胸腔镜治疗肺部微小结节(129例报告)

Surgical Treatment of Small Pulmonary Nodules Under Video-assisted Thoracoscopy(A Report of 129 Cases)

背景与目的影像技术的发展导致肺部微小结节尤其是肺磨玻璃结节(ground-glass opacity,GGO)检出逐年增多,但术前定性困难。本研究探讨肺部微小结节的临床诊断及微创手术治疗的必要性和可行性、病理诊断,微创切除及淋巴结切除的手术方式。方法对2013年12月-2016年11月接受电视胸腔镜手术(video-assisted thoracic surgery,VATS)治疗并有明确病理诊断的共129例患者的临床资料回顾性分析。所有患者术前行薄层计算机断层扫描(computed tomography,CT)扫描,其中21个微小结节术前行CT引导下Hook-wire定位,并根据病理性质及患者身体状况采用不同手术方式。结果共129个微小结节,实性结节(solid pulmonary nodule,SPN)37个,恶性比例是24.3%(9/37),术后病理结果为:肺原发性鳞状细胞癌3个,浸润性腺癌(invasive adenocarcioma,IA)3个,转移癌2个,小细胞肺癌(small cell lung cancer,SCLC)1个,错构瘤16个,其他炎症等良性病变12个;49个混合性GGO(mixed ground-glass opacity,m GGO)的恶性比例是63.3%(31/49),术后病理结果为:IA 19个,微浸润腺癌(micro invasive adenocarcioma,MIA)6个,原位腺癌(adenocarcioma in situ,AIS)4个,非典型性腺瘤样增生(atipical adenomatous hyperplasia,AAH)1个,SCLC 1个,炎症等良性病变18个;43个纯GGO(pure ground-glass opacity,p GGO)的恶性比例是86.0%(37/43),术后病理结果为:AIS 19个,MIA 6个,IA 6个,AAH 6个,炎症等良性病变6个;GGO总的恶性比例是73.9%(68/92)。52个良性病变均采用VATS肺楔形切除;原发性非小细胞肺癌(non-small cell lung cancer,NSCLC)共73例,VATS肺叶切除和淋巴结清扫33例,VATS肺楔形切除和选择性淋巴结切除6例,VATS肺段切除和选择性淋巴结切除6例,VATS肺楔形切除28例;2个转移癌和2个SCLC,采用VATS肺楔形切除术。另有6例患者术中冰冻病理存在误差,其中2例选择二次手术行肺叶切除和淋巴结清扫。45例有淋巴结病理结果NSCLC只有两例以SPN为表现的IA出现纵隔淋巴结转移,其余均未出现淋巴结转移。术后随访1个月-35个月,平均(15.1±10.2)个月,无复发及转移。结论肺部微小结节尤其是GGO,是恶性病灶的概率大,应积极外科处理;围手术期应与患者及家属充分告知冰冻病理结果存在误差可能性,避免医疗纠纷。

Background and objective The development of image technology has led to increasing detection of pulmonary small nodules year by year, but the determination of their nature before operation is difficult. This clinical study aimed to investigate the necessity and feasibility of surgical resection of pulmonary small nodules through a minimally invasive approach and the operational manner of non-small cell lung cancer（NSCLC）. Methods The clinical data of 129 cases with pulmonary small nodule of 10 mm or less in diameter were retrospectively analyzed in our hospital from December 2013 to November 2016. Thin-section computed tomography（CT） was performed on all cases with 129 pulmonary small nodules. CT-guided hook-wire precise localization was performed on 21 cases. Lobectomy, wedge resection, and segmentectomy with lymph node dissection might be performed in patients according to physical condition. Results Results of the pathological examination of 37 solid pulmonary nodules（SPNs） revealed 3 primary squamous cell lung cancers, 3 invasive adenocarcinomas（IAs）, 2 metastatic cancers, 2 small cell lung cancers（SCLCs）, 16 hamartomas, and 12 nonspecific chronic inflammations. The results of pathological examination of 49 mixed ground glass opacities revealed 19 IAs, 6 micro invasive adenocarcinomas（MIAs）, 4 adenocarcinomas in situ（AIS）, 1 atypical adenomatous hyperplasia（AAH）, 1 SCLC, and 18 nonspecific chronic inflammations. The results of pathological examination of 43 pure ground glass opacities revealed 19 AIS, 6 MIAs, 6 IA, 6 AAHs, and 6 nonspecific chronic inflammations. Wedge resection under video-assisted thoracoscopic surgery（VATS） was performed in patients with 52 benign pulmonary small nodules. Lobectomy and systematic lymph node dissection under VATS were performed in 33 patients with NSCLC. Segmentectomy with selective lymph node dissection, wedge resection, and selective lymph node dissection under VATS were performed in six patients with NSCLC. Two patients received secondary lobectomy and systematic lymph node dissection under VATS because of intraoperative frozen pathologic error that happened in six cases. Two cases of N2 lymph node metastasis were found in patients with SPN of IA. Conclusion Positive surgical treatment should be taken on patients with persistent pulmonary small nodules, especially ground glass opacity, because they have a high rate of malignant lesions. During the perioperative period, surgeons should fully inform the patients and family members that error exist in frozen pathologic results to avoid medical disputes.