1. Ububanzi bomuntu ngamunye bokuphinda kutholakale i-lung parenchymal resection
Kusukela ngeminyaka yawo-1960, kungakhathaliseki ukuthi singakanani isimila, i-lobectomy ye-anatomical isibe indinganiso yokwelashwa kokuhlinzwa komdlavuza wamaphaphu weseli ongewona omncane. Kodwa-ke, umsebenzi wamaphaphu wabantu abaneminyaka ephakathi kanye nabantu asebekhulile ngokujwayelekile umdlavuza wamaphaphu ngokuvamile ilinganiselwe. Indlela yokunciphisa ukuhlukumezeka, ukunciphisa ububanzi bokukhishwa kabusha, nokugcina ukusebenza okuningi kwamaphaphu bekulokhu kuyindikimba eyinhloko yokuhlinzwa kwe-thoracic. Izazi zokuhlinza isifuba kancane kancane zicabangela ukunciphisa ububanzi bokuhlinzwa ngemva kokuhlola ukwelashwa kwangaphambi kwesikhathi komdlavuza wamaphaphu ukuze kwandiswe kokubili. isisu ukugcinwa kokukhipha kabusha kanye nokusebenza kwamaphaphu.
Kusukela ngawo-1970 kuya kowe-1980, ngokuthuthuka kobuchwepheshe bokucabanga, ababhali abaningana babike ukuthi ukuvinjelwa okulinganiselwe kwamaphaphu kungafinyelela umphumela ofanayo ku-lobectomy kumdlavuza wamaphaphu weseli wokuqala ongeyona omncane (T1N0). Lolu hlobo lokuhlinzwa lubizwa ngokuthi ukuthengiswa okulinganiselwe. Ukuthengiswa okukhawulelwe kuchazwa njengokuphinda kutholakale i-lobe engaphansi kweyodwa, njengokukhishwa komgogodla womdlavuza wamaphaphu womzimba noma i-anatomical segmental resection (resection segment).
Ukuthengiswa okwenziwe kabusha okwenziwe endaweni kungagcina ukusebenza kwamaphaphu okuningi, kunciphise ukufa kwabantu abasebenzayo kanye nezigameko zezinkinga, futhi okungahambi kahle ukuthi kungakhuphula izinga lokuphindeka ngenxa yobubanzi bokwakhiwa okunganele nokuhluleka ukuhlanza ngokuphelele ama-N1 lymph node. Izinzuzo nezinkinga zemfundiso yokuziphendulela okwenziwe zaba sobala zisobala. Ngokusobala, ukuphendula lo mbuzo obalulekile kudinga ukuhlolwa komtholampilo okulawulwa ngokungahleliwe. Ngenxa yalokhu, isilingo semitholampilo esilawulwa ngokungahleliwe esinomthelela omkhulu emkhakheni wokuhlinzwa kwamaphaphu sesiqalile.
Ucwaningo lwe-North American Lung Cancer Study Group (LCSG) LCSG821 lunezikhungo ezingama-43 ezibamba iqhaza esivivinyweni somtholampilo esilawulwa ngokungahleliwe sokuhlinzwa ukuze kutholakale ukukhishwa kabusha kwendawo ukuze kutholakale ukwelashwa kusenesikhathi. Ingabe i-NSCLC (uhlobo lwe-peripheral, T1 N0) ingangena esikhundleni se-lobectomy. Ukuhlolwa kwathatha iminyaka engu-6 ukungena eqenjini kusukela ngo-1982, futhi imiphumela yokuqala yanyatheliswa kusukela eminyakeni engaphezu kweyishumi edlule kuya ku-1995.
Ake sibuyekeze indlela yokubhalisa nokusebenza yocwaningo: iziguli ezibhalisiwe zazinomdlavuza wamaphaphu we-peripheral onesigaba somtholampilo se-T1N0 (kwi-radiograph yesifuba esingemuva, ububanzi obude besimila babungu-≤3cm), kodwa abazange babonakale. ngokusebenzisa i-fiberoptic bronchoscopy Ku-tumor. I-pneumonectomy idinga ukususwa kwezingxenye zamaphaphu ezingaphezu kwezimbili eziseduze. Ukukhishwa kwamaphaphu kudinga ukususwa kwezicubu ezivamile zamaphaphu okungenani u-2 cm esimila. Udokotela ohlinzayo unquma ubukhulu besimila ngemva kokuvula isifuba.
