1、分 类 号 学号 2006865000016 学校代码 10487 密级 硕 士 学 位 论 文肺癌纵隔淋巴结转移及前哨淋巴结的研究学 位 申 请 人 ： 王华斌学 科 专 业 ：胸心外科指 导 教 师 ：潘铁成 教授答 辩 日 期 ：2013 年 10 月A dissertation submitted to Huazhong University ofScience and Technology for the Degree ofMaster of MedicineStudy of the mediastinal lymph node metastasis and sentinel lym
2、ph nodes of lung cancerCandidate : Wang huabinMajor : Cardiothoracic SurgerySupervisor : Prof. Pan Tiecheng MD, PhDHuazhong University of Science The metastasis rate of adenocarcinoma is significantly higher than squamous carcinoma and females are predisposed to adenocarcinoma while the rate of squa
3、mous carcinoma of males is higher; The skip metastasis was considered to be a subgroup with a better prognosis of mediastinal lymph node metastasis. It occurs frequently in the mediastinal lymph node metastasis of lung cancer, and it is the first station of lymph node metastasis like the intrathorac
4、ic lymph node metastasis. The subcarinal lymph node is one of the most common mediastinal lymph nodes of metastasis in patients with lung cancer, especially in patients with lung cancer in the lower lobe. The most common lymph nodes of metastasis of upper left lung cancer are located below and besid
5、e the aortic arch and the most common lymph nodes of metastasis of upper right lung cancer are located in the upper lymph node area.2. Most of the sentinel lymph nodes of lung cancer are located in the lung, and the most 华 中 科 技 大 学 硕 士 学 位 论 文5common sentinel lymph nodes of skip metastasis are subc
6、arinal lymph nodes. And the upper right and middle lobe lung cancer also can appear in the mediastinum; The sentinel lymph nodes of lower right lobe lung cancer can be also located in the inferior mediastinum; The sentinel lymph nodes of upper left lobe lung cancer can be also located in the superio
7、r mediastinum; The sentinel lymph nodes of lower left lobe lung cancer are distributed both in the inferior and superior mediastinum. However the sentinel lymph nodes of lung cancer may deviate from the usual drainage way. The most exact and explicit method for the sentinel lymph node is the sentine
8、l node navigation surgery under the guidance of the pattern of lymph node metastasis of lung cancer combining with the preoperative imaging examination especially the diagnosis of 18F-FDG PET/CT on the positive lymph nodes in the non-small cell lung cancer area.3. We think that due to the continuous
9、 development of modern science and technology, the development of thoracoscope and sentinel lymph node navigation technology, and the application of modern molecular biology technology in the pathological diagnosis, the mediastinal lymph node dissection of lung cancer should also adopt individualize
10、d treatment countermeasures to reduce the surgical trauma, make the operation purpose clear, perfect the scope of operation, improve the quality of life of patients, prolong the survival time of patients and improve the cure rate of lung cancer.Keywords: Lung cancer, Mediastinal lymph nodes, Metasta
11、sis, Sentinel lymph node华 中 科 技 大 学 硕 士 学 位 论 文6肺癌纵隔淋巴结转移及前哨淋巴结的研究前 言肺癌是最常见的恶性肿瘤，近年来其发病率明显增高，是癌性死亡的主要病因，被认为是目前对人类健康和生命威胁最大的恶性肿瘤。根据2012 中国肿瘤登记年报 ，肺癌发病率 53.57/10 万，肺癌死亡率 45.57/10 万，肺癌为恶性肿瘤发病率及死亡率的首位，发病率占恶性肿瘤的 18.74%，而死亡率占到恶性肿瘤的 25.24%，肺癌是一种发病率高但比其它肿瘤更难以治愈的疾病。外科治疗是非小细胞肺癌的主要治疗手段，而以胸内或胸外转移的状况对分期及预后十分重要，淋
12、巴结转移是肺癌转移的重要途径，纵隔淋巴结的转移与否是影响肺癌预后的主要因素之一，而正确的淋巴结分期是指导手术或非手术治疗方案的重要依据。目前在术前临床判断肺门和纵隔淋巴结转移的主要手段是胸部 CT 扫描，而胸部CT 判断淋巴结是否转移其准确性及特异性均不令人满意，它依赖于 CT 机的分辨率及阅片医师的临床经验，一般认为淋巴结短轴直径超过 1cm 或 1.5cm 可能为转移淋巴结，由于增大的淋巴结有可能是反应性増生，而 15%20%的癌转移淋巴结可以体积正常，因此单凭体积大小来判断淋巴结的良恶性常常不正确。正电子发射体层显像（PET）可以得到解剖影像不能得到的生理信息，可以显示病变的代谢活动，对
13、肺门和纵隔淋巴结转移的敏感性和特异性均高于 CT，联合 FDG-PET 和CT（PET/CT）对肺癌及淋巴结的定位定性诊断有所提高，但其价格昂贵，目前还不能作为肺癌术前的常规检查项目。如果肿瘤合并肺部疾病其假阳性也明显增高。或者转移淋巴结较小，其短径小于 PET/CT 的分辨率，淋巴结内的微小转移灶，淋巴结紧邻原发灶其假阴性率也会明显提高 (。在手术过程中纵隔淋巴结清除的方式根据其切除的范围可归纳为 5 种：1）淋巴结采样：根据术前影像学检查及术中所见摘除纵隔内可疑阳性的肿大淋巴结；2）系统性采样：根据淋巴结的转移规律及术前影像学的评估，常规的清除特定区域的淋巴结；3）完全性纵隔淋巴结清扫术：根据淋巴结的分布图，将纵隔淋巴结连同周围
