复杂胸壁肿瘤的外科治疗

目的:总结复杂胸壁肿瘤的临床特点与外科治疗经验。方法:回顾性分析上海交通大学医学院附属新华医院心胸外科2011年1月至2015年12月期间行复杂胸壁肿瘤切除重建手术患者的临床病理学资料,对患者临床特点、诊治方法及随访结果进行分析研究。结果:共入组25例患者,其中男16例,女9例。对25例患者均行完整肿瘤切除、胸壁重建术。4例上腔静脉或头臂静脉受侵者行人工血管置换术,2例胸骨受侵者行部分或完全胸骨切除术,1例因上腔静脉内癌栓形成行体外循环辅助胸壁肿瘤切除。术后病理诊断:恶性19例,良性6例;骨肉瘤6例(其中1例体外循环下行肿瘤切除),胸腺癌3例(均行人工血管置换术),浆细胞瘤2例,孤立性胸膜纤维瘤2例,横纹肌肉瘤2例,神经母细胞瘤2例,神经纤维瘤2例,梭形细胞癌2例,纵膈恶性间皮瘤1例(血管置换),纵膈脉管瘤1例,纵膈慢性炎性病变1例(侵犯胸骨),胸骨去分化软骨肉瘤1例(侵犯胸骨)。结论:完整切除肿瘤、一期胸壁重建是复杂胸壁肿瘤治疗的主要治疗方法。对大血管侵犯患者行新辅助放化疗后行血管置管术,对癌栓形成者行体外循环辅助取栓,对巨大胸壁肿瘤患者行肿瘤切除后钛板胸壁重建,必要时辅以手术前后放化疗,有助于提高肿瘤切除率并改善患者预后。     

纵隔胸腺囊肿的诊断及外科治疗

目的:总结纵隔胸腺囊肿的诊断和外科治疗.方法:对我院纵隔胸腺囊肿患者的临床资料进行回顾性分析.结果:全组共25例患者,其中男性11例,女性14例,平均46.1岁.全组患者术前均行胸部正侧位片检查,其中20例患者行胸部CT检查,6例行MRI检查.所有患者均接受手术治疗,并均获得完整切除.其中常规手术17例,微创手术8例,微创手术患者较常规手术患者术后住院时间短.所有手术标本均经病理证实为胸腺囊肿.共发生手术相关并发症2例,随访2个月至7年,均朱见复发.结论:胸腺囊肿的临床诊断主要依据影像学检查,CT和MRI能明确肿块的囊性特征,大多数胸腺囊肿根据其囊性特征,术前即可作出正确诊断.纵隔胸腺囊肿一经诊断应该首选手术治疗,手术应根据肿物特点选择合理的手术方式,胸腔镜等微创技术适合于纵隔胸腺囊肿的治疗.     

脂肪母细胞瘤病的临床诊治分析(附10例报告)

脂肪母细胞瘤病是比较罕见的、复杂的软组织肿瘤,临床相对缺乏认识,为了探讨脂肪母细胞瘤病的临床特点、诊断和手术要点,提高诊疗水平,回顾性分析2006年1月~2015年12月我院住院治疗的脂肪母细胞瘤病患儿的临床资料,复习国内外的相关文献.共10例, 8例男性, 2例女性,肿物发现时年龄6个月~12岁,平均2岁3个月,位于颈肩部、纵隔、椎管、腹腔、阴囊、大腿等, 4例为颈部或颈肩部等浅表位置, 6例涉及纵膈、椎管等多重要部位.经统计, 10例患儿共接受手术20次, 6例接受多次手术. 10例患儿中5例手术难度大,联合肿瘤、骨科、神经外科等科手术, 1例接受颈肩部肿物切除后腹部和躯干、阴囊等处肿物后暂时保守治疗. 10例患儿本院病理均为脂肪母细胞瘤病, 3例复发病例的病理结果有成熟倾向.末次术后随访1年~8年5个月,平均4年3个月. 7例无临床症状, 1例术后3年在院外复发后压迫气管放弃治疗后死于呼吸衰竭, 2例下肢瘫或生长发育欠佳. 4例无复发, 5例原位复发, 1例异位复发,复发时间3个月~13个月,平均10个月,复发病例肿物生长缓慢.因此,本研究认为脂肪母细胞瘤病呈浸润性生长,病理趋于成熟,如完整切除困难,不宜为追求完整切除而损伤太大,可分期多次手术或者进行减瘤术.该病复发率较高,复发病例常是散发病例,特别是位于纵隔等易残留的位置.     

