肺内淋巴结精准取材对肺癌患者术后N分期的影响

目的探讨非小细胞肺癌(NSCLC)患者肺内淋巴结转移情况及其对病理分期的影响。 方法选取2015年1月1日至2016年3月31日期间在天津市胸科医院胸外科接受肺叶或全肺切除及系统性淋巴结清扫术的177例肺癌患者进行分析。首先按照外科医师清扫的淋巴结常规取材进行病理诊断，得出N分期；由病理科医师再对第12、13组淋巴结进行分检精准取材，得出一个新的N分期，比较并分析前后两个N分期的差异。同时，进一步分析这两组淋巴结转移的危险因素。 结果全组患者共检出N1站淋巴结1 268枚，常规取材(第10、11组淋巴结)共检出736枚，精准取材(第12、13组淋巴结)共检出532枚。联合NSCLC的常规取材和肺内淋巴结的精准取材，患者的N1淋巴结检出的中位数为7枚(2～24枚)，与NSCLC的常规取材相差4枚(0～18枚)，N1淋巴结的检出数明显增加(P<0.001)。联合NSCLC的常规取材和肺内淋巴结的精准取材，共检出转移N1淋巴结240枚，中位转移数量为0枚(区间：0～7枚；第75百分位数：1枚；第90百分位数：3枚)，与NSCLC的常规取材相比(区间：0～5枚；第75百分位数：0枚；第90百分位数：2枚)，N1淋巴结的转移个数明显增加(P<0.001)。分层分析结果显示：第12、13组淋巴结的转移与手术方式、手术部位、病理类型、肿瘤大小以及纵隔淋巴结转移存在一定相关性(P<0.05)，但与患者的年龄、性别以及术后病理是否存在脉管癌栓无明显相关性(P>0.05)。有15例患者的N分期由于肺内淋巴结的精准取材由N0升为N1，占全组患者的8.4%。 结论常规NSCLC取材方式容易漏检N1区域的淋巴结，并且相当一部分还是转移淋巴结。因此，提倡NSCLC肺内淋巴结精准取材以提高病理分期的准确性。

Effects of special pathological examination on N staging of surgically resected non-small cell lung carcinoma

ObjectiveTo investigate the status of intrapulmonary lymph node metastasis and its impact on pathological staging in patients with non-smallcell lung cancer (NSCLC). MethodsA total of 177 patients undergoing lobectomy or pneumonectomy and systemic lymph node dissection for lung cancer inDepartment of Thoracic Surgery, Tianjin Chest Hospitalbetween January 2015 and March2016 were selected. A special pathological examination protocol on lobar lymph nodes (No. 12) and segmental lymph nodes (No. 13) surgical specimens was conducted after routine pathological examination. The N stage retrieved by special pathological examination protocol was compared with thatobtainedby routine pathological examination. In addition, the risk factors of the intrathoracic lymph node metastasis were explored. ResultsA total of 1268 N1 lymph nodes were examined, among which 736 were detected during routine pathological examination protocol and 532 were retrieved byspecial pathological examination protocol. The combination of routine pathological examination and special pathological examination provided a median of 7 N1 lymph nodes(range, 2 to 24), a significant increase from the number of N1 lymph nodes examined by routine pathological examination alone(4; range, 0 to 18)(P<0.001). The combination of routine pathological examination and special pathological examination led to detection of a total of 240 N1 lymph nodes with metastasis, with a median of zero (range, 0 to 7; 75th percentile, 1; 90th percentile, 3), and the number of detected lymph node metastasis was significantly higher than that in routine pathological examination alone(range, 0 to 5; 75th percentile, 0; 90th percentile, 2)(P<0.001). Stratification analysis showed surgical approach, tumor location, pathology type, tumor size and mediastinal lymph node metastasis had correlation with the metastasis of lobar lymph nodes(No. 12) and segmental lymph nodes (No. 13)(P<0.05), while age, sex and vascular cancer embolus did not(P>0.05). The pathological stage of 15 patients(8.4%) changed from N0 to N1 after specialpathological examination. ConclusionsRoutine pathological practice frequently leaves a large number of N1 lymph nodes unexamined, a clinically significant proportion of which harbor metastasis. The special pathological examination protocol is suggested to improve the accuracy of pathological staging of NSCLC.