I期肺腺癌VATS肺叶切除与亚肺叶切除预后比较

背景与目的美国国立综合癌症网络（National Comprehensive Cancer Network, NCCN）指南推荐,大部分可手术切除的肺癌首选电视辅助胸腔镜手术（video-assisted thoracoscopic surgery, VATS）解剖性肺叶切除。而研究证实肺段切除I期肺癌对肺功能的保护优于肺叶切除。目前,临床上对I期肺腺癌VATS亚肺叶切除能否获得与肺叶切除同等疗效仍未确定,现分析两种手术方式治疗I期肺腺癌预后的比较。方法回顾性研究2009年1月-2011年12月广州医科大学附属第一医院收治的I期肺腺癌患者,其中VATS肺叶切除222例,亚肺叶切除36例;对两组患者使用倾向评分匹配（propensity score matching, PSM）,比较两组患者的临床病理特征及生存预后。结果两组匹配患者35例,匹配后VATS肺叶切除组与亚肺叶切除组的术后无病生存期（disease free survival, DFS）分别为49.3个月、42.7个月,差异无统计学意义（P=0.137）;两组术后总生存期（overall survival, OS）分别为50.3个月、49.0个月,差异无统计学意义（P=0.122）。分期分层结果示,Ia期肺叶切除和亚肺叶切除两组术后DFS差异无统计学意义;而Ib期肺叶切除和亚肺叶切除两组术后DFS差异有统计学意义。结论 Ia期肺腺癌VATS亚肺叶切除的生存预后不亚于肺叶切除,Ib期肺腺癌建议选择VATS肺叶切除治疗。     

外周型孤立性肺结节的诊断和外科治疗

目的探讨外周型孤立性肺结节（solitary pulmonary nodule,SPN）的诊断方法和外科治疗策略。方法回顾性分析北京友谊医院胸外科2002年至2009年手术治疗的90例外周型SPN的临床病理资料。结果（1）SPN的术前诊断：在各种诊断方法中,CT引导肺穿刺活检诊断肺癌的准确度达85.7%,Kappa值为0.711;SPECT检查的准确度达93.3%,Kappa值为0.842。（2）外科治疗方法：全部病例先采用胸腔镜辅助下病灶楔形切除,行术中快速冰冻病理检查。如为恶性,则行肺叶切除和纵隔淋巴结清除术。（3）术后病理报告：良性病变和肺癌各占50.0%（45/90）。45例肺癌中,肺腺癌占60.0%（27/45）,肺泡细胞癌占28.9%（13/45）,其中31.1%（14/45）合并纵隔淋巴结转移（N1）,已非早期肺癌。结论SPECT检查是鉴别外周型SPN良恶性的首选无创诊断方法,对可疑肺癌的SPN应积极手术治疗。胸腔镜辅助、术中快速冰冻病理指导下的微创手术,是符合专家共识意见的、外周型SPN的主要治疗策略。     

ⅠA期肺腺癌手术方式的研究进展

目前,早期肺癌的标准术式以各类指南推荐的解剖性肺叶切除联合系统性淋巴结清扫术为主。随着人们健康意识的提高以及低剂量螺旋CT(low-dose computed tomography,LDCT)的普及,越来越多的外周型小结节被发现,这些结节的病理组织学多为肺腺癌。近年来,外科治疗技术不断向精准化、微创化方向发展。针对外周型小结节,外科手术方式也在不断发展,其目的在于保留更多肺组织和肺功能的同时,达到对肿瘤的精准切除。本文针对ⅠA期肺腺癌术前影像学、手术方式、淋巴结清扫方式、术中冰冻、病理亚型及新的病理分级系统对ⅠA期肺腺癌的诊断、治疗及预后影响进行综述。     

