1. Keɓaɓɓen ikon yinsa na huhu parenchymal resection
Tun daga shekarun 1960, ba tare da la'akari da girman ƙwayar cuta ba, lobectomy na jiki ya zama ma'auni don maganin tiyata na ciwon huhu mara ƙananan ƙwayar cuta. Duk da haka, aikin huhu na masu matsakaici da tsofaffi tare da akai-akai kwayar cutar huhu yawanci yana iyakance. Yadda za a rage raunin rauni, kunkuntar iyakar resection, da kuma riƙe ƙarin aikin huhu ya kasance babban jigon tiyata na thoracic. Masana aikin tiyata na thoracic a hankali suna yin la'akari da taƙaita iyakar aikin tiyata bayan sun bincika farkon aikin tiyata na ciwon huhu don haɓaka duka biyun. tumo resection da huhu aikin kiyayewa.
Daga 1970s zuwa 1980s, tare da ci gaban fasahar ɗaukar hoto, marubuta da yawa sun ba da rahoton cewa ƙarin iyakancewar huhu zai iya cimma irin wannan tasirin zuwa lobectomy a farkon ƙananan ƙananan ƙwayoyin huhu (T1N0). Wannan nau'in tiyatar ana kiransa iyakancewa. Definedayyadaddun ƙwayar cuta an bayyana shi azaman raguwa na ƙasa da lobe ɗaya, kamar ƙuƙwalwar ƙwaƙwalwar ƙwayar cutar huhu ta gefe ko ɓangaren ɓangaren anatomical (rabewar kashi).
Gyara yanki wanda aka tsara zai iya riƙe ƙarin aikin huhu bisa ka'ida, rage yawan mutuwar lokaci da kuma yawan rikice-rikice, kuma rashin fa'ida shine zai iya ƙara yawan saurin sake dawowa saboda rashin isasshen yanayin sakewa da rashin iya tsarkake N1 lymph nodes. Abubuwan fa'idar ka'idoji da rashin dacewar sakewa daga cikin gida bayyane suke. Babu shakka, don amsa wannan muhimmiyar tambaya tana buƙatar bazuwar gwajin asibiti. A sakamakon haka, babban cibiyoyin da ake tsammani bazuwar gwaji na asibiti tare da tasiri mai tasiri a fagen tiyatar huhu ta fara.
Rukunin Nazarin Ciwon Kan Huhu na Arewacin Amurka (LCSG) LCSG821 binciken yana da cibiyoyi 43 da ke shiga cikin gwajin gwaji na asibiti da za a iya sarrafa bazuwar don gano ɓarna na gida don jiyya da wuri. Za a iya NSCLC (nau'in gefe, T1 N0) maye gurbin lobectomy. Gwajin ya dauki shekaru 6 kafin shiga kungiyar tun daga shekarar 1982, kuma an buga sakamakon farko daga sama da shekaru goma da suka gabata zuwa 1995.
Bari mu sake nazarin ka'idodin rajista da aiki na binciken: marasa lafiya da aka yi rajista suna da ciwon huhu na huhu tare da matakin asibiti na T1N0 (a kan radiyon kirji na baya, mafi tsayin diamita na ƙwayar cuta shine ≤3cm), amma ba a gan su ba. ta hanyar fiberoptic bronchoscopy Zuwa ƙari. Pneumonectomy yana buƙatar cire fiye da sassan huhu biyu maƙwabta. Gyaran huhu na huhu yana buƙatar cire naman huhu na yau da kullun aƙalla 2 cm daga ƙari. Likitan fiɗa yana ƙayyade girman ƙwayar cuta bayan buɗe kirji.
Gwajin daskararrun sashe na ciki ya haɗa da ɓangaren huhu, lobe na huhu, hilar, da nodes na lymph na mediastinal don sanin ko N0 ne (idan ba a sami ganewar cutar ba kafin tiyata, ana buƙatar ganewar asali daskararre na ciki). Ciwon node na lymph yana ɗaukar aƙalla kumburin lymph ɗaya daga kowace ƙungiya kuma ya aika da shi don sashe daskararre. Likitan fiɗa ya kuma kimanta ko za a iya yin maganin gida yayin aikin. Bayan an sake gyara sashin huhu ko sashin huhu da kuma samfurin dukkan kungiyoyin ƙwayoyin lymph, likitan fiɗa ya kamata ya tabbatar da cewa an cire ƙari gaba ɗaya ta hanyar daskarewa. Idan an gano matakin ya wuce T1 ko N0, ya kamata a yi lobectomy nan da nan kuma a yi hukunci da cewa bai dace da yin rajista ba.
