cN0-pN2非小细胞肺癌行全胸腔镜肺叶切除手术初步体会

Primary outcome of completely thoracoscopic lobectomy for clinical NO and postoperatively pathological N2 non-small cell lung cancer

目的探讨术前临床分期N0术后病理分期N2的非小细胞肺癌患者行全胸腔镜肺叶切除手术的可行性。方法2006年9月至2010年1月施行全胸腔镜肺叶切除治疗非小细胞肺癌216例中术前临床分期NO患者206例，男103例，女103例；年龄29—85岁，平均（62．3±11．1）岁。按术后病理纵隔淋巴结是否转移分为pN0组（168例，无纵隔淋巴结转移）和pN2组（38例，存在纵隔淋巴结转移）。回顾性分析两组病例年龄、性别、肿瘤大小、位置、病理类型、分化程度、中转开胸、手术时间、术中出血、淋巴结清扫情况、引流时间、住院时间及并发症等围手术期数据。结果206例中肺叶切除203例，复合肺叶切除2例，全肺切除1例，手术过程顺利。无严重围手术期并发症，围手术期死亡1例（肺部感染至呼吸功能衰竭）。两组年龄、性别分布差异无统计学意义。pN0组肿瘤最大径明显小于pN2组[（2．6±1．6）cm对（3．7±1．9）cm，P=0．001]。pN0组肿瘤位于下叶者明显少于pN2组（31．0％对50．O％，P：0．026）。两组腺癌比例无统计学意义（82．7％对73．7％，P=0．181），但pN0组低分化癌比例明显低于pN2组（19．0％对42．1％，P=0．002）。两组中转开胸率（7．1％对7．9％，P=1．000）、手术时间[（196．1±53．7）min对（208．6±56．8）rain，P=0．202]、术中出血量[（253．2±247．9）ml对（279．0±183．3）ml，P=0．475]、术后引流时间[（7．7±3．2）天对（9．7±6．3）天，P=0．066]、住院时间[（10．6±4．6）天对（13．0±7．6）天，P=0．063]、并发症发生率（12．5％对21．1％，P=0．171）组间和纵隔淋巴结清扫站数[（3．1±1．2）对（3．3±1．1），P=0．237]，差异无统计学意义。pN0组纵隔淋巴结清扫枚数少于pN2组[（9．9±6．8）对（12．7±8．4）枚，P=0．038]。结论术前N0分期术后病理N2分期的非小细胞肺癌患者行全胸腔镜肺叶切除手术是安全可行的。

Objective To evaluate the feasibility of the completely thoracoscopic lobectomy for clinical NO and postoperatively pathological N2 non-small-cell lung cancer（NSCLC）. Methods From Sep. 2006 to Jan. 2010, 216 patients with NSCLC received completely thoracoscopic lobectomy in our center. Two hundred and six patients were clinical NO preoperatively（ 103 males and 103 females, median age of 62.3 years, rang 29 to 85 years）. They were divided into two groups based on postoperatively pathological staging, pNO group and pN2 group. Some perioperative factors including age, gender, tumor size, tumor location, pathological type, pathological differentiation, rate of conversion to thoractomy, operation time, blood loss,lymph node dissection,time of drainge,hospitalization and complications were studied and compared between two groups. Results There were 203 cases of lobectomy, 2 cases of composite lobectomy and 1 case of pneumonectomy. All procedures were carried out safely without serious complication except for one operative death result from respiratory failure. There were 168 cases in pN0 group and 38 cases in pN2 group. Age and gender were similar between two groups. The tumor size in pN0 group was smaller than that in pN2 group [ （2.6 ±1.6 ） cm vs （ 3.7 ± 1.9 ） cm, P = 0. 001 ]. The tumors in pN0 group were lesser appearance in the bilateral lower lobes（31.0% vs 50.0%, P =0. 026）. There was a approximate proportion of adenocarcinoma in two groups（ 82.7% vs 73.7%, P=0. 181 ）, but the proportion of poorly differentiated carcinoma in pNO group was significantly lower than that in pN2 group（ 19.0% vs 42.1%, P = 0. 002 ）. There were no differences in the rate of conversion to thoractomy （ 7.1% vs 7.9%, P = 1. 000）, operation time [ （ 196.1 ± 53.7 ） rain vs （ 208.6 ±56.8 ） min, P = 0. 202 ], blood loss[ （253.2 ± 247.9） ml vs（279.0 ± 183.3 ） ml, P = 0. 475 ], time of drainage[ （7.7 ± 3.2 ） days vs （9.7 ± 6.3 ） days, P = 0. 066 ], hospitalization [ （ 10.6 ±4.6 ） days vs （ 13.0 ± 7.6 ） days, P = 0.063 ] and complications （ 12.5 % vs 21.1%, P = 0.171 ）. The stations of mediastinal lymph node dissection were equivalent in two groups （ 3.1 ± 1.2 vs 3.3 ±1.1, P = 0. 237） , but there were fewer numbers of mediastinal lymph node dissection in pN0 greup（9.9 ±6.8 vs 12.7 ±8.4, P = 0. 038）. Conclusion Completely thoracoscopic lobectomy is a feasible surgical therapy for cN0-pN2 non-small-cell lung cancer without loss of curability.