1. Yakasarudzika chiyero chemapapu parenchymal resection
Kubva kuma1960, zvisinei nekukura kwebundu, anatomical lobectomy yave chiyero chekuvhiya kurapwa kweasiri diki kenza yemapapu. Nekudaro, basa remapapu revanhu vezera repakati uye vakura vane kazhinji kenza yemapapu kazhinji inogumira. Maitiro ekudzikisa kukuvara, kupfupisa chiyero che resection, uye kuchengetedza mamwe mapapu basa ragara riri iro dingindira rekuvhiya thoracic. Thoracic oparesheni nyanzvi zvishoma nezvishoma vanofunga kupfupisa chiyero chekuvhiya mushure mekuongorora kurapwa kwekutanga kwekuvhiya kenza yemapapu kuitira kuti awedzere ese ari maviri. tumarara resection uye kuchengetedza basa remapapu.
Kubva kuma1970s kuma1980s, pamwe nekuvandudzwa kwetekinoroji yekufungidzira, vanyori vakati wandei vakataura kuti yakawandisa mapapu resection inogona kuita zvakafanana kune lobectomy mune yekutanga isiri diki kenza yemapapu kenza (T1N0). Rudzi urwu rwekuvhiya runodaidzwa kunogumira resection. Yakatemerwa resection inotsanangurwa se resection yepasi peimwe lobe, senge wedge resection yeparipheral kenza yemapapu kana anatomical segmental resection (chidimbu resection).
Localised resection inogona dzidziso inochengetedza mamwe mapapu mashandiro, kudzora kufa kweperioperative uye kuitika kwematambudziko, uye chakakanganisika ndechekuti inogona kuwedzera mwero wekudzokororazve nekuda kwekukwana kukwana resection uye kutadza kuchenesa zvachose N1 lymph node. Zvakanakira nedzidziso nezvakaipira resection resection zviri pachena. Zviripachena, kuti upindure uyu mubvunzo wakakosha unoda kuongororwa kwakangoitwa kwakatemwa kiriniki. Nekuda kweizvozvo, yakawanda-yepakati inotarisira yakasarudzika yakarongedzwa kiriniki kutongwa ine simba rakakura musimba rekuvhiya kwemapapu yakatanga.
Chidzidzo cheNorth American Lung Cancer Study Group (LCSG) LCSG821 chine nzvimbo makumi mana nenhatu dziri kutora chikamu mune inongoitika inodzorwa inodzorwa muyedzo yekiriniki yekuvhiya kuti vaone kubviswa kwenzvimbo kwekutanga kurapwa. Inogona NSCLC (peripheral type, T43 N1) kutsiva lobectomy. Kuedza kwakatora makore matanhatu kupinda muboka kubva 0, uye yekutanga mhedzisiro yakaburitswa kubva anopfuura makore gumi apfuura kusvika 6.
Ngationgororei kunyoreswa uye maitiro ekushanda kwechidzidzo: varwere vakanyoresa vaive negomarara remapapu repaperipheral nekiriniki nhanho yeT1N0 (paiyo posterior anterior chest radiograph, kureba kwebundu kwaive ≤3cm), asi havana kuonekwa. kuburikidza nefiberoptic bronchoscopy Kuenda kune bundu. Pneumonectomy inoda kubviswa kwezvikamu zvinopfuura zviviri zvemapapu zviri pedyo. Wedge resection yemapapu inoda kubviswa kweakajairika mapapu tishu angangoita 2 cm kubva pabundu. Chiremba anovhiya anoona kukura kwebundu mushure mekuvhura chipfuva.
Intraoperative yechando chikamu chekuongorora chinosanganisira chikamu chemapapu, lung lobe, hilar, uye mediastinal lymph nodes kuti uone kana iri N0 (kana chirwere chegomarara chikasawanikwa usati wavhiyiwa, intraoperative yechando chikamu chinodiwa). Lymph node biopsy inotora kamwe chete lymph node kubva muboka rega rega uye inotumira kune chikamu chakaoma nechando. Chiremba akaongororawo kana kubviswa kwepanzvimbo kwaikwanisika panguva yekuvhiya. Mushure mekudzokororwa kwepapu lobe kana chikamu chemapapu uye sampling yemapoka ese emalymph node, chiremba anovhiya anofanira kusimbisa kuti bundu rabviswa zvachose nechando. Kana iyo staging ikawanikwa ichipfuura T1 kana N0, lobectomy inofanira kuitwa pakarepo uye kutongwa kuti haina kukodzera kunyoresa.