Sai kawai bayan an ƙaddara matakan da ke sama don biyan buƙatun rajista, marasa lafiya za su shiga rukunin da bazuwar. An tabbatar da rukunin bazuwar ta wayar tarho yayin aikin cibiyar bincike. Zamu iya gano cewa ƙirar binciken LCSG821 yana da matukar tsauri ko da an sanya shi a yau, don haka tsarin ƙirar binciken ya biyo baya ta hanyar ƙirar gwaje-gwajen asibiti da aka sarrafa na gaba na tiyata mai alaƙa.
Sakamakon binciken yana da ban sha'awa: Idan aka kwatanta da lobectomy, marasa lafiya da ke yin gyaran fuska na gida suna da karuwa sau uku a cikin adadin sake dawowa na gida (ƙuƙwalwar ƙwayar cuta, haɓaka sau uku, da raguwa na kashi, 2.4 karuwa), da kuma mutuwar ciwon daji. Adadin ya karu da 50%! A cikin LCSG821, 25% (122/427) na marasa lafiya tare da mataki na asibiti I (T1N0) sun sami matsayi mafi girma na N yayin ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar kuma da kuma yawan ƙwayar ƙwayar ƙwayar cuta a cikin ƙungiyoyi uku a lokacin ganewar ciwon daji sun kasance iri ɗaya. Bugu da ƙari, ba zato ba tsammani, reshe na gida bai rage yawan mace-mace ba, kuma baya ga FEV1, babu wani fa'ida a cikin aikin huhu na dogon lokaci!
Sakamakon binciken LCSG821 yana goyan bayan da ƙarfi cewa lobectomy ya kasance ma'aunin zinare don farkon sake fasalin NSCLC. Matsakaicin yawan komawa gida na resection na gida yana nuna cewa dalili na iya zama ragowar micrometastasis na lobes na huhu ko kasancewar N1 lymph node micrometastasis a cikin huhu wanda ba za a iya cire shi gaba daya ta wannan hanya ba. Bugu da ƙari, radiyon ƙirji bazai isa ba don nemo ƙananan nodules da yawa sau da yawa akan CT. Duk da haka, an wargaza LCSG a cikin 1989 saboda ba NCI ta ba da kuɗi ba, don haka binciken LCSG821 bai iya buga cikakken cikakken sakamakon ba. Wannan nadamar da binciken ya bari.
A cikin shekaru 20 tun lokacin da aka buga sakamakon binciken, ba a kalubalanci ƙarshen binciken na LCSG821 ba. Amma kawai a cikin shekaru 20 da suka gabata, fasahar gano hoto da binciken rarrabuwa na cutar sankarar huhu sun bunkasa cikin sauri. An haɗu tare da rahoton jerin shari'o'in da suka gabata na ƙaramin samfurin, ana ba da shawarar cewa wasu nau'ikan na musamman na ƙananan ciwon huhu sun isa kawai don iyakancewar huhu.
Misali, bincike ya nuna cewa yiwuwar lymph node metastasis a cikin marasa lafiya masu girman tumbi 3 zuwa 10 mm kusan 0, yayin da N2 lymph node metastasis na m huhu nodules> 2 cm na iya isa 12%. A sakamakon haka, a ƙarshen shekarun farko na karni na 21, an ƙaddamar da wani ɓangare mai mahimmanci na zamani III nazarin sarrafawa na kwatankwacin cututtukan huhu da lobectomy a Arewacin Amurka da Asiya. A wannan lokacin, zasu kalubalanci ƙarshen binciken LCSG821 a farkon farawa.
