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1、肺癌手术在肺癌综合治疗中的地位和展望上海市胸科医院二十世纪的鼠疫肺癌发病率、死亡率急骤上升五年生存率 3cm3cm，侵及主支气管但距隆突，侵及主支气管但距隆突2cm2cm；侵及脏侵及脏层胸膜，肺不张或阻塞性肺炎扩展到肺门未达全肺层胸膜，肺不张或阻塞性肺炎扩展到肺门未达全肺 T3T3侵及胸壁、横膈、纵隔胸膜或壁层心包；侵及主支气管侵及胸壁、横膈、纵隔胸膜或壁层心包；侵及主支气管距隆突距隆突 2cm2cm但未及隆突；全肺不张和阻塞性肺炎但未及隆突；全肺不张和阻塞性肺炎 T4 T4 侵及纵隔、心脏、大血管、气管、食管、椎体或隆突；侵及纵隔、心脏、大血管、气管、食管、椎体或隆突；恶性胸腔或心包积液；同
2、侧同叶的卫星灶恶性胸腔或心包积液；同侧同叶的卫星灶肺癌的TNMN N胸内淋巴结胸内淋巴结 N0N0无胸内淋巴结转移无胸内淋巴结转移 N1N1同侧支气管周围、肺门淋巴结；原发灶直接扩展到肺内同侧支气管周围、肺门淋巴结；原发灶直接扩展到肺内淋巴结淋巴结 N2N2同侧隆突下、纵隔淋巴结同侧隆突下、纵隔淋巴结 N3N3对侧纵隔、肺门淋巴结；锁骨上淋巴结对侧纵隔、肺门淋巴结；锁骨上淋巴结MM远道转移远道转移 M0M0无远道转移无远道转移 M1M1有远道转移有远道转移肺癌的TNM分期0 0期期TisTisN0M0N0M0IAIA期期T1N0M0T1N0M0IBIB期期T2N0M0T2N0M0IIAIIA期
3、期T1N1M0T1N1M0IIBIIB期期T2N1M0T2N1M0T3N0M0T3N0M0IIIAIIIA期期T1-2N2M0T1-2N2M0T3N1-2M0T3N1-2M0IIIBIIIB期期 任何任何TN3M0TN3M0T4T4任何任何NM0NM0IVIV期期任何任何TT任何任何NM1NM1肺癌分期的确立对国际标准TNM分期达成共识手术本身有助于进行正确分期有利于制定合理的治疗方案手术适应症相对统一预测预后手术操作技术改进VABBAVAVB气管残端术中冰冻切片检查减少医源性播散气管外科的开展扩大手术的适应范围合理切除病灶各式袖形、肺叶、隆突、全肺、隆突重建手术安全性的提高正确评估心肺功能储
4、备正确评估心肺功能储备手术技巧的改进、提高手术技巧的改进、提高麻醉技术的提高麻醉技术的提高术后重视呼吸道的管理术后重视呼吸道的管理对高龄病人处理能力的提高对高龄病人处理能力的提高降低了手术死亡率降低了手术死亡率40%40%1.6%1.6%减少了并减少了并发发症症54%6.4%54%6.4%减少了剖胸探减少了剖胸探查查率率5.1%3.0%5.1%3.0%围手术期治疗水平的提高慎於术前精於术中勤於术后非小细胞肺癌的治疗原则I期根治性手术II期手术+术后化疗+术后放疗叶间淋巴结N15年生存率65%肺门淋巴结N15年生存率39%III期NSCLCIIIA期可切除性病变手术+辅助治疗大块肿瘤多学科治疗5
5、年生存率1523%IIIB期局部侵犯严重，无法手术切除大部分采用放疗5年生存率67%肺癌的转移随着病期的进展，最终发生转移的可能增大脑骨肝肾上腺47%36%22%15%手手术和放、化和放、化疗1995:BJM1995:BJM 肯定以顺铂为主的术后化疗肯定以顺铂为主的术后化疗肯定以顺铂为主的术后化疗肯定以顺铂为主的术后化疗 1998:Lancet1998:Lancet否定术后否定术后否定术后否定术后6060CoCo的放疗的放疗的放疗的放疗 2001:ASCO术后化疗不能延长术后化疗不能延长术后化疗不能延长术后化疗不能延长N2-NSCLCN2-NSCLC生存期生存期生存期生存期 诱导化疗意义减少耐
6、药的肿瘤细胞数肿瘤血供尚未破坏了解肿瘤对化疗药物的反应缩小瘤体，便于切除清除潜在的微转移灶化疗和手术针对N2的非小细胞肺癌，实施诱导化疗+手术手术完全切除率 60%术后5年生存率 20-25%术后化疗以4个疗程为主，含铂方案具有生存优势倾向EffectofChemotherapytoOperationforLungCancerNSCLC MethodMethod LungCancer,100casesLungCancer,100cases(Chemotherapy(Chemotherapy OperationOperation）group,59casesgroup,59cases86.44%M
7、VPregiment86.44%MVPregiment（OperationOperation ChemotherapyChemotherapy）group,41casesgroup,41cases73.17%MVPregiment73.17%MVPregiment ChemotherapycourseChemotherapycourseCourseCourseChemoChemo OPOPOPOP ChemoChemo1-2course98.30%48.77%1-2course98.30%48.77% 3-4course1.70%48.77%3-4course1.70%48.77%Operat