Chete mushure mekunge matanho ari pamusoro apa akatsunga kusangana nezvinodiwa zvekunyoresa, varwere vachapinda muboka rakasarudzika. Iro boka risina kurongeka rakasimbiswa nerunhare panguva yekushanda nenzvimbo yekutsvakurudza. Tinogona kuona kuti magadzirirwo echidzidzo cheLCSG821 akanyanya kuomarara kunyangwe akaiswa nhasi, saka nzira yekugadzira yechidzidzo yakateverwa nemagadzirirwo akatevera akasarudzika akadzorwa ekiriniki miedzo yekuvhiya kwakabatana.
Zvigumisiro zvechidzidzo chacho zvinoodza mwoyo: Kuenzaniswa nelobectomy, varwere vari pasi pekugadzirisa resection vane kuwedzera katatu muhuwandu hwekudzoka kwemunharaunda (wedge resection, kuwedzera katatu, uye segmental resection, 2.4-fold kuwedzera), uye kufa kune chokuita nebundu. Chiyero chakawedzera ne50%! MuLCSG821, 25% (122/427) yevarwere vane kiriniki nhanho I (T1N0) vakawana N nhanho yepamusoro panguva yeintraoperative lymph node biopsy, uye huwandu hwehuwandu hwekudzoka kwenzvimbo uye kufa kunoenderana nebundu mumapoka matatu panguva yekuvhiya. tumor kuongororwa kwakafanana. Uyezve, zvisingatarisirwi, kugadziriswa kwenzvimbo hakuna kuderedza kufa kweperioperative, uye kunze kweFEV1, pakanga pasina mukana mukushanda kwemapapu kwenguva refu!
Mhedzisiro yeLCSG821 yekudzidza inotsigira zvakasimba kuti lobectomy inoramba iri chiyero chegoridhe chekutanga kudzoreredzwa NSCLC. Iyo yakakwirira yekudzoka kwenzvimbo yekudzokorora kwenzvimbo inoratidzira kuti chikonzero chinogona kunge chiri yakasara micrometastasis yemapapu lobes kana kuvapo kweN1 lymph node micrometastasis mumapapu isingagoni kubviswa zvachose nenzira iyi. Mukuwedzera, chipfuva radiographs inogona kunge isina kukwana kuwana akawanda madiki madiki anowanzo kuwanikwa paCT. Nekudaro, iyo LCSG yakabviswa muna 1989 nekuti haina kupihwa mari neNCI, saka LCSG821 kudzidza haina kukwanisa kuburitsa mhedzisiro yekupedzisira. Uku kuzvidemba kwakasiiwa nechidzidzo.
Mumakore makumi maviri kubvira pakaburitswa mhedzisiro yekutsvaga, mhedzisiro yeLCSG20 kudzidza haina kupikiswa zvine simba. Asi mumakore achangopfuura makumi maviri, iyo yekufungidzira yekuongorora tekinoroji uye yake histopathological kupatsanura kutsvagisa kwemapapu kenza yakawedzera nekukurumidza. Yakasanganiswa neyekudzokororazve nyaya nyaya mushumo wemuenzaniso mudiki, zvinokurudzirwa kuti mamwe marudzi akasarudzika ekenza diki yemapapu anokwana chete kukwana mapapu resection.
Semuenzaniso, zvidzidzo zvakaratidza kuti mukana weiyo lymph node metastasis mune varwere vane bundu size 3 kusvika 10 mm ingangoita 0, nepo N2 lymph node metastasis yemapapu akaomarara mapundu> 2 cm inogona kusvika 12%. Nekuda kweizvozvo, pakupera kwemakumi gumi ekutanga ezana ramakumi maviri nemasere, ramangwana revatengi-repakati chikamu chechitatu chakarongedzwa kudzidza kwekuenzanisa kwepinemonectomy uye lobectomy muNorth America neAsia kwakatangwa. Ino nguva, ivo vachapokana nemhedzisiro yeLCSG21 kudzidza panzvimbo yepamusoro yekutanga.
