许 博 陈献国 楼 洋 周志有
(浙江省金华市中心医院心胸外科,金华 321000)
临床研究·
胸腔镜手术治疗肺微小结节86例分析
许 博 陈献国 楼 洋 周志有
(浙江省金华市中心医院心胸外科,金华 321000)
目的 探讨胸腔镜手术在肺微小结节(直径<1 cm)诊治中的价值。 方法 回顾性分析2012年8月~2014年11月在我院行胸腔镜手术治疗的86例肺微小结节的病例资料,共100个结节。采用三孔法,术前评估结节位置,行肺楔形切除或肺段切除,术中冰冻结果回报若为良性疾病、肺泡上皮不典型增生、原位腺癌或肺转移瘤则手术结束,若为原发性肺癌则行胸腔镜肺叶切除加淋巴结清扫。 结果 86例均在胸腔镜下完成手术,无中转开胸,围手术期无严重并发症,顺利出院。术后病理示恶性肿瘤53个(53.0%)。术前CT显示直径≤5 mm的11个结节中,恶性3个(27.3%),均为原位腺癌;直径>5 mm的89个中,恶性肿瘤50个(56.2%),其中原位腺癌21个(23.6%)。 结论 胸腔镜手术治疗肺微小结节安全有效,应首选肺楔形切除和肺段切除,对于<5 mm的结节可以选择保守治疗。
肺微小结节; 胸腔镜; 原位腺癌
随着体检意识的提高及多排螺旋CT、MRI及PET-CT等检查设备的更新,直径≤1 cm的肺微小结节[1]的检出率明显升高。然而肺微小结节的诊断及治疗一直是个难题,通常采取定期影像学复查,不仅增加了病人的心理负担[2],还有可能延误治疗,使部分肿瘤病人病情进展。本研究回顾性分析2012年8月~2014年11月86例行胸腔镜手术治疗的肺微小结节的病例资料,旨在提供更合理的治疗方案。
1.1 一般资料
本组86例,男33例,女53例。年龄30~82岁,(56.0±13.2)岁。术前有症状行CT检查发现18例,其中咳嗽13例,胸痛1例,胸闷4例,其余均为无症状CT体检发现。CT提示共100个结节,其中1个结节76例,2个7例,3个2例,4个1例。结节直径4~10 mm,(7.9±1.7)mm,其中≤5 mm 11个,>5 mm 89个。结节位于右肺上叶25个,右肺中叶15个,右肺下叶12个,左肺上叶23个,左肺下叶25个。肺叶中心22个,肺外周78个。均无阻塞性肺炎、肺不张、胸腔积液、纵隔淋巴结肿大等其他病变。常规行肝胆胰脾及泌尿系彩超,头MRI,全身骨显像,未见转移征象,纤维支气管镜检查未获得阳性病理结果。70例曾行CT随访,随访时间2~14个月,(5.9±3.2)月,18例结节增大1~3 mm,(1.5±0.5)mm。
病例选择标准:所有肺微小结节。
1.2 方法
静吸复合全身麻醉,单肺通气。一般做3个切口,第7或8肋间腋中线1.5 cm切口为腔镜孔,第4或第5肋间腋前线做2~4 cm主操作孔,肩胛下角第8肋间做约0.5 cm操作孔。对于肺尖或肺表面术中容易寻找的结节,直接行肺楔形切除,切除范围距肿瘤至少2 cm;结节在肺实质内距离脏层胸膜>0.5 cm的结节,估计术中难以发现及触及,术前使用Hook-wire定位[3],方便术中寻找及完整切除。标本均送快速冰冻病理检查,结果为良性疾病、肺泡上皮不典型增生、原位腺癌或肺转移瘤则手术结束,为原发性肺癌(原位腺癌除外)则扩大手术切除范围,行肺叶切除加淋巴结清扫。对位于肺下叶背段或左肺舌段的肿瘤,楔形切除困难,或不能保证切除范围的行肺段切除;对于中央型肿瘤,行楔形切除及肺段切除都较困难且术前心肺功能良好者,直接行肺叶切除,同样根据快速冰冻病理结果,若为原发性肺癌,继续行淋巴结清扫。
86例均在胸腔镜下完成手术,行肺楔形切除40例,肺叶切除34例,肺叶联合楔形切除2例,肺段切除10例,其中联合行淋巴结清扫25例。行肺楔形切除患者中,34例由有经验的放射科医师术前采用CT引导下Hook-wire定位,术中发现脱钩2例,气胸3例。无中转开胸,术后均顺利出院,围手术期无严重并发症。手术时间(75.4±23.6)min,包括快速冰冻时间(18.0±3.6)min。手术出血量40~600 ml,平均153 ml。术后胸腔引流管留置时间2~9 d,平均3.8 d。
术后病理:100个微小结节中,肺恶性肿瘤53个,良性47个。CT提示直径≤5 mm的11个结节中,恶性3个(27.3%,均为原位腺癌),良性8个(72.7%,包括错构瘤1个,不典型增生3个,肺内淋巴结2个,炎性假瘤1个,真菌病1个;直径>5 mm的89个中,恶性50个(56.2%,包括原位腺癌21个,原位腺癌伴微小浸润18个,高分化腺癌4个,中分化鳞癌1个,高分化鳞癌2个,转移瘤4个),良性39个(43.8%,包括错构瘤3个,不典型增生14个,肺内淋巴结3个,慢性肉芽肿性炎6个,炎性假瘤4个,真菌病4个,硬化性血管瘤5个)。