A cikin 2007, an ƙaddamar da gwajin gwaji na asibiti CALGB 140503 a Arewacin Amurka. Binciken ya raba marasa lafiya da na gefe ciwon huhu mara ƙanƙanta mataki IA na ≤2 cm a diamita cikin rukunin lobectomy da sashin huhu ko siffar tsinke Ƙungiyar Resection. An shirya yiwa marasa lafiya 1258 rajista. Babban alamomin kallo sune tsira ba tare da ƙari ba, kuma alamomin na biyu sune rayuwa gabaɗaya, ƙimar sake dawowa gida da tsarin, aikin huhu, da rikice-rikice.
A cikin 2009, an ƙaddamar da gwajin gwajin asibiti na tsakiya na Japan JCOG0802. Ma'auni na yin rajista shine nau'in yanki na IA mara ƙaramar cutar kansar huhu tare da tsayin ƙari na ≤2 cm. An raba marasa lafiya bazuwar zuwa ƙungiyar lobectomy da ƙungiyar segmentectomy. , Yana shirin shigar da marasa lafiya 1100. Maƙasudin ƙarshe na farko shine rayuwa gabaɗaya, kuma ƙarshen ƙarshe na biyu shine rayuwa marar ci gaba, sake dawowa, da aikin huhun bayan aiki.
Sabbin karatun biyu sun bi tsarin binciken LCSG821, tare da irin waɗannan ka'idojin hadawa da hanyoyin tiyata. Amma waɗannan sabbin karatun biyu ba kawai sun maimaita karatun LCSG821 bane, kuma suna da sabbin kayayyaki da ƙa'idodi mafi girma don gazawar LCSG821. Da farko dai, don samun ƙarfin ƙididdigar lissafi, girman rukuni yana da yawa Fiye da lamura 1000, wannan shine girman samfurin wanda kawai za'a iya samun sa ta hanyar cibiyoyin asibiti na tiyata masu yawa.
Abu na biyu, duka sababbin karatun suna buƙatar ingantaccen ƙirar CT, wanda zai iya gano ƙananan ƙananan nodules idan aka kwatanta da LCSG821 kirji radiograph. Bugu da kari, dukkanin sabbin karatuttukan biyu kawai sun hada da cututtukan huhu na gefe ≤2 cm, ban da tsaftataccen gilashin gilashi (GGO).
A ƙarshe, marasa lafiyar da aka haɗa a cikin rukunin duk suna cikin T1a bisa ga matakin 2009 na cutar kansa ta huhu, kuma daidaituwar halittar ƙwayoyin huhu suna da yawa. Dukansu karatun suna shirin kawo ƙarshen rajista ta 2012, kuma za a bi duk marasa lafiya har tsawon shekaru 5. Dangane da binciken LCSG821, ƙila mu jira wasu shekaru biyar, ko ma shekaru goma, daga ƙarshen yin rajistar gwajin asibiti don samun sakamako na farko.
Iyakance da dabarun hoto na baya da rashin isasshen fahimtar halayen halittu na farkon cutar sankarar huhu, binciken LCSG821 a ƙarshe ya kammala cewa ɓarnawar huhu yana ƙasa da lobectomy. Lobectomy har yanzu shine madaidaicin hanya don aikin tiyata na warkarwa wanda ba ƙananan ƙwayoyin huhu ba. Tsarin pneumonectomy na gida yana iyakance ga raunin tiyata kuma yana shafi tsofaffi marasa lafiya waɗanda basu da isasshen aikin huhu. Sabbin karatu guda biyu suna ba mu sabon fata. Misalin farko ciwon nono rage girman aikin tiyata yana sa mu kuma sa ido ga canjin hanyoyin tiyata a nan gaba na ciwon huhu na farko.
Don yin gyaran cikin gida isasshen maganin ƙari, bayyananniyar preoperative da intraoperative shine mafi mahimmanci. Daidaitaccen nazarin sashin daskararre don tantance ko ƙananan kansar huhu yana kutsawa cikin abubuwan haɗin yayin aikin tiyata yana buƙatar haɓakawa. Theimar da aka annabta na ɓangaren daskararre ya fito ne daga 93-100%, amma ba duk labarai ne ke bayar da rahoto a sarari daidai da binciken sashin daskararre ba.
