【作者】 李永涛；

【导师】 于跃明；

【作者基本信息】 河北医科大学 ， 外科学， 2008， 硕士

【摘要】 目的直肠癌是常见的恶性肿瘤之一,其发病率及死亡率均较高。手术治疗是直肠癌的主要治疗手段,随着外科学、分子生物学、免疫学等学科的发展,直肠癌的手术治疗也有了很大的进展。在保证手术根治效果的同时,如何能进一步降低局部复发率,提高患者生活质量,一直是人们所关注的问题。TME手术原则的广泛推广,使直肠癌术后局部复发率显著降低。以往人们对直肠癌远端肠管及系膜切除距离很关注,也做了大量相关研究,明确了远端切除的安全距离。近年来,直肠系膜环周切缘癌浸润(circumferential margin involvement,CMI)日益受到人们的关注,而且越来越多的证据证实CMI是导致直肠癌术后局部复发的重要因素,因此,CMI的研究成为进一步降低肿瘤局部复发的关键所在。病理大组织切片能够客观且准确地观察直肠癌术后CMI的情况。这种病理学检查方法可以从整体上观察直肠癌转移灶在直肠系膜内的方位及其与肿瘤原发灶和直肠壁的关系,通过这种方法可以准确地观察手术切缘情况,判断是否存在CMI。同时结合免疫组化技术,可以发现环周切缘存在的肿瘤微转移病灶,从而进一步增加CMI的检出率。本研究通过HE染色病理大组织切片与免疫组化大切片相结合,探讨如何能进一步提高CMI的检出率,并与41例临床病例资料相结合,发现CMI的存在规律,指导临床治疗。方法1.HE染色病理大组织切片:通过大组织切片观察CMI情况与临床病理资料的关系,然后进行统计学分析。2.免疫组织化学法:采用S-P法,按照试剂盒说明书进行操作,采用1:80、1:80、1:40稀释的鼠抗人CK20、CDX2、MMP7单克隆抗体分别检测直肠癌系膜内微转移灶,发现CMI的微转移。PBS代替一抗作为阴性对照。结合临床病理资料对其结果进行相关统计学分析。结果HE染色病理组织大切片检测CMI阳性率为21.95%(9/41)。其中在肿瘤分化程度方面,高、中分化组CMI阳性率分别为16.67%(1/6)、8.00%(2/25),而在低分化组CMI阳性率高达60.00%(6/10),统计学分析显示,高、中分化组与低分化组比较存在显著性差异(P=0.004<0.05),可认为CMI在低分化组的阳性率高于高、中分化组。在肿瘤位置(肿瘤下缘距齿线距离)方面,<5cm组CMI阳性率46.15%(6/13)高于≥5cm组阳性率10.71%(3/28),统计学分析显示两组存在显著性差异(P=0.03<0.05)。在不同的术式方面,Miles组CMI阳性率46.15%(6/13)高于Dixon组的阳性率10.71%(3/28) ,统计学分析显示两组存在显著性差异(P=0.03<0.05)。而患者性别、年龄、肿瘤大体类型、浸润深度、淋巴结转移情况、手术方法(开腹/腹腔镜)方面均与CMI阳性率无明显相关性(P>0.05)。免疫组化结果显示,CK20、CDX2、MMP7切片检测CMI阳性率分别为29.27%(12/41)、31.71%(13/41)、26.83%(11/41)。其中在肿瘤分化程度方面,三项指标均证实高、中分化组CMI阳性率低于低分化组,统计学分析存在显著性差异(P<0.05)。在肿瘤位置(肿瘤下缘距齿线距离)方面,三项指标均显示<5cm组CMI阳性率高于≥5cm组,统计学显示存在显著性差异(P<0.05)。在不同的术式方面,三项指标均显示Miles手术组CMI阳性率高于Dixon手术组,统计学分析显示两组比较存在显著性差异(P<0.05)。CK20、CDX2显示患者性别、年龄、肿瘤大体类型、浸润深度、淋巴结转移情况、手术方法(开腹/腹腔镜)均与CMI阳性率无明显相关性(P>0.05)。在上述临床资料方面,MMP7显示在淋巴结转移方面,N0、N1、N2组CMI阳性率分别为8.70%(2/23)、46.15%(6/13)、60.00%(3/5),统计学分析显示N0组与N1、N2组比较存在显著性差异(P=0.009),可认为无淋巴结转移组CMI阳性率低于存在淋巴结转移组CMI阳性率。采用HE染色与免疫组化三项指标联合检测的方法共检测出15例存在CMI,阳性检出率为36.59%(15/41)。HE染色、CK20、CDX2、MMP7切片检测CMI阳性率分别为21.95%(9/41)、29.27%(12/41)、31.71%(13/41)、26.83%(11/41),两两比较CMI阳性检出率均无明显差异(P>0.05)。统计学分析显示HE染色与免疫组化三项抗体指标联合检测较单用HE染色大切片或一种抗体指标检测CMI检出率高(P<0.05)。结论1病理大组织切片能客观准确地观察直肠癌术后CMI情况,术后应常规进行该项检查。2 HE染色与免疫组化CK20、CDX2、MMP7三种指标联合检测CMI的阳性率较高。3对于术后检测存在CMI的患者,无论病理分期的早晚,都应行正规的放化疗。4肿瘤分化程度低、肿瘤位置低、存在淋巴结转移及行Miles手术是CMI存在的高危因素。5 CMI阳性率与患者的性别、年龄、肿瘤大体类型、浸润深度、手术方法(开腹/腹腔镜)无明显关系。更多还原