Muna 2007, muyedzo wekiriniki weCALGB 140503 wakasiyana-siyana unotarisirwa muNorth America wakatangwa. Chidzidzo chacho chakapatsanura varwere vane peripheral kenza yemapapu isiri-diki danho IA re ≤2 masendimita dhayamita kupinda lobectomy boka uye mapapu segment kana wedge chimiro Resection boka. Varwere 1258 vakarongerwa kunyoresa. Iwo makuru ekutarisa zviratidzo kwaive kupona-kusina bundu, uye chechipiri zviratidzo kwaive kupona kwese, kwenzvimbo uye systemic kudzokorora mwero, basa remapapu, uye perioperative matambudziko.
Muna 2009, Japan's multi-center inotarisirwa randomized controlled clinical trial JCOG0802 yakatangwa. Maitiro ekunyoresa aive peripheral type IA isiri diki cell kenza yemapapu ine bundu kureba kwe ≤2 cm. Varwere vakapatsanurwa zvisina tsarukano muboka re lobectomy uye segmentectomy boka. , Zvirongwa zvekunyoresa 1100 varwere. Mhedziso yekutanga yaive kupona kwese, uye magumo echipiri aive kufambira mberi-kusina kupona, kudzokorora, uye postoperative mapapu basa.
Zvidzidzo zviviri izvi zvakanyatso tevera dhizaini yekudzidza kweLCSG821, iine maitiro akafanana ekupinza uye ekuvhiya. Asi izvi zviviri zvitsva zvidzidzo hazvina kungodzokorora iyo LCSG821 kudzidza, uye ivo vane matsva magadzirirwo uye epamusoro matanho ekukanganisa kweLCSG821. Chekutanga pane zvese, kuitira kuti uwane simba rakaringana rehuwandu, kukura kwechikwata kwakakura Kupfuura 1000 makesi, iyi ndiyo saizi yekuenzanisira iyo inogona kungowanikwa chete neakawanda-epakati ekuvhiya ekuedzwa emakiriniki.
Chechipiri, zvese zvidzidzo zvitsva zvinoda kukwidziridzwa kwepamusoro-kwakakwenenzverwa CT, iyo inogona kuona mashoma madiki maqhumu achienzaniswa neLCSG821 chest radiograph. Uye zvakare, zvese zvidzidzo zvitsva zvaisanganisira chete maperembudzi mapundu mapundu ≤2 cm, kusasanganisa yakachena pasi-girazi opacity (GGO).
Mukupedzisira, varwere vakasanganisirwa muboka vese ndeve T1a zvinoenderana nedanho ra2009 regomarara remapapu, uye kuenderana kwehutachiona hwemapapu kwakanyanya. Dzidzo mbiri idzi dzinoronga kupedza kunyoresa muna2012, uye varwere vese vachateverwa kwemakore mashanu. Nezve kudzidza LCSG5, tinogona kumirira mamwe makore mashanu, kana kunyangwe makore gumi, kubva kumagumo emakiriniki ekuedzwa kunyoresa kuti tiwane mhedzisiro.
Yakaganhurirwa kumaitiro ekufungidzira ekudzokera kumashure uye kusanzwisisa kwakakwana kwehunhu hwebhayoloji yekenza yemapapu ekutanga, ongororo yeLCSG821 yakazopedzisira yagumisa kuti kubviswa kwemapapu kwenzvimbo kwakaderera kune lobectomy. Lobectomy ichiri nzira yakajairwa yekutanga isiri-diki cell cancer yekurapa cancer yekurapa. Localized pneumonectomy inogumira pakuvhiyiwa kwakakanganisika uye inoshanda kune vakwegura varwere vasina kukwana kushanda kwemapapu. Zvidzidzo zvitsva zviviri zvinotipa tarisiro itsva. Muenzaniso wepakutanga kenza yebonde kuderedza kuwanda kwekuvhiyiwa kunoita kuti isu titarisirewo mberi shanduko yenzira dzekuvhiya munguva pfupi iri kutevera yekenza yemapapu ekutanga.
