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.     

胃癌术前分期诊断的研究进展

目的介绍胃癌术前分期诊断常用检查方法的研究进展。方法收集近年来国内、外胃癌术前分期诊断常用检查方法的相关文献并进行分析。结果经腹超声、超声内镜、CT、MRI、PET及腹腔镜检查为胃癌术前分期诊断提供了客观依据,提高了胃癌术前分期诊断的准确性。结论各种检查技术的不断提高,有助于临床医生更好地判定胃癌术前分期,也有助于根据不同的分期实施不同的术式。     

Comparison of Laparoscopy and Laparotomy in Surgical Staging of Early-Stage Ovarian and Fallopian Tubal Cancer

Aim  To compare feasibility, accuracy, and safety of laparoscopy and laparotomy in surgical staging of early-stage ovarian and fallopian tubal cancer. Methods  Outcomes of patients with stage I ovarian and fallopian tubal cancer who underwent complete surgical staging at Asan Medical Center, Korea between 2004 and 2007 were retrospectively evaluated. Results  Nineteen patients were surgically staged through laparoscopy and 33 through laparotomy. There were no between-group differences in mean age, parity, body mass index, lymph nodes retrieved, or omentum specimen size, nor were there between-group differences in the percentage of patients who were postmenopausal, those referred for restaging, in the time interval to restaging, in those upstaged after surgery, or in those with intraoperative tumor rupture. The laparoscopy group had significantly shorter operating time (221 ± 83 min versus 275 ± 63 min, P = 0.012), less blood loss (240 ± 228 mL versus 568 ± 451 mL, P = 0.005), less transfusion requirement (5.3% versus 30.3%, P = 0.033), faster return of bowel movement (1.3 ± 0.7 days versus 3.6 ± 1.7 days. P < 0.001), and shorter postoperative hospital stay (8.9 ± 6.1 days versus 14.5 ± 5.6 days, P = 0.002) and time interval to adjuvant chemotherapy (12.8 ± 4.9 days versus 17.6 ± 8.3 days, P = 0.049). There were no postoperative complications requiring further management. After a median follow-up time of 17 months (range 1–44 months), there was no recurrence or death from disease in either group. Conclusion  Laparotomy and laparoscopy showed similar surgical staging adequacy and accuracy, and laparoscopy showed more favorable operative outcomes. Laparoscopy was safe for early-stage ovarian and fallopian tubal cancer, although follow-up time was relatively short. This paper was accepted for oral presentation at the focused plenary session of Society of Gynecologic Oncologist (SGO) 39th Annual Meeting to be held March 9–12, 2008 in Tampa, Florida, USA.     

Clinical Impact of Tumour Involvement of the Anastomotic Doughnut in Oesophagogastric Cancer Surgery

INTRODUCTION

Published colorectal cancer surgery data suggest no role for the analysis of the anastomotic doughnuts following anterior resection. The usefulness of routine histological analysis of the upper gastrointestinal doughnut is not clear. Our study assessed the impact of cancer involvement of the doughnut on clinical practice. Factors associated with doughnut involvement and the effect on patients'' survival were also analysed.

PATIENTS AND METHODS

The clinicopathological details of 462 patients who underwent potentially curative oesophagogastrectomy for cancer with a stapled anastomosis between 1994 and 2006 in two specialist centres were retrospectively analysed. Univariate, multivariate and survival analyses were carried out.

RESULTS

Approximately 5% of doughnuts (22 of 462) were histologically involved with cancer. Microscopic involvement of the proximal resection margin, local lymph node metastasis and lymphatic invasion within the main resected specimen were independently associated with doughnut involvement (all P < 0.05). However, these three factors taken together failed to predict doughnut involvement. Doughnut involvement was an independent adverse prognostic factor for overall survival (P = 0.0013).

CONCLUSIONS

In contrast to findings in colorectal surgery, doughnut involvement with cancer appears to have useful prognostic information following oesophagogastrectomy. Routine histological analysis of upper gastrointestinal doughnuts is justified. Doughnut involvement could potentially strengthen the indications for adjuvant therapy in the future.     

