国际肿瘤学杂志

国际肿瘤学杂志››2024,Vol. 51››Issue (9): 569-577.doi:10.3760/cma.j.cn371439-20240422-00095

• 论著 •上一篇下一篇

NSCLC肺内叶段淋巴结转移规律及全胸腔镜肺叶切除术中淋巴结清扫方式的选择

王清北, 朱林, 吴正国()

  1. 东南大学医学院附属南京同仁医院心胸外科，南京 211102
  • 收稿日期:2024-04-22修回日期:2024-07-11出版日期:2024-09-08发布日期:2024-10-12
  • 通讯作者:吴正国 E-mail:wuzg2@njtrh.org

Pattern of lymph node metastasis in the lung lobe of NSCLC and selection of lymph node dissection methods in complete video-assisted thoracoscopic lobectomy surgery

Wang Qingbei, Zhu Lin, Wu Zhengguo()

  1. Department of Cardiothoracic Surgery， Nanjing Tongren Hospital Affiliated to Southeast University School of Medicine， Nanjing 211102， China
  • Received:2024-04-22Revised:2024-07-11Online:2024-09-08Published:2024-10-12
  • Contact:Wu Zhengguo E-mail:wuzg2@njtrh.org

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摘要：

目的探究非小细胞肺癌（NSCLC）肺内叶段淋巴结转移规律及全胸腔镜肺叶切除术（cVATS）中淋巴结清扫方式。方法选择2015年1月至2018年11月在东南大学医学院附属南京同仁医院经cVATS治疗的NSCLC患者244例，将2015年1月至2018年4月的患者定义为训练集（n=183），2018年5月至11月的患者定义为验证集（n=61）；训练集用来建立模型，验证集用来评估模型性能。训练集中，根据淋巴结清扫方式，将患者分为系统性纵隔淋巴结清扫术（SML）组（n=93）和肺叶特异性淋巴结清扫术（LSND）组（n=90）。计算训练集患者的淋巴结转移率，比较淋巴结转移（n=55）与未转移（n=128）患者的临床资料。采用多因素logistic回归分析淋巴结转移的影响因素，根据多因素分析结果构建列线图预测模型，并对模型进行验证。比较训练集中SML组与LSND组患者的临床资料、围术期临床指标、总生存期（OS）以及术后并发症发生率。结果训练集中183例NSCLC患者淋巴结转移率为30.05%（55/183），转移淋巴结共328枚；第2~13组淋巴结中，第10（15.60%，44/282）、11（22.79%，98/430）以及12~13（15.25%，61/400）组淋巴结转移率最高。多因素分析显示，肿瘤最大径（OR=2.71，95%CI为1.82~4.09，P<0.001）、CT影像特征（OR=2.49，95%CI为1.59~6.99，P=0.001）、分化程度（OR=2.06，95%CI为1.11~3.81，P=0.010）、血清癌胚抗原（CEA）（OR=1.87，95%CI为1.42~2.58，P=0.015）、胸膜受侵（OR=1.81，95%CI为1.07~3.07，P=0.021）均是NSCLC患者发生淋巴结转移的独立影响因素。训练集和验证集的C-index分别为0.91（95%CI为0.88~0.97）和0.89（95%CI为0.84~0.96），两集的校准曲线均与理想曲线拟合良好。受试者操作特征曲线分析显示，列线图预测模型用于训练集与验证集患者鉴别诊断的曲线下面积分别为0.92（95%CI为0.87~0.96）和0.91（95%CI为0.85~0.98）。训练集中SML组与LSND组患者的手术时间[（203.08±38.26）min比（177.14±22.18）min，t=5.59，P<0.001]、术中失血量[（458.14±65.04）ml比（426.08±26.58）ml，t=4.34，P<0.001]、胸腔引流量[（1 200.14±226.58）ml比（1 114.38±164.34）ml，t=2.92，P=0.004]、拔管时间[（6.57±1.28）d比（5.02±1.12）d，t=8.71，P<0.001]、住院时间[（15.02±1.29）d比（12.08±1.57）d，t=13.86，P<0.001]比较，差异均有统计学意义。两组患者1年（96.77%比96.67%）、3年（84.95%比86.67%）、5年（75.27%比77.78%）OS率比较，差异无统计学意义（χ2=0.16，P=0.689）。两组患者不良反应总发生率[18.28%（17/93）比7.78%（7/90）]比较，差异有统计学意义（χ2=4.43，P=0.035）。结论肺内叶段淋巴结在NSCLC患者转移过程中占据相当的比例，第10、11以及12~13组的淋巴结转移率最高。肿瘤最大径、CT影像特征、分化程度、血清CEA、胸膜受侵均是NSCLC患者发生淋巴结转移的独立影响因素。与SML相比，LSND创伤更小，不良反应发生率更低。