Ukuhlolwa kwesigaba esiqandisiwe ngaphakathi kokuhlinzwa kuhlanganisa ingxenye yamaphaphu, i-lung lobe, i-hilar, nama-lymph nodes aphakathi nendawo ukuze kutholwe ukuthi ingabe i-N0 (uma ukuxilongwa kwe-pathological kungatholakali ngaphambi kokuhlinzwa, kuyadingeka ukuxilongwa kwesigaba esiqandisiwe ngaphakathi kokuhlinzwa). I-lymph node biopsy ithatha okungenani i-lymph node eyodwa eqenjini ngalinye bese iyithumela engxenyeni eqandisiwe. Udokotela ohlinzayo uphinde wahlola ukuthi kungenzeka yini ukukhishwa kabusha kwendawo ngesikhathi sokuhlinzwa. Ngemva kokukhishwa kabusha kwe-lung lobe noma ingxenye yamaphaphu kanye nokuthathwa kwesampula kwawo wonke amaqembu e-lymph node, udokotela ohlinzayo kufanele aqinisekise ukuthi isimila sisuswe ngokuphelele ngesigaba esiqandisiwe. Uma isiteji sitholakala sidlula i-T1 noma i-N0, i-lobectomy kufanele yenziwe ngokushesha futhi igwetshwe njengengafanele ukubhaliswa.
Kuphela ngemva kokuba izinyathelo ezingenhla zinqunywe ukuhlangabezana nezidingo zokubhalisa, iziguli zizongena eqenjini elingahleliwe. Iqembu elingahleliwe liqinisekiswe ngocingo ngesikhathi sokusebenza kwesikhungo socwaningo. Singathola ukuthi idizayini yocwaningo lwe-LCSG821 iqinile kakhulu ngisho noma ibekwe namuhla, ngakho-ke indlela yokuklama yocwaningo yalandelwa ukuklanywa kokuhlolwa komtholampilo okulawulwa ngokungahleliwe okwalandela kokuhlinzwa okuhlobene.
Imiphumela yocwaningo iyadumaza: Uma kuqhathaniswa ne-lobectomy, iziguli ezihlinzwa endaweni ziye zanda ngokuphindwe kathathu izinga lokuphindaphinda kwendawo (ukususwa kwe-wedge, ukwanda okuphindwe kathathu, nokukhishwa kwesigaba, ukukhuphuka okuphindwe izikhathi ezingu-2.4), nokufa okuhlobene nesimila Izinga lenyuke ngo-50%! Ku-LCSG821, ama-25% (122/427) eziguli ezinesigaba somtholampilo I (T1N0) bathola isiteji se-N esiphezulu ngesikhathi se-intraoperative lymph node biopsy, kanye nomthamo wezinga lokuphindaphinda lendawo kanye nokufa okuhlobene nesimila emaqenjini amathathu ngesikhathi sokuhlinzwa. ukuxilongwa kwe-tumor kwakufana. Ngaphezu kwalokho, ngokungalindelekile, ukukhishwa kabusha kwendawo akuzange kunciphise ukufa kwe-perioperative, futhi ngaphandle kwe-FEV1, kwakungekho nzuzo ekusebenzeni kwesikhathi eside kwamaphaphu!
Imiphumela yocwaningo lwe-LCSG821 isekela ngokuqinile ukuthi i-lobectomy ihlala iyindinganiso yegolide ye-NSCLC esheshe yakhishwa. Izinga eliphakeme lokuphinda lendawo lokuphinda likhishwe endaweni liphakamisa ukuthi isizathu singase kube i-micrometastasis esele ye-lung lobes noma ukuba khona kwe-N1 lymph node micrometastasis emaphashini engakwazi ukususwa ngokuphelele ngale nqubo. Ukwengeza, ama-radiograph esifuba angase anganeli ukuthola ama-nodule amaningi amancane avame ukutholakala ku-CT. Nokho, i-LCSG yahlakazwa ngo-1989 ngoba ayizange ixhaswe yi-NCI, ngakho ucwaningo lwe-LCSG821 alukwazanga ukushicilela imiphumela yokugcina enemininingwane. Lokhu ukuzisola okushiywe wucwaningo.
Eminyakeni engama-20 selokhu kwashicilelwa imiphumela yocwaningo, iziphetho zocwaningo lwe-LCSG821 aziphikiswanga ngamandla. Kepha eminyakeni engama-20 edlule, ubuchwepheshe bokuxilongwa kwe-imaging kanye nocwaningo lwezigaba zomdlavuza wamaphaphu seluthuthuke ngokushesha. Kuhlanganiswe nombiko wochungechunge lwamacala abuyayo wesampula elincane, kuphakanyiswa ukuthi ezinye izinhlobo ezikhethekile zomdlavuza omncane wamaphaphu zanele kuphela ekulinganisweni kwamaphaphu okulinganiselwe.
Isibonelo, ucwaningo lukhombisile ukuthi amathuba e-lymph node metastasis ezigulini ezinesayizi isimila esingu-3 kuye ku-10 mm cishe acishe abe ngu-0, kuyilapho i-N2 lymph node metastasis yamaqhubu aqinile wamaphaphu> 2 cm ingafinyelela ku-12%. Njengomphumela, ekupheleni kweminyaka eyishumi yokuqala yekhulu lama-21, kwaqalwa isifundo esilawulwa ngokungahleliwe se-pneumonectomy kanye ne-lobectomy eNyakatho Melika nase-Asia. Ngalesi sikhathi, bazophonsela inselelo isiphetho sesifundo se-LCSG821 ekuqaleni kokuqala.
