Význam mediastinální lymfadenektomie v exaktním stagingu bronchogenního karcinomu

MUDr. Vladislav Hytych, Ph.D.

Doctoral thesis

The importance of mediastinal lymphadenectomy in the exact staging of lung cancer

Abstract:

V současné době je radikální resekce plic pro bronchogenní karcinom definovaná jako resekce parenchymu doplněná o disekci mízních uzlin. Lymfadenektomie je doporučeným standardem pro stanovení stadia onemocnění a pro poţadavek kompletního odstranění nádoru s nejbliţšími odstranitelnými metastázami karcinomu v jedné době. Systematická mediastinální lymfadenektomie znamená revizi všech oblastí a skupin (ipsilaterálních) uzlin mediastina, odstranění veškerého tuku s mediastinálními uzlinami od apertury hrudní po bránici stanic uzlin N1- N9 a ošetření přívodných a odvodných lymfatických cest a cév. Umoţní stanovit postiţení homolaterálních mediastinálních uzlin a stanovit tak přesný staging onemocnění. Ponechání i jedné uzliny s metastázou karcinomu můţe ovlivnit staging, léčení, prognózu i přeţití. Jestliţe je systematická mediastinální lymfadenektomie rozhodující pro stanovení stádia onemocnění podle TNM klasifikace, potom musíme připustit i její zásadní význam v přeţití nemocných ve stadiu IIIa. Systematická lymfadenektomie je zásadní pro diagnózu IIIa stadia onemocnění a nasazení další terapie, která prodluţuje přeţití, tím i lymfadenektomie prodluţuje přeţití nemocných ve stadiu IIIa. Systematická mediastinální lymfadenektomie je conditio sine qua non chirurgické léčby nemalobuněčného bronchogenního karcinomu.

Abstract:

The work assesses the significance of mediastinal lymphadenectomy in exact staging of bronchogenic carcinoma. Total number of examined patients with non-small cell lung cancer was 60, divided into two groups. In the first group ("operated on") were 31 patients who met the preoperative criterion of negative mediastinal nodes in stage Ia and IIb of the TNM classification. In the second group ("dissected"), with a total number of 29 patients, were those who had completely diagnosed non-small cell lung cancer with affected mediastinal lymphnodes, and died on generalization of lung cancer or on terminal complications of generalizated lung cancer. In the whole group is together in both sets, "operated on" and "dissected", tumors of the right upper lobe metastasized in 47.7% into group 1 (stations N1-N4) and group 3 (station N7) and 4.6% of retrograde metastases into group 4 (N8-N9 stations). Tumors of the right middle lobe metastasized in 100% into group 3 station N7. Tumors of the lower lobe metastasized in 16.6% into group 1, in 77.1% into group 3 and in 6.3% into group 4. In tumors of the left upper lobe were retrograde metastases in 17.0% in group 1, 57.6% into group 2, 12.5% into group 3 and 12.9% into group 4. Tumors of the left lower lobe metastaseized in 15.1% into group 1, 26.7% into group 2, 38.1% into group 3 and 25.1% into group 4. In the first group ("operated on"), we took in total 713 mediastinal lymphnodes, an average of 23.3 nodes in one patient. In 87 lymphnodes were established metastases, representing 12.2% of all collected nodes. In one patient we established an average of 2.8 lymphnodes with metastasis. In the second group ("dissected"), we took in total 755 mediastinal lymphnodes, an average of 26.0 nodes in one patient. In 264 nodes metastases were established, which is 35.0%. Our patients had an average of 9.1 affected nodes. Systematic mediastinal lymphadenectomy with removal of all lymph nodes and fat enabled to determine disability of homolateral lymphnodes and so to determine exact staging of lung disease. Leaving even only one positive lympnode definitely affects staging, treatment, prognosis and survival. If systematic mediastinal lymphadenectomy is crucial for determining the stage of disease according to the TNM classification, then we must admit its importance in survival of patients in stage IIIa. To verify the hypothesis it is necessary to evaluate the survival of patients after surgery, who had precisely defined stage of disease in the group, which was further treated, and in untreated group. The group without treatment is basically the same as if mediastinal lymphadenectomy was not performed. In this group survived one year and two years 22.2%, but no one had lived more then three years. 21 In the treated group survived one year as well as two years 72.7%, 59.1% three years, four and five years survived 48.5%. Currently live 11 patients. Systematic lymphadenectomy is essential for the diagnosis of stage IIIa disease and setting of additional therapy that prolongs survival, thus lymphadenectomy prolongs survival of patients in stage IIIa. Systematic mediastinal lymphadenectomy is a "conditio sine qua non" in surgical treatment of non-small cell lung cancer.

Keywords

Rakovina plic, mediastinální lymfadenektomie, staging Lung cancer, mediastinal lymphadenectomy, staging

Language used: Czech

Date on which the thesis was submitted / produced: 19. 8. 2011

Thesis defence

• Date of defence: 25. 10. 2011
• Supervisor: prof. MUDr. Ivan Čapov, CSc.

Masaryk University

Faculty of Medicine

Doctoral programme / field:
Surgery (4-years) / Surgery