食管癌淋巴结清扫的质量控制.ppt

食管癌淋巴结清扫的质量控制 中山大学肿瘤防治中心胸科 林 鹏 背 景 ★ 目前尚无统一意见 ★ 焦点主要在于上纵隔及颈根部的清扫 ★ 无法规范化，成合理治疗、疗效比较的一大障碍 明天毛友生教授、方文涛教授 将分别详述相关的 ★ 新版诊治规范 ★ 淋巴结转移规律指导外科手术切除 二，执行新分期后对诊治的影响 ★ 原发灶位置整体上移——淋巴清扫及放疗野设计 ★ N分级以区域转移淋巴结个数为界、清扫总数多于15枚（行新辅助后手术者缺）——转移野数、区域数、转移率、融合/破碎计数 ★cTNM（包括非手术治疗）N分级的不确定性影响涵盖Ⅰ～Ⅲ分期——治案选择、疗效比较 出路 ★ 术前/非手术病例——寻找最高级别的诊断组合证据，如PET-CT、EUS-FNA、US-FNA、（Marker、纵隔镜、胸腹腔内镜？） ★手术病例——寻找兼顾诊治的合理清扫范围 颈IV区 包括下颈淋巴结，位于颈内静脉下1/3周围。胸锁关节上缘上2CM为颈IV区下界。其它各边界定义，上界：环状软骨下缘；前界和后界与颈III区相同，即胸锁乳突肌的前内缘和后缘；外界：锁乳突肌内缘；内界：颈内动脉的内缘和椎旁肌 颈V区 指颈后三角区淋巴结，沿着脊副神经下段和颈横血管分布。舌骨体上缘是颈V区上界可靠的标志。颈横血管下缘为颈V区下界。其它边界分别为：外界：颈阔肌和皮肤；内界：头夹肌、肩胛提肌和斜角肌；前界：胸锁乳突肌后缘；后界：斜方肌前侧缘 颈VI区 也称为前颈淋巴结，位于器官周围，如气管前和气管旁淋巴结、甲状腺周围淋巴结（包括喉返神经周围淋巴结）。颈VI区上界：甲状软骨体下缘；下界：胸骨柄上缘；前界：颈阔肌和皮肤；后界：气管和食管之间的间隙。外界：甲状腺内缘、皮肤和胸锁乳突肌前内缘 No. 101 Cervical paraesophageal LN Lymph nodes located around the cervical esophagus, including lymph nodes located along the recurrent laryngeal nerve and the cervical paratracheal lymph nodes. The lateral boundary is the medial border of the carotid sheath No. 104 Supraclavicular LN Lymph nodes located in the supraclavicular fossa, extending from the lower border of the cricoid cartilage superiorly, to the clavicle inferiorly, including the lower internal deep cervical lymph nodes. The medial boundary is the medial border of the carotid sheath No. 106rec Recurrent nerve LN Lymph nodes located along the recurrent laryngeal nerves in the mediastinum. The superior boundary is drawn from the cephalic border of the subclavian arteries to the suprasternal notch, and the inferior boundary is the caudal border of the recurrent laryngeal nerve curving upward on both sides No. 106recL Left recurrent nerve LN Lymph nodes located along the left recurrent laryngeal nerve No. 106recR Right recurrent nerve LN Lymph nodes located along the right recurrent laryngeal nerve No. 106pre Pretracheal LN Lymph nodes in front of the anterior wall of the thoracic trachea, and anterior to the right vagus nerve No. 106tb Tracheobronchial LN