cⅠ期周围型NSCLC纵隔淋巴结廓清范围的临床研究

目的：探讨cⅠ期周围型非小细胞肺癌(non-small cell lung cancer，NSCLC)纵隔淋巴结合理的廓清范围。方法：回顾性研究196例行系统性纵隔淋巴结廓清的cⅠ期周围型NSCLC患者的临床资料，分析临床病理特征与纵隔淋巴结转移的关系。结果：28例患者术后病理证实为N2，占14．3％(28／196)，腺癌、鳞癌患者的纵隔淋巴结转移的发生率分别为18．8％(22／117)、7．6％(6／79)，两者相比差异有统计学意义，P=0．023。ⅠA期、ⅠB期患者的发生率分剐为7．5％(5／67)．17．8％(23／129)，两者相比差异有统计学意义，P=0．049。上叶肿瘤纵隔淋巴结转移80．0％在上纵隔，下叶肿瘤纵隔淋巴结转移76．5％在下纵隔，上、下叶肿瘤均可发生隆突下淋巴结转移。结论：cⅠ期周围型NSCLC应行包括隆突下淋巴结在内的选择性区域纵隔淋巴结廓清。     

肺癌胸内淋巴结转移规律及其临床意义

目的 探讨肺癌胸内淋巴结转移的规律。方法 对318例肺切除加淋巴结廓清术患行进行临床病理分析。结果 318例患者共清除淋巴结1534组，其中转移淋巴结290组。胸内淋巴结转移率为58．5％(186／318)，其中N1转移率为27．0％(86／318)，N2转移率为31．4％(100／318)。距肺根部最近的11、10、7、4区淋巴结转移频度最高。发生跳跃式N2转移46例，占14．5％，其中上叶肺癌仅出现上纵隔跳跃式淋巴结转移；下叶肺癌及右中叶肺癌则可出现上、下纵隔跳跃式淋巴结转移。术前胸部CT扫描肺门及纵隔淋巴结肿大者中，术后病理报告阳性者占48．2％；CT扫描淋巴结阴性者中，术后病理报告阳性者占22．1％。结论上叶肺癌应常规清扫肺门、隆凸下及上纵隔淋巴结，如果无隆凸下淋巴结转移可不清扫8、9区；下叶及右中叶肺癌，无论有无肺门或隆凸下淋巴结转移，均应广泛清扫上、下纵隔淋巴结。术前胸部CT的结果不能作为淋巴结清扫的依据。     

肺癌纵膈淋巴结转移与血行转移相关性的临床研究

目的探讨非小细胞肺癌(NSCLC)纵隔淋巴结转移(N2)与血行转移的相关性,为对手术后的N2肺癌采取有针对性的辅助治疗措施提供依据.方法对96例根治性切除术后病理诊断为纵隔淋巴结转移(pN2)的NSCLC患者进行回顾性研究,选择无淋巴结转移(pN0)的NSCLC患者作为对照组,与pN2患者配对.术后两年内每6个月对患者进行随访复查一次,监测血行转移.计算两组患者血行转移的发生率,应用x2检验比较发生率的差别.结果pN2组患者手术后两年内血行转移的发生率为29.17%,多数为脑和肺转移(64.29%);pN0组患者血行转移的发生率为13.54%,两者的差别非常显著(P＜0.01).pN2肺癌患者术后发生血行转移的概率大约是pN0患者的3倍(OR=3.14).结论肺癌根治切除术后血行转移的发生与纵隔淋巴结转移有关,有纵隔淋巴结转移的患者血行转移的发生率增高.     

通过生存分析评价纵隔镜检查在非小细胞肺癌术前纵隔淋巴结分期中的作用

目的 通过生存分析评价纵隔镜检查在评估非小细胞肺癌(NSCLC)术前纵隔淋巴结状态中的作用.方法 对152例可手术NSCLC患者术前行CT和纵隔镜检查,根据纵隔镜检查结果选择不同的方案进行治疗,并进行长期随访.纵隔淋巴结分期按最终病理结果分为pN0、pN1、pN2和pN3,按CT检查分为cN0～1和cN2～3,按纵隔镜检查分为mN0～1、mN2和mN3.结果 pN0组、pN1组、pN2组和pN3组的5年生存率分别为61.7%、75.0%、32.4%和16.1%,pN0组、pN1组的生存率与pN2组、pN3组相比均显著升高(均P<0.05).cN0～1组与cN2～3组之间的生存率差异无统计学意义(P=0.670).mN0～1组与mN2组、mN3组的生存率差异均有统计学意义(均P<0.05).结论 开胸手术前行纵隔镜检查能较好地判断NSCLC患者的纵隔淋巴结转移情况,预测患者的预后.     