胸腔镜治疗肺部微小结节（129例报告）

背景与目的影像技术的发展导致肺部微小结节尤其是肺磨玻璃结节（ground-glass opacity, GGO）检出逐年增多,但术前定性困难。本研究探讨肺部微小结节的临床诊断及微创手术治疗的必要性和可行性、病理诊断,微创切除及淋巴结切除的手术方式。方法对2013年12月-2016年11月接受电视胸腔镜手术（video-assisted thoracic surgery, VATS）治疗并有明确病理诊断的共129例患者的临床资料回顾性分析。所有患者术前行薄层计算机断层扫描（computed tomography, CT）扫描,其中21个微小结节术前行CT引导下Hook-wire定位,并根据病理性质及患者身体状况采用不同手术方式。结果共129个微小结节,实性结节（solid pulmonary nodule, SPN）37个,恶性比例是24.3%（9/37）,术后病理结果为：肺原发性鳞状细胞癌3个,浸润性腺癌（invasive adenocarcioma, IA）3个,转移癌2个,小细胞肺癌（small cell lung cancer, SCLC）1个,错构瘤16个,其他炎症等良性病变12个;49个混合性GGO（mixed ground-glass opacity, mGGO）的恶性比例是63.3%（31/49）,术后病理结果为：IA 19个,微浸润腺癌（micro invasive adenocarcioma, MIA）6个,原位腺癌（adenocarcioma in situ, AIS）4个,非典型性腺瘤样增生（atipical adenomatous hyperplasia, AAH）1个,SCLC 1个,炎症等良性病变18个;43个纯GGO（pure ground-glass opacity, pGGO）的恶性比例是86.0%（37/43）,术后病理结果为：AIS 19个,MIA 6个,IA 6个,AAH 6个,炎症等良性病变6个;GGO总的恶性比例是73.9%（68/92）。52个良性病变均采用VATS肺楔形切除;原发性非小细胞肺癌（non-small cell lung cancer, NSCLC）共73例,VATS肺叶切除和淋巴结清扫33例,VATS肺楔形切除和选择性淋巴结切除6例,VATS肺段切除和选择性淋巴结切除6例,VATS肺楔形切除28例;2个转移癌和2个SCLC,采用VATS肺楔形切除术。另有6例患者术中冰冻病理存在误差,其中2例选择二次手术行肺叶切除和淋巴结清扫。45例有淋巴结病理结果NSCLC只有两例以SPN为表现的IA出现纵隔淋巴结转移,其余均未出现淋巴结转移。术后随访1个月-35个月,平均（15.1±10.2）个月,无复发及转移。结论肺部微小结节尤其是GGO,是恶性病灶的概率大,应积极外科处理;围手术期应与患者及家属充分告知冰冻病理结果存在误差可能性,避免医疗纠纷。     

15例成人型肺母细胞瘤临床分析

目的：探讨成人型肺母细胞瘤临床特点、病理特征、诊断和治疗。方法：回顾性分析1990年8月～2006年4月期间15例成人型肺母细胞瘤的临床和病理资料。结果：全组均行手术治疗，其中肺叶切除9例，双叶切除2例，肺段切除1例，肺叶切除及支气管成形1例，肺叶切除及血管成形术1例，全肺切除1例：术前诊断为肺癌11例；良性肿瘤2例，间叶源性恶性肿瘤1例和肺母细胞瘤1例。免疫组化示6例CK（＋）、EMA（＋），5例Vim（＋），1例S100（＋）。结论：成人型肺母细胞瘤是一种少见的含有类似于分化好的胎儿腺癌的原始上皮成分和原始间叶成分的双向性肿瘤．该病临床症状无特征性，术前确诊极为困难，应结合临床表现和形态学及免疫组化标记综合考虑。本病应首选手术治疗．彻底切除是手术的关键。治疗以肺叶切除加纵隔淋巴结清扫术为主，本病恶性度高，易复发和转移，预后不佳．     

