T1期非小细胞肺癌肺叶切除和亚肺叶切除的临床疗效比较

目的探讨肺叶切除和亚肺叶切除在T1期非小细胞肺癌(NSCLC)(肿瘤直径≤3 cm)外科治疗中的应用价值。 方法收集2007年1月至2014年12月在北京中日友好医院胸外科接受手术治疗的278例T1期NSCLC患者的临床资料。患者平均年龄(60.7 ± 10.4)岁。其中亚肺叶切除61例(楔形切除35例，肺段切除26例)，肺叶切除217例。腺癌占81.7%，鳞癌占12.9%，其他占5.4%；高分化癌占8.6%，中分化癌占27.0%，低分化癌占20.5%，不能确定占43.9%。在腺癌中，浸润前病变占4.0%，微浸润腺癌占7.5%，浸润性腺癌占88.5%。T1N0M0占86.7%，T1N1M0占1.1%，T1N2M0占12.2%。 结果与肺叶切除组比较，亚肺叶切除组患者年龄较大、手术时间较短、病变≤2 cm的比例较高，两组间比较差异均有统计学意义(t＝0.496，P＝0.009；t＝8.082，P＝0.029；χ²＝2.105，P＝0.002)。但两组间在1秒钟用力呼气容积(FEV₁)、FEV₁%，以及手术方式和术后并发症发生率方面，差异均无统计学意义(t＝0.065，P＝0.713；t＝2.12，P＝0.085；χ²＝0.399，P＝0.274；χ²＝0.438，P＝0.490)。对于T1N0M0的NSCLC患者，亚肺叶和肺叶切除组患者的5年生存率分别为73.9%和83.5%，差异无统计学意义(P＝0.883)。亚肺叶切除组内分析显示：楔形切除组和肺段切除组患者的5年生存率分别为79.4%和70.6%，差异无统计学意义(P＝0.979)。多因素分析显示：仅有年龄和纵隔淋巴结转移N2为预后不良的危险因素(HR＝1.07，P＝0.048；HR＝5.56，P＝0.011)。亚肺叶切除组患者的5年生存率与肺叶切除组比较差异无统计学意义(HR＝1.38，P＝0.552)。 结论对于T1N0M0的NSCLC患者，亚肺叶切除虽然不可能完全替代肺叶切除手术，但是对于肺功能储备较差的老年患者可能逐渐成为主流术式。

Comparison of outcomes between sublobar resection and lobectomy for T1 non-small cell lung cancer

ObjectiveTo compare the outcomes between sublobar resection and lobectomy for T1 non-small cell lung cancer(NSCLC)(tumor diameter ≤3 cm). MethodsThe clinical data of 278 patients with T1 NSCLC undergoing surgery in Department of Thoracic Surgery in China-Japan Friendship Hospital between January 2007 and December 2014 were collected. The mean age of these patients was (60.7±10.4) years. Sixty-one patients received sublobar resection(wedge resection, n=35; segmentectomy, n=26), and the other 217 underwent lobectomy. There was 81.7% of adenocarcinoma, 12.9% of squamous cell carcinoma, and 5.4% of cancer of other types. High differentiated, moderate differentiated and poor differentiated cancer accounted for 8.6%, 27.0% and 20.5%, respectively, and there were 43.9% cases with undermined differentiation status. In cases of adenocarcinoma, there were 4.0% preinvasive lesions, 7.5% minimally-invasive lesions and 88.5% invasive adenocarcinoma. There were 86.7% cases with T1N0M0, 1.1% cases with T1N1M0 and 12.2% cases with T1N2M0. ResultsCompared with lobectomy group, patients were much elder, the duration of operation was much shorter, and the percentage of lesion≤2 cm was significantly larger in sublobar resection group(t=0.496, P=0.009; t=8.082, P=0.029; χ²=2.105, P=0.002). There was no significant difference in forced expiratory volume in one second(FEV₁), FEV₁%, surgical procedure and incidence of postoperative complications between two groups(t=0.065, P=0.713; t=2.12, P=0.085; χ²=0.399, P=0.274; χ²=0.438, P=0.490). For NSCLC patients with T1N0M0, the 5-year survival of sublobar resection group and lobectomy group were 73.9% and 83.5%, respectively, with no significant difference(P=0.883). In sublobar resection group, the 5-year survival of patients undergoing wedge resection and segmentectomy were 79.4% and 70.6%, respectively, with no significant difference(P=0.979). Multivariate analysis indicated that only age and mediastinal lymph node metastasis N2 were risk factors for poor prognosis(HR=1.07, P=0.048; HR=5.56, P=0.011). There was no significant difference in 5-year survival between sublobar resection group and lobectomy group(HR=1.38, P=0.552). ConclusionsFor NSCLC patients with T1N0M0, though sublobar resection can not totally substitute lobectomy, it may become a main surgical procedure for senior patients with poor pulmonary reserve.