肺纵隔淋巴结转移的临床预测

目的：探讨肺癌临床病理生理特征与纵隔淋巴结转移的相关性。方法：对378例行肺切除加纵隔淋巴结廓清术后的肺癌患者进行回顾性研究,应用Logistic回归分析判定预测有意义的相关性因素,应用X^2检测判定不同危险因素组间纵隔淋巴结转移发生率的判别。结果全部378例患者中,纵隔淋巴结转移105列,转移率为27．8％,多因素分析显示,腺癌、CT扫描阳性（纵隔淋巴结增大）和病理分别为T3是纵隔淋巴结转移有意义的预测指标（P＜0．001）。316例胸部CT扫描阴性患者中,纵隔淋巴结转移为23．4％（74／316）。多因素分析显示,腺癌、病理分期为T2和3腺癌患者的纵隔淋巴结转移发生率为33％,显著高于鳞癌的15．3％（P＜0．01）。结论对CT扫描阳性、腺癌及病理分期为T3的患者应该考虑有纵隔淋巴结转移可能性。对CT扫描阴性的临床分期T2和T3腺癌患者亦应高度怀疑纵隔淋巴结转移存在的可能性。     

肺癌淋巴结转移特点的临床分析

目的探讨原发性肺癌胸内淋巴结转移特点及转移方式，为确定肺癌术中淋巴结廓清范围提供依据。方法按Naruke肺癌淋巴结分布图作为淋巴结廓清标志，对105例肺癌行完全性切除及系统性淋巴结廓清术。结果105例肺癌，共清除淋巴结801枚。N1占15．9％(59／371枚)，N2占14．9％(64／430枚)。跳跃性N2共12例，分布在纵隔第2、4、5、6、7组淋巴结。肺原发肿瘤大小与淋巴结转移之间无明显关系。小细胞肺癌淋巴结转移率最高，腺癌淋巴结转移率亦高于鳞癌。肺癌淋巴结可呈跳跃式纵隔转移，且肺下叶癌较肺上叶癌多见。结论肺癌淋巴结转移具有多组别、多区域及跳跃性特点，系统性胸内淋巴结廓清在肺癌术中应常规应用。     

cⅠ期周围型NSCLC纵隔淋巴结廓清范围的临床研究

目的:探讨cⅠ期周围型非小细胞肺癌(nonsmall cell lung cancer,NSCLC)纵隔淋巴结合理的廓清范围。方法:回顾性研究196例行系统性纵隔淋巴结廓清的cⅠ期周围型NSCLC患者的临床资料,分析临床病理特征与纵隔淋巴结转移的关系。结果:28例患者术后病理证实为N2,占14.3%(28/196),腺癌、鳞癌患者的纵隔淋巴结转移的发生率分别为18.8%(22/117)、7.6%(6/79),两者相比差异有统计学意义,P=0.023。ⅠA期、ⅠB期患者的发生率分别为7.5%(5/67)、17.8%(23/129),两者相比差异有统计学意义,P=0.049。上叶肿瘤纵隔淋巴结转移80.0%在上纵隔,下叶肿瘤纵隔淋巴结转移76.5%在下纵隔,上、下叶肿瘤均可发生隆突下淋巴结转移。结论:cⅠ期周围型NSCLC应行包括隆突下淋巴结在内的选择性区域纵隔淋巴结廓清。     