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。     

直肠腔内超声对直肠癌术前分期的临床价值

目的探讨直肠腔内超声(TRUS)对评估直肠癌术前分期的临床价值。方法对118例经肠镜活检病理证实为直肠癌患者行TRUS检查,观察肿块内部回声、肿瘤浸润肠壁深度及与周围组织器官的关系,根据TN分期标准进行术前分期,并与术后病理分期进行对照。结果 TRUS评估直肠癌T分期完全符合率为86.4%(102/118),T1~T4的敏感度分别为80.0%、82.3%、91.6%、83.9%和特异度分别为100.0%、90.4%、90.0%、98.8%;Kappa值为0.734,超声分期与病理分期高度一致(P0.05),对评估淋巴结转移的灵敏度为81.4%(79/97),特异度为71.4%(15/21)。结论 TRUS对评估直肠癌浸润深度及淋巴结转移等有较高的准确性,为治疗方案的选择提供可靠的参考信息。     

CT对膀胱癌局部分期的准确性及影响因素分析

目的：探讨CT对膀胱癌局部分期的准确性以及影响因素。方法：回顾性分析44例肿瘤直径大于1cm且CT、上无明显其他盆腔脏器侵犯的膀胱癌患者临床资料，对比CT的局部分期与手术后病理分期。结果：CT对膀胱癌局部分期总的准确率为43．2％，有52.3％患者存在过高分期。直径1～2cm或大于4cm肿瘤CT分期较直径2～4cm肿瘤更为准确；原位复发的肿瘤分期准确性低于初发或异位复发的肿瘤；移行细胞癌的分期水确件高于非移行细胞癌；有蒂的肿瘤分期准确性高于广基肿瘤。结论：CT对膀胱癌局部分期的作用有限，受到肿瘤大小、基底情况、复发位置以及肿瘤病理类型的影响。     

Diagnostic Laparoscopy for Primary and Secondary Liver Malignancies: Impact of Improved Imaging and Changed Criteria for Resection

Background Diagnostic laparoscopy (DL) combined with laparoscopic ultrasonography (LUS) has previously shown positive results as a staging modality for liver malignancies. Recent improvements in noninvasive diagnostic imaging techniques such as multiphasic spiral computed tomography, together with the policy that bilobar disease or the number of lesions is no longer considered an absolute exclusion criterion for curative resection, could reduce the additional value of DL. This study retrospectively analyzed the efficacy of DL combined with LUS for liver malignancies to assess the effect of improved imaging and changed criteria for resection.Methods All patients with primary or metachronous secondary liver malignancy eligible for resection in 1997 to 2002 were included.Results DL combined with LUS was performed in 84 consecutive patients (56 men and 28 women; mean age, 59 years) with primary (n = 33) or secondary (n = 51) liver malignancies. DL showed unresectability in 13 patients (39%) with primary malignancy. Exploratory laparotomy showed that an additional 5 (25%) of the remaining 20 patients had unresectable disease. DL showed unresectability in 5 patients (12%) with colorectal liver metastasis (n = 43). At laparotomy, another 7 (18%) of the remaining 38 patients had unresectable disease. In five patients (13%) from the latter group, LUS could not be performed because of adhesions from previous surgery.Conclusions DL combined with LUS is an adequate staging modality for primary liver malignancies. For colorectal liver metastasis, more liberal resection criteria, a high failure rate due to adhesions from previous surgery, and better preoperative imaging probably resulted in a lower efficacy.     

