高级别宫颈鳞状上皮内病变治疗后病灶残留、复发及妊娠

摘要：高度宫颈鳞状上皮内病变（HSIL）是宫颈癌前病变。未接受治疗的HSIL约17%的概率可进展为浸润癌。因此,准确规范地处理宫颈病变,特别是HSIL是预防宫颈癌的重要手段。ASCCP推荐冷刀锥切术（CKC）和宫颈环形电切（LEEP）为主要诊疗手段。然而部分患者接受治疗后仍存在病灶残留、复发及进展的风险。目前各研究报道HSIL治疗后发生病灶残留、复发及进展的差异较大,且术后病灶残留、复发的危险因素、术后随访方式尚无定论。本文旨在综述HSIL治疗后病灶残留及复发危险因素、处理、随访及妊娠相关问题,从而临指导临床治疗。     

Hospital Revenue,Cost, and Contribution Margin in Inpatient Versus Outpatient Primary Total Joint Arthroplasty

BackgroundRemoval of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty.MethodsWe reviewed all patients who underwent TKA or THA after these procedures were removed from the inpatient-only list. Patients were statistical significance into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-squared tests.ResultsAmong Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (P < .001), although there was no statistical significance difference between cohorts for TKA (P = .501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (P < .001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (P < .001).ConclusionOur analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at a risk of losing access to care.Level III EvidenceRetrospective Cohort Study.     

Surgical margin status after radical retropubic prostatectomy

This month there are two mini-reviews on aspects of prostate cancer. The first, from the USA, presents the implications of surgical margin status after radical prostatectomy and the potential role of adjuvant radiation therapy. The second, from the USA and Belgium, discusses the use of hormonal therapy for PSA-only recurrence of prostate cancer after previous local therapy. In the third mini-review, the condition known as hypoactive sexual desire disorder is described, and that it is often ignored or erroneously treated as erectile dysfunction suggests to the authors that education of doctors and patients is required. Finally, there is a mini-review of conventional and alternative methods for providing analgesia in renal colic.     

喉癌手术切缘中P53、Bcl-2、Survivin的表达与预后关系

[目的]研究P53、Bcl-2、Survivin在喉鳞状细胞癌手术切缘的表达与预后关系。[方法]116例术后患者按肿瘤复发情况分成4组,分别为复发﹤1年,≥1﹤3年,≥3﹤5年,≥5年组(包括5年后无复发),应用免疫组织化学方法检测各组喉癌手术切缘的P53、Bcl-2、Survivin表达情况。[结果]在复发﹤1年,≥1﹤3年,≥3﹤5年,≥5年4个组中P53的表达分别是57.1%,37.5%,45.8%,18.4%(P﹤0.05);Bcl-2的表达分别是71.4%,42.5%,20.8%和13.2%(P﹤0.01);Survivin在4组中的表达分别是92.9%,85%,50%,21.1%(P﹤0.01)。Bcl-2与P53在喉癌切缘中表达有负相关(rs=-0.262,P﹤0.01);Bcl-2和Survivin表达有正相关性(rs=0.272,P﹤0.01)。[结论]喉癌手术切缘中P53、Bcl-2、Survivin的表达在喉鳞状细胞癌的发生、发展中可能起重要作用,并对喉鳞状细胞癌的早期诊断、预后判断有意义。     

全脊椎整块切除术--一种治疗原发性恶性脊柱肿瘤的新手术方法

[目的]介绍一种整体切除脊柱原发性恶性肿瘤并使肿瘤治愈成为可能的新手术技术“全脊椎整块切除术”。背景资料：传统切除脊柱原发性恶性肿瘤的方法,是从肿瘤病灶内分块进行逐步切除。而经组织病理学证实,手术切缘较宽或较窄的病灶外整块切除的报告却鲜为有之。[方法]全脊椎整块切除术是在前路椎间支撑器植入,后路脊柱器械固定的情况下进行整块椎板切除和整块椎体切除的新手术技术。有5例息有原发性恶性肿瘤的患者及2侧患有巨细胞瘤的患者施行了这种手术。除l例患者在术后7个月时因肿瘤转移到纵隔而死亡外,其余所有患者的观察期为2～6．5a。[结果]除1例病人之外的所有患者在手术之后均获得了满意的临床效果,并且没有严重的并发症发生。经组织学研究证实,除椎弓根外,均获得了较宽或较窄的手术边缘,但在病变影响到椎管和脊柱的后方时,则需采用病灶内切除的传统方式。1例死于肿瘤转移的患者,其死亡原因与手术没有直接的相关性,且肿瘤切除的部位也没有局部复发的迹象。[结论]全脊椎整块切除术的优势在于,它是将整个椎体分两次予以完全切除,也就是一次切除椎体的一半,这种技术远胜于分块逐步切除的模式,并且是一次性完成整个手术的全过程。“全脊椎整块切除术”为脊柱原发性恶性肿瘤的治疗提供了一个更具有挑战性的手术方法。     