Ngo-2007, kwaqaliswa isilingo somtholampilo esilawulwa ngokungahleliwe esisezikhungweni eziningi esingahleliwe se-CALGB 140503 eNyakatho Melika. Ucwaningo luhlukanise ngokungahleliwe iziguli ezine-peripheral umdlavuza wamaphaphu ongewona omncane isigaba IA sika-≤2 cm ububanzi sibe yiqembu le-lobectomy kanye nengxenye yamaphaphu noma umumo we-wedge Iqembu lokuhlinza. Iziguli eziyi-1258 kuhlelwe ukuthi zibhaliswe. Izinkomba eziyinhloko zokubhekwa kwakuwukusinda ngaphandle kwesimila, futhi izinkomba zesibili kwakuwukusinda okuphelele, izinga lendawo kanye nesistimu yokuphindaphinda, ukusebenza kwamaphaphu, kanye nezinkinga ze-perioperative.
Ngo-2009, isilingo somtholampilo sase-Japan esilawulwa ngokungahleliwe esisezikhungweni eziningi esineziko eziningi saqaliswa. Indlela yokubhalisa kwakuwuhlobo lwe-peripheral IA umdlavuza wamaphaphu wengqamuzana ongewona omncane onesimila ubude obungu-≤0802 cm. Iziguli zazihlukaniswe ngokungahleliwe zibe iqembu le-lobectomy kanye neqembu le-segmentectomy. , Ihlela ukubhalisa iziguli eziyi-2. Isiphetho esiyinhloko kwakuwukusinda sekukonke, futhi izindawo zokugcina zesibili kwakuwukusinda-mahhala, ukuphindaphinda, nokusebenza kwamaphaphu ngemva kokuhlinzwa.
Lezi zifundo ezimbili ezintsha zilandele ukwakheka kocwaningo lwe-LCSG821, ngezinqubo ezifanayo zokufakwa nezinqubo zokuhlinzwa. Kepha lezi zifundo ezimbili ezintsha aziphindanga nje kuphela isifundo se-LCSG821, futhi zinemiklamo emisha namazinga aphezulu okushiyeka kwe-LCSG821. Okokuqala, ukuze kuzuzwe amandla wezibalo anele, usayizi weqembu mkhulu Kunamacala angaphezu kwe-1000, lesi yisayizi lesampula elingatholakala kuphela ngokuhlolwa komtholampilo okuhlinzekwa ngezikhungo eziningi.
Okwesibili, zombili izifundo ezintsha zidinga i-CT ethuthukisiwe enesinqumo esiphezulu, engathola amaqhubu amancane amaningi uma kuqhathaniswa ne-LCSG821 chest radiograph. Ngaphezu kwalokho, zombili lezi zifundo zazihlanganisa kuphela izicubu zamaphaphu ezisemaphethelweni ≤2 cm, ngaphandle kwe-opacity glass-pure pure (GGO).
Ekugcineni, iziguli ezifakwe eqenjini zonke ezakwa-T1a ngokwesigaba somdlavuza wamaphaphu sango-2009, kanti ukungaguquguquki kwemvelo kwezimila zamaphaphu kuphezulu kakhulu. Zombili lezi zifundo zihlela ukuqeda ukubhalisa ngo-2012, kanti zonke iziguli zizolandelwa iminyaka emihlanu. Ngokubhekisele ocwaningweni lwe-LCSG5, kungadingeka ukuthi silinde eminye iminyaka emihlanu, noma ngisho neminyaka eyishumi, kusukela ekugcineni kokubhaliswa kwesilingo somtholampilo ukuthola imiphumela yokuqala.
Ilinganiselwe kumasu okucabanga okubuyela emuva kanye nokuqonda okunganele kwezici zebhayoloji zomdlavuza wamaphaphu wakuqala, ucwaningo lwe-LCSG821 lwagcina luphethe ngokuthi ukukhishwa kwamaphaphu kwendawo kungaphansi kune-lobectomy. I-lobectomy iseyinqubo evamile yokuhlinzwa okwelapha umdlavuza wamaphaphu kwasekuqaleni okungewona omncane. I-pneumonectomy yasendaweni ikhawulelwe ekuhlinzeni okusengozini futhi isebenza ezigulini esezikhulile ezinokungasebenzi kahle kwamaphaphu. Izifundo ezimbili ezintsha zisinika okulindelekile okusha. Isibonelo sokuqala umdlavuza webele ukunciphisa ububanzi bokuhlinzwa kusenza sibheke phambili ekushintsheni kwezindlela zokuhlinza esikhathini esizayo esiseduze somdlavuza wamaphaphu wakuqala .
