以多发磨玻璃影为表现肺癌的评价和处理

近年来,肺部磨玻璃影(ground-glass opacity,GGO)逐渐得到临床医生关注,GGO多数情况下呈惰性,但也可进一步发展为肺癌.肺多发GGO肺癌大部分为多原发癌(multiple primary lung cancer,MPLC),不是肺内转移癌.对于怀疑为多发GGO肺癌,治疗方式主要为手术切除,同时获得病理诊断,通过不同病灶的驱动基因检测最终明确多原发癌的诊断.手术方式可以选择亚肺叶切除或楔形切除最主要的病灶.研究表明最主要病灶的直径和病灶类型与预后明显相关,而遗留的GGO病灶是否长大、是否出现新的GGO病灶、是否所有的GGO病灶被处理对患者的预后影响小.该文旨在正确评价和处理肺多发GGO肺癌.     

肺多发磨玻璃结节处理策略的研究进展

随着多层螺旋CT技术的发展和肺癌筛查的广泛开展,肺多发磨玻璃结节(groundgrass opacity,GGO)检出率明显增高.肺多发GGO中以纯磨玻璃密度(pure ground-glass opacity,pGGO;无实性成分)结节为主,病理主要包括不典型腺瘤样增生(atypical adenomatous hyperplasia,AAH)、原位腺癌(adenocarcinoma in situ,AIS)及微浸润腺癌(minimally invasive adenocarcinoma,MIA).肺多发GGO的病理特点及处理策略与肺单发GGO有明显差异.多数临床医生对肺多发GGO缺乏了解,工作中对发现的肺多发GGO不能制定合理的随访策略及正确的手术治疗方案.     

胸腔镜手术联合PET/CT诊疗44例肺磨玻璃样病变临床分析

0 引言 在CT征象上以表现磨玻璃样(ground-glass opacity,GGO)病变为特征的肺结节目前在临床肺癌早期筛查上逐渐受到重视,手术后病理证实其与细支气管肺泡癌(bronchoalveolar carcinoma,BAC)密切相关[1].肺GGO病变在PET可能表现为假阴性[2-3],目前尚缺乏利用PET对表现为GGO的肺结节性病变进行详细研究的资料,因此本文对此作了初步探讨.     

肺局限性磨玻璃样病灶的外科处理

早期发现、早期诊断、早期治疗是提高肺癌长期生存率的关键。近年来,应用低剂量螺旋CT检查,筛查出表现为磨玻璃样病灶(ground-glass opacity,GGO)的早期肺癌。如何恰当评估、何时以及如何处理GGO是胸外科医生面临的重要课题。本组收集了北京协和医院胸外     

局限性肺部磨玻璃影对早期肺癌的诊断价值

目的研究局限性肺部磨玻璃影(f GGO)对早期肺癌的诊断价值。方法将98例行胸部CT示肺部有局限性的直径≤5 cm fGGO的患者根据病理诊断将其分为Ⅰ期肺癌组与良性病变组,比较2组病例的CT征象、不同TNM分期肺癌病例中单纯型磨玻璃影(pGGO)与混合型磨玻璃影(mGGO)的差异,并评价f GGO诊断Ⅰ期肺癌的灵敏度、特异度、预测值及诊断一致率。结果Ⅰ期肺癌与良性病变分别为63例与35例,mGGO组的恶性率(71.21%)高于pGGO组(50.00%)(P<0.05)。随着肺癌病例TNM分期的提高,pGGO的比例呈降低趋势,而m GGO的比例呈升高趋势,差异有统计学意义(P<0.05)。肺癌组fGGO呈毛刺征(93.65%)、分叶征(74.60%)及血管集束征(80.95%)的比例均高于良性病变组(分别为45.71%、31.43%、51.43%)(均P<0.05)。根据CT fGGO表现对90例患者获得了正确的诊断,总一致率为91.84%(McNemar χ~2=0.50,P=0.727),灵敏度为92.06%,特异度为91.43%。阳性预测值为95.08%,阴性预测值为86.49%。结论 fGGO是早期肺癌的重要表现,病灶出现毛刺征、分叶征或血管集束征时提示恶性可能性大。     

