【作者】 张春明；

【导师】 王斌全；

【作者基本信息】 山西医科大学 ， 耳鼻咽喉—头颈外科学， 2008， 博士

【摘要】 目的喉癌是耳鼻咽喉-头颈外科常见的恶性肿瘤之一,手术是喉癌治疗的主要手段。由于喉解剖部位的不规则性及肿瘤浸润生长呈三维性,喉癌原发灶的安全完整切除要求准确把握肿瘤的黏膜切缘、黏膜下浸润及基底浸润程度。手术切缘的癌细胞残留可能导致手术失败,引起局部复发。科学确定外科切缘是决定喉癌患者术后生存率及喉功能保留的核心因素。本课题通过利用组织病理学及生物学等多种方法,对喉癌切缘进行立体研究,了解喉癌的三维浸润特征,从而对开展以安全切缘为基础的喉癌外科治疗提供一定的理论依据。方法用流式细胞术检测喉癌组织及癌旁0.5cm、1.0cm、2.0cm处黏膜组织异倍体率、DNA指数;用免疫组织化学方法检测喉癌组织及癌旁0.5cm、1.0cm、2.0cm处增殖细胞核抗原及基质金属蛋白酶-2的表达;用喉癌组织大体手术标本沿长轴取肿瘤最大面的组织切片,观察并测出喉癌组织在黏膜下潜性浸润距离;比较不同部位、不同T分期及不同形态的喉癌组织黏膜下浸润情况;行常规病理学观察及细胞角蛋白-19免疫组织化学染色,检测其在深部切缘的表达情况,观察喉癌组织基底浸润特征。结果1.喉癌组织与癌旁0.5cm、1cm、2cm处黏膜DNA含量和PCNA表达有显著性差异;2.喉癌组织与癌旁0.5cm、1cm处黏膜组织中MMP-2的表达有显著性差异,MMP-2的阳性表达率与喉癌颈淋巴结转移及肿瘤T分期存在相关性;3.不同部位、不同T分期及不同喉癌大体形态的黏膜下浸润距离:喉癌声门型和声门上型两者没有统计学差异;喉癌T_1-2期和T_3-4期两者有统计学差异;喉癌外生型、溃疡浸润型和混合浸润型中,前者分别与后两型比较,均有显著性差异,后两型之间无显著性差异;4.CK-19在喉癌组织基底远侧不同距离的表达与T分期存在相关性,与肿瘤原发灶位置也存在相关性。结论1.能够反映喉癌细胞增殖和侵袭特性一些生物学指标从喉癌组织向周围黏膜组织移行过程中渐趋正常,根据这个规律可以提出喉癌0.5cm的基本安全切缘与1.0cm的理想安全切缘;2.喉癌原发灶T分期越晚,肿瘤黏膜下浸润程度越重;外生型喉癌的黏膜下浸润程度轻,溃疡浸润型、混合浸润型喉癌黏膜下浸润程度重;局部晚期的溃疡浸润型、混合浸润型喉癌应慎行喉部分切除术;3.喉癌手术深部安全切缘,因肿瘤浸润范围（即T分级）不同而不同;喉癌组织基底远侧的喉部组织,如肌肉组织、结缔组织和软骨组织等,未发现CK-19阳性表达;喉部的弹性膜、软骨膜和软骨是癌组织侵袭的屏障,是喉癌手术基底切除的解剖标志。更多还原

【Abstract】 Objective:Laryngeal carcinoma（LC） is a frequent malignant tumor in department of otolaryngology.Surgical operation is the most important method for the treatment of laryngeal carcinoma.For the irregularity of LC region and infiltrating in three dimensions,the completed and safety excision of LC requests us to grasp the mucous margin and infiltrating of submucous and fundament.Residence of carcinoma cell in surgical margin can lead to the failure of operation and local recurrence.Definiting the surgical margin sciencely is the nuclear factor for survival rate and laryng-function reservation after operation.In this topic,we study the surgical margin in three dimensions by ways of histothology and biology.After comprehending the infiltrating character of LC in three dimensions,we can provide some guidance for the treatment of LC.Methods:The specimens acquired from laryngeal cancer and adjacent tissue at the site of 0.5cm,1cm and 2cm were detected by approaches of flow cytometry to get DNA index.By ways of immunohisto-chemistry we detect the expression of PCNA and matrix metalloproteinase-2（MMP-2） in laryngeal cancer and the adjacent tissue of cancer.Cases with LC were vertically cut-down along tumor long axis,and were slivered into sections by which laryngeal carcinoma sub mucosal infiltrating distance was measured under microscope. Laryngeal carcinoma latent sub mucosal infiltrating extend was compared among different location,different T staging and external appearance.Specimens were performed with pathology observation and study of CK-19 expression.Results:1.The difference of DNA content and expression of PCNA in laryngeal carcinoma and the tissue at the site of 0.5 cm,1cm,2cm away from laryngeal carcinoma was significant.2.There was significant difference of matrix metalloproteinase-2 expression between laryngeal carcinoma and the tissue at the site of 0.5cm,1cm away from laryngeal cancer.3.The values of laryngeal carcinoma sub mucosal infiltrating distance with different location, T staging and external appearance were different.There was no significant difference between glottic carcinoma and supraglottic carcinoma,yet there was significant difference between T_1/2 and T_3/4 laryngeal carcinoma.In exogenic type,ulcerating infiltrating type and mixed infiltrating type,there was significant differences between the first and the second type,and between the first and the third type,no significant difference between the first and the third type.4.There was correlation between the expression of CK-19 at deepness surgical margin and T staging,also for the primary localization and the expression of CK- 19.Conclusions:1.The index inflecting the proliferating and infiltrating of laryngeal carcinoma cell turned gradually into normal level from laryngeal cancer tissue to the normal tissue.According to this regularity,0.5cm away from laryngeal cancer periphery may be determined as basic safe surgical margin,and 1.0cm may be determined as satisfactory safe surgical margin.2.As laryngeal carcinoma T stage developing,tumor submucosal infiltrating extent is becoming more extensive.Laryngeal carcinoma submucosal infiltrating extents with ulcerating infiltrating and mixed infiltrating type are more extensive than exogenic type.The cases with local advanced ulcerating infiltrating and mixed infiltrating laryngeal carcinoma should be prudent to be performed by partial laryngectomy.3.Different staging,different the deepness surgical margin of laryngeal cancer.Expression of CK-19 was negative in the extremital tissue of laryngeal cancer fundament,such as muscular tissue,connective tissue and cartilage tissue.They were also anatomic landmark of LC operation and barricade of LC invasive.更多还原