神经胶质瘤的治疗策略

神经胶质瘤是来源于神经上皮的肿瘤,是颅内最常见的恶性肿瘤,约占中枢神经系统肿瘤的40%~50%。主要分为星型细胞瘤、胶质母细胞瘤、少突胶质细胞瘤、髓母细胞瘤、室管膜瘤等。如何提高胶质瘤的治疗效果,提高病人的生命质量,仍是神经外科医生面临的巨大难题。     

神经胶质瘤的治疗策略

神经胶质瘤是来源于神经上皮的肿瘤,是颅内最常见的恶性肿瘤,约占中枢神经系统肿瘤的40%~50%。主要分为星型细胞瘤、胶质母细胞瘤、少突胶质细胞瘤、髓母细胞瘤、室管膜瘤等。如何提高胶质瘤的治疗效果,提高病人的生命质量,仍是神经外科医生面临的巨大难题。     

硬脊膜内外多发性神经鞘膜瘤7例诊治分析

目的:回顾分析硬脊膜内外多发性的神经鞘膜瘤的手术治疗疗效及注意事项.方法:我院2001-2011年间脊柱病区收治的椎管内肿瘤患者中,共发现7例硬脊膜内外多发性的神经鞘膜瘤.肿瘤发生部位:胸段3例,腰段2例,2例为胸段肿瘤位于硬膜内,腰段肿瘤位于硬膜外呈哑铃型向椎管外生长.临床表现为隐袭性、进行性双下肢麻木、无力、僵硬和不灵活,行走不稳等症状.治疗方法:全部手术肿瘤摘除,5例一期行硬膜内外同时摘除肿瘤,2例不同节段的肿瘤采取分期手术.结果:全部病例经1-9年随访,肿瘤未见复发.病理报告:均为神经鞘膜瘤.结论:临床上硬脊膜内外多发性的神经鞘膜瘤较少见,容易漏诊漏治.术前应注意详细查体,仔细阅片,术中注意切除硬膜外的肿瘤后,观察硬膜有无异常表现,手术是治疗该病的有效方法.     

儿童坏死性肺炎9例临床分析

为提高对坏死性肺炎临床表现的认识和诊治成功率,收集自2007年8月~2012年7月入住本院经肺组织病理确诊为坏死性肺炎的9例患儿资料,通过分析临床表现、影像学资料、病理和微生物学检查结果,并结合治疗经过和转归,讨论儿童坏死性肺炎的诱因、早期诊断与相关治疗手段。9例患儿（男6例、女3例）年龄1~7岁（平均3.5岁）,持续发热11~43 d（平均22 d）。4例接受机械通气治疗,5例病原学检查为阳性,8例计算机断层扫描（CT）提示肺内出现多发小空洞。9例患儿均存在肺实变伴胸腔积液,病理学诊断为大片肺坏死伴炎性浸润,进行外科手术介入治疗并存活,术后10个月CT提示肺结构恢复正常。结果表明,儿童坏死性肺炎常见病原菌为肺炎链球菌和肺炎支原体;胸部CT扫描结果需结合临床综合判断;坏死性肺炎患儿经积极抗感染及手术治疗预后良好。     

食管穿孔外科治疗22例临床分析

目的:探讨食管穿孔的诊断、临床特征与外科治疗方法.方法:回顾分析1999年-2009年我院收治的食管穿孔22例.结果:本组病例4例保守治疗,2例行颈部脓肿切开引流,8例行单纯食管穿孔修补术,3例行纵隔及胸腔脓肿清除术并引流,1例行食管下段切除、胃代食管弓上吻合术,2例行食管修补并肺叶切除,2例行空肠双管造瘘加纵隔胸腔引流,2例因经济原因放弃治疗出院.治愈19例,治愈率86.3%,死亡1例,死亡率4.5%.结论:早期诊断和及时采取正确的处理措施是提高本病治愈率,降低死亡率的关键.     

23例儿童霍奇金淋巴瘤临床分析(英文)