磨玻璃型肺癌诊治研究进展

低剂量螺旋CT筛查可以降低肺癌致死率，同时随着计算机成像技术的普及，越来越多的人在行肺CT检查时发现肺内结节，其中有一部分表现为磨玻璃样阴影。磨玻璃样结节(ground-glass opacity，GGO)在胸部CT上表现为肺密度云雾样增高，但不掩盖支气管及肺血管结构的阴影。GGO是一种非特异性表现，病因包括肿瘤、感染、局部出血或间质纤维化等。近年来，表现为局灶性GGO的早期肺癌发病率逐渐增高，特别是亚洲、女性及非吸烟患者。因此，有必要对表现为GGO的结节进行良恶性鉴别，为临床治疗制定指导决策。     

肺部磨玻璃影的诊断与治疗进展

近年来,肺部磨玻璃影(ground-glass opacity,GGO)逐渐得到了肿瘤科和胸外科医生的普遍关注.GGO是指肺部CT表现为密度轻微增加,增加程度小于实性改变,呈模糊的云雾状,并可见其内血管和支气管纹理.GGO多数情况下呈惰性,但也可进一步发展为肺腺癌,这使其治疗方案的选择颇为棘手;近年来GGO发现率的日益增加也使其关注度得到大大提升.许多报道都从组织学、放射诊断学、治疗学等多个方面对GGO的诊治进行了探讨.本文综述了近10年来学界对GGO的诊断和处理的进展,希望临床医生能更好地认识这个问题,在临床工作中收集并总结更多循证学证据,以指导未来的临床诊治方案的选择.     

日本临床肿瘤研究组肺癌外科系列研究之回顾与解读

手术切除是目前治疗早期非小细胞肺癌(NSCLC)最有效的方式。20世纪90年代以来, 由于越来越多的磨玻璃结节(GGO)被检出, 早期肺癌的病理学类型逐渐发生转变。术前薄层CT可以较好地预测GGO的恶性程度与淋巴结转移, 对影像学预测的低度恶性结节可以进行安全的局限性切除, 这使得肺叶切除术的地位受到了质疑。JCOG0201研究确定了肺腺癌的放射学非侵袭性标准以后, 日本临床肿瘤研究组(JCOG)及西日本肿瘤研究组(WJOG)陆续开展了一系列前瞻性的影像学指导研究, 以探讨早期肺癌的最佳手术方式。JCOG0804是一项单臂、非随机、验证性试验, 评估亚肺叶切除(楔形切除术和肺段切除术)在GGO为主型周围型肺癌中的有效性及安全性, 研究的主要终点是5年无复发生存率。JCOG0802/WJOG4607L是一项多中心、开放标签、Ⅲ期、随机、对照、非劣效性研究, 主要研究肺段切除术与肺叶切除术对小周围型NSCLC的非劣效性, 研究的主要终点是5年总生存率。JCOG1211也是一项非随机验证性研究, 验证肺段切除术在临床T1N0期GGO为主型肺癌中的有效性, 研究的主要终点是5年无复发生存率。J...     

肺内磨玻璃影的分子生物学研究进展

近年来,低剂量CT广泛应用于早期肺癌的筛查,肺内磨玻璃影(ground-glass opacity,GGO)的检出率逐渐升高。多数学者认为它与早期肺腺癌密切相关,其定性诊断和早期治疗对于提高早期肺癌患者的诊断率与生存率具有重要意义。关于GGO的影像学诊断、定位方法及手术方式进展国内外已有许多报道,现重点将近年来与其分子生物学方面相关的研究进展综述如下。     

肺磨玻璃结节的影像学、病理学特点及临床管理

随着CT应用于肺癌的筛查,检出了越来越多的肺癌玻璃结节（GGO）,不过这其中良恶性混杂,让人难以辨识。而本文总结了现今最新的GGO影像学及病理学特点,发现这两者之间并非绝无联系。同时我们还回顾了多个学会的最新指南,讨论了GGO的管理及随访。此外有创的活检和GGO标记后手术切除是亟待发展的领域。早期肺癌的标准治疗仍是微创的肺叶切除及淋巴结清扫术,不过近来有研究表明亚肺叶切除也有一定的可行性,这或许会引领未来肺癌的治疗方向。     

The surgical management of stage I and stage II lung cancer

There have been recent advances in the treatment of non-small cell lung cancer (NSCLC). Surgical resection remains the cornerstone in the treatment of patients with stages I and II NSCLC. Anatomic lobectomy combined with hilar and mediastinal lymphadenectomy constitutes the oncologic basis of surgical resection. The surgical data favor video-assisted thoracic surgery (VATS) lobectomy over open lobectomy and have established VATS lobectomy as a gold standard in the surgical resection of early-stage NSCLC. However, the role of sublobar pulmonary resection, either anatomic segmentectomy or nonanatomic wedge resection, in patients with subcentimeter nodules may become important.     