周围型非小细胞肺癌淋巴结隐匿转移的临床相关因素分析

目的:探讨与周围型非小细胞肺癌(non-small cell lung cancer,NSCLC)淋巴结隐匿转移有关的临床病理因素.方法:复习191例接受肺癌根治性手术的临床N<,0>M<,0>周围型NSCLC,分析肿瘤的大小、部位、病理类型、脏层胸膜有无受侵、血清CEA、CA199、CA125及肿瘤组织p53蛋白等8个临床病理参数与淋巴结转移的关系.结果:全组淋巴结转移率[pN1和(或)pN2转移]为44.5%(85/191);纵隔淋巴结转移率(pN2转移)为25.1%(48/191).单因素分析显示,脏层胸膜受侵(P=0.001)、血清CEA升高(P=0.001)、肿瘤部位(P=0.043)与pN1和(或)pN2转移显著相关.脏层胸膜受侵(P=0.000)、血清CEA升高(P=0.000)、腺癌(P=0.022)与pN2转移显著相关.Logistic多元回归分析显示,脏层胸膜受累、血清CEA值升高是影响pN1和(或)pN2转移的独立预后因素,脏层胸膜受累、血清CEA值升高、pN1转移是影响pN2转移的独立预后因素.结论:周围型NSCIC具有较高的隐匿性淋巴结转移率.血清CEA升高、胸膜侵犯是淋巴结转移的高危险因素,建议须进一步检查(纵隔镜、PET-CT);腺癌较易出现纵隔淋巴结转移,而鳞癌少见.肺门淋巴结有转移时易出现纵隔淋巴结转移.     

RT-PCR法检测MUC1 mRNA诊断肺癌纵隔淋巴结隐匿转移

目的：探讨对常规病理检查漏诊的肺癌纵隔淋巴结转移病灶的诊断方法。方法：应用逆转录聚合酶链反应法（RT－PCR），检测pN0.1期非小细胞肺癌患者（NSCLC）纵隔淋巴结中MUC1基因mRNA的表达。结果：5枚肺良性疾病的局部淋巴结无MUC1基因mRNA表达，5枚经病理检查证实有淋巴结转移癌的NSCLC纵隔淋巴结中均检测中MUC1mRNA表达，实验组19例患者的78例枚纵隔淋巴结中有6枚检测到MUC1mRNA表达，从而诊断为纵隔淋巴结隐匿转移。结论：应用RT－PCR法检测纵隔淋巴结中MUC1基因mRNA的表达可以提高临床对肺癌纵隔淋巴结转移诊断的准确性。     

纵隔淋巴结受累程度对Ⅲ期非小细胞肺癌预后的影响

目的 :探讨淋巴结受侵的程度及转移的范围与Ⅲ期非小细胞肺癌 (NSCLC)预后的关系及Ⅲ期NSCLC的手术适应证。方法 :回顾分析 1988年～ 1998年间 ,淋巴结廓清术后病理诊断为纵隔淋巴结转移 (pN2 )的 136例NSCLC患者的临床资料 ,根据术前的淋巴结分期、淋巴结受侵的程度及转移的范围分组。Kaplan Meier计算生存率 ,绘出生存曲线、用Log Rank检验比较不同组别的生存差别。结果 :不同的临床、病理因素中 ,淋巴结受侵的程度对预后的影响最大。淋巴结结外转移组的五年生存率低于结内转移组 ,分别为 9.8%和 18.8%。Log rank检验显示两组间差别具有显著的统计学意义 (P <0 .0 5 )。结论 :淋巴结结外转移的N2 患者预后不良。对手术中纵隔淋巴结活检冰冻病理证实转移灶局限在淋巴结内者 ,可采取根治性切除 ;对于淋巴结转移已突破外膜者 ,手术应该以姑息切除为主要目的     

Skipping Metastasis to Mediastinal Lymph Nodes in Non-small Cell Lung Cancer: A Clinical Study on the Reasonable Extent of Dissection

1　ＩｎｔｒｏｄｕｃｔｉｏｎＭｅｔａｓｔａｓｉｓｔｏｍｅｄｉａｓｔｉｎａｌｌｙｍｐｈｎｏｄｅｓｗｉｔｈｏｕｔｉｎｖｏｌｖｅ ｍｅｎｔｏｆｔｈｅｈｉｌａｒｎｏｄｅｉｓｄｅｆｉｎｅｄａｓｓｋｉｐｐｉｎｇｍｅｔａｓｔａｓｉｓ(ｓｋｉｐｐｉｎｇＮ2 ) [1] ,ｗｈｉｃｈｗａｓｆｏｕｎｄｉｎ 7% 37%ｏｆｔｈｅｒｅ ｓｅｃｔｅｄＮ2 ｐａｔｉｅｎｔｓ[2 ,3 ] .ＳｋｉｐｐｉｎｇＮ2ｈａｄａｎｉｍｐｏｒｔａｎｔｐｌａｃｅｉｎｍｅｄｉａｓｔｉｎａｌｎｏｄａｌｄｉｓｓｅｃｔｉｏｎ .Ｈｏｗｅｖｅｒ,ｆｅｗｓｔｕｄｙｗａｓｐｕｂｌｉ…     