Wataƙila za a sami matsala game da kimar ɓangarorin ƙari daga sassan daskararre, musamman ma lokacin da aka yi amfani da kayan abinci ta atomatik a ɓangarorin biyu. An yi ƙoƙari don yin kwalliya ko wanke magudanar ruwa, da kuma nazarin kimiyyar lissafi na gaba. Lokacin yin aikin gyara sublobar, nazarin sashin daskararre na tsaka-tsakin, hilar, ko wasu ƙwayoyin lymph da ake tuhuma yana da amfani don kimanta yanayin. Lokacin da aka samo ƙwayoyin lymph masu kyau, matuƙar mai haƙuri ba shi da takunkumin aiki na zuciya, ana ba da shawarar lobectomy.
Tsara tsarin sarrafa binciken asibiti galibi ana nufin shi ne a wuraren da ra'ayoyi masu kyau da mara kyau ke karo da juna. Daga ƙirar gwajin gwaji na sama, zamu iya ganin babban maƙasudin rikice-rikice da mahimman maganganu na sakewar sublobar.
Ga adenocarcinoma mai diamita kasa da 2cm, babban bangaren GGO shine JCOG 0804, kuma ingantaccen bangaren bai wuce 25% ba, wanda yayi daidai da MIA tare da mafi girman infiltrating kasa da 0.5cm. Mahimmin sashi shine 25-100%, wanda yayi daidai da LPA a cikin adenocarcinoma mai lalacewa tare da ɓangaren ɓarna fiye da 0.5 cm; CALGB 140503 bai fayyace rabon ƙarfi da GGO ba, kuma yawan jama'ar da suka yi rajista galibi adenocarcinoma ne na mamayewa.
Don haka, don ciwon huhu na huhu na AAH da AIS tare da mafi kyawun halayen halitta a cikin ƙungiyar JCOG 0804, ana iya karɓar ra'ayoyin al'ada na yau da kullum don kallo ko resection subblobar, kuma babu wata sabuwar shaida don zaɓin hanyoyin tiyata na MIA-LPA-ID ƙasa da ƙasa. fiye 2cm. A wannan lokacin, ba gaggawa ba ne don faɗaɗa alamun asibiti don ƙaddamarwa na gida, amma yana yiwuwa a yi aikin tiyata a cikin tsofaffi marasa lafiya da rashin aikin huhu. A halin yanzu, Wang Jun da sauransu Sin Har ila yau, suna gudanar da bincike na asibiti game da resection subblobar tare da lobectomy a cikin tsofaffin ciwon daji na huhu.
Hoto: Karatuttukan likitancin yanki sun sanya yawan mutane da sabon tsari na adenocarcinoma na huhu
2. Keɓancewa gwargwadon ƙwayar lymphadenectomy: Nazarin cibiyoyin da bazuwar sarrafawa game da girman kwayar cutar ta kwalejin Oncology da Tiyata ta Amurka na shekaru goma.
ACOSOG-Z0030 ta sanar da sakamakon. Saboda ƙayyadaddun ƙirar binciken, kamar yadda muka sa ran, wannan mummunan sakamakon binciken ne: babu bambanci a cikin rayuwa gaba ɗaya tsakanin ƙungiyar samfurin tsari da ƙungiyar rarraba tsarin, kuma mediastinum shine 4% An ƙaddamar da matakin ƙwayar lymph. kamar yadda N0 yayin aikin da kuma N2 bayan an raba su (ma'ana cewa kashi 4% na marasa lafiya da suka karɓi samfurin ƙwayar cuta ba a cire su gaba ɗaya ba, kuma wannan ɓangaren na marasa lafiya na iya rasa fa'idodin ilimin likitancin adjuvant na gaba.
Kafin yin amfani da ƙarshen wannan binciken ga aikin likita, ya zama dole a kula da abubuwa biyu na "babban zaɓin al'amuran farko" da "canji a cikin batun ƙirar ƙirar lymphadenectomy ta al'ada" a cikin ƙirar binciken: 1. Bayanan da aka sanya: Cancerananan ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar cuta tare da N0 da ba ta hilar N1, T1 ko T2; 2. Hanyar tsayar da cututtukan cututtuka: intrathoracic lymph nodes ta hanyar mediastinoscopy, thoracoscopy ko thoracotomy; 3. Ra'ayin samfur da rarrabawa: daskarewa a cikin intraoperative Bayan nazarin halittu, an rarraba cututtukan cikin rashin tsari zuwa rukuni-rukuni.