Surgical Outcomes of Lobectomy Versus Limited Resection for Clinical Stage I Ground-Glass Opacity Lung Adenocarcinoma 2 Centimeters or Smaller

BackgroundTo compare the surgical outcomes of patients with clinical stage I ground-glass opacity (GGO) lung adenocarcinomas with maximum diameters of ≤ 2 cm who underwent lobectomy versus limited resection.Patients and MethodsWe retrospectively reviewed cases of clinical stage I GGO lung adenocarcinoma with a diameter ≤ 2 cm that were treated via lobectomy or limited resection in our department between January 2011 and September 2018. The clinical characteristics and surgical outcomes were analyzed using a propensity score–matched comparison and a Cox regression model.ResultsA total of 552 patients were identified; 128 patients with pure GGO were excluded. Four hundred twenty-four patients met our criteria, including 242 (57.1%) who underwent lobectomy and 182 (42.9%) who underwent limited resection. No perioperative mortality occurred in either group. The overall 5-year survival rate of the entire cohort was 88%. Patients who underwent limited resection tended to have a shorter operation time, smaller blood loss volume, fewer removed nodes, and a shorter postoperative stay. However, the groups did not differ in terms of postoperative complications. Lobectomy and limited resection could lead to equivalent overall survival in patients with GGO-dominant tumor, while lobectomy showed better overall survival than limited resection in patients with solid-dominant tumor.ConclusionPatients with small GGO lung adenocarcinoma had a favorable prognosis after surgery. The oncologic surgical procedures of lobectomy and limited resection yielded comparable outcomes in patients with clinical stage I GGO-dominant lung adenocarcinomas ≤ 2 cm, while lobectomy showed better survival than limited resection in patients with solid-dominant tumor.     

局部晚期非小细胞肺癌的扩大手术治疗

目的探讨局部晚期非小细胞肺癌的外科手术治疗方法及其疗效.方法对4例局部晚期非小细胞肺癌分别施行肺叶袖状切除、肺叶袖状切除 肺动脉袖状切除(部分心包切除)、肺叶袖状切除 肺动脉袖状切除 上腔静脉部分切除、人造血管置换术.结果 4例局部晚期非小细胞肺癌均施行完全性手术切除(R0),无一例发生围手术期并发症及死亡,手术后随访期间未发现肿瘤局部复发和(或)转移.讨论非小细胞肺癌患者确诊时多数已属局部晚期病变,对该类患者施行袖状肺叶切除术、袖状肺叶切除 肺动脉袖状切除术[包括心包和(或)心房部分切除术]是较全肺切除术更为安全的手术治疗方式.对于合并上腔静脉综合征的患者,亦有可能手术治疗.诱导治疗及肺外科手术技巧的发展,使完整切除肺病变及受累的邻近结构(上腔静脉,肺动脉等)已成为可能.     

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。     

早期非小细胞肺癌外科治疗进展

 外科手术是早期肺癌治疗的首选。肺癌的标准术式是肺叶切除加淋巴结清扫。但淋巴结清扫对肺癌的治疗作用尚存争议。近年来以胸腔镜为代表的微创胸外科技术在临床广泛开展,胸腔镜肺叶切除的安全性已得到认可,但用于肺癌的外科治疗是否能达到如同开胸手术一样的功效,尚未达成共识。医学影像技术进步使更多的早期肺癌得以被发现,对于直径小于2 cm的周围型肺癌,肺段切除或楔形切除能否取代肺叶切除成为此类型肺癌的标准手术方式,还有待新的证据出现。     