肺黏液腺癌伴发气道播散的相关因素及预后分析

目的:研究伴有气道播散（spread through air spaces,STAS）的肺黏液腺癌临床病理特征,揭示影响肺黏液腺癌发生STAS的相关因素,分析STAS阳性对肺黏液腺癌患者预后的影响,并探究STAS阳性患者肺组织切除的合理范围。方法:收集2017年3月至2021年9月术后病理确诊的214例肺黏液腺癌患者,根据病理结果是否存在 STAS,将其分为STAS阳性组（48例）和STAS阴性组（166例）,通过分析患者的临床病理特征来揭示影响肺黏液腺癌发生STAS的因素及STAS阳性对患者生存的影响,并进一步探讨STAS阳性患者肺组织切除范围和生存之间的关系。结果:肺黏液腺癌STAS阳性与肿瘤T分期具有明显相关性,而与患者性别、年龄、吸烟、饮酒、肿瘤家族史、病理TNM分期、肿瘤位置等因素无关。STAS阳性影响患者的术后生存,STAS阳性组患者术后生存劣于STAS阴性组。STAS阳性对患者术后生存的影响与肺组织切除范围有关,行亚肺叶切除患者术后生存STAS阳性组劣于STAS阴性组,而行肺叶切除患者STAS的发生不影响术后生存。结论:肿瘤的大小是影响肺黏液腺癌STAS阳性的重要因素,STAS阳性影响患者的术后生存,STAS阳性患者术后生存受益于足够的切除范围。     

病理亚型在Ⅰ期肺腺癌手术方式选择中作用的研究进展

摘 要：诊断技术的进步使越来越多的Ⅰ期肺腺癌被早期发现。手术切除是Ⅰ期肺腺癌的首选治疗方式。2011年,新的肺腺癌病理亚型分类标准由国际肺癌研究会/美国胸科学会/欧洲呼吸学会提出。2015年,气道内播散这一新的病理学特征被引入最新版的WHO分型。近年来的研究显示病理亚型在影响Ⅰ期肺腺癌患者预后的同时对手术方式选择也有重要的指导作用。既往回顾性研究提示术中冰冻病理在诊断肺腺癌病理亚型方面有着较好的准确性,未来可以用于指导Ⅰ期肺腺癌手术方式的选择。     

肺叶切除术与肺楔形切除术治疗Ⅰb期老年非小细胞肺癌患者的疗效比较

目的:探讨肺叶切除、肺楔形切除两种手术方式治疗Ⅰb期老年非小细胞肺癌（NSCLC）患者的疗效。方法:收集130例NSCLC患者为研究对象,根据手术方式的不同,将患者分为肺叶切除组与肺楔形切除组,比较两组患者的预后差异。结果:与肺楔形切除组相比,肺叶切除组患者的手术时间、胸管引流时间明显更长,失血量更多,差异具有统计学意义（P＜0.05）,但两组患者的术后并发症发生率、并发症类型、住院时间无明显差异（P＞0.05）。肺叶切除组、肺楔形切除组的总体生存率分别为76.9%（70/91）、82.1%（32/39）,复发率分别为32.9%（30/91）、38.5%（15/39）,差异均无统计学意义（P＞0.05）。病理分级、病理类型、T分期、胸膜侵犯是影响患者5年生存率的独立性危险因素（P＜0.05）,非腺癌类型、存在胸膜侵犯、病理分级越低、T分期越高,患者的5年生存率就越低。病理分级、病理类型、T分期是影响患者复发率的独立性危险因素（P＜0.05）,非腺癌类型、病理分级越低、T分期越高,患者的复发率越高。结论:对Ⅰb期老年NSCLC患者,肺楔形切除可在保留更多肺组织的基础上取得与肺叶切除相似的远期生存率及复发控制率,值得临床推广。     

82例肺部炎性假瘤的外科治疗

目的探讨肺部炎性假瘤的临床特点、诊断和治疗。方法回顾我院自1995年1月至2005年1月期间收治82例肺部炎性假瘤患者的临床资料。结果全组患者均行手术治疗且病愈出院,术前诊断为炎性假瘤32例,结核球12例,肺癌12例,错构瘤7例,肺部占位病变性质待定19例;行肺叶切除59例（80.0%）,肺叶楔型切除16例（19.5%）,肺段切除6例（7.3%）,全肺切除1例（1.2%）。结论肺炎性假瘤是肺实质内的增生性肉芽肿,由于其临床表现和影像学特征缺乏特异性,诊断困难,误诊率高,常误诊为肺癌,有必要提高对本病的认识。治疗原则仍为手术治疗,术中常规组织冰冻检查是决定手术方式的关键,手术应尽可能保留正常肺组织。     