胃切除方式对胃中部癌患者预后的影响

目的探讨胃切除方式对胃中部癌患者预后的影响。方法回顾性分析1998年1月至2005年12月间福建医科大学附属协和医院收治的222例胃中部癌患者的临床资料,其中行开腹远端胃大部切除术66例（DG组）,行开腹全胃切除术患者156例（TG组）,比较两组患者术后5年的生存率。结果DG组和TG组术后5年生存率分别为63．9％和49．8％,差异具有统计学意义（P〈0．05）。但相比之下,TG组患者肿瘤更大、分期更晚、肿瘤位于小弯侧者居多（均P〈0．01）。按TNM分期进行分层预后分析显示,相同病期的两组患者术后5年生存率的差异均无统计学意义（均P〉0．05）。无论是以4cm、5cm还是6cm作为近切缘截点,不同近切缘距离患者5年生存率的差异均无统计学意义（均P〉0．05）。多因素预后分析显示,浸润深度、淋巴结转移和TNM分期是独立预后影响因素（均P〈0．05）;而胃切除方式并不是独立预后因素（P〉0．05）。结论胃中部癌患者如果能够达到根治手术的要求,其预后不受胃切除方式的影响,行远端胃大部切除术是可行的。     

舌鳞状细胞癌安全切缘宽度的定量研究

目的:分析舌鳞癌的扩散距离与相关病理参数间的关系,为临床上对不同个体舌鳞癌的安全切缘宽度的确定提供理论依据。方法:将30例舌鳞癌标本行定位及固定后,按冠状位每隔3mm作连续切片,常规HE染色。运用Photoshop软件对切片图像进行锐化处理,确定肿瘤边缘,测量扩散距离,按相关病理参数分组进行统计学分析。结果:病理Ⅰ级与Ⅱ、Ⅲ级的2组舌鳞癌的扩散距离之间无显著性差异(P>0.05);T1、T2与T3、T4的2组舌鳞癌的扩散距离之间无显著性差异(P>0.05)。肿瘤厚度小于5mm及大于5mm的2组舌鳞癌的扩散距离之间有显著性差异(P<0.05);小于5mm的扩散距离在4mm以内,大于5mm的扩散距离在9.5mm以内。浸润方式为Ⅰ型与Ⅱ型及Ⅲ、Ⅳ型的3组舌鳞癌的扩散距离之间有显著性差异(P<0.05);Ⅰ型的扩散距离在2.5mm以内,Ⅱ型的扩散距离在7mm以内,Ⅲ、Ⅳ型的扩散距离在9.5mm以内。结论:舌鳞癌的扩散距离与肿瘤的T分期及病理分级无明显关系;舌鳞癌的厚度与肿瘤扩散距离关系密切;同时发现肿瘤的浸润方式与肿瘤扩散距离关系密切,对不同个体舌鳞癌安全切缘宽度的确定具有临床意义。     

A uniform residual tumor (R) classification

BACKGROUND:

Since the introduction of the TNM residual tumor (R) classification, the involvement of resection margins has been defined either as a microscopic (R1) or a macroscopic (R2) demonstration of tumor directly at the resection margin (“tumor transected”).

METHODS:

The recognition of the importance of the circumferential resection margin (CRM) in patients with rectal cancer patients raises the need for an alternative definition of resection margin involvement, namely, the importance of delineating tumor with a minimal distance from the CRM of ≤1 mm (CRM‐positive) from tumor directly at the resection margin. The different use of both definitions of resection margin involvement prevents valid comparisons between reports on treatment results.

RESULTS:

To avoid confusion by different definitions, the authors proposed including the minimal distance between tumor and resection margin into the current R classification.

CONCLUSIONS:

By using the proposed expanded classification, comparisons of new data with previous publications will be possible. Cancer 2009. © 2009 American Cancer Society.     

眼睑整复手术中的睑缘再造

目的研究眼睑整复手术中睑缘再造的重要性及睑缘再造的手术方式。方法22例(22眼),分别采用不包括睑缘重建和包括睑缘重建的方式进行眼睑整复手术。结果眼睑整复时未进行睑缘再造者,多出现重建区皮肤面内卷进入结膜面,较少出现在重建区结膜面外卷进入皮肤面的情况。均有不等的角膜刺激症状,严重者角膜上皮损伤,形成角膜新生血管。眼睑整复同时进行睑缘再造者,术后睑缘逐步恢复平滑外观,未出现以上异常表现。结论睑缘重建是眼睑整复手术的重要组成部分。     

Histological features of early hepatocellular carcinomas and their developmental process: for daily practical clinical application Hepatocellular carcinoma

Based on clinical and pathological experience, indistinct margin-type hepatocellular carcinomas (HCCs) were considered to be typical early-stage HCCs with good prognosis. For histological diagnosis, the assessment of stromal invasion (tumor invasion into portal tracts and fibrous septa) is very important. In differentiating stromal invasion from pseudoinvasion (benign hepatic tissue in the fibrous stroma), the following 5 items are useful: (1) macroscopic or panoramic views of the histological specimen, (2) amount of fibrous components of the stroma, (3) destruction of the structure of portal tracts, (4) loss of reticulin fibers around cancer cells, and (5) cytokeratin 7 immunostaining for ductular proliferation. Parenchymal features of early HCCs are summarized as follows: (1) thin trabecular structure, (2) hypercellularity, (3) hyperstainability of cytoplasm, and (4) microacinar formation. Detailed understanding of the total biopsy procedure and various difficult lesions is necessary for a correct biopsy diagnosis. Evaluation of noncancerous tissue is also required to attain a better understanding of the developmental process and clinical stages of HCCs.