Marulli Giuseppe, Verderi Enrico, Comacchio Giovanni M, Monaci Nicola, Natale Giuseppe, Nicotra Samuele, Rea Federico
Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital, University of Padova, Padova, Italy.
J Vis Surg. 2018 Jan 17;4:15. doi: 10.21037/jovs.2017.12.23. eCollection 2018.
In the last decades, the use of video-assisted thoracoscopic surgery (VATS) lobectomy for the treatment of early stage non-small cell lung cancer is continuously growing. This is mainly due to the development of more advanced surgical devices, to the rising incidence of peripheral lung tumors and is also favored by the increased reliability of preoperative staging techniques. Despite this progress, postoperative unexpected nodal upstaging is still a relevant issue. Aim of this study is to identify possible predictors of unexpected nodal upstaging in patients affected by cT1-3N0 NSCLC submitted to VATS lobectomy.
A total of 231 cases of cT1-3N0 patients submitted to thoracoscopic lobectomy at our centre between June 2012 and October 2016 were retrospectively reviewed. All data regarding clinical staging by means of computed tomography (CT) and positron-emission tomography (PET)/CT were collected and reviewed. The subsequent pathological staging has been analyzed, with special regards to the possible type of nodal involvement, and the number of pathological nodal stations.
Most of the patients included in this study were in a clinical stage cT1aN0, cT1bN0 (stage IA) and cT2aN0 (stage IB), 86 (37.2%) patients, 73 (31.6%) patients and 62 (26.8%) patients, respectively. Postoperative histopathological analysis showed that the most frequent tumor histotype was adenocarcinoma (192 patients, 83.1%). Thirty-eight (16.5%) patients had a nodal upstaging; among these, 17 (7.4%) patients had N2 disease (8 patients with isolated mediastinal nodal involvement, 9 patients with N1 + N2 disease) and 21 (9.1%) patients had an isolated hilar nodal involvement (N1). At bivariate analysis, the clinical T (cT)-parameter (P=0.023), the histotype (P=0.029) and the pathological T (pT)-parameter (P=0.003) were identified as statistically significant predictors of nodal upstaging. Concerning the type of nodal upstaging, the pT was found to be statistically significant (P=0.042). At bivariate analysis for the number of involved nodal stations, a statistical significance was highlighted for the parameters cT (P=0.030) and pT (P=0.027). With linear logistic regression, histology as well as pT reached statistical significance (P=0.0275 and P=0.0382, respectively). No correlation was found between nodal upstaging and the intensity of FDG uptake in the primary lung tumor or with the timing between PET and surgery.
There is a strong correlation between the clinical staging of the parameter T evaluated with CT and the possible unexpected nodal upstaging. The same correlation with nodal upstaging is found for pT. At equal clinical stage, in patients affected by adenocarcinoma of the lung the relative risk of having a postoperative unexpected nodal upstaging is almost 7 times higher than in patients with squamous cell carcinoma.
在过去几十年中，电视辅助胸腔镜手术（VATS）肺叶切除术用于治疗早期非小细胞肺癌的应用不断增加。这主要归因于更先进手术设备的发展、周围型肺肿瘤发病率的上升，以及术前分期技术可靠性的提高。尽管取得了这一进展，但术后意外的淋巴结分期上调仍是一个相关问题。本研究的目的是确定接受VATS肺叶切除术的cT1-3N0非小细胞肺癌患者意外淋巴结分期上调的可能预测因素。
回顾性分析了2012年6月至2016年10月期间在本中心接受胸腔镜肺叶切除术的231例cT1-3N0患者。收集并复查了所有通过计算机断层扫描（CT）和正电子发射断层扫描（PET）/CT进行临床分期的数据。分析了随后的病理分期，特别关注淋巴结受累的可能类型和病理淋巴结站的数量。
本研究纳入的大多数患者处于临床分期cTlaN0、cT1bN0（IA期）和cT2aN0（IB期），分别为86例（37.2%）、73例（31.6%）和62例（26.8%）患者。术后组织病理学分析显示，最常见的肿瘤组织学类型是腺癌（192例患者，83.1%）。38例（16.5%）患者出现淋巴结分期上调；其中，17例（7.4%）患者为N2期疾病（8例为孤立性纵隔淋巴结受累，9例为N1+N2期疾病），21例（9.1%）患者为孤立性肺门淋巴结受累（N1）。在二元分析中，临床T（cT）参数（P=0.023）、组织学类型（P=0.029）和病理T（pT）参数（P=0.003）被确定为淋巴结分期上调的统计学显著预测因素。关于淋巴结分期上调的类型，发现pT具有统计学意义（P=0.042）。在对受累淋巴结站数量的二元分析中，cT（P=0.030）和pT（P=0.027）参数具有统计学意义。通过线性逻辑回归，组织学以及pT均达到统计学意义（分别为P=0.0275和P=0.0382）。未发现淋巴结分期上调与原发性肺肿瘤中FDG摄取强度或PET与手术之间的时间间隔存在相关性。
通过CT评估的参数T的临床分期与可能的意外淋巴结分期上调之间存在强烈相关性。pT与淋巴结分期上调也存在相同的相关性。在相同临床分期下，肺腺癌患者术后意外淋巴结分期上调的相对风险几乎比鳞状细胞癌患者高7倍。