Ukuze wenze ukwelashwa kabusha okwenziwe ngokwasendaweni okwanele okwanele, ukwelashwa okucacile kokuhlinzwa nokuhlinzwa kungukhiye. Ukunemba kokuhlaziywa kwesigaba esifriziwe ukuthola ukuthi umdlavuza omncane wamaphaphu unezingxenye ezingena ngaphakathi ngesikhathi sokuhlinzwa udinga ukuthuthukiswa ngokwengeziwe. Inani elibikezelwe lesigaba esifriziwe lisukela ku-93-100%, kepha akuzona zonke izindatshana ezibika ngokusobala ukunemba kokuhlaziywa kwesigaba esifriziwe.
Kungaba nenkinga ngokuhlolwa kwamamaki we-tumor avela ezingxenyeni ezibandisiwe, ikakhulukazi lapho okusetshenzisiwe okuzenzakalelayo kusetshenziswe ezinhlangothini zombili. Imizamo yenziwe ukukhuhla noma ukugeza i-gutter, kanye nokuhlaziywa kwe-cytological okwalandela. Lapho wenza i-sublobar resection, ukuhlaziywa kwesigaba esineqhwa kwama-interlobular, hilar, noma amanye ama-lymph node asolisayo kuyasiza ukuhlola isiteji. Lapho kutholakala ama-lymph node amahle, inqobo nje uma isiguli singenayo imikhawulo yokusebenza kwe-cardiopulmonary, i-lobectomy iyanconywa.
Umklamo wezilawuli zocwaningo lomtholampilo uvame ukubhekiswa ezindaweni lapho ukubuka okuhle nokubi kushayisana kakhulu. Kusukela ekwakhiweni kwezivivinyo zomtholampilo ezingenhla, singabona ukugxila okuyinhloko okuyimpikiswano namaphuzu abucayi wokuthengiswa kabusha kwe-sublobar.
Kwi-adenocarcinoma enobubanzi obungaphansi kuka-2cm, ingxenye esemqoka ye-GGO i-JCOG 0804, futhi ingxenye eqinile ingaphansi kuka-25%, elingana ne-MIA enengxenye enkulu kakhulu yokungena engaphansi kuka-0.5cm. Ingxenye eqinile ingu-25-100%, okulingana ne-LPA ku-adenocarcinoma engenayo enento yokungena engaphezulu kuka-0.5 cm; I-CALGB 140503 ayicacisi isilinganiso se-solid kanye ne-GGO, futhi isibalo sabantu ababhalisiwe ikakhulukazi i-adenocarcinoma ehlaselayo.
Ngakho-ke, kumdlavuza wamaphaphu we-AAH kanye ne-AIS onokuziphatha okungcono kwebhayoloji eqenjini le-JCOG 0804, ukubukwa kwamanje okujwayelekile kungamukelwa ukuze kubhekwe noma kukhishwe kabusha i-sublobar, futhi abukho ubufakazi obusha bokukhethwa kwezindlela zokuhlinzwa ze-MIA-LPA-ID ezingaphansi. awu 2cm. Ngalesi sikhathi, akuphuthumayo ukwandisa izinkomba zomtholampilo zokukhishwa kwendawo, kodwa kungenzeka ukwenza ukuhlinzwa okuphazamisekile ezigulini esezikhulile ezinomsebenzi ompofu wamaphaphu. Njengamanje, u-Wang Jun nabanye ku China futhi benza ucwaningo lomtholampilo mayelana nokususwa kwe-sublobar ngokumelene ne-lobectomy kubantu asebekhulile abanomdlavuza wamaphaphu.
Umdwebo: Ucwaningo lomtholampilo olungaphansi kwe-lobar resection lubhalise inani labantu kanye nokuhlelwa okusha kwe-lung adenocarcinoma
2. Ukwenza kube ngokwakho ubukhulu be-lymphadenectomy: Ucwaningo olulawulwa ngokulawulwa ngokungahleliwe kwezinga le-lymphadenectomy yi-American College of Oncology and Surgery iminyaka eyishumi.
I-ACOSOG-Z0030 imemezele imiphumela. Ngenxa yemininingwane yomklamo wocwaningo, njengoba besilindele, lolu wucwaningo lomphumela ongemuhle: awukho umehluko ekusindeni okuphelele phakathi kweqembu lamasampula ahlelekile kanye neqembu lokuhlukaniswa okuhleliwe, kanti i-mediastinum ingu-4% Isiteji se-lymph node sathathwa. njenge-N0 ngesikhathi sokusebenza kanye ne-N2 ngemva kokuhlukaniswa (okusho ukuthi i-4% yeziguli ezithole isampula ye-non-lymph node zazingasuswanga ngokuphelele, futhi le ngxenye yeziguli ingase ilahlekelwe izinzuzo ze-adjuvant chemotherapy elandelayo.