目的:分析儿童青少年霍奇金淋巴瘤(HL)患者的病理特征、临床表现及其预后影响因素。方法:收集青岛大学医学院附属医院血液儿科2001年5年至2013年8月收治的23例经病理确诊的儿童青少年HL患者的临床资料,采用Fisher确切概率法等进行各组间差异检验。结果:确诊病例共23例,中位年龄7.5岁,男:女发病比例=6.7:1,Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期分别占13.0%、26.2%、30.4%、30.4%;结节性淋巴细胞为主型(NLPHL)1例(4.3%),经典型HL22例(95.7%):混合细胞型(MC)10例(43.5%),淋巴细胞为主型(LP)11例(47.9%),结节硬化型(NS)1例(4.3%);受累部位以颈部淋巴结最多见,其次依次为纵隔、腹腔及腹膜后、脾、骨骼、肺组织等,其中巨大纵隔肿块者2例;具有B症状者8例(34.7%)。化疗2个疗程评估总有效率为100%,完全缓解(CR)率69.6%,部分缓解(PR)率30.4%。Ⅰ期和Ⅱ期患者CR率100%,明显高于Ⅲ期和Ⅳ期患者(50%),P0.05;23例患者7例复发,复发率Ⅲ期和Ⅳ期患者为46.2%,Ⅰ期和Ⅱ期患者为11.1%,前者高于后者(P=0.0098);有B症状与无B症状患者之间复发率有显著统计学差异(P=0.019);2例有巨大包块患者皆复发;各病理分型与疾病的复发间差异无统计学意义(x2=2.695,P0.05)。结论:儿童霍奇金淋巴瘤预后相对较好,但Ⅲ期和Ⅳ期、合并B症状及大肿块或大纵隔肿瘤的患者复发率高,应依据疾病危险度分层治疗,以期更好的预后。     

胸腔镜肺楔形切除术与胸腔镜肺叶切除加纵隔淋巴结清扫术治疗早期非小细胞肺癌患者的临床效果比较

目的:对比分析胸腔镜肺楔形切除术与胸腔镜肺叶切除加纵隔淋巴结清扫术治疗早期非小细胞肺癌患者的临床效果。方法:选择2012年1月～2016年12月我院心胸外科收治的70例早期非小细胞肺癌患者,将其随机分为两组。对照组采取胸腔镜肺叶切除加纵隔淋巴结清扫术治疗,观察组采取胸腔镜肺楔形切除术治疗。比较两组的手术情况、术后情况、预后情况以及生存情况。结果:观察组的术中出血量以及手术时间明显短于对照组(P0.05),术后总引流量、留置引流管时间、术后住院时间以及VAS疼痛评分均明显低于对照组(P0.05)。观察组术后1年的手术切缘转移率为0.00%(0/35),死亡率为11.43%(4/35),均明显低于对照组(P0.05)。两组的局部复发率、复发率、胸腔内转移率、淋巴结转移率、远处转移率、肿瘤相关性死亡率相比无明显的差异(P0.05)。对照组患者的无病进展生存期为8.24个月(95%CI:9.34～6.27),中位生存期为15.29个月(95%CI:12.14～21.78);观察组患者的无疾病进展生存期为11.26个月(95%CI:9.37～14.35),中位生存期为18.13个月(95%CI:15.24～22.36),均明显长于对照组(P0.05)。结论:胸腔镜肺楔形切除术治疗早期非小细胞肺癌患者的临床效果明显优于胸腔镜肺叶切除加纵隔淋巴结清扫术治疗。     

经皮穿刺椎弓根椎体成形术治疗胸腰椎椎体转移肿瘤的临床疗效

目的:进一步探讨经皮穿刺椎弓根途径椎体成形术与传统保守治疗方法的临床比较差异,从而为临床相关实践提供借鉴和参考依据。方法:2014年12月至2015年5月医院临床收治的胸腰椎椎体转移肿瘤患者共计88例,根据治疗方法分成研究组(经皮穿刺椎弓根途径椎体成形术组)和对照组(传统保守治疗方法组),每组患者44例。观察和比较两组患者实施不同治疗后的临床满意度。结果:研究组患者手术1d、1个月、3个月、6个月和1年后的临床满意度均显著的高于对照组,且组间比较差异均有统计学意义(P0.05)。结论:经皮穿刺椎弓根途径椎体成形术治疗胸腰椎椎体转移肿瘤的临床综合效果显著,与传统保守治疗方法相比较可有效改善和提高患者的生活质量。     

