma. Special reference to repeated pulmonary resections

Pulmonary resection of metastatic lesions from colorectal adenocarcinoma was performed in 35 patients. The cumulative 5-year survival was 38%. The primary site of cancer was the colon in about half of the patients. Patients with a solitary metastasis or tumors smaller than 3 cm in diameter survived longer than did patients with multiple metastases or tumors larger than 3 cm but the differences were not significant. Other factors, including age, sex, histologic grade of tumor, location and stage of primary carcinoma, location of pulmonary metastases, disease-free interval, and type of pulmonary resection, had no apparent influence on survival time. The lung was the major site of recurrence following pulmonary resection. Seven patients underwent two or more pulmonary resections for metastasis from a colorectal carcinoma. At the time of last follow-up, four patients were alive and free of recurrent disease at 5, 34, 39, and 58 months after the second pulmonary resection. These data suggest that some patients will survive for a long time following pulmonary resection of colorectal metastases, and for highly selected patients, repeated pulmonary resection may further extend survival.