Eur J Cardiothorac Surg：肺叶切除治疗第二原发性肺癌效果更佳

对于早期肺癌来说，亚肺叶切除一直是一个具有争议的问题。针对这一问题，来自意大利帕多瓦大学胸心外科的Andrea Zuin等通过对比亚肺叶切除术（包括肺段切除术及肺楔形切除术）和肺叶切除术治疗第二原发肺癌的效果，来判断两者的优劣。该研究结果发表在2013年5月8日的欧洲心胸外科杂志（European Journal of Cardio-Thoracic Surgery）上。结果表明相对于亚肺叶切除，肺叶切除具有较好的疗效和5年生存率。
该研究收集了自1995年1月到2010年12月的121例第二原发肺癌的患者，这些患者都是依据Martini and Melamed提出的第二原发性肺癌诊断标准诊断为第二原发性肺癌。其中23例同期肿瘤，98例不同期肿瘤。作为第二次治疗，我们实施了61例肺叶切除术（包括17例全肺切除术），38例肺楔形切除术，22例肺段切除术。病理结果：腺癌49例，鳞癌38例，支气管肺泡细胞癌14例，腺鳞癌8例，大细胞癌2例，未分化癌5例，其他病理类型5例。全组5年生存率为42%，手术死亡率为2.5%（3例），术后并发症为19%（22例）。在术后并发症方面，对比肺叶切除组、亚肺叶切除组、全肺切除组（肺叶切除组12.8%、亚肺叶切除组27.7%、全肺切除组30.8%）。在手术方式上，相对于亚肺叶切除来说，肺叶切除组5年生存率更好一些（肺叶切除组为57.5%，亚肺叶切除组为36%）。相对于肺叶切除组，全肺组的生存率欠佳（肺叶切除组为57.5%，全肺组20%）
根据Andrea Zuin等的经验，肺叶切除术仍然是第二原发性肺癌的首选治疗方式，但是对于肺功能差的患者，亚肺叶切除也是一种有效的治疗方式。在亚肺叶切除中楔形切除等非解剖性切除的效果不尽人意，但是肺段切除等解剖性切除其5年生存率和肺叶切除术很接近，所以对于肺功能差的患者，或者具有肺功能性疾病的患者，肺段切除不适是一种较好的治疗方式，在最大限度保留了肺组织的基础上，切除了病灶，同时也能取得不错的疗效，而全肺切除对于患者术后长期生存来说是一项不良的预后因素，不建议选择。

Is lobectomy really more effective than sublobar resection in the surgical treatment of second primary lung cancer?
OBJECTIVES
Sublobar resection for early-stage lung cancer is still a controversial issue. We sought to compare sublobar resection (segmentectomy or wedge resection) with lobectomy in the treatment of patients with a second primary lung cancer.
METHODS
From January 1995 to December 2010, 121 patients with second primary lung cancer, classified by the criteria proposed by Martini and Melamed, were treated at our Institution. We had 23 patients with a synchronous tumour and 98 with metachronous. As second treatment, we performed 61 lobectomies (17 of these were completion pneumonectomies), 38 atypical resections and 22 segmentectomies. Histology was adenocarcinoma in 49, squamous in 38, bronchoalveolar carcinomas in 14, adenosquamous in 8, large cells in 2, anaplastic in 5 and other histologies in 5.
RESULTS
Overall 5-year survival from second surgery was 42%; overall operative mortality was 2.5% (3 patients), while morbidity was 19% (22 patients). Morbidity was comparable between the lobectomy group, sublobar resection and completion pneumonectomies (12.8, 27.7 and 30.8%, respectively, P = 0.21). Regarding the type of surgery, the lobectomy group showed a better 5-year survival than sublobar resection (57.5 and 36%, respectively, P = 0.016). Compared with lobectomies, completion pneumonectomies showed a significantly less-favourable survival (57.5 and 20%, respectively, P = 0.001).
CONCLUSIONS
From our experience, lobectomy should still be considered as the treatment of choice in the management of second primary lung cancer, but sublobar resection remains a valid option in high-risk patients with limited pulmonary function. Completion pneumonectomy was a negative prognostic factor in long-term survival.