食管癌大体肿瘤靶区的体积分级与病理T分期的关系

目的 拟定出食管癌大体肿瘤靶区(GTV)的体积分级界限值,为非手术治疗食管癌的临床分期提供依据.方法 将607例行根治性切除术的胸段食管癌患者的术前CT图像传输到三维适形放疗计划系统中,勾画出食管病变局部的GTV,并计算GTV的体积大小.比较术后不同病理T分期时GTV体积的差异,分析GTV体积与病理T分期的关系及其对预后的影响.以各病理T分期的GTV体积中位值为依据,并考虑生存曲线的分离程度,筛选出合适的GTV体积分级界限值.结果 食管癌GTV的长度、最大直径和体积均与术后病理T分期呈正相关(均P<0.001).除术后病理T3期与T4期的GTV长度、最大直径和体积差异未见统计学意义外,其他各病理T分期的上述指标间的差异均有统计学意义(均P<0.001).以术后不同病理T分期的GTV体积中位值为依据,将食管癌GTV体积分为3级,即≤5.0 cm3、5.1～13.0 cm3和>13.0 cm3,与病理T1、T2、T3～4期的符合率达73.8%,两者的一致性较好(Kappa=0.40).GTV体积1、2、3级患者的术后5年生存率分别为78.1%、31.5%和33.5%(P<0.0001).综合考虑预后情况后,将食管癌GTV体积分为4级,即≤5.0cm3、5.1～13.0 cm3、13.1-39.0 cm3和>39.0 cm3,与术后病理T分期的符合率仅为54.7%,GTV体积四分级与术后病理T分期间的一致性较差(Kappa=0.24).GTV体积1、2、3、4级患者的术后5年生存率分别为78.1%、31.5%、36.2%和27.5%(P<0.0001).结论 食管癌GTV长度、最大直径和体积均与术后病理T分期呈正相关关系,GTV体积的三分级标准与术后病理T分期的一致性较好.     

食管癌淋巴结转移术前CT扫描与术后病理诊断一致性研究

目的 探讨食管癌术前CT扫描诊断淋巴结转移与术后病理结果的一致性,为食管癌放疗靶区勾画提供参考标准.方法 回顾分析本院接受食管癌根治性切除术的618例患者,术前均未行放化疗,术后病理资料完整.均于术前1周在本院行颈、胸、腹部CT检查,将CT图像经网络以数字化形式传输到三维治疗计划系统,并经三维重建成像.观察测量并记录CT诊断淋巴结转移的敏感性、特异性、准确率,与术后病理诊断一致率比较行x2检验或Fisdher's精确法.结果 全组淋巴结转移率为39.2%,下颈及锁上区、上纵隔、中纵隔、下纵隔及上腹区的转移率胸上段分别为3.2%、20.8%、6.4%、2.4%、8.0%,胸中段分别为1.5%、7.8%、22.0%、3.5%、22.8%,胸下段分别为0%、2.0%、21.4%、6.1%、32.7%.术前CT对食管癌淋巴结转移诊断的敏感性、特异性、准确率分别为58.3%、70.7%、65.9%.全组CT诊断0、1、2、≥3个淋巴结转移与术后病理证实转移的一致率分别为72.4%、32.2%、58.3%、73.1%(x2=82.61,P=0.000).胸上段癌中CT诊断无淋巴结转移与术后病理证实的一致率高于1个淋巴结转移与术后病理证实的一致率(85.8%∶36.8%,P=0.000);胸中段癌中CT诊断0、1、2、≥3个淋巴结转移与术后病理的一致率分别为71.1%、30.1%、55.6%、77.8%(x2=55.14,P=0.000).结论 术前CT扫描尚能比较准确地反映食管癌淋巴结转移的分布规律,尤其诊断无淋巴结转移和3个以上淋巴结转移时与术后病理的一致率最高,而诊断1个淋巴结转移时与术后病理的一致率最低,为根治性切除术后放疗的靶区勾画提供一定参考.