胸部肿瘤患者放疗中肺功能指标的变化及放射性肺炎的影响因素分析

目的:研究胸部肿瘤患者放疗中肺功能指标的变化并分析放射性肺炎的影响因素。方法:将2018年3月至2019年3月于我院接受放疗的胸部肿瘤患者100例记为观察对象,按照是否发生放射性肺炎分为肺炎组28例与无肺炎组72例。分别比较两组的临床资料、放疗前后肺功能及放疗参数,并采用多因素Logistic回归分析放射性肺炎的影响因素。结果:放疗后两组第1秒用力呼气容积(FEV_1)、FEV_1/用力肺活量(FVC)、一氧化碳弥散量(DLCO)均高于放疗前,且肺炎组放疗前、后FEV_1、FEV_1/FVC、DLCO均低于无肺炎组(均P0.05)。两组年龄、肿瘤类型、化疗史、美国东部肿瘤合作组(ECOG)评分、放疗靶区比较差异有统计学意义(均P0.05)。肺炎组计划靶区(PTV)、受到一定剂量以上照射的肺体积占全肺总体积的百分数(V_(dose))、平均肺计量(MLD)、正常组织并发症概率(NTCP)、总射野数高于无肺炎组(均P0.05)。经多因素Logistic回归分析可得:胸部肿瘤放疗患者放射性肺炎的独立危险因素有肺癌、化疗史、ECOG评分为2分、放疗靶区以肺野为主、PTV、MLD、V_(dose)、NTCP、总射野数、FEV_1、FEV_1/FVC(均P0.05)。结论:放疗可有效改善胸部肿瘤患者的肺功能,其中肺癌、化疗史、ECOG评分为2分、放疗靶区以肺野为主以及PTV、MLD、V_(dose)、NTCP、总射野数、FEV_1、FEV_1/FVC是放射性肺炎的影响因素。     

Fine needle aspiration cytology of a skeletal metastasis of adult Wilms' tumor. A case report

BACKGROUND: Nephroblastoma (Wilms' tumor) is the most common malignant tumor of the kidney in children but is rare in adults. The stage and histopathology of the tumor are the most important prognostic indicators. The common sites of metastasis are lung, liver and lymph nodes. Skeletal metastasis is exceedingly rare in both pediatric and adult nephroblastoma. We report an unusual case of a skeletal metastasis of adult nephroblastoma that developed nine years after the diagnosis of a typical nephroblastoma of favorable histology and that was diagnosed by computed tomography (CT)-guided fine needle aspiration cytology. CASE: Following a right radical nephrectomy for adult nephroblastoma and two local recurrences two and three years later, a 74-year-old woman presented with low back pain. CT and magnetic resonance imaging revealed lytic lesions in the 10th and 12th thoracic vertebrae. Smears prepared from specimens obtained through CT-guided fine needle aspiration biopsy were moderately cellular, with small, round cells arranged singly and in loosely cohesive clusters. These cells had inconspicuous nucleoli and scanty to moderate amounts of cytoplasm. The cells were also positive for cytokeratin and vimentin and appeared similar to areas of blastema in the original tumor. CONCLUSION: A definitive diagnosis of metastatic adult nephroblastoma in thoracic vertebrae was made possible by CT-guided fine needle aspiration cytology in conjunction with clinical and radiologic findings and by using ancillary modalities, such as immunohistochemical studies.     

The contribution of the cerebellum to mental and social functions in developmental age

Here are present the data concerning the intellectual, language and frontal performances of 24 children who had undergone surgery because of cerebellar hemispheric or vermis tumors and one girl with viral cerebellitis. The children with right cerebellar tumors presented auditory sequential memory and language processing disturbances; those with left cerebellar tumors showed deficits in spatial tests and visual sequential memory. The girl with cerebellitis showed a complex neuropsychological picture with impairment in processing language and in general sequential functions. Lesions of the vermis lead to two pictures: 1) a postsurgical mutism that could be subdivided into speech disorders (even to the extent of anarthria) and true language disturbances similar to frontal aphasia; and 2) behavioral disturbances ranging from irritability to a truly autistic response. These data seem to support the recently attributed role of the cerebellum as a modulator of the superior mental and social functions.     

Observations on the effect of radiotherapy,followed by injection of pig lymph node cells,in reducing the number of pulmonary tumors induced by intravenous injection of tumor cells into isogenic mice

Summary Pulmonary tumors were produced in A. strain mice by intravenous injection of A. strain mammary carcinoma cells. The mesenteric lymph nodes of pigs were immunized by implantation of fragments from the same tumors into the pig mesentery.Tumor-immune pig lymph node cells when injected IV 7 days after tumor cells did not reduce the number of tumors, counted on day 14. However, when preceded by 200 rad thoracic irradiation on day 3 (which increased the number of pig cells settling in the lungs) tumor-immune cells given IV reduced the number of tumors compared with the effect of irradiation alone, or in combination with nonimmune pig cells.When tumor-immune pig cells were injected IP on day 7 (following thoracic irradiation on day 3), no antitumor effect was observed. Thus immediate pig cell/tumor cell contact is important in order to obtain an antitumor effect.Pig cells immunized against a human bladder carcinoma did not reduce pulmonary tumor formation by one of the mouse tumors.     