Samfurori masu dauke da cutar huhu na dama 2R, 4R, 7 da 10R, da kuma samfurin gefen hagu 5, 6, 7, 10L kungiyar lymph nodes, da kuma cire duk wani nau'in kwayar lymph da ake tuhuma; marasa lafiya da aka sanya wa rukunin samfurin ba su karɓar ƙarin ƙwanƙolin ƙwayar lymph, bazuwar su ga Marasa lafiya a cikin ƙungiyar rarraba ƙarin ci gaba da cire ƙwayoyin lymph da nama mai ƙwanƙwasa a cikin iyakar alamomin jikin mutum, gefen dama: madaidaiciyar ƙugu ta sama, ƙarancin jijiyoyin jini na sama, maɓuɓɓugar jini ta musamman, mufuradi jijiyoyin jini, jijiyoyin jini da jijiyoyin jini (2R da 4R), kusa da jijiyar jini ta baya (3A) da kuma cutar baya (3P) lymph nodes; gefen hagu: duk kyallen burodin kumburin lymph (5 da 6) suna shimfidawa tsakanin jijiyoyin phrenic da jijiyar farji zuwa hagu babba, ba sa bukatar kwayar cutar lymph tsakanin babbar taga mai huhun huhu da kuma kare jijiyar jijiyoyin wuya.
Ba tare da la'akari da ko hagu ko dama ba, duk kayan haɗin lymph node masu ƙarancin kusanci tsakanin hagu da dama babban birki (7), da dukkan ƙwayoyin lymph node akan ƙananan jijiyar huhu kuma kusa da esophagus (8, 9) ya kamata a tsabtace . Bayan pericardium da kuma saman esophagus, kada a sami ƙwayar ƙwayar lymph kwata-kwata, kuma yakamata a cire dukkan ƙwayoyin huhu na huhu da na lymph nodes (11 da 12) yayin cire huhu.
Kafin yin amfani da wannan ƙaddamarwa ga aikin likita, dole ne mu kula da bangarori biyu na "zaɓin marasa lafiya na farko" da "canje-canje a cikin batun ƙididdigar aikin LN" a cikin ƙirar binciken: ① Marasa lafiyar da aka haɗa sun kasance N0 tare da matakin ilimin lissafi da N1 ba tare da hilum ba, T1 Ko T2 mataki ba ƙaramin kwayar cutar huhu ba (NSCLC); Daidaitaccen yanayin ilimin cuta ta hanyar medastinoscopy, thoracoscopy ko thoracotomy biopsy intrathoracic LN; Patients marasa lafiyan marasa lafiya sun kasance bazuwar rarraba zuwa rukuni mai samfuri da tsari bayan nazarin ilimin lissafi na ƙungiyar Tsabtace biopsy daskararre.
Bayan kwatanta tare da binciken da bazuwar cibiya guda ɗaya ta Wu et al. A cikin 2002, ƙarshe na ƙarshe ya kasance mai taka tsantsan: idan sakamakon daskararre na tsarin hilar tsarin da kuma samfoti na LN a lokacin tiyata ba su da kyau, ƙarin rarrabawar LN na tsarin ba zai iya kawo marasa lafiya Don tsira da fa'ida ba. Wannan ƙaddamarwa ba ta shafi majinyata da aka gano suna da ciwon huhu na farko da madaidaicin matakin ƙwayar cuta N2 kawai ta hanyar hoto. Matsayin asibiti bisa ga positron emission tomography (PET) -CT bai yi daidai da matakin tiyata ba, idan ba a yi amfani da shi ba yayin tiyata Dole ne a yi aikin tiyata a cikin wannan binciken daidai da Wu Kuma sauran shawarwari, yi amfani da tsaftacewa na LN na yau da kullun don inganta daidaito. na tsarawa da inganta rayuwa.