Abstract：

Objective To analyze the rule of lymph node metastasis, compare the preoperative computed tomographic findings with pathological diagnosis in thoracic esophageal carcinoma and to evaluate the clinical value. Methods Six hundred and eighteen patients with esophageal carcinoma after radical resection were enrolled. All patients did not receive any preoperative radiotherapy or chemotherapy, having complete information of postoperative pathological reports. CT scanning were applied to all patients in our hospital. The CT image were transmitted to the three-dimensional treatment planning system via the network at digital format and be reconstructed. In which system the sensitivity, specificity and accuracy rates in diagnosis of lymph node metastasis of the preoperative CT image were observed, measured and recorded. x2 test or Fisdher's statistical methods was adopted for comparing the concord rate of preoperative CT scanning with postoperative pathological diagnosis. Results Lymph nodes metastasis were defected in 242 of the 618 treated patients(39.2%), The rate of lymph node metastasis present in lower neck, upper-mediastinum,middle-mediastinum, lower-mediastinum, and superior abdomen regions in upper-thoracic esophageal carcinoma were 3.2% ,20.8% ,6.4% ,2.4% and 8.0%, in middle-thoracic esophageal carcinoma 1.5%,7.8% ,22.0% ,3.5% and 22.8%, and in lower-thoracic esophageal carcinoma 0% ,2.0% ,21.4% ,6.1% and 32.7%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value,younden index and accuracy rates of diagnosis of lymph node metastasis with preoperative CT scan were 58.3%, 70.7%, 56.2%, 72.5%, 29.0% and 65.9%, respectively. The concordance rate of 0, 1, 2 and ≥ 3 lymph node metastasis by preoperative CT scanning with postoperative pathological diagnosis were 72.4%, 32.2% , 58.3% and 73.1%, respectively in whole group(x2 = 82. 61, P = 0.000). The concordance rate of no lymph node metastasis by CT scan comparing with that by postoperative pathological diagnosis was higher than that of the 1 lymph node metastasis in upper-thoracic esophageal carcinoma 3 lymph node metastasis were 71.1%, 30.1%, 55.6% and 77.8%, respectively(x2 =55.14,P =0.000.Conclusions Preoperative CT image can accurately predict the distribution patterns of the lymph node metastasis in esophageal carcinoma. The concordance rate was the highest in diagnosis of 0 and ≥3 lymph node metastasis, the lowest in diagnosis of one lymph node metastasis. These findings are valuable for definition of the target range of radiotherapy after radical resection of esophageal carcinoma.     

金银花水煎液对放射性食管炎患者的免疫调节作用

目的:观察金银花水煎液对放射性食管炎患者的免疫调节作用。方法:选取150例食管癌放射治疗患者,随机分为对照组及观察组,每组各75例,对照组患者根据照射剂量给予相应剂量地塞米松治疗,观察组在对照组患者治疗的基础上给予金银花水煎液,比较两组患者在放射治疗后,放射性食管炎发生率、发病程度、炎性因子(TNF-α、IL-6、TGF-β1)、免疫因子(IgG、CRP、补体C3及补体C4)、淋巴细胞亚群变化情况。结果:观察组患者放射性食管炎发生率低于对照组(P＜0.05),发病程度低于对照组,两组患者接受放射治疗后各炎性因子水平均升高,观察组患者炎性因子水平低于对照组(P＜0.05);免疫因子CRP水平低于对照组(P＜0.05),IgG及补体C3水平高于对照组(P＜0.05);观察组患者CD3+T、CD4+T及CD4+/CD8+水平高于对照组(P＜0.05),观察组患者不良反应发生情况优于对照组。结论:金银花水煎液可有效抑制放射治疗引起的患者免疫功能下降情况,增强免疫水平,降低放射性食管炎发生率。     

