非小细胞肺癌纵隔淋巴结转移危险因素分析及术前纵隔镜检查的应用策略

目的 探讨纵隔镜技术评估非小细胞肺癌(NSCLC)术前纵隔淋巴结状态(是否存在转移)的临床应用策略.方法 2000年10月至2007年6月,对临床连续收治的经病理确诊的临床分期为Ⅰ～Ⅲ期的NSCLC患者152例,分别采用CT和纵隔镜技术评估纵隔淋巴结状态.根据纵隔淋巴结最终病理结果,计算CT下纵隔肺门淋巴结阴性NSCLC的纵隔镜检查阳性率和实际纵隔淋巴结转移发生率.以患者性别、年龄、肿瘤部位、病理类型、肿瘤T分期、肿瘤类型(中央型或外周型)、CT下纵隔淋巴结大小和血清癌胚抗原(CEA)水平等作为预测因子,进行纵隔淋巴结转移危险因素的单因素和多因素分析.结果 69例CT下纵隔肺门淋巴结阴性NSCLC,纵隔镜检查阳性8例,阳性率为11.6%;实际纵隔淋巴结转移14例,发生率为20.1%.62例临床Ⅰ期(cT1～2NOMO)NSCLC,纵隔镜检查阳性7例,阳性率为11.3%;实际纵隔淋巴结转移12例,发生率为19.4%.对全部152例NSCLC患者纵隔淋巴结转移危险因素的分析结果显示,病理类型和CT下纵隔淋巴结大小是纵隔淋巴结转移的独立危险因素.对69例CT下纵隔肺门淋巴结阴性NSCLC患者纵隔淋巴结转移危险因素的分析结果显示,病理类型是纵隔淋巴结转移的独立危险因素.结论 对于CT下纵隔淋巴结短径≥1 cm的NSCLC患者,术前必须进行纵隔镜检查;对于腺癌患者,即使是CT下纵隔肺门淋巴结短径<1 cm,术前也应该进行纵隔镜检查.     

A case of endobronchial squamous cell lung cancer successfully treated with weekly chemotherapy of carboplatin and paclitaxel

A 69-year-old man had undergone low anterior resection and a right lobe resection of the liver for rectum cancer and metastatic liver tumor at the age of 66 years. He presented at our hospital because of an abnormal shadow on a CT chest scan, which indicated a tumor shadow 2.5 cm in size in the lingular lobe and enlarged hilar and mediastinal lymph nodes. A bronchoscopic tumor biopsy revealed pulmonary metastasis from the rectum cancer. Bronchoscopic examination also identified an endobronchial squamous cell lung cancer, which almost completely obstructed the orifice of B1 and B2. We concluded that the patient had squamous cell lung cancer with metastases in the mediastinal lymph nodes. He was initially treated with weekly chemotherapy with carboplatin (AUC 1.25) and paclitaxel (70 mg/m2). The endobronchial tumor was markedly reduced in size after 2 weeks of the chemotherapy. Furthermore, after 6 weeks of the chemotherapy, the tumor had disappeared completely, and 11 days later, lower division segmentectomy and hilar and mediastinal lymph node dissection were performed. Pathological examination revealed no metastases in the lymph nodes. The patient has continued to receive chemotherapy as an outpatient and has been well without recurrence of any metastases for over 16 months.     

CT横断面上肺癌淋巴引流区域的界定及勾画

背景与目的：肺癌常有肺门和纵隔淋巴结转移，在三维适形放疗（3 dimensional conformal radiation therapy，3-DCRT）中，不同医师基于CT图像勾画的淋巴引流区域有明显差别。本研究在CT横断面上定义肺门和纵隔淋巴引流区界线，以减少靶区勾画的差异。方法：收集2004年11月-2005年11月中山大学附属肿瘤医院非小细胞肺癌（non-small-cell lung cancer，NSCLC）患者治疗前CT、PET／CT，选择一中等身材女性胸部CT增强扫描图像（Dicom格式）作为模板，将肺门和纵隔阳性淋巴结标注在模板CT相应位置，根据淋巴引流区域的定义和转移淋巴结的实际情况用Adobe photoshop CS软件标出界线，并在Exomio 2．0系统上进行各淋巴结区的勾画。结果：收集40位NSCLC患者胸部CT增强扫描资料（其中10位行PET／CT），在CT模板上标注了278枚淋巴结。确定了1．2R、1-2L、3A、3P、4R、4L、5、6、7、8、10-11R、10-11L组淋巴结区域的界线，在模板CT上根据标注淋巴结勾画出以上淋巴结区域。结论：在CT横断面上对肺门和纵隔淋巴区域界线的准确定义有助于肺癌转移淋巴结的分组和分期诊断，有助于提高淋巴引流区勾画的一致性和可重复性。     