Ngaphambi kokusebenzisa iziphetho zalolu cwaningo ekusebenzeni komtholampilo, kuyadingeka ukuthi unake izici ezimbili "zokukhetha okuphezulu kwamacala okuqala" kanye "nokushintsha komqondo wobubanzi bendabuko be-lymphadenectomy" ekwakhiweni kocwaningo: 1. Amacala abhalisiwe: Umdlavuza wamangqamuzana ongewona omncane one-pathological N0 kanye ne-non-hilar N1, T1 noma T2; 2. Indlela eqondile yokuqalwa kwezifo: ama-lymph node we-intrathoracic ngokusebenzisa i-mediastinoscopy, i-thoracoscopy noma i-thoracotomy; 3. Umqondo wesampuli kanye nokuhlukaniswa: ukuqhwa kwe-intraoperative Ngemuva kwe-biopsy, i-pathology yahlukaniswa ngezikhathi ezithile ngamaqembu.
Amasampula omdlavuza wamaphaphu ohlangothini lwesokudla i-2R, 4R, 7 ne-10R group lymph node, namasampula ohlangothi lwangakwesobunxele ama-lymph node we-5, 6, 7, 10L, futhi asuse noma yimaphi ama-lymph node asolisayo; iziguli ezinikezwe iqembu lesampula azitholi okunye ukwenziwa kabusha kwe-lymph node, okungahleliwe ezigulini eziseqenjini le-dissection kususwe ngokuhlelekile ama-lymph node kanye nezicubu ezinamafutha ezizungezile ngaphakathi kwendawo yezimpawu zomzimba, uhlangothi lwangakwesokudla: i-lobe bronchus engaphezulu kwesokudla, umthambo ongaziwa, munye umthambo, i-vena cava ephakeme kanye ne-trachea (2R ne-4R), eduze kwesitsha sangaphakathi segazi (3A) kanye ne-retrotracheal (3P) lymph node; ohlangothini lwesobunxele: zonke izicubu ze-lymph node (5 no-6) ezinwebeka phakathi kwe-phrenic nerve kanye ne-vagus nerve ku-bronchus main kwesobunxele, engadingi izicubu ze-lymph node phakathi kwewindi le-artery main pulmonary kanye nokuvikela i-laryngeal regurgitation nerve.
Kungakhathalekile ukuthi ishiywe noma ilungile, zonke izicubu ze-lymph node eziphakathi kwe-bronchus (7) engakwesokunxele nangakwesokudla, nazo zonke izicubu ze-lymph node ku-ligament ephansi yamaphaphu futhi eduzane ne-esophagus (8, 9) kufanele ihlanzwe. . Ngemuva kwe-pericardium naphezu kobuso, akufanele kube khona izicubu ze-lymph node, futhi wonke ama-lung lobes kanye nama-lymph node (11 no-12) we-interlobular kufanele asuswe ngesikhathi sokuvuselelwa kwamaphaphu.
Ngaphambi kokusebenzisa lesi siphetho ekusebenzeni komtholampilo, kufanele sinake izici ezimbili "zokukhethwa kweziguli zakuqala" kanye "nezinguquko kumqondo we-LN resection scope" ekwakhiweni kocwaningo: ① Iziguli ezifakiwe bekuyi-N0 enesigaba sokugula kanye ne-N1 ngaphandle kwe-hilum, T1 Noma T2 isigaba somdlavuza ongewona omncane wamaphaphu wamangqamuzana (NSCLC); Isiteji esiqondile se-pathological esebenzisa i-mediastinoscopy, i-thoracoscopy noma i-thoracotomy biopsy intrathoracic LN; Iziguli ze-ra intraoperative zahlukaniswa ngezikhathi ezithile zaba yiqembu lesampula kanye ne-systemic ngemuva kwesiteji se-pathological se-biopsy Cleaning group.
Ngemva kokuqhathanisa nesikhungo esisodwa esilawulwa ngokungahleliwe isifundo sikaWu et al. Ngo-2002, isiphetho sokugcina sasiqaphe kakhulu: uma imiphumela eqandisiwe yesampula ye-systemic hilar kanye ne-mediastinal LN ngesikhathi sokuhlinzwa yayingeyinhle, okunye ukuhlukaniswa kwe-LN kwesistimu akukwazanga ukuletha iziguli Ukuze ziphile futhi zizuze. Lesi siphetho asisebenzi ezigulini ezitholwe zinomdlavuza wamaphaphu osaqala kanye nesigaba esiqondile se-pathological N2 kuphela ngokuthwebula izithombe. Isiteji somtholampilo esisekelwe ku-positron emission tomography (PET) -CT ayilingani nesiteji sokuhlinzwa, uma singasetshenziswa ngesikhathi sokuhlinzwa Isiteji sokuhlinzwa kulolu cwaningo kufanele senziwe ngokuhambisana ne-Wu Kanye nezinye iziphakamiso, sebenzisa ukuhlanza kwe-LN okuhlelekile ukuze kuthuthukiswe ukunemba. wesiteji nokwenza ngcono ukusinda.