腹腔镜子宫内膜癌分期手术的临床效果观察

目的探讨腹腔镜子宫内膜癌分期手术的临床疗效及预后。方法 2005年1月～2011年3月243例子宫内膜癌行分期手术,其中腹腔镜分期手术75例,开腹分期手术168例,比较2组手术时间、术中出血量、并发症、术后胃肠功能恢复时间、术后住院时间、生存情况。结果腹腔镜组清扫淋巴结总数显著多于开腹组[(27.1±11.2)枚vs.(22.6±9.7)枚(t=3.182,P=0.002)];腹腔镜组术中出血量(315.1±108.0)ml显著少于开腹组(851.6±246.9)ml(t=-18.047,P=0.000);腹腔镜组排气时间(1.8±0.7)d显著早于开腹组(2.6±0.8)d(t=-7.475,P=0.000);腹腔镜组尿管拔除时间(8.5±5.3)d明显早于开腹组(12.5±6.0)d(t=-4.971,P=0.000);腹腔镜组术后住院时间(13.7±7.1)d与开腹组(14.9±6.5)d无统计学差异(t=-1.292,P=0.198);2组生存率和无瘤生存率无统计学差异(χ2=0.351,P=0.553;χ2=0.000,P=0.998)。结论腹腔镜子宫内膜癌分期手术的疗效与开腹手术相当,但腹腔镜手术淋巴结切除数量多,出血量少,排气时间短,更具微创价值。     

第8版国际抗癌联盟和美国癌症联合委员会胃癌TNM分期系统简介及解读

目前胃癌的TNM分期已经成为临床胃癌诊疗的首选参考依据。在国际抗癌联盟(UICC)、国际胃癌协会(IGCA)和美国癌症联合委员会(AJCC)的共同协作推动下,通过对全世界范围内胃癌大数据的收集与分析,于2016年10月颁布了第8版胃癌TNM分期系统。第8版TNM分期系统对食管-胃结合部及贲门癌分期标准的选择做出了明确的定义;同时还在单一分期系统的基础上新增了临床TNM分期(cTNM)和新辅助治疗后分期(ypTNM)。此外,新版的分期系统将N3的两个亚组N3a和N3b作为独立组别纳入到分期系统,还对组织学分级进行了一些调整。总的来说,相比第7版胃癌TNM分期系统,新版的分期系统可以指导临床医生更加合理地制定治疗方案,更加科学地评价治疗效果,更加准确地评估预后。然而,随着临床广泛应用和进一步验证,以及新的预测因子的发现,必将会有新的分期系统替代和完善旧的分期系统。     

Hand-Assisted Staging Laparoscopy for Suspected Malignancies of the Pancreas

Fewer than 20% of patients with pancreatic cancer have resectable tumours at the time of diagnosis. In two patients with a pancreas neoplasm a laparoscopic staging work-up was performed. Because of the described limitations of laparoscopy, we propose to switch to a hand-assisted procedure. In our opinion the benefits of hand-assisted laparo-scopic surgery, such as safe blunt digital dissection, restoration of tactile feedback and restored proprioception, account for greater accuracy in TNM staging and in the assessment of resectability of pancreatic cancer.     

Prognostic Significance of p53 and Ki67 Proteins Expression in Greek Gastric Cancer Patients

Aim: The variability of prognosis of gastric cancer (GC) within a pathological stage necessitates the identification of subgroups of patients with a more aggressive disease. The role of p53 and Ki67 expression in gastric carcinoma is far from being fully established. The aim of the present study was to evaluate the expression of p53 and Ki67 in gastric cancer and correlate the findings with several clinicopathological features and prognosis. Materials and methods: Tissue samples from 93 patients treated by gastric resection for gastric carcinoma between 1996 and 2001 were used. Formalin-fixed paraffin-embedded tumors were studied by immunohistochemistry, using monoclonal antibodies to p53 and Ki67. The results were correlated with clinicopathological features and survival. Results: Stronger expression of p53 was related with tumor size greater than 5 cm and advanced stage. Stronger expression of Ki67 correlated with higher ratio of the number of metastatic lymph nodes to the total number of dissected lymph nodes (metastatic lymph node [MLN] ratio) and advanced stage. Moreover, p53 and Ki67 overexpression, tumor size greater than 5 cm, MLN ratio, depth of invasion, lymph node metastasis, stage III and IV and infiltrative macroscopic appearance were adverse prognostic factors. The levels of p53 and Ki67, the MLN ratio, the tumor size (above 5 cm) and the stage of the disease were identified as independent prognostic factors of survival.