可手术非小细胞肺癌淋巴结转移特点及其临床意义

目的：分析可手术非小细胞肺癌（non-small cell lung cancer ,NSCLC ）区域淋巴结的转移特点,探讨其在手术淋巴结清扫范围的选择以及术后放射治疗靶区勾画中的意义。方法：回顾性分析浙江省肿瘤医院2005年1 月至2010年12月810 例NSCLC 患者的临床资料,分析区域各组淋巴结转移频度以及肿瘤原发病灶与区域淋巴结转移部位的相关性。结果：NSCLC 区域淋巴结转移与患者年龄、肿瘤大小、组织学类型及肿瘤部位相关（P 值分别为0.013、0.000、0.009 和0.000）。 不同肿瘤原发部位有不同的淋巴结易转移区域。结论：左肺原发肿瘤中病灶大、组织学类型为腺癌的患者易发生区域淋巴结转移。非小细胞肺癌在纵隔淋巴结的转移中,右上肺癌主要转移至上纵隔2～4 区;右中肺和右下肺癌主要转移至上纵隔2～4 区、隆突下;左上肺癌主要转移至上纵隔2～4 区、主动脉弓下;左下肺癌主要转移至动脉弓下及隆突下。在手术选择淋巴结清扫范围及术后放射治疗靶区勾画时应特别注意这些淋巴结转移频度较高的区域。     

非小细胞肺癌的淋巴结转移相关因素及规律的探讨

  目的  探讨原发性非小细胞肺癌(NSCLC)年龄、性别、吸烟指数、肿瘤大小、病理类型、细胞分化程度与淋巴结转移的关系, 分析纵隔淋巴结转移的临床规律及分布特点。  方法  对96例非小细胞肺癌行肺切除术和淋巴结清扫术的患者进行临床病理分析。  结果  淋巴结转移与年龄、性别、吸烟指数无关, 肿瘤大小与淋巴结转移差异无统计学意义。高、中、低分化癌淋巴结转移率分别为15.8%、47.8%和59.0%, 肿瘤分化程度越低, 纵隔淋巴结转移率越高(P < 0.05)。病理类型与淋巴结转移无相关性, 鳞癌、腺癌的N₂转移率分别为13.6%、34.0%。肺腺癌较鳞癌易发生纵隔淋巴结转移(P < 0.05)。中心型肺癌与周围型肺癌纵隔淋巴结转移率差异无统计学意义(P > 0.05)。跳跃性N₂有12例, 跳跃式纵隔转移共9例。肺癌常跨区域纵隔转移, 肺下叶癌跨区域纵隔转移与肺上叶癌比较差异无统计学意义(P > 0.05)。  结论  非小细胞肺癌的淋巴结转移与细胞分化程度有密切关系, 与年龄、性别、吸烟指数、病理类型、原发肿瘤大小无关; 肺腺癌较鳞癌易发生纵隔淋巴结转移; 多数肺癌的淋巴结转移遵循由近及远、自上而下、由肺内经肺门再向纵隔的顺序转移规律; 部分纵隔淋巴结的转移呈"跳跃式"; 肺切除术时,施行系统性胸内淋巴结清扫是必要的。      