非小细胞肺癌纵隔淋巴结转移的临床病理探讨

目的 :从病理角度探索非小细胞肺癌纵隔淋巴结 (N2 )转移的特点。方法 :为 10 0 3例非小细胞肺癌患者行肺切除及淋巴结清除术 ,对 334例 N2 淋巴结转移进行临床病理分析。结果 :病理类型与 N2 转移关系密切 ,鳞癌 N2 转移率显著低于腺癌、腺鳞癌 ;N2 转移率随肿瘤长径增加而增加 ;N2 转移淋巴结的分布范围较为广泛 ,最密集的部位是第 3、7、5组淋巴结 ;中心型肺癌 N2 转移率明显高于周围型肺癌。结论 :为获得根除性切除 ,广泛、彻底清除同侧肺门、支气管和纵隔淋巴结是十分必要的。     

In vivo identification of sentinel lymph nodes for clinical stage I non-small cell lung cancer for abbreviation of mediastinal lymph node dissection

BACKGROUND: We previously reported that an identification of sentinel lymph node (SN) with a techenetium-99m (99mTc) tin colloid by ex vivo counting, i.e. the radio-activity of dissected lymph nodes, was a reliable method of establishing the first site of nodal metastasis in non-small cell lung cancer [J. Thorac. Cardiovasc. Surg. 124(2002)486]. However, for SN navigation surgery, SN should be identified before lymph node dissection (in vivo) but not after that (ex vivo). In order to reduce mediastinal lymph node dissection for clinical stage I non-small cell lung cancer (NSCLC) by SN navigation surgery, the SN identifications for hilar lymph nodes by ex vivo counting, and for mediastinal lymph nodes by in vivo, were evaluated. METHODS: Intra-operative SN identification using 99mTc tin colloid was conducted on 104 patients with clinical stage I NSCLC who had had major lung resections with mediastinal lymph node dissections. The hilar SNs were identified by ex vivo counting (after lung resection) and the mediastinal SNs were identified by in vivo counting (before lymph node dissection). To evaluate the accuracy of mediastinal SN identification by in vivo counting, it was compared with the data by ex vivo counting. RESULTS: SNs were identified in 84 patients (81%). SNs were identified at the hilum by ex vivo counting in 78 patients (93%) and at the mediastinum by in vivo counting in 40 patients (48%). While 15 patients had lymph node metastases, i.e. N1 in six and N2 in nine, the SNs could be found to have metastases during operation in 13 of the 15 patients (87%). The in vivo counting of the mediastinum missed out the mediastinal SNs identified by ex vivo counting in four of the 84 patients (5%). CONCLUSION: If the hilar SNs identified by ex vivo counting and the mediastinal SNs identified by in vivo counting had no metastases, then mediastinal lymph node dissection could be abbreviated for patients with clinical stage I NSCLC.     

306例肺癌的淋巴结转移规律

目的 探讨可切除性肺癌的胸内淋巴结转移规律。方法 从l992年1月至2000年l2月，对306例肺癌患者施行根治性切除术和系统性胸内淋巴结清扫，分别记录各区淋巴结的数量、大小、颜色和质地，并进行病理检查。结果 全组共清扫胸内2456个区的46l4个淋巴结，平均每例15.1个。经病理检查证实其中521个区的954个淋巴结存在转移癌。胸内淋巴结的转移率高达61．8％，纵隔淋巴结的转移率高达43．5％。围绕肺门或肺根部的11、10、7、5和4区淋巴结的转移频度比远离肺根部的9、6、3、2、l区淋巴结高。小细胞肺癌的淋巴结转移率明显高于非小细胞肺癌(P＜0.01)。淋巴结转移率与淋巴结的大小、颜色和质地均有密切关系(尸＜0.00l，P＜0.00l，P＜0.001)。结论 多数肺癌的淋巴结转移遵循由近及远、自下而上、由肺内经肺门再向纵隔的顺序转移规律，少数纵隔淋巴结转移呈“跳跃式”。肺切除术时施行系统性胸内淋巴结清扫是必要的。     

