非小细胞肺癌淋巴结清扫方式临床研究

目的 比较非小细胞肺癌不同纵隔淋巴结清扫方式间的差异,为规范化开展肺癌淋巴结清扫临床研究提供依据.方法 在202例Ⅰa-Ⅲa期肺癌中进行前瞻性临床对照试验,比较常规清扫(RMLD)和全纵隔骨骼化清扫(SCLD)两种术式,分析手术经过和术后病理分期情况.结果 RMLD 107例,SCLD 95例.两组术前一般情况、临床分期及肺切除方式无明显差异,SCLD组平均扫除淋巴结组数显著高于RMLD组(8.9组对6.2组,P＜0.001),术后总体并发症(14.7%对14.0%,P=0.884)和病死率(2.1%对1.9%,P=0.904)无差异,但SCLD组分别有3例(3.2%)右侧乳糜胸和左侧喉返神经损伤发生.术后病理证实两组组织学类型及分期无明显差异,RNLD和SCLD组pN2分别占27.1%和24.2%(P=0.888),跳跃性纵隔转移率(RMLD 9.3%对SCLD 7.4%,P=0.613)以及纵隔多组转移率(RMLD 15.0%对SCLD 16.8%,P=0.714)亦无明显差异.分析纵隔各组淋巴结转移率发现上叶肺癌下纵隔转移率＜5%,而中、下叶肺癌上、下纵隔转移率均＞10%;cT1病例以及低度恶性肿瘤无一发生纵隔转移.结论 对非小细胞肺癌行常规纵隔清扫可达到与全纵隔骨骼化清扫同样的分期效果,后者手术风险并不高于常规清扫,但应避免右侧乳糜胸和左侧喉返神经损伤的发生;上叶肺癌仅需扫除上纵隔淋巴结而无需常规清扫下纵隔;早早期肺癌以及低度恶性肿瘤没有必要进行常规纵隔清扫.

Mediastinal lymph node dissection for non-small cell lung cancer

Objective To evaluate the results of different styles of mediastinal lymph node dissection for non-small cell lung cancer (NSCLC).Methods A prospective controlled clinical trial was carried out in 202 patients with NSCLC who underwent either routine mediastinal dissection (RMLD) or skeletonized complete mediastinal dissection (SCLD).Surgery outcomes and histologicalstaging were recorded for statistical analysis.Results There were 107 patients in the RMLD group and 95 patients in the SCLDgroup.The demographic characteristics,clinical staging,and types of resection were similar between the two groups.The numbers of resected lymph nodes in SCLD group were significantly higher than that in RMLD group(8.9 vs.6.2,P＜0.001).Overall morbidity and mortality were comparable between two groups (14.7% vs.14.0%,P=0.884;2.1% vs.1.9%,P=0.904).In SCLD group,post-operative chylothorax was occurred in 3 patients (3.2%) and recurrent laryngeal nerve palsy in3 (3.2%).No significant difference was detected in histological types or pathological staging between the two groups.The pN2 rates were similar after RMLD and SCLD(27.1% vs.24.2%,P=0.888).There was no difference in term s of skip mediastinal nodal involvement (RMLD9.3% vs.SCLD7.4%,P=0.613) or multi-station mediastinal metastasis (RMLD 15.0% vs.SCLD 16.8%,P=0.714 ) between tow groups.Inferior mediastinal metastasis was documented in less than 5% in tumors located in the upper lobes,while metastases from middle and lower lobe tumors to both superior and inferior mediastinum were above 10%.No mediastinal involvement was found in clinically T1 diseases or in low-grade malignant tumors.Conclusion For NSCLC staging,the routine mediastinal dissection is comparable to skeletonized complete mediastinal dissection.Although skeletonized complete mediastinal dissection did not increase surgical risk,postoperative chylothorax and recurrent nerve injury should be avoided.Dissection of the inferior mediastinum may not be necessary for upper lobe tumors,early stage or low-grade malignant tumors.Future studies on systemic lymph node dissection for lung cancers shall take into consideration the existing evidences.