关键词:癌，非小细胞肺,淋巴转移,全胸腔镜肺叶切除术

Abstract:

ObjectiveTo explore the pattern of lymph node metastasis in the lung lobes of stage Ⅱa non-small cell lung cancer （NSCLC） and the lymph node dissection method during complete video-assisted thoracoscopic lobectomy surgery （cVATS）.MethodsA total of 244 patients with NSCLC who underwent cVATS treatment at Nanjing Tongren Hospital Affiliated to Southeast University School of Medicine from January 2015 to November 2018 were selected. Patients admitted from January 2015 to April 2018 were defined as the training set （n=183）， and patients admitted from May 2018 to November 2018 were defined as the validation set （n=61）. The training set was used to build the model， and the validation set was used to evaluate the performance of the model. In the training set， patients were divided into systematic meditational lymphadenectomy （SML） group （n=93） and lobe-specific systematic node dissection （LSND） group （n=90） based on lymph node dissection methods.The lymph node metastasis rate of patients in the training set was calculated， and the clinical data of patients with （n=55） and without （n=128） lymph node metastasis were compared. Multivariate logistic regression was used to analyze the influencing factors of lymph node metastasis， and a nomogram prediction model was constructed based on the results of the multivariate analysis， and the model was validated. Clinical data， perioperative clinical indicators， overall survival （OS）， and incidence of postoperative complications were compared between the SML group and LSND group in the training set.ResultsIn the training set， the lymph node metastasis rate of 183 patients with NSCLC was 30.05% （55/183）， with a total of 328 metastatic lymph nodes； from the 2nd to the 13th groups of lymph nodes， the 10th （15.60%， 44/282）， the 11th （22.79%， 98/430）， and the 12th to the 13th （15.25%， 61/400） groups had the highest lymph node metastasis rate. Multivariate analysis showed that maximum tumor diameter （OR=2.71， 95%CI： 1.82-4.09，P<0.001）， CT imaging features （OR=2.49， 95%CI： 1.59-6.99，P=0.001）， degree of differentiation （OR=2.06， 95%CI： 1.11-3.81，P=0.010）， serum carcinoembryonic antigen （CEA） （OR=1.87， 95%CI： 1.42-2.58，P=0.015）， and pleural invasion （OR=1.81， 95%CI： 1.07-3.07，P=0.021） were all independent influencing factors for the occurrence of lymph node metastasis in Ⅱa NSCLC patients. The C-index of the training set and the validation set were 0.91 （95%CI： 0.88-0.97） and 0.89 （95%CI： 0.84-0.96）， respectively， and the calibration curves of the two sets were well fitted to the ideal curves. Receiver operating characteristic curve analysis showed that， the area under curve of the nomogram prediction model used for differential diagnosis of patients in the training and validation sets were 0.92 （95%CI： 0.87-0.96） and 0.91 （95%CI： 0.85-0.98）， respectively. There were statistically significant differences in surgical time [（203.08±38.26） minvs.（177.14±22.18） min，t=5.59，P<0.001]， intraoperative blood loss [（458.14±65.04） mlvs.（426.08±26.58） ml，t=4.34，P<0.001]， thoracic drainage volume [（1 200.14±226.58） mlvs.（1 114.38±164.34） ml，t=2.92，P=0.004]， extubation time [（6.57±1.28） dvs.（5.02±1.12） d，t=8.71，P<0.001]， hospital stay [（15.02±1.29） dvs.（12.08±1.57） d，t=13.86，P<0.001） between the SML group and the LSND group in the training set. There was no statistically significant difference in OS rate between two groups of patients at 1 year （96.77%vs.96.67%）， 3 years （84.95%vs.86.67%）， and 5 years （75.27%vs.77.78%） （χ2=0.16，P=0.689）. There was a statistically significant difference in the overall incidence of adverse reactions [18.28%（17/93）vs.7.78%（7/90）] between two groups of patients （χ2=4.43，P=0.035）.ConclusionIntrapulmonary segment lymph node accounts for a considerable proportion in the metastasis process of NSCLC， with the highest degree of lymph node metastasis rate in groups 10， 11， and 12-13. Maximum tumor diameter， CT imaging features， degree of differentiation， serum CEA， and pleural invasion are all independent influencing factors for the occurrence of lymph node metastasis in NSCLC patients. Compared with SML， LSND has less trauma and a lower incidence of adverse reactions.

Key words:Carcinoma， non-small-cell lung,Lymphatic Metastasis,Complete video-assisted thoracoscopic lobectomy surgery