Lung cancer with isolated skip metastasis to an abdominal lymph node

BACKGROUND: Lung cancer is usually diagnosed at an advanced stage with metastases present in 40% of patients. The preferential sites of extrapulmonary spread include lymph nodes, liver, brain, adrenal gland, and bone. Direct lymphatic metastases to abdominal lymph nodes without involvement of lobar, hilar or mediastinal lymph nodes is rare. CASE REPORT: We report a case of adenocarcinoma of the lung in the left lower lobe, with isolated metastasis to an abdominal lymph node detected by positron emission tomography (PET), followed by confirmation with surgical exploration. CONCLUSION: The low incidence reported for skip metastasis to the abdominal lymph nodes may be attributed to an underestimation in the past. With the advent of PET computed tomography (PET-CT) and its use as a standard pre-operative staging modality for lung cancer, one should anticipate an increased incidence of skip metastasis.     

肺癌侵袭近端支气管壁的临床病理探讨

目的探讨不同组织类型肺癌向近端支气管壁侵袭的规律。方法对１５１例中心型肺癌手术切除标本近端支气管进行不同断面的病理学研究。其中,全肺切除标本４１例,肺叶切除标本１１０例。结果癌细胞沿管壁粘膜下层或多层面直接侵袭是癌扩延的主要方式,９６．６％的癌侵袭发生在距瘤缘１．５ｃｍ以内的管壁上。其侵袭距离与病理类型、侵袭方式及ＴＮＭ分期因子（ｐＴ、ｐＮ）相关。转移淋巴结对管壁的侵袭也是癌扩延不容忽视的形式。结论为获得根治切除,支气管切端距瘤缘的安全界限原则上应超过１．５ｃｍ,并须彻底清除肺门纵隔淋巴结     

Mediastinal lymph node metastases from gastrointestinal carcinoma

Mediastinal and hilar lymphadenopathy secondary to gastrointestinal metastases rarely have been reported and have been considered to occur only in conjunction with lymphangitic lung spread. The current report is of 15 cases of hilar and mediastinal metastases secondary to pancreatic, gastric, and colonic primary tumors. In only three of these cases was lymphangitic lung involvement noted. Possible pathways of spread of these tumors to the mediastinal lymph nodes are discussed.     

30例小细胞肺癌的CT表现

目的分析小细胞肺癌的CT表现特点,以提高对该病的认识和诊断能力。方法回顾性分析30例经病理证实的小细胞肺癌的螺旋CT表现。结果中央型肺癌24例,CT表现为肺门分叶状结节或肿块,伴阻塞性肺炎5例（20.8%）,阻塞性不张3例（12.5%）,21例（84.5%）纵隔淋巴结肿大。25例行CT增强,其中23例肿块和淋巴结均匀强化,11例（45.8%）纵隔大血管被包埋,周围型6例,表现为边缘规整的结节状或葡萄状。结论小细胞肺癌以中心型为主,呈实体性生长,CT上肿块密度较均匀,易侵犯支气管及纵隔大血管,伴肺门、纵隔淋巴结转移。     

Sarcoid-like hilar and mediastinal lymphadenopathy in a patient with metastatic testicular cancer

Previous reports indicate that enlarged hilar and mediastinal lymph nodes due to sarcoid-like reactions may develop after curative resection of testicular cancer, and their presence does not necessarily denote neoplastic recurrence. Reports further suggest that coexisting pulmonary nodules in this setting may be related to nodular sarcoidosis. A patient developed progressive hilar and mediastinal adenopathy associated with multiple pulmonary nodules after apparent curative resection of a testicular embryonal cell cancer. Biopsy specimens from the mediastinal lymph nodes demonstrated granulomas, suggesting the diagnosis of nodular sarcoidosis. Needle aspiration of the pulmonary nodules, however, revealed metastatic testis cancer. Sarcoid-like mediastinal reactions occur after resection of testis cancer, but biopsies should be performed on coexisting pulmonary nodules to exclude pulmonary metastases.     