肺结核合并肺癌患者手术治疗的疗效及预后分析

目的:探讨肺结核合并肺癌的临床特征及对手术治疗疗效的影响。方法:回顾性分析2014年01月至2018年06月西安市胸科医院胸外科手术治疗的53例患者的临床资料,其中观察组17例为肺结核合并肺癌,对照组36例为肺癌,术后随访至2019年06月。统计分析两组患者的性别、年龄、症状、吸烟情况、肿瘤标志物、手术情况以及术后生存期等相关指标。结果:两组性别、年龄、症状、肿瘤标志物、结核感染T细胞检验、结核抗体、肿瘤位置、吸烟指数、体力状况评分、手术时间、术中出血量、住院日、病理类型、病理分期、术后并发症均无显著差异（P＞0.05）。两组术前明确诊断率（47.1% vs 27.8%,P=0.382）差异无统计学意义;两组手术方式［（常规开胸9例,胸腔镜6例,中转开胸2例） vs （常规开胸10例,胸腔镜25例,中转开胸1例）,P=0.043］、手术切除范围［（亚肺叶3例,肺叶3例,肺叶及淋巴结清扫11例） vs （亚肺叶1例,肺叶1例,肺叶及淋巴结清扫34例）,P=0.021］、切口长度［15.0 cm（6.5,23.5）cm vs 6.5 cm（5.0,11.5）cm,P=0.006］、术中冰冻病理确诊率（17.6% vs 63.9%,P=0.000）差异具有统计学意义。两组术后1年、3年、4年生存率无显著差异（Log-rank test χ2=0.091,P=0.763）。结论:肺结核合并肺癌术前明确诊断率低,术中冰冻病理送检率低,术中易漏诊肺癌,根治性切除率低;肺结核合并肺癌手术治疗效果较好,预后与单纯肺癌无显著差异。     

The changing histopathology of lung cancer: a review of 1682 cases.

We have reviewed the histopathology of lung cancer patients seen over the past 13 years at RPMI. Assessment of this data indicates that adenocarcinoma is becoming progressively more prevalent as related to the other forms of lung cancer. Factors which in part may account for this increased prevalence are: 1) changes in criteria for reading histopathology of lung cancer, particularly since 1967; 2) the increased incidence of lung cancer among the female population who have a propensity for adenocarcinoma; and 3) occupational and environmental factors. In 1974 adenocarcinoma for the first time became the most prevalent type of lung cancer at RPMI. Whatever the reason, if our data are truly representative of a national trend, adenocarcinoma will soon become the most prevalent type of lung cancer in the United States. This fact may result in an increasing death rate since the present 18-month survival rate for adenocarcinoma is substantially less than for squamous cell carcinoma, which has in the past been the prevalent form of the disease. As the smoking habits of women more closely approximate those of men, we expect that the incidence and mortality of lung cancer will prove to be quite similar in both sexes.     

TTF-1在小细胞肺癌和肺腺癌中的表达及其临床意义

目的:探讨甲状腺转录因子-1（TTF-1）在小细胞肺癌(SCLC)和肺腺癌中的表达及其临床意义。方法:采用免疫组化SP法检测79例SCLC组织和270例肺腺癌组织中TTF-1的表达情况,统计患者的临床资料,分析TTF-1表达与临床特征的相关性,采用Kaplan-Meier曲线对随访数据进行预后分析。结果:SCLC（P＜0.001）和肺腺癌（P＜0.001）组织中TTF-1的表达率均显著高于癌旁肺组织,SCLC组织中TTF-1的阳性表达率明显高于肺腺癌组织（P=0.007）。SCLC组织中TTF-1的阳性表达水平与术前血清神经元特异性烯醇化酶（NSE）水平呈正相关（P=0.007）,TTF-1表达阴性的患者,中位生存期明显短于表达阳性的患者（19.639个月 vs 38.754个月,P=0.043）。肺腺癌组织中TTF-1的阳性表达水平与区域淋巴结转移程度（P=0.046）、术前血清癌胚抗原（CEA）水平（P=0.016）呈正相关,TTF-1的表达水平与中位生存期无关（P=0.167）。 SCLC预后独立危险因素有术前血清NSE升高和TTF-1阴性表达;肺腺癌预后独立危险因素是区域淋巴结转移。 结论:TTF-1可作为SCLC和肺腺癌鉴别诊断的分子标志物,可能对SCLC患者的预后有一定的指导意义。     