对于直径≤1 cm的肺微小结节一直无明确的诊疗方案[4],其治疗的困惑主要在于诊断上的困难,由于PET-CT的费用较为昂贵,且假阳性率高,通常根据Fleischner学会肺非实性结节处理指南[5],首选定期CT复查,尤其是低剂量CT[6]。根据结节的CT特征考虑恶性可能[7],如磨玻璃征、分叶或切迹、短毛刺征、典型胸膜凹陷征,或定期随访后结节无明显变化或增大,结节内实性成分增多者,选用胸腔镜手术治疗[8,9],其目的是切除病灶明确诊断,及彻底治疗。
与传统开胸手术相比,胸腔镜手术具有创伤小、术后恢复快、住院时间短、术后并发症少等优点,且在早期肺癌的治疗中,具有同样的安全性及彻底性[10]。由于肺微小结节直径小,即便切除后也很难寻找,因此术前通过CT评估结节位置及术前采用CT引导下Hook-wire定位[4]尤为重要。肺楔形切除与肺叶切除相比有较高的局部复发率,主要与切缘阳性及肺门淋巴结未完全清扫有关[11],而胸腔镜肺楔形切除对于早期肺癌,尤其高龄、合并心肺功能不全[12,13]及肺内转移瘤者[14]具有明显的优势。根据术中冰冻结果,若为恶性,采取肺叶切除加系统性淋巴结清扫或采样。若术前CT明确结节位于下叶背段或左肺舌段,怀疑恶性可能时,术中直接行肺段切除加系统性淋巴结清扫术,因为肺段切除较肺楔形切除更符合肿瘤手术的原则,切除范围足够大,对肺实质内引流的淋巴组织可以一并切除。研究显示对于直径<2 cm的早期肺癌,肺段切除和肺叶切除的远期生存无明显差异[15],且肺段切除可以降低围手术期并发症发生率,对老年患者尤为合适[16],可以选择性应用于Ⅰa期肺癌或不易行肺楔形切除的肺转移瘤和良性结节[17,18]。然而从手术技术层面上讲,肺段切除手术难度大,而舌段切除和背段切除相对简单。对于其余肺段或跨段的结节,估计局部切除困难时可直接行肺叶切除。
肺原位腺癌生长缓慢,通常无淋巴结转移,手术切除后效果良好,若完整切除可以达到治愈,5年生存率达100%[19],通常采用胸腔镜下肺楔形切除或肺段切除,其有效率和肺叶切除相当,完全可以替代传统的肺叶切除[20]。Trails等[21]将原位腺癌和不典型腺瘤样增生共同归为癌前病变。本组术后病理肺恶性肿瘤占53%(53/100),原位腺癌占所有恶性肿瘤的45.3%(24/53)。术前CT显示直径≤5 mm的结节中,恶性占27.3%(3/11),均为原位腺癌;>5 mm的结节中,恶性肿瘤占56.2%(50/89),其中原位腺癌23.6%(21/89)。由此认为,对于直径≤5 mm的结节,即便是恶性结节,也多为原位腺癌,可以采取较为保守的治疗方案;而对于>5 mm的结节,可以按照指南[5]进行定期随访,若在短期内未消失,或结节增大,实性成分增多,应早期手术治疗,毕竟其恶性肿瘤比例较高。
综上所述,随着影像学的发展及微创外科的进步,对于肺内微小结节的诊治,可以行短期的定期随访,制定下一步治疗方案。对于直径≤5 mm的结节采取保守的治疗态度,而对直径>5 mm的结节,在定期复查后怀疑肿瘤时,应积极胸腔镜手术治疗。在手术方式的选择方面,应首选肺楔形切除和肺段切除,而不是传统的肺叶切除。
1 van’t Westeinde SC,de Koning HJ,Xu DM,et al.How to deal with incidentally detected pulmonary nodules less than 10mm in size on CT in a healthy person.Lung Cancer,2008,60(2):151-159.
2 Marcus MW,Raji OY,Field JK.Lung cancer screening: identifying the high risk cohort.J Thorac,2015,7(2):156-162.
3 谢宗涛,蔡 炜,李 芝,等.带钩钢丝CT引导下肺小结节定位在胸腔镜手术中的应用.中华胸心血管外科杂志,2013,29(12):754-756.
4 Ost DE,Gould MK.Decision making in patients with pulmonary nodules.Am J Respir Crit Care Med,2012,185(4):363-372.
5 刘士远,李 琼.Fleischner学会肺非实性结节处理指南解读.中华放射学杂志,2013,47(3):197-201.
6 Infante M,Berghmans T,Heuvelmans MA,et al.Slow-growing lung cancer as an emerging entity: from screening to clinical management.Eur Respir,2013,42(6):1706-1722.