Evaluation of p53 alterations in occult lymph node metastases

BACKGROUND AND OBJECTIVES: This study was designed to evaluate p53 alterations in occult lymph node metastases. METHODS: We examined 41 patients with stage I non-small-cell lung cancer. We investigated p53 gene mutation by polymerase chain reaction and single-strand conformation polymorphism analysis of exons 5-8, p53 protein accumulation by immunostaining with monoclonal antibody DO-7, and detection of tumor cells in lymph nodes by immunohistochemistry with monoclonal antibodies to cytokeratin (CK). RESULTS: p53 gene mutation was detected in 34% of tumors and nuclear p53 accumulation in 46%. CK-positive cells in the hilar and mediastinal region lymph nodes were detected in 43.9% of patients and 29.3%, respectively. Of the 14 cases with p53 mutation and the 19 cases with p53 accumulation, 12 and 15 had micrometastases in the hilar or mediastinal lymph nodes, respectively. However, p53 alterations were not significantly associated with occult lymph node metastases. In cases with occult lymph node metastases, the 5-year survival was 81. 9% for the p53 wild-type group and 45.8% for the p53 mutation group. CONCLUSIONS: p53 alterations are not correlated with occult lymph node metastases, while p53 gene mutation is considered to be an unfavorable prognostic marker in patients with occult lymph node metastases. J. Surg. Oncol. 2000;73:143-147.     

Role of skip metastasis to mediastinal lymph nodes in non-small cell lung cancer

BACKGROUND: Skip metastasis to mediastinal lymph nodes is a well-known phenomenon in non-small cell lung cancer (NSCLC). Little is reported in the literature about its clinical importance. It is still under discussion whether any prognostic differences exist between resected NSCLC with either skip metastases or continuous mediastinal lymph node metastases (N2). PATIENTS AND METHODS: We analyzed retrospectively the data of 45 patients with a pN2-stage, who underwent resection for NSCLC. Seventeen of these patients (37.8%), showing no metastatic involvement of hilar (N1) lymph nodes, were compared to the remaining 28 patients with infiltration of hilar nodes (N1) as well as N2 nodes. RESULTS: Multivariate analysis showed no statistically significant difference between the skip metastasis and the continuous N2 group regarding sex, age, histology, T- or M-status. The frequency of skip metastasis was higher in patients with a primary tumor in the upper lobe (n = 12, 71%) compared to the lower lobe (n = 5, 29%). This difference was not statistically significant. In patients with a non-continuous lymph node spread, 29 out of 119 resected mediastinal lymph nodes were infiltrated (1.7 per patient, range: 1-10). Compared to 83 metastatic involved lymph nodes out of 198 resected mediastinal nodes (three per patient, range: 1-10) in patients with involvement of N1 and N2 nodes (P = 0.034, Mann-Whitney test). The 5-year survival rate of pN2 patients with skip metastasis was 41% compared to 14% in patients with involvement of N1 and N2 nodes (P = 0.019). CONCLUSIONS: pN2 patients with mediastinal lymph node skip metastasis have a more favorable prognosis compared to pN2 patients with continuous infiltration of the regional lymph nodes. Patients with a continuous lymph node involvement show an increased number of infiltrated mediastinal lymph nodes per patient compared to patients with a non-continuous spread. Skip metastasis is an independent prognostic factor of survival. The presence of skip metastasis seems to be a unique subgroup of pN2 disease in NSCLC.     