Role of skip metastasis to mediastinal lymph nodes in non-small cell lung cancer

BACKGROUND: Skip metastasis to mediastinal lymph nodes is a well-known phenomenon in non-small cell lung cancer (NSCLC). Little is reported in the literature about its clinical importance. It is still under discussion whether any prognostic differences exist between resected NSCLC with either skip metastases or continuous mediastinal lymph node metastases (N2). PATIENTS AND METHODS: We analyzed retrospectively the data of 45 patients with a pN2-stage, who underwent resection for NSCLC. Seventeen of these patients (37.8%), showing no metastatic involvement of hilar (N1) lymph nodes, were compared to the remaining 28 patients with infiltration of hilar nodes (N1) as well as N2 nodes. RESULTS: Multivariate analysis showed no statistically significant difference between the skip metastasis and the continuous N2 group regarding sex, age, histology, T- or M-status. The frequency of skip metastasis was higher in patients with a primary tumor in the upper lobe (n = 12, 71%) compared to the lower lobe (n = 5, 29%). This difference was not statistically significant. In patients with a non-continuous lymph node spread, 29 out of 119 resected mediastinal lymph nodes were infiltrated (1.7 per patient, range: 1-10). Compared to 83 metastatic involved lymph nodes out of 198 resected mediastinal nodes (three per patient, range: 1-10) in patients with involvement of N1 and N2 nodes (P = 0.034, Mann-Whitney test). The 5-year survival rate of pN2 patients with skip metastasis was 41% compared to 14% in patients with involvement of N1 and N2 nodes (P = 0.019). CONCLUSIONS: pN2 patients with mediastinal lymph node skip metastasis have a more favorable prognosis compared to pN2 patients with continuous infiltration of the regional lymph nodes. Patients with a continuous lymph node involvement show an increased number of infiltrated mediastinal lymph nodes per patient compared to patients with a non-continuous spread. Skip metastasis is an independent prognostic factor of survival. The presence of skip metastasis seems to be a unique subgroup of pN2 disease in NSCLC.     

In vivo identification of sentinel lymph nodes for clinical stage I non-small cell lung cancer for abbreviation of mediastinal lymph node dissection

BACKGROUND: We previously reported that an identification of sentinel lymph node (SN) with a techenetium-99m (99mTc) tin colloid by ex vivo counting, i.e. the radio-activity of dissected lymph nodes, was a reliable method of establishing the first site of nodal metastasis in non-small cell lung cancer [J. Thorac. Cardiovasc. Surg. 124(2002)486]. However, for SN navigation surgery, SN should be identified before lymph node dissection (in vivo) but not after that (ex vivo). In order to reduce mediastinal lymph node dissection for clinical stage I non-small cell lung cancer (NSCLC) by SN navigation surgery, the SN identifications for hilar lymph nodes by ex vivo counting, and for mediastinal lymph nodes by in vivo, were evaluated. METHODS: Intra-operative SN identification using 99mTc tin colloid was conducted on 104 patients with clinical stage I NSCLC who had had major lung resections with mediastinal lymph node dissections. The hilar SNs were identified by ex vivo counting (after lung resection) and the mediastinal SNs were identified by in vivo counting (before lymph node dissection). To evaluate the accuracy of mediastinal SN identification by in vivo counting, it was compared with the data by ex vivo counting. RESULTS: SNs were identified in 84 patients (81%). SNs were identified at the hilum by ex vivo counting in 78 patients (93%) and at the mediastinum by in vivo counting in 40 patients (48%). While 15 patients had lymph node metastases, i.e. N1 in six and N2 in nine, the SNs could be found to have metastases during operation in 13 of the 15 patients (87%). The in vivo counting of the mediastinum missed out the mediastinal SNs identified by ex vivo counting in four of the 84 patients (5%). CONCLUSION: If the hilar SNs identified by ex vivo counting and the mediastinal SNs identified by in vivo counting had no metastases, then mediastinal lymph node dissection could be abbreviated for patients with clinical stage I NSCLC.     

非小细胞肺癌纵隔淋巴结跳跃性转移的研究

目的 探讨非小细胞肺癌（NSCLC）纵隔淋巴结跳跃性与非跳跃性与非跳跃性转移的临床特点及预后的差异。方法 以1982-1994年间我院行手术治疗的176例ⅢA期有纵隔淋巴结转移的NSCLC患者为研究对象,其中53例不伴有肺门淋巴结转移,称为跳跃组;123例伴有肺门淋巴结转移,称为非跳跃组,将纵隔淋巴结分为3个区域,分析两组患者淋巴结转移范围及其与生存率的关系。结果 在跳跃组中,有49例（92.5%)纵隔淋巴结转移局限于1个区域（L1）,而在非跳跃组中有45例（36.6%),纵隔淋巴结转移扩至2或3个区域L2或L3）,跳跃组的5年生存率为29.3%,高于非跳跃组（12.2%,P=0.038),且在同一L1上,跳跃组5年生存率（32.1%)亦高于非跳跃组（15.3%,P=0.042)。结论 NSCLC患者纵隔淋巴结跳跃性转移为纵隔淋巴结转移病变中独特的一个亚群。     