Isiphetho salolu cwaningo sincike ekwandisweni kwezindlela ezinqala zokusebenza ngaphambi kokusebenza emazweni aseYurophu nawaseMelika, futhi kukhombisa umqondo waseMelika wokufaka ukubaluleka kokubekwa esiteji kuka-pre-operative naphakathi kwe-operative. Ngenxa yokuthi izindlela ezisetshenziswayo ezisezingeni eliphezulu e-China namanje azanele, kanye nokwehluka kwesampuli yendabuko kanye nomqondo ohleliwe wokuphindwa kwe-LN kulolu cwaningo, lesi siphetho okwamanje asikulungele ukukhushulwa kulesi sigaba eChina .
Ukuhlukaniswa kwe-nodal okukhethiwe kubhekisa ekuhlukanisweni kwe-lymph node okwenzelwe umuntu ngamunye okususelwa endaweni yesimila, ukubonakaliswa kwe-imaging / pathological, kanye nokulethwa okubandayo kwe-intraoperative komdlavuza wamaphaphu wokuqala.
Ngokuthuthuka kobuchwepheshe bokuxilongwa kwe-imaging eminyakeni yamuva nje, kutholakale ukutholakala okuningi kokucabanga ukuthi i-opacity yengilazi yomhlaba (i-GGO) iyona nto eyinhloko, kanti i-morphology ye-pathological ikakhulukazi ukukhula okufana nokunamathela. . Ngabe lezi zinhlobo ezithile zingathola kuphela i-lymphadenectomy ekhethiwe ngaphandle kokuthinta ukusinda nokuphindeka kwendawo? Ucwaningo oluvela eJapan lukhombisa ukuthi izinga lokusinda kweminyaka eyishumi yeziguli ezinomdlavuza wamaphaphu osezingeni lokuqala ezitholwe ngokuhlola lidlula ama-10%.
Izimila zivame ukuba zincane, futhi iziguli eziningi zinobubanzi besimila obungu-1-2 cm noma ingilazi eneqhwa. Njengoba kungabonakala kokungenhla, iningi lolu hlobo lomdlavuza we-GGO wamaphaphu kanye ne-pathology AAl-AIS-MIA-LPA iyagqagqana, ama-lymph node kanye ne-extrapulmonary metastasis rate iphansi, futhi amangqamuzana omdlavuza nawo asesimeni esiqinile. Ngaphezu kwalokho, kuneziguli eziningi esezikhulile, impilo ejwayelekile ibuthaka, futhi ngezifo ezingalapheki, ukukhetha i-lymph node dissection kungazuza kakhulu.
Ezigulini ezithile, ukunciphisa ukuhlukaniswa kwama-lymph nodes e-intrathoracic ezigulini ezinomdlavuza wamaphaphu ongewona omncane, kuyadingeka ukuba kube nendlela engakwazi ukubikezela ngokuphumelelayo ukuba khona kwe-lymph node metastasis. Sidinga ukufingqa i-pathological anatomy yomdlavuza wamaphaphu lymph node metastasis, amathuba okuba ne-lymph node metastasis I-GGO-adenocarcinoma, futhi iphinde inciphise ukwenzeka kwezinsalela ze-lymph node lapho kufakwa ukukhishwa kwe-lymph node okukhethiwe.
Ubukhulu besisu bodwa abukho lapho kunqunywa ukuthi ngabe i-adenocarcinoma isetshenzisiwe yini. Ukuhlukaniswa okuhleliwe kwe-lymph node kusekelwe ku-20% wamaphaphu adenocarcinoma ngaphansi kuka-2cm no-5% ngaphansi kuka-1cm ane-lymph node metastasis ngesisekelo sethiyori.
Ngokomthetho we-lymph node metastasis we-lobe lobe lapho kutholakala khona isimila sokuqala, ukuhlukaniswa okuqondile kwe-lobe kunganciphisa ubukhulu bokuhlinzwa. Yize kungakabi bikho ukuvumelana ngalokhu kusebenza, "ubukhulu obulodwa bufanelana ngokuphelele" nama-lymph node. Ukuhlanza kungaba nezinzuzo ezithile uma kuqhathaniswa nokuhlanza. Ngaphezu kwalokho, ukuhlaziywa okubuyiselwe emuva kukhombisile ukuthi kumdlavuza we-T1 kanye ne-T2 wamaphaphu, i-adenocarcinoma ithambekele kakhulu kuma-mediastinal lymph node metastasis kune-squamous cell carcinoma.