肺癌纵隔淋巴结转移及广泛廓清的价值

目的研究肺癌纵隔淋巴结转移（Ｎ２）频度、分布范围及特点,为广泛廓清提供依据。方法总结９年间手术切除３８６例肺癌患者的临床资料。术中按Ｎａｒｕｋｅ肺癌淋巴结分布图对肺门、同侧纵隔淋巴结进行广泛廓清。结果Ｎ２１４７例,占３８．１％,清除转移Ｎ２２８９组。Ｎ２转移率在鳞癌、腺癌、小细胞癌及大细胞癌分别为３０．１％、４４．１％、４８．０％及５０．０％。肺上叶Ｎ２７１例,清除转移Ｎ２１４６组。上纵隔转移１２４组,占８４．９％;下纵隔转移２２组,占１５．１％。肺下叶（包括中叶）Ｎ２７６例,清除转移Ｎ２１４３组。下纵隔转移６７组,占４６．９％;上纵隔转移７６组,占５３．１％。跳跃式转移７９例,占Ｎ２转移的５３．７％。跳跃式纵隔转移１６例,占１０．９％。结论肺癌纵隔淋巴结转移具有跳跃性、多发性。只有广泛清除了上下纵隔淋巴结,才有可能达到根治。     

Immunolymphoscintigraphy of pulmonary and mediastinal lymph nodes in dogs: a new approach to lung cancer imaging

Despite improved resolution with new imaging techniques, surgical confirmation of mediastinal lymph node status is often required for reliable staging of patients with non-small cell lung cancer. Recent scintigraphic studies suggest that s.c. administration of radiolabeled antibodies can be more efficient than the i.v. route for targeting regional lymph nodes in animals and humans. To determine if this approach could be applied to the lymphatics of the lung, we injected both specific and irrelevant radiolabeled monoclonal antibodies via a flexible fiberoptic bronchoscope through the mucosa of lobar bronchi in normal dogs. The injected antibodies were expected to drain by way of local lymphatic vessels toward the central lymph nodes, in effect following the same pathway as do cells metastasizing to these nodes during early regional tumor dissemination. To accomplish this, anesthetized dogs were intubated and then coinjected with the two labeled antibodies [600 microCi/100 micrograms (total)] through a fiberoptic bronchoscope. The animals were serially imaged and then autopsied 14-36 h after injection. Individual hilar and carinal nodes contained over 1% of the injected 131I-labeled specific antibody dose and the average selectivity was 2.5:1 with respect to a coinjected irrelevant IgG. Distant organs (mesenteric lymph node, liver, spleen, bone marrow, and lung parenchyma other than the injection site) contained much less radioactivity, and those sites accumulated a greater fraction of the non-specific labeled antibody. The ratio of iodine-131 to iodine-125 counts between hilar/carinal lymph nodes and abdominal lymph nodes ranged from 15:1 to 100:1. These initial studies indicate efficient delivery of antibody to a subset of the regional nodes via pulmonary lymphatics. They suggest the feasibility of this technique which may be of use in the detection and perhaps therapy of human lung cancer metastases in regional lymph nodes.     

肺腺鳞癌淋巴结转移规律的探讨

目的 分析肺腺鳞癌淋巴结转移(LNM)的特点.方法 对361例肺腺鳞癌患者的临床资料进行回顾性分析.淋巴结分区和TNM分期采用国际抗癌联盟(UICC)标准(1997年).统计分析采用χ2检验、Log rank检验和Cox比例风险模型分析.结果 361例肺腺鳞癌纵隔LNM途径表现为:左肺上叶癌首先转移到主.肺动脉窗淋巴结,右肺上叶癌首先转移到下气管旁淋巴结,两侧下叶肺癌首先转移到隆突下淋巴结,右肺中叶肺癌以向上转移为主.纵隔淋巴结跳跃转移以隆突下最为多见,其次为主-肺动脉窗和下段气管旁.发生单一站纵隔淋巴结跳跃转移的患者预后好于其他LNM者.结论 不同部位肺腺鳞癌的LNM途径和跳跃转移部位有所不同,治疗时应加以考虑.不同转移模式的患者预后不同,发生单一站纵隔淋巴结跳跃转移的患者预后可能较好.     

