电视纵隔镜在可切除非小细胞肺癌术前系统性纵隔淋巴结切除中的应用

Systematic video-assisted mediastinoscopic lymphadenectomy in the treatment of resectable non-small cell lung cancer

目的探讨应用电视纵隔镜对可切除非小细胞癌患者行术前系统性纵隔淋巴结切除的可行性。方法对56例术前检查发现有影像学纵隔淋巴结肿大的非小细胞肺癌患者，电视纵隔镜下行系统性纵隔淋巴结切除，同时记录手术时间、出血量、并发症、每例切除各组纵隔淋巴结数目。其中纵隔淋巴结阴性和单站转移的患者在术后2周行根治性肺癌手术，对2站及以上转移的患者行术前新辅助化疗2周期后行根治性手术。手术中对已行纵隔镜系统性淋巴结切除的区域再次探查，了解有无淋巴结残留。结果全组56例患者经电视纵隔镜行术前系统性纵隔淋巴结切除，耗时26—86min，平均（42±13．5）min；术中平均出血少于40m1，全组无并发症，无死亡，平均住院3天。共切除淋巴结682枚，每例5～24枚，平均（12．4±6．7）枚；发现转移淋巴结170枚。第2、4、5、7和8各组淋巴结切除率分别为54．5％、92．7％、58．2％、100％和61．8％。术后诊断分期为N。者13例，N：者42例，M者1例。纵隔淋巴结阴性13例和单站转移26例的患者在术后2周接受根治性肺癌手术，2站（包括2站）以上纵隔淋巴结转移的16例患者，先进行2周期的术前新辅助化疗，再进行根治性手术。经术中对纵隔镜淋巴结切除区域再次探查发现有5例共16枚淋巴结残留，分别分布于第2、4、7组，所有残留淋巴结切除送病理检查，结果均为阴性。因此，纵隔镜系统淋巴结切除的N2淋巴结诊断率可达100％，90．9％（50／55），患者达到完全切除。结论应用电视纵隔镜对非小细胞肺癌行术前系统性纵隔淋巴结切除安全可行，可进一步提高纵隔淋巴结诊断准确性，更加有助于针对不同患者选择个体化的治疗方案，在新辅助治疗和微创治疗中有重要作用，可深入研究以便于进一步规范肺癌个体化多学科综合治疗策略。

Objective This study was performed to assess the clinical feasibility of video-assisted mediastinoscopic lymphadenectomy in the treatment of resectable lung cancer. Methods Between March 2011 and May 2012, we retrospective- ly analyzed the data from 56 patients who underwent video-assisted mediastinoscopic lymphadenectomy（VAMLA）. In patients receiving tumour resection subsequently, radicality of the previous mediastinoscopic dissection was controlled during thoracoto- my. Results Mean operative time of video-assisted mediastinoscopic lymphadenectomy was （42..0 ＋ 13.5 ） rain （ range of 26 - 86 min）. Mean number of resected lymph nodes was 12.4 ~ 6.7 （range of 5 -24 ）. In video-assisted mediastinoscopic lymph- adenectomy, the rates of lymph node dissection of stations 2,4,5,7,8 were 54.5% , 92.7% , 58.2% , 100% , 61.8% , re- spectively, there was no operative mortality and morbility. 90.9% patients achieved radical dissection. Conclusion Video-assisted mediastinoscopic lymphadenectomy is a clinically feasible procedure and provides more accurate staging of mediastinal node in lung cancer patients. It also plays an important role in minimal invasive surgery and neoadjuvant therapy.