The contribution of the cerebellum to mental and social functions in developmental age

Here we present the data concerning the intellectual, language, and frontal performances of 24 children who have undergone surgery because of cerebellar hemisphere or vermis tumors and one girl with viral cerebellitis. The children with right cerebellar tumors presented auditory sequential memory and language processing disturbances; those with left cerebellar tumors showed deficits in spatial tests and visual sequential memory. The girl with cerebellitis showed a complex neuropsychological picture with impairment in processing language and general sequential functions. Lesions of the vermis lead to two pictures: (1) a postsurgical mutism that could be subdivided into speech disorders (even to the extent of anarthria) and true language disturbances similar to frontal aphasia and (2) behavioral disturbances ranging from irritability to a truly autistic response. These data seem to support the recently attributed role of the cerebellum as a modulator of the superior mental and social functions.     

Malignant tumors during the first 2 decades of life in the offspring of atomic bomb survivors.

The risk of cancer (incidence) prior to age 20 years has been determined for children born to atomic bomb survivors and to a suitable comparison group. Tumor ascertainment was through death certificates and the tumor registries maintained in Hiroshima and Nagasaki. The rationale for the study stemmed from the evidence that a significant proportion of such childhood tumors as retinoblastoma and Wilms tumor arise on the basis of a mutant gene inherited from one parent plus a second somatic cell mutation involving the allele of this gene. Gonadal radiation doses were calculated by the recently established DS86 system, supplemented by an ad hoc system for those children for one or both of whose parents a DS86 dose could not be computed but for whom an ad hoc dose could be developed on the basis of the available information. The total data set consisted of (1) a cohort of 31,150 live-born children one or both of whose parents received greater than 0.01 Sv of radiation at the time of the atomic bombings (average conjoint gonad exposure 0.43 Sv) and (2) two suitable comparison groups totaling 41,066 children. Altogether, 43 malignant tumors were ascertained in the children of exposed parents, and 49 malignant tumors were ascertained in the two control groups. A multiple linear regression analysis revealed no increase in malignancy in the children of exposed parents. However, examination of the data suggested that only 3.0-5.0% of the tumors of childhood that were observed in the comparison groups are associated with an inherited genetic predisposition that would be expected to exhibit an altered frequency if the parental mutation rate were increased. There is thus far no confirmation of the positive findings that Nomura found in a mouse system.     

A massive dose of allogeneic platelet gel for wound hemostatic therapy on patients with giant thoracic aortic aneurysm: report of 2 cases

Autologous platelet-rich plasma (PRP) or platelet gel (PG) has been widely used in clinical treatment. Allogeneic PRP or PG may also become a safe and effective alternative method. In this study, two cases with giant thoracic aortic aneurysm were reported where massive doses of allogeneic PG were used to spray the thoracic aortic aneurysm wall suture wrapped in artificial blood vessels, tumors blood vessel wall anastomotic site, and incision site of surgical operation. The volumes of 220 mL and 250 mL PG were applied on two patients respectively, to clot bleeding and decrease the mediastinal and pericardial drainage days after operation. The drainage tubes were pulled out on the 4^th day after operation. The patients were transferred from ICU to a cardiothoracic surgery ward on the 4^th and 5^th day respectively. This study suggests that allogeneic platelet concentrate, as a source of PRP to prepare PG, may be used to promote and help the clotting and wound healing on surgical operation.     

PBL 与LBL 教学法在胸外科临床教学中的对比研究

目的:对比研究以问题为中心教学法(PBL)与基于课堂的学习(LBL)即传统教学法在胸外科临床教学中教学的效果.方法:随机抽取临床专业学生100名,随机分为LBL教学组及LBL教学组各50人.在学习结束时,采用闭卷考试的形式进行成绩考核;同时采用不记名问卷调查,进行两种教学效果和教学模式的评价.结果:共纳入99例学生,分析显示PBL教学法与LBL教学法对医学生相关知识的掌握有影响.PBL教学法的教学模式在理论成绩与实践考核等方面优于传统教学法.结论:采用PBL教学法有助于提高学生的自主临床思维、提高学生的学习积极性,最终可以有效提高学习效果.     

Differential characteristics of the thoracic and abdominal mammary glands from mice

The anatomical and physiological characteristics of thoracic and abdominal mammary glands were investigated in order to understand why the incidence of mammary tumors is higher in the former. Epithelium in explants from both sets of glands required DNA synthesis, insulin, cortisol, and prolactin for full differentiation as measured by alpha-lactalbumin accumulation. The temporal pattern and magnitude of response were the same with respect to both DNA synthesis and differentiation; however, the epithelium in explants from the thoracic glands required concentrations of hormones for alpha-lactalbumin accumulation only one-half to one-third those from abdominal glands. Tumor distribution did not appear to correlate with mammary gland histology, size, or epithelial content.