肺腺鳞癌淋巴结转移规律的探讨

目的 分析肺腺鳞癌淋巴结转移(LNM)的特点.方法 对361例肺腺鳞癌患者的临床资料进行回顾性分析.淋巴结分区和TNM分期采用国际抗癌联盟(UICC)标准(1997年).统计分析采用χ2检验、Log rank检验和Cox比例风险模型分析.结果 361例肺腺鳞癌纵隔LNM途径表现为:左肺上叶癌首先转移到主.肺动脉窗淋巴结,右肺上叶癌首先转移到下气管旁淋巴结,两侧下叶肺癌首先转移到隆突下淋巴结,右肺中叶肺癌以向上转移为主.纵隔淋巴结跳跃转移以隆突下最为多见,其次为主-肺动脉窗和下段气管旁.发生单一站纵隔淋巴结跳跃转移的患者预后好于其他LNM者.结论 不同部位肺腺鳞癌的LNM途径和跳跃转移部位有所不同,治疗时应加以考虑.不同转移模式的患者预后不同,发生单一站纵隔淋巴结跳跃转移的患者预后可能较好.     

肺腺鳞癌淋巴结转移规律的探讨

目的 分析肺腺鳞癌淋巴结转移(LNM)的特点.方法 对361例肺腺鳞癌患者的临床资料进行回顾性分析.淋巴结分区和TNM分期采用国际抗癌联盟(UICC)标准(1997年).统计分析采用χ2检验、Log rank检验和Cox比例风险模型分析.结果 361例肺腺鳞癌纵隔LNM途径表现为:左肺上叶癌首先转移到主.肺动脉窗淋巴结,右肺上叶癌首先转移到下气管旁淋巴结,两侧下叶肺癌首先转移到隆突下淋巴结,右肺中叶肺癌以向上转移为主.纵隔淋巴结跳跃转移以隆突下最为多见,其次为主-肺动脉窗和下段气管旁.发生单一站纵隔淋巴结跳跃转移的患者预后好于其他LNM者.结论 不同部位肺腺鳞癌的LNM途径和跳跃转移部位有所不同,治疗时应加以考虑.不同转移模式的患者预后不同,发生单一站纵隔淋巴结跳跃转移的患者预后可能较好.     

重组人血管内皮抑素联合GC方案治疗晚期非小细胞肺癌1例报道

A 43-year-old female with a 3-month history of paroxysmal irritating cough presented progressive chest tightness and shortness of breath. Laboratory data showed elevated carcino-embryonic antigen (CEA). Further imaging studies revealed a soft tissue mass shadow was in right middle lobe lung with mediastinal and sub-carinal lymph nodes enlarged. Biopsy diagnosis: moderately and poorly differentiated adenocarcinoma of the lung. Clinical diagnosis: central non-small cell lung cancer (NSCLC) of right middle lobe (C_IVT₄N₂M₁), lung adenocarcinoma G2-3, malignant pleural effusion, pericardial effusion, hilar and mediastina lymph node metastases. After 4 cycles of endostar plus GC therapy, imaging studies revealed showed soft tissue mass in right middle lobe disappeared, and evaluation of short-term result was complete remission (CR). PFS has been seven months till now. Therefore, this report provided strong evidence that endostatin combined GC treatment for advanced NSCLC is safe and effective, which can prolong survival and improve quality of life.     

肺腺鳞癌淋巴结转移规律的探讨

目的 分析肺腺鳞癌淋巴结转移(LNM)的特点.方法 对361例肺腺鳞癌患者的临床资料进行回顾性分析.淋巴结分区和TNM分期采用国际抗癌联盟(UICC)标准(1997年).统计分析采用χ2检验、Log rank检验和Cox比例风险模型分析.结果 361例肺腺鳞癌纵隔LNM途径表现为:左肺上叶癌首先转移到主.肺动脉窗淋巴结,右肺上叶癌首先转移到下气管旁淋巴结,两侧下叶肺癌首先转移到隆突下淋巴结,右肺中叶肺癌以向上转移为主.纵隔淋巴结跳跃转移以隆突下最为多见,其次为主-肺动脉窗和下段气管旁.发生单一站纵隔淋巴结跳跃转移的患者预后好于其他LNM者.结论 不同部位肺腺鳞癌的LNM途径和跳跃转移部位有所不同,治疗时应加以考虑.不同转移模式的患者预后不同,发生单一站纵隔淋巴结跳跃转移的患者预后可能较好.