8、ionTimeOperationTimeChemoChemo OPOP141.8646.64141.8646.64-p-p 0.050.05OPOP ChemoChemo137.5030.74137.5030.74BloodLoseduringOperationBloodLoseduringOperation ChemoChemo OPOP588.14632.07588.14632.07-p-p 0.050.05OPOP ChemoChemo490.00276.24490.00276.24 DrainagevolumeafterOperationDrainagevolumeafterOpera
9、tion (firstday(firstdaypostoperative)postoperative) ChemoChemo OPOP426.61187.98426.61187.98_p_p 0.050.05OPOP ChemoChemo470.13199.20470.13199.20Conclusion(1)Chemotherapyincreasetherisksof(1)Chemotherapyincreasetherisksofoperationoperation(general(generalcondition)condition)(2)Fibrosisisanunderlyingri
10、skfactorfor(2)Fibrosisisanunderlyingriskfactorforbloodloss,itsbloodloss,itsnecessarytopaymoreattentiononcarefullynecessarytopaymoreattentiononcarefullyhemostasiahemostasia(3)Todecreasetherisksofpostoperative(3)Todecreasetherisksofpostoperativecomplication,complication,sufficientintervalafterchemothe
11、rapy,sufficientintervalafterchemotherapy,preoperativepreoperativeprepareandpropermanagementafterprepareandpropermanagementafteroperationareoperationarethekeyfactorsthekeyfactors对SCLC外科手术的认识单纯手术是否有益？先手术后综合能否提高疗效？诱导+外科能否长期带病生存？小细胞肺癌的治疗I-II期局限期手术化疗4+综合一般N1以上期别化2手术化4+综合手术辅以综合为当前争取疗效、争取根治的必要途径Surgicaltre
12、atmentforsmallcelllungcancerMethodLungCancer,145cases(Chemo/Radio Operation）group,64cases(Operation Chemo/Radio）group,81casesOperativeStyleLobectomy69Pneumonectomy68SleeveLobectomy7Segmentectomy1 TheSurvivalrateofSurgeryChemo/RadioTherapyGroupTheSurvivalrateofSurgeryChemo/RadioTherapyGroup 1year 3ye
13、ars5yearsIa100.00%50.00% 50.00%Ib100.00% 42.90% 28.60%IIa100.00%85.70%71.40%IIb86.70%46.70%13.30%IIIa52.50%5.00%5.00%IIIb40.00%0.00%0.00%SurvivalrateofChemo/RadioSurgerytherapyGroup0 020204040606080801001001201201 12 23 34 45 55 Year5 YearSurvivaltime%IaIbIIaIIbIIIaIIIbTheSurvivalrateofSurgeryChemo/
14、RadioTheSurvivalrateofSurgeryChemo/RadioTherapyGroupTherapyGroup1year3years5years1year3years5yearsIaIa100.00%100.00%87.50%87.50% 50.00%50.00%Ib66.60%Ib66.60% 16.70%16.70% IiaIia80.00%80.00% 80.00%80.00% 60.00%60.00%IibIib90.00%90.00% 20.00%20.00% 20.00%20.00%IIIaIIIa79.10%79.10% 20.80%20.80% 4.20%4.20%IIIbIIIb72.10%72.10% 9.00%9.00%9.00%9.00%Conclusion1.SurgeryshouldbethefirstchoiceoftreatmentforearlyTNMstagingpatients2.OperationshouldbeconsideredastreatmentmethodandcombinedwithchemotherapyforSCLC肺癌提倡以外科为主的综合治疗手术化学疗法放射疗法免疫生物中医中药提高5年生存率10%3040%
