术后病理N2（ⅢA）期非小细胞肺癌的全胸腔镜肺叶切除术疗效

Outcomes of unexpected pathologic N2 disease after total video-assisted thoracic surgery Iobectomy for non-small cell lung cancer

目的探讨术后发现病理N2（ⅢA）期非小细胞肺癌全胸腔镜肺叶切除术治疗的疗效。方法回顾性分析35例（10．1％，35／348例）、接受全胸腔镜肺叶切除术、术前临床分期Ⅰ期而术后意外发现病理N2阳性的非小细胞肺癌患者的临床资料，总结其临床特征、术后短期疗效、复发模式以及中期预后。结果全组无围手术期死亡。26例直接行肺叶切除，9例先行楔形切除、后行肺叶切除。所有患者完成RO切除，中位手术时间190min，中位术中出血量200ml。术中清扫N2站纵隔淋巴结中位4站和10个淋巴结，其中转移阳性中位1站和2个淋巴结，有18例为单站N2淋巴结转移。术后中位胸腔引流8天，中位住院11天。12例出现并发症15例次，均经对症治疗后好转。所有患者按规范接受4个疗程含铂双药方案辅助化疗。患者均随访1—55个月，中位值23个月。至随访期末（2011年4月），25例生存，1年和2年总生存率分别为80．9％和67．9％，未达到中位OS。16例患者术后复发，其中局部复发5例，远处转移11例。1年和2年无瘤生存率分别为71．9％和44．2％。中位无瘤生存时间（DFS）20个月（95％可信区间8．1～31．9个月）。将患者按单站或多站N2转移分为两个亚组进行分层分析，结果显示，单站N2阳性和多站N2阳性患者的1年、2年总生存率分别为87．7％、78．9％和67．6％、59．1％。1年、2年无瘤生存率分别为88．9％、49．4％和55．3％、39．5％。中位DFS分别为23个月（95％可信区间8．1～31．9个月）和16个月（95％可信区间2．9～29．0个月），单站N2阳性患者的预后好于多站N2阳性患者。结论对于术前经仔细分期无N2淋巴结转移的NSCLC患者，只要技术可行，应积极行全胸腔镜肺叶切除术，即使术后病理证实存在纵隔N2淋巴结转移，多数也是微小转移或者单站转移，亦可以达到根治手术要求，获得令人满意的疗效。

Objective To assess early and medium outcomes of pathologic N2 disease unexpectedly detected in patients undergoing total video-assisted thoracic surgery lobectomy for non-small cell lung cancer. Methods Between Sep. 2006 and Dec. 2010, 348 patients with Non-small cell lung cancer underwent total video-assisted thoracic surgery lobectomy, and within them, 35 （10.1% ） were found to have pathologic N2 disease after operation. We retrospectively reviewed the clinical and pathologic features of patients with unexpected N2 disease after video-assisted thoracic surgery lobectomy and their early and medium outcomes, including survival and recurrence pattern. Results No perioperative mortality was noted. 26 patients received a lobectomy directly, and the other 9 patients after a wedge resection. All the patients had R0 resection. The medium operation time was 190 minutes and medium blood loss was 20Oral. The medium stations and numbers of dissected N2 lymph nodes in operation were 4 and 10, respectively. And the medium stations and numbers of metastatic N2 Lymph nodes were 1 and 2, respectively. Among patients with pathologic N2 disease, 18 （51.4%） had single-station involvement. The median duration of chest tube placement was 8 days. The median length of hospital stay was 11 days. 15 complications occurred in 12 （ 34.3% ） patients. All of the patients underwent adjuvant chemotherapy with platinum postoperatively. The median follow-up time was 23 months. The 1- and 2-year overall survival （OS） was 80.9% and 67.9%, and the medium OS was not reached. During follow-up, 16 （45.7 % ） patients had a recurrence. The pattern of recurrence was locoregional in 5, distant in 11. The1- and 2-year disease-free survival （DFS） was 71.9% and 44.2%, and the medium DFS was 20 months （95%, 8.1 to 31.9 months）. Divided the patients with pathologic N2 disease into two groups considering single-station involvement or not, the 1- and 2-year OS and DFS for the single-station group and for the multiple-station group were 87.7% , 78.9% ; 88.9% , 49.4% and 67.6%, 59.1% ; 55.3%, 39.5%. The medium DFS for both the two groups was 23 and 16 months respectively. Con- dusion For non-small cell lung cancer with NO disease confirmed by an exactly preoperative staging workups, if it is feasible in technology, a total video-assisted thoracic surgery lobectomy should be recommended. Even if N2 lymph node metastasis is unexpectedly detected postoperatively, the metastasis was mostly micro- or single-station involved, and a similar outcome with conventional thoraeotomy can be achieved.