Kuti uwane resection resection yakakwana maronda kurapwa, kujekesa preoperative uye intraoperative kuongororwa ndiyo kiyi. Kurongeka kwechikamu chakaomeswa nechando kuona kuti kenza yemapapu diki inopinza zvinhu panguva yekuvhiya inoda kuwedzererwa. Iko kwakafanotaurwa kukosha kwechikamu chakaomeswa nechando kubva pa93-100%, asi kwete zvinyorwa zvese zvinonyatsotaura kururamisa kwechikamu chechando chakawongorora.
Panogona kuve nechinetso nekuongororwa kwemarara margins kubva muzvikamu zvechando, kunyanya kana otomatiki ezvishandiswa ave achishandiswa kumativi ese maviri. Kuedza kwakaitwa kukwesha kana kushambidza iyo gutter, uye inotevera cytological ongororo. Paunenge uchiita sublobar resection, chando chikamu kuongorora kweiyo interlobular, hilar, kana imwe yekufungidzira lymph node inobatsira kuongorora iyo staging. Kana zvakanaka maLymph node akawanikwa, sekureba sekunge murwere asina cardiopulmonary function zvinorambidzwa, lobectomy inokurudzirwa.
Dhizaini yemakiriniki ekutsvagisa ekudzora anowanzo tariswa kunzvimbo dzinowanikwa zvakanaka uye zvisirizvo. Kubva pane dhizaini yemakiriniki ekuedzwa ari pamusoro, tinogona kuona kukakavara kukuru uye pfungwa dzakakomba dze sublobar resection.
Kune adenocarcinoma ine dhayamita isingasviki 2cm, chikamu chikuru cheGGO iJCOG 0804, uye chikamu chakasimba chiri pasi pe25%, iyo yakaenzana neMIA ine chikamu chikuru chinopinda chisingasviki 0.5cm. Iyo yakasimba chikamu ndeye 25-100%, iyo yakaenzana neLPA mune invasive adenocarcinoma ine chikamu chinopinda chinopfuura 0.5 cm; CALGB 140503 haitsanangure chiyero cheyakasimba neGGO, uye huwandu hwevanhu vakanyoresa hunonyanya kukanganisa adenocarcinoma.
Naizvozvo, kune iyo AAH neAIS kenza yemapapu ine hunhu huri nani muboka reJCOG 0804, maonero emazuva ano anogona kugamuchirwa kuti atariswe kana kuti sublobar resection, uye hapana humbowo hutsva hwesarudzo yeMIA-LPA-ID nzira dzekuvhiya zvishoma. kupfuura 2cm. Panguva ino, hazvisi zvekukurumidzira kuwedzera zviratidzo zvekliniki zvekugadziriswa kwepanyika, asi zvinokwanisika kuita kuvhiyiwa kunokanganisa kune varwere vakwegura vane urombo hwemapapu. Parizvino, Wang Jun nevamwe vari mukati China vari kuitawo tsvakiridzo yekiriniki nezve sublobar resection versus lobectomy mune vakura kenza yemapapu.
Mufananidzo: Sub-lobar resection kliniki yekudzidza yakanyoreswa huwandu uye hutsva hutsva hwemapapu adenocarcinoma
2. Kufananidza kwehuwandu hweiyo lymphadenectomy: Iyo yakawanda-yepakati yakarongedzwa yakarongedzwa kudzidza yehukuru hweiyo lymphadenectomy neAmerican College yeOncology uye Kuvhiya kwemakore gumi.
ACOSOG-Z0030 yakazivisa zvabuda. Nekuda kwehunhu hwemagadzirirwo echidzidzo, sezvataitarisira, ichi chidzidzo chemhedzisiro yakaipa: hapana mutsauko mukupona kwese pakati peboka resampling rakarongeka neboka rakarongeka rekuparadzanisa, uye mediastinum i4% Iyo lymph node nhanho yakatorwa sample. seN0 panguva yekushanda uye N2 mushure mekuparadzaniswa (zvinoreva kuti 4% yevarwere vakagamuchira kwete-lymph node sampling havana kubviswa zvakakwana, uye chikamu ichi chevarwere chinogona kurasikirwa nekubatsirwa kweanotevera adjuvant chemotherapy.