Arshen wannan binciken ya ta'allaka ne ga faɗakarwar ingantattun hanyoyin gabatar da shirye-shirye a cikin ƙasashen Turai da na Amurka, kuma ya nuna manufar Amurka game da ɗora muhimmanci ga shirin fara aiki da intanet na N. Dangane da gaskiyar cewa hanyoyin da ake bi na yau da kullun a kasar Sin ba su isa ba, da kuma bambance-bambance daga samfurin gargajiya da kuma tsari na yau da kullun na LN a cikin wannan binciken, wannan ƙaddamarwa a halin yanzu ba ta dace da ci gaba a wannan matakin a China ba .
Addamarwar rarrabawar ƙira tana nufin rarrabawar lymph ƙuduri na mutum bisa ga yanayin ƙwayar cuta, bayyanar hoto / cututtukan cututtuka, da isar da ƙoshin ciki na farkon cutar kansa na huhu.
Tare da ci gaba da fasahar gano hoto a cikin 'yan shekarun nan, an gano karin binciken da aka gano cewa rashin gilashin gilashi na kasa (GGO) shi ne babban bangaren, kuma ilimin halittar jikin mutum ya fi dacewa da girma. . Shin waɗannan takamaiman nau'ikan za su iya shan zaɓin lymphadenectomy kawai ba tare da shafar rayuwa da sake dawowa gida ba? Bincike daga Japan ya nuna cewa adadin rayuwar marasa lafiya na shekaru 10 masu fama da cutar sankarar huhu da aka samu ta hanyar bincike ya wuce 85%.
Umananan yara ƙari ne ƙanana, kuma yawancin marasa lafiya suna da ƙwayar ƙari na 1-2 cm ko ma gilashin sanyi. Kamar yadda ake iya gani daga sama, yawancin irin wannan hoton na GGO na cutar huhu da cututtukan zuciya AAH-AIS-MIA-LPA sun haɗu, ƙwayoyin lymph da extraarin ƙwayar metastasis mai ƙarancin ƙarfi, kuma ƙwayoyin kansar suma suna cikin kwanciyar hankali. Bugu da ƙari, akwai tsofaffi marasa lafiya da yawa, lafiyar gaba ɗaya ba ta da kyau, kuma tare da cututtuka na yau da kullun, zaɓin rarraba lymph kumburi na iya amfanuwa da ƙari.
A cikin wasu marasa lafiya, don kunkuntar da dissection Lymthoracik a cikin marasa lafiya na ciwon mara, ya zama dole a yi annabta hanyar da za ta iya annabta da yadda yakamata ta kasance da inganci. Muna buƙatar taƙaita ilimin halittar jiki na ciwon daji na huhu na ƙwayar lymph metastasis, yuwuwar cutar kumburin lymph metastasis a ciki GGO-adenocarcinoma, da kuma rage abin da ya faru na metastatic Lymph node sharuɗɗa lokacin amfani da zaɓaɓɓen resection na lymph nodes.
Girman ƙari shi kaɗai ya ɓace don tantance ko adenocarcinoma ya inganta. Tsarin lymph node rarrabawa yana dogara ne akan 20% na adenocarcinoma na huhu ƙasa da 2cm kuma 5% ƙasa da 1cm suna da ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar cuta ta jiki ta hanyar XNUMX% na adenocarcinoma na huhu kasa da XNUMXcm kuma XNUMX% kasa da XNUMXcm suna da ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar cuta ta hanyar ka'idar.
Dangane da dokar lymph node metastasis na huhu na huhu inda asalin ƙwayar cuta take, rarraba takamaiman ƙwanƙwasa ƙwanƙwasa na iya rage girman tiyata. Kodayake har yanzu ba a sami yarda a kan wannan aikin na musamman ba, gabaɗaya “girmansa ɗaya ya dace” da ƙwayoyin lymph. Tsaftacewa na iya samun wasu fa'idodi idan aka kwatanta da tsabtatawa. Bugu da kari, wani nazari na waiwaye ya nuna cewa a cikin cututtukan huhu na T1 da T2, adenocarcinoma ya fi saurin kamuwa da cutar lymph node metastasis fiye da ƙwayar sankara.