Radical lymph node dissection for gallbladder cancer: indications and limitations

Radical lymph node dissection provides survival benefit for patients with pT2 or more advanced gallbladder carcinoma tumors only if potentially curative resection is feasible; it must always be considered when planning a resection or re-resection for robust patients with pT2 or more advanced gallbladder carcinoma tumors. The degree of radical lymphadenectomy depends on clinically assessed nodal status: portal lymph node dissection is limited to cN0 disease; extended portal nodal dissection is indicated for cN0 and a modest degree of cN1 disease; peripancreatic lymph node dissection with pancreaticoduodenectomy is indicated for selected cases of evident peripancreatic nodal disease and/or direct organ involvement. Extended resection with extensive lymphadenectomy should be limited to expert surgeons because it may cause serious morbidity and mortality.     

Mediastinal restaging: EUS-FNA offers a new perspective

STUDY OBJECTIVE: We hypothesized that transoesophageal endoscopic ultrasound guided fine needle aspiration (EUS-FNA) has the potential to be a valuable and accurate new diagnostic technique for mediastinal restaging in non-small cell lung cancer (NSCLC) after induction chemotherapy. The current restaging modalities either have a low diagnostic accuracy (computed tomography (CT) scan of the thorax) or they are invasive, can be technically difficult and are therefore not commonly performed (remediastinoscopy). METHODS AND PATIENTS: Nineteen consecutive patients with NSCLC and proven ipsilateral or subcarinal lymph node metastases (N2 disease) who had been treated with induction chemotherapy underwent mediastinal restaging by EUS-FNA. Patients had either a partial response (n=14) or stable disease (n=5) based on sequential CT scans of the thorax. INTERVENTIONS: EUS-FNA was performed in an ambulatory setting with biopsy of mediastinal lymph nodes (LN). No complications occurred. When EUS-FNA restaged the mediastinum as no regional lymph node metastasis (N0), surgical resection of the tumour with lymph node sampling or dissection was performed. RESULTS: The positive predictive value, negative predictive value, sensitivity, specificity and diagnostic accuracy of EUS-FNA in restaging mediastinal LN were 100, 67, 75, 100 and 83%, respectively. CONCLUSIONS AND SIGNIFICANCE: EUS-FNA qualifies as an accurate, safe and minimally invasive diagnostic technique for the restaging of mediastinal lymph nodes after induction therapy in NSCLC. In the future EUS-FNA might play an important role in the mediastinal restaging in NSCLC, particularly to identify the subgroup of down staged patients who benefit most from further surgical treatment.     

手术前PET-CT对非小细胞肺癌纵隔淋巴结转移的诊断价值

目的探讨术前PET-CT显像对非小细胞肺癌(NSCLC)纵隔淋巴结转移的诊断价值。方法选取2011年10月至2012年8月间进行手术根治或纵隔淋巴结活检的25例NSCLC患者。所有患者术前均行PET-CT检查,并根据手术或纵隔镜结果进行诊断及分期,计算PET-CT对诊断纵隔淋巴结的准确性、灵敏度、特异度、阳性预测值和阴性预测值。结果 25例患者中,纵隔淋巴结阳性率为28.0%。PET-CT对诊断纵隔淋巴结转移的准确性、灵敏度、特异度、阳性和阴性预测值分别为76.0%、57.1%、83.3%、57.1%和83.3%。3例假阴性患者的纵隔最大淋巴结短径分别为1.0、0.9和0.7cm。3例假阳性患者均为炎性增生。结论 PET-CT对NSCLC手术患者纵隔淋巴结转移的诊断灵敏度较低,特异度和阴性预测值较高。因此,PET-CT显示为阳性的纵隔淋巴结,有必要行纵隔镜检查;而阴性者则可不需行纵隔镜检查。