分检肺段及亚段淋巴结对肺癌病理分期准确性的影响

目的 探讨肺段及亚段淋巴结在肺癌手术中的阳性检出率及对病理分期的影响.方法 此项前瞻性研究入选自2007年2月至2008年2月北京肿瘤医院胸外二科收治的90例肺癌手术切除病例,分别进行肺门(10组)、叶间(11组)、肺叶(12组)、肺段(13组)及亚段(14组)淋巴结分站检测,结合临床资料进行统计学分析.结果 (1)全组淋巴结清扫中位数29(11～50)枚,纵隔淋巴结清扫中位数17(6～35)枚,10～14组淋巴结清扫中位数12(2～26)枚,13～14组淋巴结清扫中位数4(1～17)枚.全组中10组、11组、12组、13+14组淋巴结转移率分别为12.2%、6.7%、23.3%和38.9%.(2)全组中无淋巴结转移(NO)患者42例,肺门及肺内淋巴结转移(N1)27例(其中12例仅出现13～14组转移,15例为10～12组转移或与13～14组转移并存).如果13～14组淋巴结漏检,NO期诊断准确率仅77.8%(42/54),而N1期漏诊率达44.4%(12/27).(3)33例≤3 cm的外周型肺癌中,如果仅行肿瘤所在段的肺段切除术,12～13组漏检率达12.1%(4/33).如果行更小范围的楔形切除术,12～14组淋巴结漏检率达到18.2%(6/33).结论 肺段及亚段淋巴结在肺癌转移过程中占据相当的比例,需要进行这两组淋巴结的分检以提高分期诊断的准确性.此外,局限性的肺切除术应严格指征,并规范第一站淋巴结的清扫工作.

Role of pulmonary segmental and sub-segmental lymph nodes in pathological staging of lung cancer

Objective To investigate the metastatic rate of segmental and/or sub-segmental lymph nodes and their roles in pathological staging after a major pulmonary resection. Methods This prospective study recruited 90 cases of pulmonary resection performed at our department from February 2007 to February 2008. Hilar lymph nodes (No. 10), interlobar nodes (No. 11), lobar nodes (No. 12) , segmental nodes (No. 13) and subsegmental nodes (No. 14) were resected and their clinic data analyzed. Results (1) The median number of total lymph nodes harvested, mediastinal nodes, nodes from No. 10-14 and nodes from No. 13-14 were 29 (11-50) , 17 (6-35) , 12 (2-26) and 4 (1-17) respectively. Lymph node metastatic rate from No. 10, No. 11, No. 12, No. 13 + 14 were 12. 2% , 6. 7% , 23. 3% and 38. 9% respectively. (2) Forty-two cases of NO and 27 cases of N1 were diagnosed in this group. The N1 subgroup included 12 cases of No. 13-14 metastasis solely and 15 cases of No. 10-12 and No. 13-14 metastasis simultaneously. If an analysis of No. 13-14 was omitted, the diagnostic accuracy of NO could only reach 77. 8% and 44. 4% cases would be under-staged from Nl. (3) In 33 cases of peripheral lung cancers smaller than 3 cm in diameter, 12. 1% of metastatic lymph nodes from No. 12-13 would be left in the original place if a segmental resection was performed. Similarly, 18. 2% of metastatic lymph nodes could be neglected for wedge resection cases. Conclusion Metastasis to segmental or subsegmental lymph nodes accounts for a large part of lung cancer patients. Therefore an analysis of these nodes can improve the accuracy of pathological staging. Secondly, limited pulmonary resection needs to follow a strict indication in consideration of the potential metastasis to segmental or subsegrnental lymph nodes in peripheral small lung cancers.