Lacquet L K
Department of Thoracic and Cardiac Surgery, University Hospital St. Radboud, Nijmegen, The Netherlands.
Acta Chir Belg. 1996 Nov-Dec;96(6):245-51.
Surgical resection of non-small cell lung cancer (NSCLC) is the treatment of choice if complete resection is possible. There is consensus regarding a pretreatment minimal staging. For the pre-operative exploration CT scan (with contrast) and mediastinoscopy are complemental. Accepted is the New International Staging system with TNM. The 5-year survival following complete resection is stage-dependent. For stage I disease (T1-2, N0 M0) lobectomy is generally possible. The overall 5-year postoperative survival is 65%. No postoperative adjuvant treatment is necessary. For stage II (T1-2 N1 M0) lobectomy is possible in 70% of patients. The overall 5-year postoperative survival is 42.9%. Survival is affected by histology and T-status. The incidence of local recurrence can be reduced by postoperative radiotherapy. For stage III A (T1-3 N0-2 M0) surgery or combined modality treatment is indicated. The overall 5-year postoperative survival is 22.2%. For chest wall involvement (T3) en bloc resection of lung and partial chest wall is performed if possible. The 5-year survivors share common features: asymptomatic before operation, non-smokers, no rib erosion, squamous cell carcinoma, limited chest wall resection and N0 status. Pancoast tumours (T3) are treated according to the Paulson protocol with low dose pre-operative radiotherapy, complete en bloc resection, and postoperative radiotherapy in case of incomplete resection. Long-term survival after pre-operative irradiation and complete resection is possible. N1 or N2 disease is an adverse prognostic factor. When N2 disease is unsuspectedly discovered at operation, complete resection with mediastinal lymphadenectomy is indicated. The subgroup with the best prognosis is the group with negative mediastinoscopy, lobectomy and minimal N2. Multimodal therapy with chemo- or chemoradiotherapy is investigated. The results demonstrate the longest survival in patients with complete resection after major response to chemotherapy. For stage III B (T4 any N M0; any T N3 M0) surgery is usually not indicated and most patients are candidates for radio- or chemotherapy or both. The overall 5-year postoperative survival is 5.6% with 0% for N3 but 8.2% for T4 patients, after extended resection as intrapericardial pneumonectomy, sleeve pneumonectomy, partial resection of the superior vena cava and miscellaneous partial resections. Postoperative radiotherapy may improve local control. For stage IV (any T any N M1) combined surgery can be effective for solitary adrenal or brain metastases. A reported 7.5% 5-year survival was mainly for intrapulmonary metastases, also considered as satellite nodules. Careful follow-up of patients operated for lung cancer is necessary, as the incidence of metachronous lung cancer is as high as 10% for the long survivors. Reoperation with an economic but complete resection is the treatment of choice in the absence of metastases or other contraindications.
如果有可能进行完整切除，非小细胞肺癌（NSCLC）的手术切除是首选治疗方法。对于术前最低限度分期已达成共识。术前探查时，CT扫描（增强）和纵隔镜检查互为补充。目前公认的是采用TNM分期的新国际分期系统。完整切除后的5年生存率取决于分期。对于Ⅰ期疾病（T1-2，N0 M0），通常可行肺叶切除术。总体术后5年生存率为65%。无需术后辅助治疗。对于Ⅱ期（T1-2 N1 M0），70%的患者可行肺叶切除术。总体术后5年生存率为42.9%。生存率受组织学类型和T分期影响。术后放疗可降低局部复发率。对于ⅢA期（T1-3 N0-2 M0），建议进行手术或综合治疗。总体术后5年生存率为22.2%。对于胸壁受累（T3），如果可能应行肺和部分胸壁整块切除。5年生存者有共同特征：术前无症状、不吸烟者、无肋骨侵蚀、鳞状细胞癌、胸壁切除范围有限且N0状态。潘科斯特瘤（T3）按照保尔森方案治疗，即术前低剂量放疗、完整整块切除，若切除不完全则术后放疗。术前放疗和完整切除后有可能长期生存。N1或N2疾病是不良预后因素。术中意外发现N2疾病时，应行完整切除并纵隔淋巴结清扫术。预后最佳的亚组是纵隔镜检查阴性、肺叶切除且N2最少的组。正在研究化疗或放化疗的多模式治疗。结果表明，化疗后有主要反应且完整切除的患者生存时间最长。对于ⅢB期（T4任何N M0；任何T N3 M0），通常不建议手术，大多数患者适合放疗或化疗或两者联合。总体术后5年生存率为5.6%，N3患者为0%，但T4患者行扩大切除如心包内肺切除术、袖状肺叶切除术、上腔静脉部分切除术及其他各种部分切除术后为8.%。术后放疗可改善局部控制。对于Ⅳ期（任何T任何N M1），联合手术对孤立性肾上腺或脑转移可能有效。报告的5年生存率为7.5%，主要针对肺内转移，也被视为卫星结节。对肺癌手术患者进行仔细随访很有必要，因为长期生存者中异时性肺癌的发生率高达10%。在无转移或其他禁忌证的情况下，再次手术并进行经济但完整的切除是首选治疗方法。