Conclusions: In gastric cancer, the expression of p53 and Ki67 provides significant information about prognosis. The routine evaluation of p53 and Ki67 levels could be a useful tool in identification of patient with more aggressive disease and contribute to a better therapeutic approach.     

制订2009第7版食管癌TNM分期标准

目的报告参与制订2009第7版食管癌国际TNM分期的国际协作研究结果。方法收集全世界13个协作单位的4628例食管癌单纯切除病例的资料，采用全新的统计学模型，综合各预后影响因素反向归纳至最合理的TNM分期。结果全组总的1、5、10年死亡率分别为78％、42％、31％。远期生存的主要影响因素为肿瘤侵犯深度、淋巴结转移数目、有无远处转移、肿瘤的组织学类型和分化程度。将其优化组合后新的TNM分期中T1应细化为T1a和T1b，T4应细化为T4a和T4b，N应当根据淋巴结的转移数目分级，M1的亚分级应当取消，且应加入肿瘤组织学类型（H）和分化程度（G）因素。结论2009第7版食管癌分期标准重新定义了T、N、M，并分期为0、Ⅰa、Ⅰb、Ⅱ、Ⅲa、Ⅲb、Ⅳ期，可更好地预测食管癌患者手术切除治疗的预后。     

Robotic-Laparoscopic Rectal Cancer Excision Versus Traditional Laparoscopy

Background and Objectives:

Robotic surgery has been advocated for the radical excision of rectal cancer. Most data supporting its use have been reported from European and Asian centers, with a paucity of data from the United States documenting clear advantages of the robotic technique. This study compares the short-term outcome of robotic versus laparoscopic surgery.

Methods:

Consecutive patients who underwent laparoscopic (group 1) or robotic (group 2) rectal cancer excision at a single institution over a 2-year period were retrospectively reviewed. The main outcome measures were operative time, blood loss, conversion rates, number of lymph nodes, margin positivity, length of hospital stay, complications, and readmission rates.

Results:

Forty-two patients were analyzed. The median operative time was shorter in group 1 than that in group 2 (240 minutes vs 260 minutes, P = .04). No difference was noted in blood loss, transfusion rates, intraoperative complications, or conversion rates. There was no difference in circumferential or distal margin positivity. The median length of stay was shorter in group 1 (5 days vs 6 days, P = .05). The 90-day complication rate was similar in both groups (33% vs 43%, P = .75), but there was a trend toward more anastomotic leaks in group 1 (14% vs 0%, P = .23). Similarly, a non–statistically significant trend toward a higher readmission rate was noted in group 1 (24% vs 5%, P = .18).

Conclusion:

Robotic rectal cancer excision yielded a longer operative time and hospital length of stay, although immediate oncologic results were comparable. The need for randomized data is critical to determine whether the added resource utilization in robotic surgery is justifiable.     

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。     

早期卵巢癌腹腔镜与开腹分期手术的对比分析

目的探讨腹腔镜早期卵巢癌分期手术的有效性和安全性。方法回顾性分析2006年5月～2009年7月期间手术治疗的早期卵巢癌44例,其中腹腔镜组19例,开腹组25例,比较2组手术时间、术中出血量、术后排气时间、术后并发症、淋巴结切除数量及术后住院时间。结果与开腹组相比,腹腔镜组术中出血显著减少[(161.1±97.7)mlvs(398.0±278.6)ml,t=-3.945,P=0.000],术后肛门排气时间显著缩短[(1.7±0.8)dvs(2.7±1.0)d,t=-3.389,P=0.002)。2组手术时间[(283.0±74.7)minvs(266.6±65.5)min]、术后住院时间[(13.4±4.9)dvs(13.2±6.6)d]、盆腔淋巴结切除率[84.2%(16/19)vs96.0%(24/25)]和数量(20.8±6.5vs20.7±13.8)、术后并发症发生率[10.5%(2/19)vs20.0%(5/25)]差异均无显著性(P0.05)。结论小样本量的临床研究提示,早期卵巢癌腹腔镜分期手术具有出血少、恢复快等优势,可作为早期卵巢癌手术治疗的新选择。但远期效果仍待探索。