Thoracoscopic lobectomy for the management of non-small cell lung cancer

Surgical resection is the primary treatment for early-stage non-small cell lung cancer (NSCLC). While open thoracotomy is the most frequently performed approach for lobectomy, minimally invasive surgical resection is a safe and viable alternative. Thoracoscopic lobectomy, also termed video-assisted thoracoscopic surgery lobectomy, is defined as the anatomic resection of an entire lobe of the lung—including mediastinal lymph node dissection—using a thoracoscope and an access incision without using a mechanical retractor and spreading of the ribs. As the procedure has evolved and been studied, thoracoscopic lobectomy has been demonstrated to be a safe and oncologically effective strategy in the surgical management of patients with stage I or II NSCLC, as well as selected patients with stage III NSCLC after induction therapy. Advantages of this approach include less postoperative pain, shorter chest tube duration and subsequent length of stay, fewer overall complications, better compliance with adjuvant chemotherapy, faster return to full activity, and greater preservation of pulmonary function.     

两种术式治疗老年Ⅰ期非小细胞肺癌的预后分析

目的:探讨不同手术方式（肺楔形切除和肺叶切除）对70岁以上Ⅰ期非小细胞肺癌患者预后的影响。方法:回顾性分析于2000年1 月至2006年1 月230 例接受手术治疗的70岁以上Ⅰ期非小细胞肺癌患者的临床资料,对其预后和影响预后的临床因素进行分析。结果:单因素分析结果显示,吸烟史、T 分期、手术方式、淋巴结清扫是患者预后的影响因素（P < 0.05）。 多因素分析提示,手术方式、T 分期、淋巴结清扫均是影响70岁以上Ⅰ期NSCLC 患者预后的独立因素（P < 0.05）。 肺楔形切除组5 年生存率42.2%（35/ 83）,肺叶切除组5 年生存率50.3%（74/ 147）,组间差异有统计学意义（P < 0.05）。 进一步分层分析T 1a 的Ⅰ期非小细胞肺癌患者,行肺楔形切除和肺叶切除的5 年生存率差异无统计学意义（51.9% vs . 53.3% ,P > 0.05）。与肺叶切除组相比,肺楔形切除组手术时间短（P = 0.035）、术中失血少（P = 0.031）、术后住院时间短（P = 0.045）。 结论:肺叶切除+ 系统性淋巴结清扫术仍是70岁以上Ⅰ期非小细胞肺癌患者首选的手术方式;T 1a 期患者行肺楔形切除可获得与肺叶切除相近的远期收益,同时肺组织损失较小,对肺功能差的高龄T 1a 期患者推荐行肺楔形切除术。      

Indication and role of the video-assisted thoracic surgery (VATS) for the primary lung cancer

With advances in diagnostic technology, small peripheral lung cancer can be readily detected. Currently, the technique of endoscopic-surgery has become available for the treatment, and also video-assisted thoracic surgery (VATS) has proved useful for the treatment or diagnosis of early lung cancer. We report here our experience in surgical therapy with VATS and summarize recent reports which have focused on VATS for NSCLC. In the field of diagnosis, needle aspiration cytology or partial resection by VATS is available for small peripheral lesions. Either can play a significant role in staging for lung cancer or clarifying an unknown pleural effusion. VATS segmentectomy or partial resection with curability is applied to select cases. VATS lobectomy in NSCLC at clinical stage I could well be acceptable based on many recent reports and our result. This may be a valuable approach and a promising treatment for clinical stage II in the near future.     

Surgery: therapeutic indications.

Although never proven to be superior in a large, prospective randomized trial, surgical resection remains the treatment of choice for early stage non-small cell lung cancer (NSCLC). In stages IA, IB, IIA, IIB and resectable IIIA surgical treatment offers the best long-term prognosis when a complete resection can be performed. Standard operations include lobectomy, bilobectomy and pneumonectomy. Whenever possible, lobectomy is the procedure of choice. Lesser resections like segmentectomy or wedge excision are rarely indicated in primary NSCLC. Specific lung parenchyma saving operations include tracheo- and bronchoplastic procedures which are indicated in selected cases of centrally located NSCLC. Extended resections include removal of lung together with another organ or structure as thoracic wall, pericardium, diaphragm or superior sulcus. En bloc excision of the involved structure is advised. Accurate peroperative evaluation will determine the extent of resection and if possible, a pneumonectomy should be avoided because of its high mortality and morbidity rate. Surgical resection after induction therapy for early stage or locally advanced NSCLC is feasible, but is often more complex and carries a higher risk, especially when a right pneumonectomy has to be performed after induction chemoradiotherapy.