选择性纵隔淋巴结清扫:精准医学时代的精准手术

Selective mediastinal lymph node dissection:Precision surgery in the era of precision medicine

随着低剂量CT筛查的普及,早期肺癌的检出率逐年升高。根治性肺叶切除术联合系统性淋巴结清扫(systematic nodal dissection,SND)依旧是可手术肺癌患者的标准治疗方式,然而目前对于无转移淋巴结是否应行SND仍存在争议。不必要的淋巴结清扫在增加手术难度的同时也会造成额外的手术创伤,此外无转移淋巴结近年来被报道在免疫治疗中发挥关键作用。如何减少早期肺癌患者纵隔淋巴结清扫的手术创伤是现代化“肺癌微创手术3.0”理念的重要组成部分。选择性纵隔淋巴结清扫策略旨在清扫有肿瘤转移淋巴结,同时保留正常纵隔淋巴结。既往研究表明综合分析肺癌肺段特异性部位、影像学及术中冰冻病理等特征可精准预测纵隔淋巴结转移规律,由此形成的个体化选择性纵隔淋巴结清扫策略在前瞻性临床试验中得到验证,这为早期肺癌患者接受更加个体化的选择性淋巴结清扫“精准手术”策略提供了重要依据。

Along with the popularity of low-dose computed tomography lung cancer screening,an increasing number of early-stage lung cancers are detected.Radical lobectomy with systematic nodal dissection(SND)remains the standard-of-care for operable lung cancer patients.However,whether SND should be performed on non-metastatic lymph nodes remains controversy.Unnecessary lymph node dissection can increase the difficulty of surgery while also causing additional surgical damage.In addition,non-metastatic lymph nodes have been recently reported to play a key role in immunotherapy.How to reduce the surgical damage of mediastinal lymph node dissection for early-stage lung cancer patients is pivotal for modern concept of"minimally invasive surgery for lung cancer 3.0".The selective mediastinal lymph node dissection strategy aims to dissect lymph nodes with tumor metastasis while preserving normal mediastinal lymph nodes.Previous studies have shown that combination of specific tumor segment site,radiology and intraoperative frozen pathology characteristics can accurately predict the pattern of mediastinal lymph node metastasis.The personalized selective mediastinal lymph node dissection strategy formed from this has been successfully validated in a recent prospective clinical trial,providing an important basis for early-stage lung cancer patients to receive more personalized selective lymph node dissection with"precision surgery"strategies.