Long-term survival in three patients with metastatic non-small cell lung cancer treated with gefitinib

Gefitinib, a tyrosine kinase inhibitor of epidermal growth factor receptor (EGFR), produces radiographic regression and symptom relief in patients with refractory advanced non-small cell lung cancer. However, it remains controversial whether gefitinib improves patient survival. We report three cases of refractory metastatic non-small cell lung cancer who have survived approximately 3 years since they first started gefitinib. These long-term survivors were Japanese female non-smokers with adenocarcinoma, who often had multiple lung metastases and were effectively re-treated with gefitinib. One patient had a surgical specimen available for DNA extraction and showed deletions in exon 19 of EGFR. Our experience suggests that gefitinib may improve long-term survival in selected patients. Further studies are required to identify biomarkers downstream of the EGFR mutations that are involved in multiple lung metastases and which could identify those patients who may benefit from gefitinib re-treatment.     

Lung cancer among Chinese women

A case-control study involving interviews with 672 female lung cancer patients and 735 population-based controls was conducted to investigate the high rates of lung cancer, notably adenocarcinoma, among women in Shanghai. Cigarette smoking was a strong risk factor, but accounted for only about one-fourth of all newly diagnosed cases of lung cancer. Most patients, particularly with adenocarcinoma, were life-long non-smokers. The risks of lung cancer were higher among women reporting tuberculosis and other pre-existing lung diseases. Hormonal factors were suggested by an increased risk associated with late menopause and by a gradient in the risk of adenocarcinoma with decreasing menstrual cycle length, with a 3-fold excess among women who had shorter cycles. Perhaps most intriguing were associations found between lung cancer and measures of exposure to cooking oil vapors. Risks increased with the numbers of meals cooked by either stir frying, deep frying or boiling; with the frequency of smokiness during cooking; and with the frequency of eye irritation during cooking. Use of rapeseed oil, whose volatiles following high-temperature cooking may be mutagenic, was also reported more often by the cancer patients. The findings thus confirm that factors other than smoking are responsible for the high risk of lung cancer among Chinese women and provide clues for further research, including the assessment of cooking practices.     

Carbohydrate status detecting by PNA is changeable through cancer prognosis from primary to metastatic nodal site: A possible prognostic factor in patient with node-positive lung adenocarcinoma

Carbohydrates antigens in cancer cells are considered to be important molecules, which may play a critical role for metastasis. To elucidate the prognostic relevance of the expression of peanut agglutinin (PNA) binding carbohydrates in patients with lung adenocarcinoma, we investigated the PNA binding carbohydrates immunohistochemically in both of primary tumors and involving nodal lesions. A total of 62 patients with node-positive primary lung adenocarcinoma, who had undergone complete resection and regional nodes dissection were subjected to this study. There were no significant correlations between PNA staining rates and clinicopathological variables. The survival rate of patients who had positive PNA staining in both of primary tumor and nodal lesion was significantly higher than those of patients in the other groups. Furthermore, the loss of the staining rate of PNA was an independent prognostic factor beside the lymphatic vessel invasion using multivariate analysis. The expression of PNA binding carbohydrates in tumor tissue and nodal lesion would be a novel significant prognostic factor for patients with node-positive lung adenocarcinomas.     