食管癌大体肿瘤靶区的体积分级与病理T分期的关系

Objective Using the volume calculating function of treatment planning system of 3DCRT to work out the value of GTV standard classifications and to provide the reference for clinical staging of esophageal carcinoma. Methods Six hundred and seven patients underwent radical resection of thoracic esophageal carcinoma in our hospital, and their pre-operative CT images were transmitted in digital format to the three-dimensional conformal radiotherapy planning system by the network. Esophageal lesion GTV targets were outlined, and their volumes were automatically computed by the planning system. Compared the differences of the GTV volumes in different pathological T stages, and analyzed the relationship between GTV volumes and pathological T stages. According to the median volume of GTV at different pathological T stages, divided the values of GTV volume coresponding to different T stages and selected the suitable classification standard of GTV volume. Results The esophageal carcinoma GTV length, maximum diameter and volume were related to pathological T staging and with a positive correlation (all P < 0. 001 ). The Spearman correlation coefficient (r) was 0.376, 0.466 and 0.464, respectively, P < 0.001. Except that the length, maximum diameter and volume of GTV in pathological T3 and T4 had no significant difference, other indicators of the pathological T stages showed significant differences between the groups (P < 0. 001 ). According to the median volume of GTV at different pathological T stages, the GTV volumes were divided into three grades; ≤5.0 cm3,5. 1-13.0 cm3,and > 13.0 cm3. When compared them with pathological T1, T2, and T3 -T4 stages, the coincidence rate was 73. 8%. The consistency was good between the GTV volume grades and pathological T stages ( Kappa = 0. 40, P < 0. 001 ). Hie overall 5-year survival rates of GTV grades 1,2,3 were 78. 1% , 31.5% and 33. 5% , respectively (P < 0. 0001). If the GTVs were divided into four grades; ≤5.0 cm3,5.1-13.0 cm3,13.1-39.0 cm3 ,and >39.0 cm3, the coincidence rate of GTV volume grades and pathology T staging was only 54. 7% , and the consistency was poor, Kappa = 0.24,P<0.001. The overall 5-year survival rate of GTV 1, 2, 3, 4 were 78. 1% , 31.5% , 36.2% and 27.5%, respectively ( P < 0.0001). Conclusion The length, maximum diameter and volume of esophageal carcinoma GTV are related to pathological T staging with a positive correlation. The classification that esophageal carcinoma GTVs divided into three grades has a good coincidence with the pathological T staging.     

金银花水煎液对放射性食管炎患者血管内皮糖萼标志物水平的影响

目的:观察金银花水煎液对放射性食管炎(radiation esophagitis,RE)患者血管内皮糖萼标志物水平的影响。方法:选取120例接受放射治疗的食管癌患者，患者随机分为对照组及治疗组，每组各60例。对照组患者根据照射剂量给予地塞米松治疗，观察组患者给予地塞米松联合金银花水煎液治疗。比较两组患者放射治疗后RE发生情况，测定糖萼损伤标志物(Syndecan-1、硫酸乙酰肝素、透明质酸)、金属蛋白酶MMP-9水平，观察患者炎性因子及氧化应激水平(TNF-α、IL-6、COX-2、MDA)变化情况,利用侧流暗场成像技术测定舌下血管内皮糖萼厚度变化情况，测定不同RTOG分级患者糖萼损伤情况。结果:与对照组比较，观察组患者RE发生时间推迟、发生程度及发生率降低(P＜0.05)；患者糖萼损伤标志物、炎性因子、氧化应激水平及金属蛋白酶MMP-9含量显著降低(P＜0.05)；舌下微循环血管内皮糖萼厚度显著升高(P＜0.05)。RE患者糖萼损伤水平与RTOG分级呈正相关，糖萼厚度与RTOG分级呈负相关。结论:金银花水煎液可有效减轻RE患者血管内皮糖萼的损伤，其作用机制可能与金银花水煎液的抗炎、抗氧化作用有关。     

金银花水煎液联合地塞米松治疗放射性食管炎

目的:观察金银花水煎液联合地塞米松对放射性食管炎的治疗效果，并探讨其可能存在的作用机制。方法:选取156例食管癌患者作为研究对象，所有患者随机分为对照组及治疗组，对照组给予地塞米松(10 mg/d)，治疗组口服金银花水煎液并根据照射剂量给予不同剂量地塞米松治疗。观察两组患者放射性食管炎的发生率及发病程度、发生时间、持续时间、T淋巴细胞亚群及后期生活质量变化情况。结果:对照组放射性食管炎发生率为59.0%，治疗组放射性食管炎发生率为25.6%，两组患者比较差异显著(P＜0.05)；治疗组患者放射性食管炎发生时间推迟，持续时间缩短，CD3+T、CD4+T比例显著升高(P＜0.05)，CD4+/CD8+比值显著升高(P＜0.05)，KPS评分及体重改善。结论:利用金银花水煎液联合地塞米松可有效降低患者放射性食管炎的发生，改善患者生活质量，其作用机制可能与清热解毒，增强患者免疫功能有关。     