7 Shi CZ,Zhao Q,Luo LP,et al.Size of solitary pulmonary nodule was the risk factor of malignancy.J Thorac Dis,2014,6(6):668-676.
8 Mun M,Kohno T.Video-assisted thoracic surgery for clinical stage I lung cancer in octogenarians.Ann Thorac Surg,2008,85(2):406-411.
9 Rocco G.One-port (uniportal) video-assisted thoracic surgical resections-a clear advance.J Thorac Cardiovasc Surg,2012,144(3):27-31.
10 臧 鑫,赵 辉,王 俊,等.全胸腔镜与开胸肺叶切除治疗临床Ⅰ/Ⅱ期非小细胞肺癌的多中心对比.中华胸心血管外科杂志,2014,30(5):285-289.
11 El-Sherif A,Fernando HC,Santos R,et al.Margin and local recurrence after sublobar resection of non-small cell lung cancer.Ann Surg Oncol,2007,14(8):2400-2405.
12 Cattaneo SM,Park BJ,Wilton AS,et al.Use of video-assisted thoracic surgery for lobectomy in the elderly results in fewer complications.Ann Thorac Surg,2008,85(1):231-236.
13 Whitson BA,Andrade RS,Boettcher A,et al.Video-assisted thoracoscopic surgery is more favorable than thoracotomy for resection of clinical stage I non-small cell lung cancer.Ann Thorac Surg,2007,83(6):1965-1970.
14 汪进益,洪 暄,刘 刚,等.电视胸腔镜手术治疗肺转移瘤38例报告.中国微创外科杂志,2014,14(9):805-808.
15 Okumura M,Goto M,Ideguchi K,et al.Factors associated with outcome of segmentectomy for non-small cell lung cancer long-term follow-up study at a single institution in Japan.Lung Cancer,2007,58(2):231-237.
16 杨胜利,杨 劼,古卫权,等.两孔全胸腔镜老年肺部疾病手术48例临床分析.中国微创外科杂志,2014,14(7):615-617.
17 林宗武,蒋 伟,王 群,等.胸腔镜解剖性肺段切除术20例临床分析.中国胸心血管外科临床杂志,2012,19(3):270-273.
18 Schuchen MJ,Abbas G,Awais O,et al.Anatomic segmentectomy for the solitary pulmonary nodule and early stage lung cancer.Ann Thorac Surg,2012,93(6):1780-1787.
19 Vazquez M,Carter D,Brambilla E,et al.Solitary and multiple resected adenocarcinomas after CT screening for lung cancer:histopathologic features and their prognostic implications.Lung Cance,2009,64(2):148-154.
20 Koike T,Togashi K,Shirato T,et al.Limited resection for noninvasive bronchioloalveolar carcinoma diagnosed by intraoperative pathologic examination.Ann Thorac Surg,2009,88(4):1106-1111.
21 Trails WD,Brambilta E,Noguchi M,et al.International association for the study of lung cancer/American Thoracic Society/European Respiratory Society.International muhidisciplinary classification of lung adenocarcinoma.J Thorac Oncol,2011,6(2):244-285.
(修回日期:2015-06-05)
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Video-assisted Thoracic Surgery for Small Lung Nodules: Analysis of 86 Cases
XuBo,ChenXianguo,LouYang,etal.
DepartmentofCardiacandThoracicSurgery,JinhuaMunicipalCentralHospital,Jinhua321000,China
Correspondingauthor:ChenXianguo,E-mail:xgchen@163.com
Objective To explore the value of video-assisted thoracic surgery in the diagnosis and treatment of small lung nodules. Methods We retrospectively analyzed 86 patients with 100 small lung nodules who received thoracic surgery from August 2012 to November 2014 in our hospital. After assessment of nodal position before surgery, pulmonary wedge resection or lung segment resection was performed by using a 3-port thoracoscopic surgery. If the result of the intraoperative frozen pathology showed benign pulmonary diseases, atypical adenomatous hyperplasia, adenocarcinoma in situ, or pulmonary metastases, the surgery was finished. If it was the primary lung cancer, lobectomy plus lymph nodes dissection was then performed. Results The video-assisted thoracic surgery was accomplished in all the 86 patients, without conversion to thoracotomy. No serious perioperative complications occurred. All the patients were discharged from hospital. Postoperative pathology of malignant tumor accounted for 53.0%. Among the 11 nodules less than or equal to 5 mm in diameter under preoperative CT examinations, there were 3 adenocarcinomas in situ (27.3%). Among the 89 nodules larger than 5 mm in diameter under preoperative CT scanning, there were 50 cases of malignant tumors (56.2%), including 21 adenocarcinomas in situ (23.6%). Conclusions Thoracoscopic surgery is safe and effective in the treatment of small lung nodules. The preferred operation method should be the wedge resection and segmentectomy. The nodules with diameter less than 5 mm can be treated conservatively.
Small lung nodule; Thoracoscopy; Adenocarcinoma in situ
,E-mail:xgchen@163.com
R734.2
A
1009-6604(2015)09-0824-03
10.3969/j.issn.1009-6604.2015.09.016
2015-01-24)