Usati washandisa mhedziso yechidzidzo ichi kuchirongwa chekurapa, zvakakosha kuti utarise kune izvo zviviri zvinhu zve "kukwirira kusarudza kwezviitiko zvekutanga" uye "shanduko mune pfungwa yechinyakare lymphadenectomy scope" muchirongwa chekudzidza: 1. Makesi akanyoreswa: Isiri-diki kenza yemapapu kenza ine pathological N0 uye isiri-hilar N1, T1 kana T2; 2. Yakajeka pathological staging nzira: intrathoracic lymph node kuburikidza nemastastinoscopy, thoracoscopy kana thoracotomy; 3. Pfungwa yesampling uye dissection: intraoperative chando Mushure me biopsy, hutachiona hwakakamurwa zvisingaite mumapoka.
Rutivi rworudyi gomarara remapapu sampu 2R, 4R, 7 uye 10R boka lymph node, uye yekuruboshwe masampuli 5, 6, 7, 10L boka lymph node, uye rinobvisa chero fungidziro yema lymph node; varwere vakagoverwa kuboka rekutora havagamuchirezve lymph node resection, yakasarudzika kune Varwere muboka rekupatsanura zvakabvisa zvakarongeka ma lymph node uye akakomberedza matishu emukati mukati mechikamu cheatomical mamaki, kurudyi kurudyi: kumusoro kwembongoro bronchus, isina kusimba tsinga, imwe mutsinga, vena cava yepamusoro uye trachea (2R uye 4R), padyo neiyo yeropa yeropa (3A) uye retrotracheal (3P) lymph node; kuruboshwe: ese lymph node tishu (5 ne6) achiwedzera pakati peiyo phrenic nerve uye iyo vagus nerve kuruboshwe kuruboshwe bronchus, isingade lymph node tishu pakati peiyo huru pulmonary arteri hwindo uye kudzivirira iyo laryngeal regurgitation nerve.
Kunyangwe zvasara kana kurudyi, ese epasi-proximal lymph node tishu pakati peboshwe uye kurudyi main bronchus (7), uye ese lymph node tishu ari pazasi mapapu ligament uye padhuze nesophagus (8, 9) inofanirwa kucheneswa. . Mushure me pericardium uye nechepamusoro pegurokuro, hapafanire kunge paine lymph node tishu zvachose, uye ese mapapu lobes uye interlobular lymph node (11 ne12) anofanirwa kubviswa panguva yemapapu resection.
Tisati tashandisa mhedziso iyi kukiriniki yekudzidzira, isu tinofanirwa kutarisisa kune maviri maficha e "kusarudzwa kwevarwere vekutanga" uye "shanduko mune pfungwa yeLN resection scope" muchirongwa chekudzidza: isina hilum, T0 Kana T1 nhanho isiri-diki kenza yemapapu kenza (NSCLC); ② chaiyo pathological staging nenzira yemastastinoscopy, thoracoscopy kana thoracotomy biopsy intrathoracic LN; ③ intraoperative varwere vaigara vachikamurwa kuita sampling boka uye systemic mushure mekuratidzira kwehutachiona hwechando biopsy Kuchenesa boka.
Mushure mekuenzanisa ne-single-center randomized controlled study naWu et al. Muna 2002, mhedziso yekupedzisira yakanga yakangwarira zvikuru: kana migumisiro yechando ye systemic hilar uye mediastinal LN sampling panguva yekuvhiyiwa yakanga isina kunaka, imwezve systemic LN dissection haina kukwanisa kuunza varwere Kuti vararame uye vabatsirwe. Mhedziso iyi haishande kune varwere vanoonekwa vaine kenza yemapapu ekutanga uye chaiyo pathological nhanho N2 chete kuburikidza nekufungidzira. Chirwere chekiriniki chinobva pa positron emission tomography (PET) -CT haina kuenzana nedanho rekuvhiya, kana isina kushandiswa panguva yekuvhiyiwa Nzvimbo yekuvhiya muchidzidzo ichi inofanira kuitwa maererano neWu Uye mamwe mazano, shandisa yakarongeka LN kuchenesa kuvandudza kururama. yekugadzira uye kunatsiridza kupona.