Don ƙananan ƙwayoyin ƙwayoyin ƙwayoyin ƙwayoyin ƙwayoyin ƙwayoyin ƙwayoyin ƙwayoyin cuta waɗanda ba su da ƙasa da 2 cm kuma ba su haɗa da ƙwayoyin hanji ba, damar lymph node metastasis ƙanana ne. Asamura da sauran karatuttukan suna ba da shawarar cewa za a iya guje wa rarraba lymph node a cikin marasa lafiya da keɓaɓɓiyar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ≤ 2 cm ko marasa lafiya tare da ɓangaren daskararren ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar cuta ba tare da metastasis ba.
Hada ingantattun nau'ikan adenocarcinoma irin su AIS, MIA da LPA na iya kyakkyawan hango yanayin kamuwa da cutar. Bincike ta Kondo et al. Ya nuna cewa adenocarcinoma na gefe tare da dogon diamita na -1cm da Noguchi ƙananan cututtukan ƙwayar cutar huhu nau'in A / B (daidai da AAH-AIS-MIA-LPA), bambancin sa yana da kyau kuma yanayin hangen nesa yana da kyau. Marasa lafiya tare da mataki na asibiti Ia na iya yin la'akari da raguwa da ƙwanƙwasa ƙwayoyin lymph ƙuduri. Duk lokacin da gefen daskararre da takamaiman ƙwayoyin lymph suka kasance marasa kyau yayin aikin tiyata, za a iya kaucewa mafi girman keɓaɓɓiyar rarraba lymph.
Matsuguma da sauran nazarin sun nuna cewa hotunan hoto shine ƙari tare da GGO> 50% da haɓaka-kamar ci gaba, kuma yiwuwar lymph node metastasis ko mamaye jirgin ruwa na lymphatic yana da ƙasa ƙwarai. Nazarin ya nuna cewa wadannan marasa lafiyar sun dace da takaita aikin tiyata.
An gabatar da sabon rarraba lymph node don farkon NSCLC, gami da takamaiman rabe-raben kodin na huhu wanda Surungiyar Tiyata Tiyata ta Turai (ESTS) ta gabatar da samfurin lymph node samfurin ACOSOG.
Saboda yawan shirye-shiryen binciken kansar huhu yana ci gaba da ƙaruwa, adenocarcinoma rarrabuwa wanda IASLC / ATS / ERS suka haɓaka shima yana kawo mana sabbin wahayi. Kamar yadda Van Schill et al. An ba da rahoto, bayan sakewar sublobar da samfurin lymph node samfurin, AIS da MIA ba su da cuta na tsawon shekaru 5 Zamanin rayuwa na iya kaiwa 100%. Sabili da haka, yadda za a zaɓi marasa lafiya tare da sublobar ko lobectomy da samfurin lymph node samfurin zama mahimmanci.
Gabaɗaya, buƙatar ƙunsar iyakokin ƙwayar ƙwayar lymph a cikin ciwon huhu ba ta da gaggawa kamar na ciwon nono da kuma m. melanoma, saboda ayyukan na biyu suna da tasiri kai tsaye ga aiki da ingancin rayuwa. Ko da yake babu wata shaida har zuwa yau cewa tsattsauran ra'ayi na ƙwayar lymph yana ƙaruwa da rikitarwa kuma yana da tasiri mai mahimmanci akan rayuwar marasa lafiya bayan tiyatar ciwon huhu, amma.
Wannan baya nufin cewa babu buƙatar gwada zaɓin lymph node rarrabawa. Har ila yau, aikin tiyatar ƙananan ƙananan huhu har yanzu yana buƙatar mu don ci gaba da bincike, don neman mafi daidaituwa tsakanin "sakewa" da "ajiyar wuri" don inganta tasirin magani da ƙimar rayuwa.
3. Summary
Ga cututtukan huhu ƙasa da 2cm a diamita, Kodama et al.'Tsarin dabarun rarraba tiyata na keɓaɓɓu na mutum don cutar sankarar huhu ya cancanci tunani da la'akari. Wannan binciken ya haɗa da HRCT SPNs tare da diamita ƙasa da 2cm. Hoto ba shi da wata ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar cuta. Dabarun kara yawan kewayon tiyata da kara karfin abu a hankali.
