临床T1aN0M0肺腺癌淋巴结转移预测因素分析

Factors predicting lymph node metastasis in clinical stage T1aN0M0 lung adenocarcinomas

目的分析T1aN0M0肺腺癌患者淋巴结转移的危险因素。方法在上海市胸科医院2011年1月至2012年12月行连续手术切除的5312例非小细胞肺癌患者中，选择273例临床分期为T1aN0M0肺腺癌的患者进行回顾性分析。根据CT检查结果分为纯磨玻璃影（GGO）、GGO带有实性成分（实性成分直径〈5ram）、部分实性结节（实性成分直径≥5mm）及纯实性结节。对相关的临床资料及病理特征进行单因素和多因素分析，寻找淋巴结转移的高危因素。结果人选的273例患者均行薄层CT扫描，其中103例（37．7％）为纯GGO，118例（43．2％）为GGO带有实性成分（实性成分直径〈5mm），13例（4．8％）为部分实性结节（实性成分直径≥5mm），39例（14．3％）为纯实性结节。共有18例（6．6％）患者有淋巴结转移，N1和N2淋巴结转移者分别为11例（6．5%）和7例（4．1％）。所有纯GGO及实性成分直径〈5mm的患者术后均无淋巴结转移。多因素分析显示T1a肺腺癌患者淋巴结转移的危险因素为有症状、实性成分直径≥5mm以及癌胚抗原（CEA）水平增高者（CEA〉5ng／ml）。多因素分析也显示纯实性结节的淋巴结转移因素为空气支气管征、肿瘤大小、有症状出现以及CEA水平增高者（95％CI：2．001～5．990，P=0．035；95％CI：1．0003．980，P=0．021；95％CI：1．8872．663，P=0．020；95％CI：1．514～8．498，P=0．013）。结论临床分期为T1aN0M0的肺腺癌患者，如果影像学表现为实性成分直径〈5mm或表现为纯GGO者无淋巴结转移，应避免淋巴结清扫。但是对于临床上纯实性结节或者实性部分直径〉5mm者，特别是CEA〉5ng／ml或者出现临床症状者，应该行系统性淋巴结清扫。

Objective To determine the risk factors of lymph node metastasis in clinical stage TlaNOM0 lung adenocarcinomas. Methods Among a consecutive of 5 312 patients with non-small lung cancer undergoing surgical resection at Shanghai Chest Hospital between January 2011 and December 2012, the clinical records of 273 patients with clinical stage T1aN0M0 lung adenocarcinomas were retrospectively analysed. Preoperative CT categorized the tumors of 273 patients as pure ground glass opacity（GGO）, GGO with minimal solid components （diameter of solid part〈 5 mm）, part-solid （diameter of solid parts≥5 mm） and pure solid. Relevant clinicopathologic features were investigated to identify the risk factors of lymph node metastasis using univariate and multivariate analysis. Results Thin-section CT was performed among all the 273 patients, among whom 103 （37.7%） were pure GGO, 118 （43.2%） GGO with minimal solid components（diameter of solid part〈5 mm）, 13 （4.8%） part-solid （diameter of solid parts≥5 mm）, and the other 39 （14.3%） pure solid. There were 18 （6.6%）patients with lymph node metastasis. The incidences of N1 and N2 nodal involvement were 6.5% （11 patients） and 4.1% （7 patients）, respectively. No lymph node metastasis occurred in patients with pure GGO and GGO with minimal solid components （diameter of solid part〈5 mm）. Multivariate analysis indicated that symptoms at presentation, diameter of solid parts≥5 mm and increased carcinoembryonic antigen （CEA） titer were risk factors of lymph node metastasis of Tla lung adenocarcinomas. Multivariate analysis also revealed that air bronchogram sign, tumor size, symptoms at presentation and increased abnormal CEA titer were risk factors of lymph node metastasis of pure solid tumors （95%CI： 2. 001-5. 990, P=0. 035 ; 95 %CI： 1. 000-3. 980, P = 0. 021 ; 95% CI： 1. 887-2. 663, P = 0. 020 ; 95 % CI： 1.514-8. 498, P = 0. 013）. Conclusions Lymph node dissection should not be performed among patients of clinical stage T1aN0M0 lung adenoeareinomas with GGO with minimal solid components （diameter of solid part≤ 5 mm）, or among pure GGO with no lymph node metastasis. However, systematic lymph node dissection should be performed for pure solid tumors or part-solid, especially in patients with CEA 〉5 ng/ml or symptoms at presentation.