Mhedziso yechidzidzo ichi yakavakirwa mukushambadzira kwema pre-operative nzira dzakakodzera dzekuratidzira munyika dzeEurope neAmerica, uye inoratidza pfungwa yeAmerica yekukoshesa kukosha kune pre-operative uye intra-operative N staging. Tichifunga nezve chokwadi chekuti nzira dzekuvhiya dzakatwasuka muChina dzichiri kukwana, pamwe nemisiyano kubva pakuongorora zvetsika uye nepfungwa yakarongeka yeRN resection muchidzidzo chino, mhedziso iyi parizvino haina kukodzera kusimudzirwa panguva ino kuChina .
Kusarudza nodal dissection kunoreva kune yakasarudzika lymph node dissection yakavakirwa pane bundu nzvimbo, imaging / pathological kuratidzwa, uye intraoperative chando kuendesa yekenza yemapapu yekutanga.
Nekufambira mberi kwekufungidzira yekuongorora tekinoroji mumakore achangopfuura, zvakawedzera uye zvakawandisa zvekufungidzira zvakawanikwa kuti pasi-girazi opacity (GGO) ndicho chikamu chikuru, uye chirwere chetsika morphology inonyanya kutevedzera-sekukura. . Iyi mhando chaiyo inogona kungoitwa yakasarudzika lymphadenectomy pasina kukanganisa kupona uye kudzoka kwenzvimbo? Tsvagiridzo kubva kuJapan inoratidza kuti makore gumi ekupona kwevarwere vane gomarara remapapu rekutanga-rakawanikwa nekuwongorora rinodarika 10%.
Mamota anowanzo kuve madiki, uye varwere vazhinji vane dhayamita dhayamita ye 1-2 cm kana girazi rine chando. Sezvinoonekwa kubva pamusoro, mazhinji erudzi urwu rwekufungidzira GGO kenza yemapapu uye hutachiona AAH-AIS-MIA-LPA inopindirana, lymph node uye Iyo extrapulmonary metastasis rate yakaderera, uye maseru emukenza ariwo mune yakagadzikana mamiriro. Zvakare, kune vazhinji varwere vakura, hutano hwese hwakashata, uye nezvirwere zvisingaperi, kusarudza lymph node dissection inogona kubatsira zvakanyanya.
Mune vamwe varwere, kuderedza dissection ye intrathoracic lymph nodes kune varwere vasina-diki kenza yemapapu emapapu , zvakakosha kuva nenzira inogona kunyatsofanotaura kuvapo kwe lymph node metastasis. Isu tinofanirwa kupfupisa iyo pathological anatomy yekenza yemapapu lymph node metastasis, mukana we lymph node metastasis mukati GGO-adenocarcinoma, uye zvakare kuderedza kuitika kwemetastatic lymph node residues paunoshandisa yakasarudzwa lymph node resection.
Ukuru hwebundu roga harisipo pakuona kana adenocarcinoma ine metastasized. Yakarongeka lymph node dissection yakavakirwa pa20% yemapapu adenocarcinoma isingasviki 2cm uye 5% isingasviki 1cm ine lymph node metastasis pane dzidziso.
Zvinoenderana nemutemo wema lymph node metastasis wemapapu lobe panowanikwa bundu rekutanga, lobe-yakatarwa nodal dissection inogona kudzikisira chiyero chekuvhiyiwa. Kunyangwe hazvo paine kusiri kuwirirana pane ino kushanda, zvakazara "saizi imwe inokodzera zvese" lymph node. Kuchenesa kunogona kuve nezvakanaka zvichienzaniswa nekuchenesa. Uye zvakare, kuongororwa kwekudzokorodza kwakaratidza kuti muT1 uye T2 kenza yemapapu, adenocarcinoma inonyanya kutarisana nemastastinal lymph node metastasis kupfuura squamous cell carcinoma.