【Abstract】 ObjectiveRectal cancer is one of the common malignant tumors,its incidence and mortality are still high.Surgical treatment is still the first choice of management for Patients.with the development of surgery,molecularbiology and immunology etc,Surgical treatment also have great development.how to reduce local recurrence ulteriorly,improve PostoPerative life quality,at the same time,ensure the effect of surgical treatment,become a hot question .Widely introduction of total mesorectal exeision(TME) had significantly reduce local recurrence following the curative resection.beforetime,people attached importance to the distal clearance margin and had done many research,defined a safe distal clearance margin.currently,people pay more attention to the circumferential margin involvement,and more and more researches had proved that circumferential margin involvement was a important factor of local recurrence after the curative rese- ction.Researches of circumferential margin involvement is a key of reducing the local recurrence.Pathologic large slice can observe circumferential margin involvement distinctly.it can observe holistic mesorectal,the orientation of metastasis,and make sure the relation of metastasis and the primary affection.this method can accurately find circumferential margin involvement,combine with immunohistochemical technique,it can find micrometastasis in circumferential resection margin,enhance the check-up rates of circumferential margin involvement.This study combined pathologic large slice and Immun- ohistochemical technique to discuss how to enhance the check-up rates of circumferential margin involvement,and studied 41 patients’clinicopathlogic characteridtion,detected the rule of circumferential margin involvement,and leaded a reasonable clinical treatment.Methods1.Pathologic large slice with hematoxylin and eosin:we used this method to detect the relationship between circumferential margin involvement and clincopathologic features,then analyzed the results.2.Immunohistochemistry was performed by using the SP method. We used mouse anti-CK20 (1:80 dilution), mouse anti-CDX2 (1:80 dilution),mouse anti-MMP7 (1:40 dilution) to detect circumferential margin involvement in samples, then analyzed the results with the clincopathologic features .Results9 patients (21.95%) with positive circumferential resection margin were detected by pathologic large slice with hematoxylin and eosin.On differentiation of tumour,60.7% poorly differentiated specimens were detected circumferential margin involvement,while moderate and well-differentiated cancer specimens were only 8.00% and 16.7% respectively (P=0. 004<0.05).About station of tumour,positive circumferential resection margin was more frequent in<5cm specimens (46.15%),compared with≥5cm specimens(10.71%)(P=0.003 <0.05).About different operation mode(Miles/Dixon), positive circumferential resection margin was more frequent in Miles specimens(46.15%),Compared with Dixon specimens(10.71%) (P=0.003<0.05).No significant correlations were found between circumferential resection margin and other clincopathologic features,such as gender,age,tumor invasion,lymph node metast- asis,pathology general classification,operation method (P>0.05).By immunohistochemistry analysis on samples,CK20, CDX2,MMP7 detect positive circumferential resection margin 29.27%(12/41)、31.71%(13/41)、26.83%(11/41) respectively. About differentiation of tumour,three antibodies proved that positive circumferential resection margin was more frequent in poorly differentiated specimens than moderate and well-differentiated specimens(P<0.05).About station of tumour,three antibodies proved that positive circumferential resection margin was more frequent in<5cm specimens than in≥5cm specimens (P<0.05).CK20 and CDX2 proved that no significant correlations were found between circumferential resection margin and other clincopathologic features,such as gender,age, tumor invasion,lymph node metastasis,pathology general classi- fication,operation method(P>0.05).But about lymph node metastasisand, MMP7 prove that 8.70% N0 lymph node metastasis specimens were detected circumferential margin involvement, while N1 and N2 lymph node metastasis specimens were 46.15% and 6.00% respectively (P=0. 009).15 patients (36.59%) with positive circumferential resection margin were detect by combining pathologic large slice and im-munohistochemical technique.large slice with H-E,CK20,CDX2, MMP7 detected positive circumferential resection margin 21.95%,29.27%(12/41)、31.71%(13/41)、26.83%(11/41) respectively.There were no significant difference between each other (P>0.05).Combining pathologic large slice and immunohistochemical technique could get more positive circumferential resection margin than single method or sigle antibody(P<0.05)Conclusions1 Pathologic large slice can observe circumferential margin involvement distinctly.It should be a routine examination following the curative resection.2 Combining pathologic large slice and immunohistoch- emical technique could get more positive circumferential resection margin.3 Whether TNM stage is early or not,the patient who have positive circumferential resection margin should get normally postoperative adjuvant therapy. 4 Circumferential resection margin of middle and rectal cancer has significant correlation with tumor differentiation, tumor station,lymph node metastasis,different operation mode (Miles/Dixon).5 Circumferential resection margin of middle and rectal cancer has no significant correlation with gender,age,tumor invasion,pathology general classification,operation method.更多还原