目的

探讨肝癌淋巴转移的相关因素、转移规律、治疗方法,以及对疗效和预后的影响。

方法

分析21例肝癌合并肝外淋巴结转移的病理类型、转移部位、术前术后诊断符合率、手术治疗、术后辅助治疗和生存率。

结果

21例中原发性肝癌19例:肝细胞癌(HCC)12例、胆管细胞癌5例、混合型肝癌2例,转移性肝癌2例。肿瘤位于I段(尾状叶右段),V段,V、VIII段,VII、VIII段和V、VI段各1例,II、III段3例,II-IV段6例,VI、VII段5例,肿瘤侵及全肝2例。肿瘤直径最小4.5cm,最大15cm,平均直径7.5cm。术前诊断肝外淋巴结转移7例(33.4%,7/21),其余均为术中探查所发现,术前漏诊率66.6%(14/21)。肿瘤单侵犯第8组淋巴结10例(47.61%),第8、12组4例(19.04%),累计淋巴侵犯超过3组以上,即7～9组和(或)8、11～13组5例(23.80%),单纯侵犯第13组和14组各1例(9.52%)。此外,同时合并胆囊、肝外胆管、廉状韧带或肝十二指肠韧带脂肪组织转移3例。3组淋巴结以上被侵犯或合并远处淋巴结及组织转移的10例中,HCC 3例,占HCC组的25%(3/12);胆管细胞癌3例,占该组的60%(3/5);混合型肝癌、转移性肝癌各2例,100%(4/4)。2例HCC术后肝内或远处淋巴转移再次手术。21例术后平均生存时间7.8月,最短3个月,最长34个月。5例存活超过12个月的患者术后均接受了TACE或肝脏局部化疗。

结论

肝癌淋巴结侵犯以第8组淋巴结受累的几率最高,达91%(19/21),而淋巴结转移的严重程度与肝癌的病理类型有关。由于术前漏诊率较高,应重视术前临床资料的分析和术中的仔细探查,尤其是第8组淋巴结。转移淋巴结的清扫和术后综合治疗对改善此类患者的预后有积极意义。淋巴结的清除相对肝癌的切除更困难,熟练掌握肝门淋巴外科的技术和要点是关键。

Objective

To investigate the related factors that effect on lymphonoid metastasis of liver cancer,pathway of lymphatic invasion,surgical procedures,postoperative adjuvant therapies and the prognosis of patients.

Methods

21 cases of liver cancer with lymphonoid metastasis were analyzed in this study,including the pathology of tumor,tumor invasion of regional lymph nodes,accordant rates of pre-and postoperative diagnosis,treatments,postoperative therapies and survival of the patients.

Results

The pathological diagnosis of liver cancer included:HCC in 12,cholangiocellular carcinoma in 5,mixed hepatoma and secondary liver cancer in 2 respectively.Liver tumor located in segment I,V,ⅤandⅧ,ⅤandⅥ,ⅦandⅧin 1 case respectively,segment II andⅢin 3,segmentⅡ-Ⅳin 6,VI andⅦin 5 and diffuse invasion in 2 cases.The average diameter of the tumor was 7.5 cm.Lymphonoid invasion was diagnosed preoperatively in 7 patients(33.4%),and the rest were diagnosed intraoperation(66.6%).The group 8 of lymph node was involved in 10 cases(47.6%),group 8 and 12 in 4(19%),more than 3 groups were invaded in 5(23.8%),and distal group 13 or 14 was singly involved in 1 respectively(9%).In addition,there were 3 cases of the 21 patients with tumor metastasis to gall bladder,extrahepatic bile duct and other tissues.In the 10 patients with more than 3 groups lymph nodes invasion or distal lymphatic and other tissue metastasis,3 were HCC(3/12),accounting for 25%of the HCC cases,3 were cholangiocellular carcinoma(3/5,60%),mixed liver caner and secondary liver cancer were 2 respectively(4/4,100%).Two cases of HCC were reoperated on due to tumor recurrence.The mean survival of the 21patients was 7.8 months,shortest 3months and longest 34 months.5 cases receiving postoperative chemotherapies survived more than 12 months.

Conclusion

It has been suggested from our study that the most prevalent invasion of lymph node in liver cancer is the group 8,about 91%(19/21).The severity of lymphatic involvement is related to the pathological pattern of the tumor.As the relatively high missdiagnostic rate preoperation,it should be emphasized that careful preoperative assessment of clinical data and intraoperative exploration(especially the lymph node of group 8)are needed.Resection of the implicated lymph nodes and postoperative adjuvant therapies will be of benefit for the patients to improve the prognosis.Because it is rather difficult to remove the involved lymph nodes,it is necessary for a surgeon to master the essential technique of lymphatic resection.