Kune peripheral squamous cell carcinoma iyo iri pasi pe2 cm uye isingasanganisi iyo visceral pleura, mukana weiyo lymph node metastasis idiki. Asamura uye zvimwe zvidzidzo zvinoratidza kuti lymph node dissection inogona kudzivirirwa kune varwere vane squamous cell carcinoma ine dhayamita ye ≤ 2 cm kana varwere vane intraoperative hilar lymph node yechando chikamu chisina metastasis.
Kubatanidza zvakanyatsosiyaniswa adenocarcinoma subtypes senge AIS, MIA uye LPA zvinogona zvirinani kufanotaura metastasis. Tsvagiridzo yaKondo et al. Yakaratidza kuti peripheral adenocarcinoma ine dhayamita refu ye ≤1cm uye Noguchi diki gomarara remapapu pathological mhando A / B mhando (yakaenzana neAAH-AIS-MIA-LPA), mutsauko wayo wakanaka uye kufungidzira kwakanaka. Varwere vane kiriniki danho Ia vanogona kufunga wedge resection uye lobectomy-yakatarwa lymph node resection. Chero bedzi iyo mazaya echando uye makobvu-akasarudzika lymph node asina kunaka panguva yekuvhiyiwa, yakakura hombe ye lymph node dissection inogona kudzivirirwa.
Matsuguma uye zvimwe zvidzidzo zvakaratidza kuti kufungidzira ibundu rine GGO> 50% uye pathologically inonamira-sekukura, uye mukana we lymph node metastasis kana lymphatic yekukwira ngarava yakanyanya kuderera. Zvidzidzo zvakaratidza kuti varwere ava vanokodzera kudzikisa huwandu hwekuvhiya.
New lymph node dissections dzakarongerwa yekutanga NSCLC, kusanganisira chaiwo mapapu lobe dissections akarongerwa neEuropean Thoracic Surgery Association (ESTS) uye lymph node system sampling inotsanangurwa neACOSOG.
Nekuti huwandu hwehurongwa hwekuongorora gomarara remapapu hunoramba huchiwedzera, iyo adenocarcinoma kurongwa kwakagadziriswa neIASLC / ATS / ERS kunotiunzirawo zvakawanda zvinokurudzira. SaVan Schill et al. Yakataurwa, mushure me sublobar resection uye lymph node sampling, AIS neMIA vanga vasina chirwere kwemakore mashanu Iyo nguva yekupona inogona kusvika 5%. Naizvozvo, nzira yekusarudza varwere vane sublobar kana lobectomy uye kusarudza lymph node sampling inova yakakosha.
Kazhinji, kudiwa kwekudzikisa chiyero che lymph node dissection mukenza yemapapu haisi yekukurumidzira seyekenza yemazamu uye yakaipa. melanoma, nekuti mashandiro evaviri ekupedzisira ane tarisiro yakananga pakushanda uye kunaka kwehupenyu. Kunyangwe pasina humbowo kusvika parizvino kuti yakakura lymph node dissection inowedzera matambudziko uye ine mhedzisiro yakakosha pahupenyu hwevarwere mushure mekuvhiyiwa kenza yemapapu, asi.
Izvi hazvireve kuti hapana chikonzero chekuedza kusarudza lymph node dissection. Chiyero chekuvhiya chekenza yemapapu diki ichiri kuda kuti isu tiongororezve, kuti tiwane chiyero chakanakisa pakati pe "resection" uye "reservation" yekugadzirisa maitiro ekurapa uye hupenyu hwehupenyu.
3. pfupiso
Kune kanzura dzemapapu dzisingasviki 2cm muhupamhi, Kodama et al. ZVINOTARISIRWA zvakasiyana zvehurongwa hwekurapa kenza yemapapu inokodzera kutarisa kwedu nekufungisisa. Ichi chidzidzo chaisanganisira HRCT SPNs ine dhayamita isingasviki 2cm. Kufungidzira hakuna hilar mediastinal lymph node metastasis. Iyo zano rekuwedzera iwo marange ekuvhiya resection uye kuwedzera iyo yakasimba chinhu zvishoma nezvishoma.