Nge-peripheral squamous cell carcinoma engaphansi kuka-2 cm futhi engafaki i-visceral pleura, ithuba le-lymph node metastasis lincane. I-Asamura nolunye ucwaningo lukhombisa ukuthi i-lymph node dissection ingagwenywa ezigulini ezine-squamous cell carcinoma enobubanzi obungu- ≤ 2 cm noma iziguli ezine-intraoperative hilar lymph node frozen section without metastasis.
Ukuhlanganisa ama-subtypes adenocarcinoma ahlukaniswe kahle njenge-AIS, MIA ne-LPA kungabikezela kangcono i-metastasis. Ucwaningo olwenziwe nguKondo et al. Kuboniswe ukuthi i-peripheral adenocarcinoma enobubanzi obude be-≤1cm nohlobo lwe-A / B lomdlavuza omncane wamaphaphu uhlobo lwe-A / B (olingana ne-AAH-AIS-MIA-LPA), umehluko wayo muhle futhi ukubikezela kuhle. Iziguli ezinesigaba somtholampilo i-Ia zingacubungula ukukhishwa kwe-wedge kanye ne-lobectomy-specific lymph node resection. Uma nje umugqa weqhwa nama-lymph node aqondene ne-lobes engemihle ngesikhathi sokuhlinzwa, kungagwenywa uhla olukhulu lwe-lymph node dissection.
IMatsuguma nolunye ucwaningo lukhombisile ukuthi i-imaging iyisigaxa esine-GGO> 50% nokukhula okufana nokubambelela ngokwe-pathologically, futhi kungenzeka ukuthi ukuhlaselwa kwe-lymph node metastasis noma ukuhlaselwa komkhumbi i-lymphatic kuphansi kakhulu. Ucwaningo lukhombisile ukuthi lezi ziguli zikulungele ukunciphisa ububanzi bokuhlinzwa.
Kuhlongozwe ukuhlukaniswa okusha kwe-lymph node kwe-NSCLC yokuqala, kufaka phakathi ukuhlukaniswa kwamaphaphu athile okuphakanyiswe yi-European Thoracic Surgery Association (ESTS) kanye nesampuli yohlelo lwe-lymph node ehlongozwe yi-ACOSOG.
Ngoba inani lezinhlelo zokuhlola umdlavuza wamaphaphu ziyaqhubeka nokwanda, ukuhlukaniswa kwe-adenocarcinoma okwenziwe yi-IASLC / ATS / ERS nakho kusilethela izikhuthazo eziningi ezintsha. NjengoVan Schill et al. Kubikiwe, ngemuva kokuphinda kutholakale i-sublobar resection kanye ne-lymph node sampling, i-AIS ne-MIA bebengenazo izifo iminyaka engu-5 Isikhathi sokusinda singafinyelela ku-100%. Ngakho-ke, ukuthi ungazikhetha kanjani iziguli ezine-sublobar noma i-lobectomy kanye nesampuli ye-lymph node ekhethiwe kubaluleke kakhulu.
Ngokuvamile, isidingo sokunciphisa ububanzi be-lymph node dissection kumdlavuza wamaphaphu asiphuthumi njengaleyo yomdlavuza webele kanye ne-malignant. melanoma, ngoba ukusebenza kokubili kokugcina kunomthelela oqondile emsebenzini kanye nekhwalithi yokuphila. Nakuba bungekho ubufakazi kuze kube manje bokuthi ukuhlukaniswa kwe-lymph node okubanzi kwandisa izinkinga futhi kunomthelela omkhulu ezingeni lempilo yeziguli ngemva kokuhlinzwa komdlavuza wamaphaphu, kodwa
Lokhu akusho ukuthi asikho isidingo sokuzama ukuqhekeka kwe-lymph node. Ububanzi bokuhlinzwa komdlavuza omncane wamaphaphu usadinga ukuthi siqhubeke nokuhlola, ukuthola ibhalansi enhle kakhulu phakathi kwe- "resection" kanye "nokubhuka" ukwenza ngcono umphumela wokwelashwa kanye nekhwalithi yempilo.
I-3. Isifingqo
Kumdlavuza wamaphaphu ongaphansi kuka-2cm ububanzi, u-Kodama et al. ISU elizoba isu elenzelwe ukuhlinzekwa ngokwezigaba lokuhlinzwa lomdlavuza wamaphaphu lifanelwe ukubhekisiswa kwethu futhi sikucabangele. Lolu cwaningo lufaka ama-HRCT SPNs enobubanzi obungaphansi kuka-2cm. Ukufanekisa akunayo i-hilar mediastinal lymph node metastasis. Isu lokukhulisa uhla lokuphinda kutholwe ukuhlinzwa nokukhulisa isakhi esiqinile kancane kancane.