胸段食管癌的淋巴结转移规律及其对确定术后放射治疗靶区范围的价值

目的 分析胸段食管癌淋巴结转移的规律及其影响因素,探讨食管癌术后放疗的靶区范围.方法 收集763例接受根治性切除的胸段食管癌患者的临床病理资料,分析淋巴结转移规律及影响因素.结果 763例胸段食管癌患者共清除淋巴结5846枚,病理证实转移711枚,转移度为12.2%;出现淋巴结转移者297例,转移率为38.9%.胸上段癌淋巴结转移率为28.5%,明显低于胸中段癌(38.8%)和胸下段癌(43.4%).胸上段癌以锁骨上和气管旁淋巴结的转移度和转移率最高.胸中段癌的上行和下行转移均存在,上行主要转移至锁骨上、气管旁和食管旁,下行主要转移至贲门和胃左动脉旁.胸下段癌则主要向食管旁、贲门和胃左动脉旁转移,其中胃左动脉旁的转移度和转移率均显著高于胸上段癌和胸中段癌(均P<0.01).采取左胸单切口的592例患者中,胸上、中、下段癌的淋巴结转移率分别为37.0%、37.9%和41.4%,差异无统计学意义(P=0.715).多因素Logistic回归分析表明,病变长度、浸润深度、脉管瘤栓和远处转移是影响胸段食管癌淋巴结转移的主要因素(均P<0.05).结论 临床上可以根据食管癌的病变长度、浸润深度、脉管瘤栓和远处转移选择需行术后预防照射的患者,根据不同病变部位、不同手术方式及TNM分期,确定术后预防照射的靶区范围.     

丹参酮ⅡA通过抑制PI3K/Akt/mTOR信号通路促进人喉癌Hep-2细胞凋亡和自噬的研究

目的 研究丹参酮ⅡA对人喉癌Hep-2细胞凋亡和自噬的影响，并基于磷脂酰肌醇3激酶/蛋白激酶B/哺乳动物雷帕霉素靶蛋白(PI3K/Akt/mTOR)信号通路探讨其可能作用机制。方法 分别以不同浓度丹参酮ⅡA(0,2,4,8,16,32μmol/L)干预对数生长期人喉癌Hep-2细胞48 h, CCK-8法检测细胞增殖抑制率，计算半抑制浓度(IC50)作为后续实验药物浓度。取对数生长期人喉癌Hep-2细胞，设空白组、丹参酮ⅡA组、丹参酮ⅡA+IGF-1(PI3K激活剂)组、丹参酮ⅡA+LY294002(PI3K抑制剂)组，各组给予相应干预48 h后，CCK-8法、Annexin V-FITC/PI双染法、GFP-LC3荧光质粒转染法检测细胞增殖抑制率、凋亡率和自噬体形成情况，Western blot法检测B细胞淋巴瘤-2(Bcl-2)、Bcl-2相关X蛋白(Bax)、激活型半胱氨酸蛋白酶-3(Cleaved Caspase-3)、微管相关蛋白1轻链3(LC3)、PI3K、p-PI3K、Akt、p-Akt、mTOR、p-mTOR蛋白表达情况。结果 丹参酮ⅡA对Hep-2细胞增殖抑制作用呈现...     

食管癌肿瘤体积与病理T分期对照研究

目的 探讨食管癌肿瘤体积（GTV）与病理T分期的关系,为食管癌临床T分期提供参考指标。方法 2005年1月~2005年12月手术治疗的食管癌患者208例,术前均行胸部CT扫描,应用三维治疗计划系统勾画食管癌GTV-T靶区,并计算GTV-T体积,测量食管病变的最大直径及病变长度,同时记录术中实测食管病变长度,分析CT扫描显示的食管癌GTV-T体积及各径线与术后病理T分期间的关系。结果 CT图像上勾画的GTV长度与术中实测食管病变长度间未见统计学差异（t=-1.786,P=0.076）。T1期GTV T体积与T2、T3、T4期的GTV T体积之间差异有统计学意义（P<0.05）。T2期与T3期的GTV-T体积相比差异也有统计学意义（P<0.05）,但T2期与T4期的GTV-T体积相比未见统计学差异,T3期与T4期的GTV T体积之间亦未见统计学差异。CT显示食管病变的长度及病变在最大层面上的直径T1、T2期与T3、T4期对比差异均有统计学意义（P<0.05）,而T3与T4期间差异无统计学意义。结论 随着食管癌T分期的增加,肿瘤体积逐渐增大,CT扫描显示的GTV体积有可能成为指导食管癌临床T分期的参考指标。