Lura da bin diddigi an yi su ne don raunin da bai fi 1 cm tsayi ba kuma tsarkakakken GGO. Idan ƙari ko ƙari ya karu a lokacin lura, an yi aikin sake sublobar ko lobectomy. Idan ragowar raguwa ta kasance tabbatacciya ko ƙwayar lymph ta daskarewa tabbatacciya, to an yi aikin lobectomy da rarraba tsarin lymph node.
Don GGO mai ƙarfi na 11-15mm, ana yin aikin ɓangaren huhu da samfurin lymph node. Idan maƙasudin raguwa ya kasance tabbatacce ko ƙwayar lymph ta daskarewa tabbatacce, to ana canza lobectomy da rarraba tsarin lymph node;
Don raunin raunuka masu ƙarfi 11-15mm ko 16-20mm mai ƙarfi na GGO, aikin huhun huhu da rarraba lymph node dissection ana yin su. Idan maƙasudin raguwa ya zama tabbatacce ko ƙwayar lymph ta daskarewa tabbatacciya, to sai a canza raunin huhu da rarraba tsarin lymph node;
Don raunin raunuka 16-20mm, ana yin aikin lobectomy da rarraba tsarin lymph node. A cikin wannan dabarun, DFS da OS na ƙuntatawa na haɓakawa har yanzu suna da fifiko fiye da lobectomy, suna ba da shawarar cewa babban mahimmin abin da ke faruwa na GGO-lung adenocarcinoma har yanzu halayen halittu ne na ƙari kanta, don haka yana ba da shawarar dabarun sake keɓancewa na mutum.
Na huɗu, ra'ayin da aka ba da shawara
Hoto yana kusa da 100% tsarkakakkun cututtukan GGO a ƙarƙashin 10mm, la'akari da bin CT don AIS ko MIA, maimakon cirewar tiyata nan da nan.
Lobectomy shine daidaitaccen aikin tiyata don farkon sankarar huhu. AIS-MIA-LPA na iya yin la'akari da raunin sublobar, amma har yanzu muna sa ran saurin sake dawowa bayan samar da bincike na asibiti.
A halin yanzu, ingantaccen tsarin aikin cikin gida yana buƙatar aƙalla rarraba ƙwayoyin lymph bisa ƙayyadadden ƙarancin huhu. A cikin wani rukuni na musamman na GGO [cT1-2N0 ko ba hilar N1], samfurin lymph node samfurin yafi dacewa fiye da rarraba tsarin lymph node.
Don AIS da MIA, samfurin lymph node samamme da rarrabawa bazai zama dole ba, amma har yanzu akwai karancin binciken sarrafawa bazuwar don tabbatar da cewa a yanzu, ana iya amfani da shi ta hanyar amfani da marasa lafiya tare da tsufa, ƙofar aikin huhu, da cututtuka da yawa.
Daidaitaccen aikin daskararren bincike na abubuwanda suka kunshi hancin ciki da yanayin gefen gefen bayan sakewar sublobar yana bukatar a kara tabbatar da shi, kuma tsarin binciken daskararren cikin yana bukatar a kara daidaita shi don kyakkyawan jagorar yanke shawara a cikin intraoperative.
A halin yanzu, daga cikin shawarwarin tiyata na sabon rabe-raben, ga wasu marasa lafiya da ke fama da cutar sankarar huhu, ba a riga an tabbatar da matsayin aikin gyaran kafa na karkashin kasa da kuma zabar lymph node resection ba, kawai bari mu ga wani yanayi. Sabunta kowane nau'i na maganin kulawa zaiyi aiki mai tsayi sosai.
Wannan yana buƙatar haɓaka hanyoyin ingantaccen tsari kamar PET / mediastinoscopy / EBUS, ƙididdigar daskararren aiki na babban abin da ya shafi ciwon huhu na huhu, ƙananan ƙwayoyin lymph da ƙarancin yanki. Don kyakkyawan jagorancin yanke shawara na mutum yayin aiki. Sabon rarrabuwa na adenocarcinoma na huhu ya ga mummunan yanayin karkacewa zuwa sama na mummunan raunin cutar huhu daga ƙwarewa zuwa shaidar da ta dogara da keɓancewa.