Ukuqaphela nokulandela kwenziwa izilonda ezingaphansi kwe-1 cm ne-GGO emsulwa. Uma ukukhuliswa kwesigaxa noma ukuminyana kwenyuka ngesikhathi sokubuka, kwenziwa i-sublobar resection noma i-lobectomy. Uma umugqa wokuthengiswa kabusha ubulungile noma i-lymph node ibifriziwe, khona-ke kwenziwa i-lobectomy kanye ne-systemic lymph node dissection.
Kwi-GGO eqinile engaphelele ye-11-15mm, resection segment resection kanye ne-lymph node sampling ziyenziwa. Uma umkhawulo wokuthengiswa kabusha uvumile noma i-lymph node ineqhwa elihlelekile, khona-ke i-lobectomy ne-systemic lymph node dissection ziyashintshwa;
Okwezilonda eziqinile eziyi-11-15mm noma i-GGO eqinile eyi-16-20mm ngokwengxenye, ukwenziwa kwengxenye yamaphaphu kanye nokuhlukaniswa kwe-lymph node kuyenziwa. Uma umugqa wokuphinda usebenze kahle noma i-lymph node ineqhwa elihlelekile, khona-ke ukubuyiswa kwamaphaphu kanye ne-systemic lymph node dissection kuyashintshwa;
Ngezilonda eziqinile eziyi-16-20mm, kwenziwa i-lobectomy kanye ne-systemic lymph node dissection. Kuleli qhinga, i-DFS ne-OS yokuphinda kuvinjelwe kusesezingeni eliphakeme kakhulu kune-lobectomy, okuphakamisa ukuthi isici esiyinhloko sokubikezela se-GGO-lung adenocarcinoma kuseyizici zebhayoloji zesimila uqobo, ngaleyo ndlela sincoma amasu wokuphinda abe wodwa.
Okwesine, indawo yokubuka enconyiwe
Ukufanekisa kusondele ku-100% izilonda ze-GGO ezimsulwa ezingaphansi kwe-10mm, cabanga ukulandelwa kwe-CT kwe-AIS noma i-MIA, kunokukhishwa ngokushesha kokuhlinzwa.
I-Lobectomy inqubo evamile yokuhlinzwa yomdlavuza wamaphaphu wokuqala. I-AIS-MIA-LPA ingahle icabangele ukukhishwa kabusha kwe-sublobar, kepha sisabheke phambili kuzinga lokuphindaphinda kwangemva kokuhlinzwa elinikezwe ucwaningo lomtholampilo olulindelekile.
Njengamanje, ukulinganiswa okunembile kokuhlinzwa kudinga okungenani i-lymph node dissection ngokususelwa ekucacisweni kwamaphaphu lobe. Esiqeshini esikhethekile se-GGO [cT1-2N0 noma i-non-hilar N1], isampuli ye-lymph node isampuli ifaneleka kakhulu kune-systemic lymph node dissection.
Kwi-AIS ne-MIA, isampuli ye-lymph node kanye nokuhlukaniswa kwemisipha kungahle kungadingeki, kepha kusekhona ukungabi khona kwezifundo ezilawulwa ngokungahleliwe ukuqinisekisa ukuthi njengamanje, kungasetshenziswa ngokukhetha ezigulini ezineminyaka yobudala, umkhawulo womsebenzi wamaphaphu, nezifo eziningi.
Ukunemba kokuhlolwa okubandayo kwe-intraoperative kwezingxenye zokungena ngaphakathi kwamapulmoni kanye nesimo semkhawulo ngemuva kokuphinda kutholakale kabusha kwe-sublobar kudinga ukuphinde kuqinisekiswe, futhi inqubo yokuhlolwa eqandisiwe ye-intraoperative idinga ukwenziwa eminye imigomo ukuqondisa kangcono ukwenziwa kwezinqumo kwe-intraoperative.
Njengamanje, phakathi kwezincomo ezihlinzekwayo zokwahlukaniswa okusha, kwezinye iziguli ezinomdlavuza wamaphaphu, isimo se-sublobar resection kanye ne-lymph node resection ekhethiwe asikakasungulwa ngokuphelele, ake sibone umkhuba. Ukuvuselelwa kwanoma yiluphi uhlobo lomqondo wokwelashwa kuzohamba ngenqubo ende impela.
Lokhu kudinga ukwenziwa kwande kwezindlela ezinqala zokuhlinza ezifana ne-PET / mediastinoscopy / EBUS, ukuhlolwa okubandayo kwe-intraoperative kokugxilwe okuyinhloko komdlavuza wamaphaphu, ama-lymph node wesifunda kanye nemikhawulo yokuphinda isebenze. Ukuqondisa kangcono ukuthathwa kwezinqumo okwenziwe ngesikhathi sokusebenza. Ukwahlukaniswa okusha kwe-lung adenocarcinoma kufakazele inqubo engemihle yokukhuphuka yokukhuphuka okungalungile komdlavuza wamaphaphu kusuka kokuhlangenwe nakho kuye ebufakazini obususelwa ekwenzeni komuntu ngamunye.