Estrogen adversely affects the prognosis of patients with lung adenocarcinoma

Estrogen has been postulated to contribute to the development and progression of lung cancer. We examined the epidemiologic evidence, explored the characteristics of estrogen receptors (ER) in lung adenocarcinoma, and investigated the effect of estrogen on lung cancer cell migration, including the signaling pathway involved. For epidemiologic evidence, a total of 1434 consecutive non‐small cell lung cancer patients who underwent standardized staging and homogenous treatment were prospectively enrolled from January 2002 to December 2008, and followed until December 2012. The possible prognostic factors to be analyzed included stage, age, gender, menopausal status, smoking history and histology. For laboratory study, lung cancer cell lines A549 and PE089 and malignant pleural effusions from the patients with lung adenocarcinoma were used. We found that the premenopausal patients had more advanced disease and a shorter survival among the never‐smoking female patients with lung adenocarcinoma. ERβ was the predominant ER in the lung cancer cell lines. We proposed a different pathway that estrogen upregulated the expression of osteopontin and then promoted cell migration through αvβ3 integrin binding and activated MEK‐ERK signaling pathway, which is a common downstream pathway with epidermal growth factor receptor (EGFR) activation. An additive effect of ER antagonists and EGFR antagonists on the inhibition of cell migration was also noted. Our results suggest that estrogen adversely affects the prognosis of patients with lung adenocarcinoma. Osteopontin contributed to the cross‐talk between ER and EGFR signaling pathways. Estrogen, with its receptor, has the potential to be a prognosticator and a therapeutic target in lung cancer.     

~(89)锶治疗不同病理类型肺癌转移性骨痛的疗效分析

 目的　研究89锶 (89Sr)治疗肺癌骨转移痛的疗效及其与肺癌病理类型的关系。方法　 4 6例肺癌骨转移痛患者 (腺癌 30例 ,鳞癌 12例 ,未分化癌 4例 )予89Sr治疗 ,追踪观察患者的骨痛缓解情况。结果89Sr治疗后骨痛得到不同程度地缓解 ,总有效率为 76 .1% ,其中对腺癌的转移性骨痛的有效率为 80 % ;对鳞癌的转移性骨痛的有效率为 75 % ,二者之间比较差异有显著性 (P <0 .0 0 1)。结论　89Sr治疗肺癌骨转移痛疗效较好 ,腺癌的疗效优于鳞癌。     

Expression of Coxsackievirus and Adenovirus Receptor in Human Lung Cancer: Possible Clinical Significance

OBJECTIVE To explore the relationship between CAR and the development of human lung cancer, as well as to provide the basis for the clinical treatment of lung cancer using an adenovirus vector-based gene therapy.METHODS CAR expression was assessed immunohisto-chemically in tumoral, paraneoplastic and normal samples from 112 lung cancer patients. At the same time, the mRNA and protein expression of CAR in 32 cases were determined by RT-PCR and Western blot. The relationship between CAR expression and clinicopathologic parameters was statistically analyzed.RESULTS There was no expression of CAR in normal lung tissue but a little in paraneoplastic tissue. The positive rate was 43% in squamous cell carcinoma, and 70% in adenocarcinoma.Both were much significantly higher than that in paraneoplastic tissue. The CAR expression level in adenocarcinoma was higher than that in squamous cell cancer, mRNA expression by RT-PCR and protein expression by Western blot were consistent with immunohistochemistry results.CONCLUSION CAR is overexpressed in human lung cancer,especially in adenocarcinoma. This data offer the reliable basis for adenovirus-mediated gene therapy of lung cancer; more important, CAR may take part in the formation or development of lung cancer; this may be exploitable for the development of antibody-directed therapy in human lung cancer.     

Epidermal growth factor receptor mutations are associated with gefitinib sensitivity in non-small cell lung cancer in Japanese

The protein-kinase family is the most frequently mutated gene family found in human cancer. Gefitinib, an ATP-competitive inhibitor of epidermal growth factor receptor (EGFR), also appears to be particularly effective in adenocarcinoma of the lung and in patients without smoking history. To determine whether lung tumors sensitive to gefitinib contained mutations within the tyrosine kinase (TK) domain of EGFR, we screened exons 18-23 of EGFR of tumors in 20 patients with non-small cell lung cancer (NSCLC) who had been treated with gefitinib. Nine (45%) tumors had TK domain mutations. All mutations were observed in adenocarcinoma. Seven (77.8%) of 9 cases with mutated types showed sensitivity to gefitinib, while no cases of 11 with wild type showed gefitinib sensitivity. Such mutations were more frequently observed in patients who had never smoked (5/8 or 62.5%) than in smokers (4/12 or 33.3%). The patients with mutations of EGFR to have a more favorable prognosis than those with wild type (p=0.033). These data show that adenocarcinomas from patients who had never smoked comprise a specific subset of patients with NSCLC sensitive to gefitinib treatment.