Department of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut 06520-8062, USA.
Ann Thorac Surg. 2012 Aug;94(2):347-53; discussion 353. doi: 10.1016/j.athoracsur.2012.04.059. Epub 2012 Jun 27.
Unsuspected lymph node metastases are found in the surgical specimens of 10% to 25% clinical stage I lung cancers. Video-assisted thoracic surgery (VATS) is a minimally invasive alternative to thoracotomy. Because detection of clinically occult metastases is dependent on the completeness of surgical lymph node dissection, the influence of surgical approach on nodal evaluation is of interest. We determined the frequency of nodal metastases identified in clinically node-negative tumors by thoracotomy ("open") and VATS approaches to approximate the completeness of surgical nodal dissections.
The Society of Thoracic Surgery database was queried for lobectomies and segmentectomies from 2001 to 2010.
A total of 11,531 (7,137 open and 4,394 VATS) clinical stage I primary lung cancers were resected. Nodal upstaging was seen in 14.3% (1,024) in the open group and 11.6% (508) in the VATS group (p<0.001). Upstaging from N0 to N1 was more common in the open group (9.3% versus 6.7%; p<0.001); however, upstaging from N0 to N2 was similar (5.0% open and 4.9% VATS; p=0.52). Among 2,745 propensity-matched pairs, N0 to N1 upstaging remained less common with VATS (6.8% versus 9%; p=0.002).
During lobectomy or segmentectomy for clinical N0 lung cancer, mediastinal nodal evaluation by VATS and thoracotomy results in equivalent upstaging. In contrast, lower rates of N1 upstaging in the VATS group may indicate variability in the completeness of the peribronchial and hilar lymph node evaluation. Systematic hilar dissection is encouraged, particularly as more surgeons adopt the VATS approach.
10%至 25%的 I 期临床肺癌患者的手术标本中发现了未被怀疑的淋巴结转移。电视辅助胸腔镜手术（VATS）是开胸手术的一种微创替代方法。由于临床隐匿性转移的检测取决于手术淋巴结清扫的完整性，因此手术方法对淋巴结评估的影响是值得关注的。我们通过开胸（“开放”）和 VATS 方法确定了临床淋巴结阴性肿瘤中发现的淋巴结转移的频率，以近似手术淋巴结清扫的完整性。
从 2001 年到 2010 年，我们对胸外科协会数据库中的肺叶切除术和肺段切除术进行了查询。
共切除了 11531 例（7137 例开胸手术和 4394 例 VATS）临床 I 期原发性肺癌。开放组中有 14.3%（1024 例）发生淋巴结分期升级，VATS 组中有 11.6%（508 例）发生淋巴结分期升级（p<0.001）。开放组中 N0 到 N1 的分期升级更为常见（9.3%对 6.7%；p<0.001）；然而，N0 到 N2 的分期升级相似（开放组 5.0%，VATS 组 4.9%；p=0.52）。在 2745 对倾向评分匹配的病例中，VATS 时 N0 到 N1 的分期升级仍然较少（6.8%对 9%；p=0.002）。
在临床 N0 肺癌的肺叶切除术或肺段切除术期间，VATS 和开胸术的纵隔淋巴结评估导致了等效的分期升级。相比之下，VATS 组中 N1 分期升级的发生率较低可能表明支气管周围和肺门淋巴结评估的完整性存在差异。应鼓励系统地进行肺门解剖，特别是随着越来越多的外科医生采用 VATS 方法。
