【作者】 黄晶晶；

【导师】 王俊；

【作者基本信息】 南京医科大学 ， 外科学（胸心外）， 2023， 硕士

【摘要】 目的:亚肺叶切除术治疗肺实质外周早期非小细胞肺癌已逐步被接受,但肺实质外周具体范围尚无三维层面的定量划分方法。本研究拟首先探讨深度比方法在三维空间内定量划分肺实质区域、判定肺结节深度位置的可行性。随后,探索针对直径≤2cm的磨玻璃为主型肺结节,实施“以病灶为中心,肺亚段为解剖单元”手术策略时,手术规划范围的影响因素以及手术疗效。方法:本研究为回顾性研究,分两部分进行。第一部分,根据测量单元的不同,设置胸腔组、肺叶组和对称3分区组。每个研究对象都需要在3个组内完成二维与三维的深度比测量。随后,比较组内及组间深度比测量结果的异同。第二部分,回顾性分析2015年8月-2020年11月期间,于我院胸外科接受手术治疗的173例肺结节患者的临床资料(女117例),中位年龄54(45,63)岁。按手术方式不同将患者分为单一肺亚段切除组、单一肺段切除组、联合肺亚段切除组、单一肺段联合邻近肺亚段切除组,比较术前、术中及术后相关资料。结果:第一部分,3组肺结节的组内深度比分区结果一致性均为100%;3组肺结节的组间深度比测量结果一致性不同(Fleiss’s Kappa value分别为0.511,95%CI:0.507-0.515,P<0.001;0.517,95%CI:0.513-0.522,P<0.001;0.923,95%CI:0.919-0.928,P<0.001)。第二部分,无围术期死亡,术后无复发、转移。四个手术组在性别(P=0.351)、年龄(P=0.586)、吸烟(P=0.349)、基础疾病(P=0.645)、影像学最大径(P=0.334)、深度位置(P=0.810)、手术时间(P=0.175)、手术切缘(P=0.772)、病理类型(P=0.644)、术后漏气(P=0.925)、术后引流量(P=0.334)、术后引流天数(P=0.267)、术后住院时间(P=0.560)等方面差异无统计学意义。针对段内结节,多元Logistic回归提示,单一肺亚段切除术比单一肺段切除术对结节影像学最大径(OR=0.245,95%CI:0.065-0.929,P=0.039)、深度位置(OR=0.182,95%CI:0.040-0.836,P=0.028)限制更为严苛。二元logistic回归提示,手术切缘规划≥2cm时,中带结节对直径限制更多(OR=2.998,95%CI:1.294-6.950,P=0.010)。结论:基于对称3分区为测量单元的深度比测量方法能够更准确地在三维空间中测量肺结节的肺实质内深度位置。针对直径≤2cm磨玻璃为主型肺结节,规划以“病灶为中心,肺亚段为解剖单元”的手术策略安全可行。肺结节直径、深度位置是段内结节规划单一肺亚段手术方式的重要影响因素。直径≤2cm的外带肺结节适合规划手术切缘≥2cm的肺亚段为解剖单元的手术方式。更多还原

【Abstract】 Objectives: Sublobar resection for early stage non-small cell lung cancer in the periphery of the lung parenchyma has been gradually accepted,but there is no quantitative method to delineate the specific extent of peripheral lung parenchyma at the three-dimensional level.In this study,we intend to first investigate the feasibility of depth ratio method to quantitatively delineate the lung parenchyma area and determine the depth location of lung nodules in three-dimensional space.Subsequently,we will investigate the factors affecting the surgical planning scope and the surgical efficacy of the "lesion-centered,pulmonary subsegment as anatomical unit" surgical strategy for pulmonary nodules with a ground-glass-dominant and ≤2cm in diameter.Methods: This is a retrospective study and was conducted in two parts.In the first part,3 measurement groups were set up according to the measurement units: the thoracic group,the lobar group,and the symmetrical 3 sectors group.Each study subject was required to complete 2-dimensional and 2-dimensional depth ratio measurements in all three groups.Subsequently,the similarities and differences of depth ratio results were compared.In the second part,the clinical data of 173 patients(117 females)with a median age of 54(45,63)years who underwent surgical treatment for pulmonary nodules at our thoracic surgery department between August2015 and November 2020 were retrospectively analyzed.The patients were divided into mono-subsegmentectomy group,mono-segmentectomy group,combined subsegmentectomy group,and mono-segmentectomy combined with adjacent subsegmentectomy group according to the different surgical procedures,and the data related to preoperative,intraoperative,and postoperative periods were compared.Results: In the first part,the consistency of depth ratio measurements within the 3groups was 100%;the consistency of depth ratio measurements between the 3 groups was different(Fleiss’ s Kappa value of 0.511,95% CI: 0.507-0.515,P<0.001;0.517,95% CI: 0.513-0.522,P < 0.001;0.923,95% CI: 0.919-0.928,P < 0.001).In the second part,there was no perioperative death and no postoperative recurrence or metastasis.The four surgical groups were not significantly different in terms of gender(P=0.351),age(P=0.586),smoking(P=0.349),basic disease(P=0.645),maximum diameter of imaging(P=0.334),location at depth(P=0.810),operative time(P=0.175),surgical margins(P=0.772),type of pathology(P=0.644),postoperative air leak(P=0.925),postoperative drainage volume(P=0.334),postoperative drainage days(P=0.267),and postoperative hospital stay(P=0.560)were not statistically significant differences.For intra-segmental nodules,multivariate logistic regression suggested that mono-subsegmentectomy was more restrictive than mono-segmentectomy in terms of maximum nodule imaging diameter(OR=0.245,95%CI: 0.065-0.929,P=0.039),depth location(OR=0.182,95%CI: 0.040-0.836,P=0.028).Binary logistic regression suggested that the middle region nodes were more restrictive in terms of diameter when the surgical margin planning was ≥2 cm(OR=2.998,95% CI: 1.294-6.950,P=0.010).Conclusions: Depth ratio based on the symmetrical 3 sectors unit enables more accurate measurement of the depth location of pulmonary nodules within the lung parenchyma in 3D space.For pulmonary nodules with a ground-glass-dominant and≤2 cm in diameter,the surgical strategy of "lesion-centered,pulmonary subsegment as anatomical unit" is safe and feasible.Lung nodule diameter and depth location are important factors influencing the planning of mono-subsegmentectomy for intra-segmental nodules.Pulmonary parenchymal peripheral nodules ≤2 cm in diameter are suitable for surgery with subsegmentectomy as anatomic units and surgical margins ≥2 cm.更多还原