Kucherechedza nekutevera kwakaitwa maronda madiki pane 1 cm uye yakachena GGO. Kana kukura kwechirwere kana huwandu hwakawedzera panguva yekutarisa, sublobar resection kana lobectomy yakaitwa. Kana iyo resection margin yaive yakanaka kana iyo lymph node yaive nechando yakanaka, saka lobectomy pamwe ne systemic lymph node dissection yakaitwa.
Kune yakasarudzika solid GGO ye11-15mm, yemapapu chidimbu resection uye lymph node sampling inoitwa. Kana resection margin iri yakanaka kana iyo lymph node iri chando yakanaka, saka lobectomy uye systemic lymph node dissection inoshandurwa;
Kune 11-15mm yakasimba maronda kana 16-20mm chikamu chakasimba GGO, yemapapu chikamu resection uye lymph node dissection inoitwa. Kana iyo resection margin iri yakanaka kana iyo lymph node ine chando yakanaka, saka mapapu resection uye systemic lymph node dissection inoshandurwa;
Kune 16-20mm yakasimba maronda, lobectomy uye systemic lymph node dissection inoitwa. Mune ino zano, DFS uye OS yekumanikidza resection ichiri yakanyanya kukwirira kune lobectomy, zvichiratidza kuti chikuru chirevo cheGGO-lung adenocarcinoma ichiri hunhu hwehupenyu hwebundu iro pacharo, nekudaro vachikurudzira akasarudzika maitiro ekutsiva.
Chechina, chakakurudzirwa maonero
Kufungidzira kuri padyo ne100% yakachena GGO maronda ari pasi pegumi, funga nezve CT kuteedzera kweAIS kana MIA, pane kukurumidza kuvhiya.
Lobectomy ndiyo yakajairika nzira yekuvhiya yekenza yemapapu yekutanga. AIS-MIA-LPA inogona kufunga nezve sublobar resection, asi isu tichiri kutarisira iyo postoperative yekudzokorora mwero inopihwa neanotarisirwa emakiriniki ekutsvaga.
Parizvino, chaiyo intraoperative staging inoda ingangoita lymph node dissection yakavakirwa pane yemapapu lobe yakatarwa. Muchikamu chakakosha cheGGO [cT1-2N0 kana isiri-hilar N1], systemic lymph node sampling inonyanya kukodzera kupfuura systemic lymph node dissection.
Kune AIS neMIA, lymph node sampling uye dissection inogona kunge isingadiwe, asi kuchine kushaikwa kwezvidzidzo zvakarongedzwa zvakasarudzika kuratidza kuti parizvino, inogona kushandiswa kusarudzwa kune varwere vane zera repamberi, yemapapu basa chikumbaridzo, uye zvirwere zvakawanda.
Iko kurongeka kweiyo intraoperative chando kuongororwa kwepulmonary nodular inopinza zvinoriumba uye mamiriro emahombekombe mushure me sublobar resection inoda kuenderera mberi ichiongororwa, uye iyo intraoperative yechando yekuongorora maitiro inoda kuwedzererwa kumisikidzwa kutungamira zvirinani kutungamira kwekuita-kuita sarudzo.
Parizvino, pakati pemazano ekuvhiya echikamu chitsva, kune vamwe varwere vane gomarara remapapu, chinzvimbo che sublobar resection uye yakasarudzika lymph node resection haisati yanyatso simbiswa, ingoti regai tione maitiro. Kuvandudzwa kwemhando ipi neipi yekurapa pfungwa kunoenda kuburikidza neyakareba nzira.
Izvi zvinoda kufarirwa kweanoshanda preoperative nzira dzekutepfenyura dzakadai sePET / mediastinoscopy / EBUS, kuongororwa kwechando kwechimbichimbi kweiyo yekutanga tarisiro yekenza yemapapu, yenharaunda node node uye resection margins. Kutungamira zvirinani kuita kwakasarudzika kwekutora sarudzo panguva yekushanda. Iyo nyowani kupatsanurwa kwemapapu adenocarcinoma yakaona iyo yakaipa yekukwira kumusoro nzira yekusagadzikana resection yekenza yemapapu kubva pane chiitiko kune humbowo-hwakavakirwa kune wega.
