全肺切除并自体肺移植术治疗Ⅲ期中央型肺癌1例临床分析

Lung autotransplantation after total lung resection for stageⅢcentral lung cancer in one patient

目的 探讨1例Ⅲ期中央型肺癌患者行全肺切除离体第三窿突重建并动脉再造后自体肺移植治疗的临床疗效。方法 2023年8月18日郑州大学第一附属医院行左全肺切除并自体肺移植治疗的Ⅲ期中央型肺癌患者1例,男,52岁。患者以“间断咳嗽、咳痰2月余”为主诉入院,入院前1周外院行气管镜检查,组织病理会诊结果示(左肺门活检)高级别鳞状上皮内瘤变(鳞状上皮原位癌)。入院后胸部增强CT扫描提示左肺中央型肺癌伴左肺上叶部分肺组织不张并部分肺组织实变,左肺代偿性肺气肿;肺功能检查提示中重度阻塞性为主的混合型通气障碍;骨扫描、头颅MRI、腹部CT检查未见异常。结合病史及相关检查诊断为左肺上叶中央型鳞癌,临床分期T2N2M0。采用信迪利单抗+白蛋白结合型紫杉醇+卡铂方案新辅助治疗4个疗程肿块未见缩小。经多学科会诊,建议手术治疗。考虑患者肺功能差,无法耐受全肺切除,且肿瘤局部侵犯范围较大,袖式肺叶切除有肿瘤残留,拟行左全肺切除并自体肺移植术。先切除左全肺,体外分离左下肺及左肺动脉干,切除受侵的中间肺动脉干、部分左下叶支气管,然后取自体心包,重建左肺下叶动脉干,修剪左下叶背段、基底段支气管,重建第三隆突,将气管、动脉重建后的左下肺置入胸腔行自体肺移植。记录手术情况及术后随访资料。结果 手术过程顺利,手术时间295 min,血流阻断时间140 min,支气管吻合及包埋时间35 min,动脉吻合时间14 min,静脉吻合时间8 min,术中出血量600 mL。术后无并发症发生。术后组织病理示中分化鳞癌,支气管残端阴性,送检淋巴结有转移,组织病理分期T2aN1M0。术后第3天胸部CT示左下肺复张良好,左下肺各段支气管通畅。患者术后恢复良好,正常生活不受限,未再行肺功能检查,于术后2周出院。术后1个月复查气管镜、肺动脉CT血管造影未见明显支气管狭窄及血栓形成。随访至2023年12月,患者锻炼康复中。结论 对于广泛累及支气管/肺动脉的Ⅲ期中央型肺癌患者,采用全肺切除离体重建支气管、肺动脉后自体肺移植术可保留功能肺组织,改善术后生活质量,安全有效。

Objective To investigate the clinical effect of lung autotransplantation with third carinal and arterial reconstructions after total lung resection in the treatment of one patient with stageⅢcentral lung cancer.Methods On August 18,2023,a 52-year-old male patient with stageⅢcentral lung cancer underwent lung autotransplantation after left total lung resection in the First Affiliated Hospital of Zhengzhou University.He was admitted to hospital with the chief complaints of“intermittent cough and sputum for more than 2months”.A tracheoscopy was performed in another hospital one week before admission,with the histopathological results(biopsy of the left hilum of the lung)of high-grade squamous intraepithelial neoplasia(squamous carcinoma in situ).After admission,he received contrast-enhanced chest CT scan,revealing central lung cancer of left lung complicated with atelectasis in the upper lobe of the left lung and consolidation in some lung tissues,as well as compensatory emphysema in the left lung.Lung function examination indicated mixed ventilation disorder with moderate to severe obstruction.Bone scan,head MRI and abdominal CT showed no abnormalities.On the basis of medical history and related examination results,he was diagnosed with central squamous carcinoma of the upper lobe of the left lung,with a clinical stage of T_2N_2M_0.After 4 courses of neoadjuvant treatment with Sindilizumab+albumin-binding paclitaxel+carboplatin,the mass showed no shrinking.A multidisciplinary consultation recommended surgical treatment.Left total lung resection plus lung autotransplantation was proposed since the total lung resection was intolerable because of poor lung function,and sleeve lobectomy had residual tumor because of the large local invasion of the tumor.The whole left lung was removed first,the left lower lung and left pulmonary artery trunk were separated in vitro,and the invaded middle pulmonary artery trunk and part of the left lower lobe bronchus were removed.The left inferior pulmonary artery trunk was reconstructed from autologous pericardium.The dorsal and basal bronchus of the left inferior lobe were pruned and the third carina was reconstructed.The left lower lung with reconstructed third carina and artery was placed into the chest for lung autotransplantation.The intraoperative and postoperative clinical data were recorded.Results The surgery was performed smoothly in 295min.The blood flow was blocked for 140min.The bronchial anastomosis and embedding were finished in 35min.The arterial anastomosis was done in 14 min,and the venous anastomosis was done in 8 min.The intraoperative bleeding was600mL.No postoperative complications occurred.The histopathological results showed moderately differentiated squamous cell carcinoma,with no residual tumor in the bronchial stump.The resected lymph nodes were found metastasis,and the histopathological stage was T_(2a)N_1M_0.On the third day after surgery,chest CT scan showed a good reexpansion of the left lower lung and patency of bronchus.The patient recovered well after surgery,with no restriction on normal life,and was discharged 2weeks after surgery without further lung function examination.Tracheoscopy and CT angiography of pulmonary artery 1month after surgery showed no obvious stenosis or thrombosis.The patient was followed up till December 2023,and had kept exercising and recovering.Conclusion For patients with stageⅢcentral lung cancer with extensive bronchial/pulmonary artery involvement,lung autotransplantation after total lung resection and bronchial and pulmonary artery reconstruction in vitro can preserve functional lung tissue and improve postoperative quality of life,and it is safe and effective.