據(jù)11月24日刊《美國醫(yī)學會雜志》上的一項研究披露,，比較2種確定疑似非小細胞型肺癌（NSCLC）病期的策略發(fā)現(xiàn)，創(chuàng)傷性較小的那種方法對辨識某種已經(jīng)擴散的肺癌更為有效,，這種方法可能會減少某些病人中的非必要的外科手術(shù)及其相關(guān)的不良反應,。
肺癌是全世界最常被診斷的癌癥（每年有135萬人被診斷患有肺癌）；肺癌也是最常見的癌癥死亡原因（每年有120萬人死于肺癌）,。根據(jù)文章的背景資料,，確定癌癥病期是治療病人的一個重要的部分，因為癌癥分期對治療具有指導作用并對預后有價值,。但是通過手術(shù)來確定癌癥病期有局限性,，而且還會導致不必要的開胸術(shù)（即切開胸廓），而開胸術(shù)可能導致手術(shù)后患者健康的顯著損害及更高的死亡風險,。
目前的肺癌分期指南確認超聲內(nèi)鏡成像（用光纖內(nèi)窺鏡對內(nèi)臟進行超聲波檢查）是一種用外科進行癌癥分期來發(fā)現(xiàn)淋巴結(jié)?。ㄊ占∽兘M織）的微創(chuàng)性備選方法 （如果超聲內(nèi)鏡成像沒有發(fā)現(xiàn)淋巴結(jié)轉(zhuǎn)移的話再采用手術(shù)癌癥分期）?？v隔（即肺附近的胸腔內(nèi)空間）組織的癌癥分期常常是由縱隔鏡檢查的方法來進行的,，這是一種外科診斷方法。文章的作者寫道：“目前人們還不知道,，起初用超聲內(nèi)鏡成像方法來對縱隔組織肺癌進行分期是否會提高淋巴結(jié)肺癌轉(zhuǎn)移的發(fā)現(xiàn)率,，以及降低不必要的開胸術(shù)的發(fā)生率 。”
荷蘭萊頓的萊頓大學醫(yī)療中心的Jouke T. Annema, M.D., Ph.D.及其同事對僅用外科癌癥分期相對于超聲內(nèi)鏡成像的方法（也就是將經(jīng)食道及支氣管內(nèi)超聲波相結(jié)合）加上隨后的外科癌癥分期法進行了比較,。這一隨機對照的多中心試驗是在2007年2月至2009年4月間進行的,，其中有241位患者罹患可切除的（疑似）NSCLC；根據(jù)計算機或正電子發(fā)射斷層攝影（這些都是成像技術(shù)）,，這些患者具有做縱隔分期的指針,。這些病人或是接受外科癌癥分期或是接受超聲內(nèi)鏡成像法加上外科癌癥分期（如果在超聲內(nèi)鏡成像檢查中沒有發(fā)現(xiàn)淋巴結(jié)癌癥轉(zhuǎn)移的話）。在沒有縱隔腫瘤轉(zhuǎn)移的證據(jù)的情況下,，病人將接受開胸術(shù)加上淋巴結(jié)切割術(shù),。
文章的作者寫道：“我們證明,，在罹患可切除的NSCLC病人中,，以超聲內(nèi)鏡成像法來開始縱隔淋巴結(jié)癌癥分期大大提高了淋巴結(jié)癌癥轉(zhuǎn)移的檢測率；并且,，與僅用外科癌癥分期的方法相比,，不必要的開胸術(shù)發(fā)生率降低了50%以上。此外,，超聲內(nèi)鏡成像法不需要做全身麻醉,，它是患者的首選方法。與外科癌癥分期相比,，它被認為是成本效益高的方法,。”
研究人員補充說,，鑒于超聲內(nèi)鏡成像法的敏感性與縱隔鏡類似（分別為85% vs. 79%）及超聲內(nèi)鏡成像法的并發(fā)癥發(fā)生率較低（為1%，而縱隔鏡的并發(fā)癥發(fā)生率為6%）,，超聲內(nèi)鏡成像檢查應該成為縱隔淋巴結(jié)癌癥分期的第一個步驟,。（生物谷Bioon.com）
生物谷推薦英文摘要：
JAMA. 2010;304(20):2245-2252. doi:10.1001/jama.2010.1705
Mediastinoscopy vs Endosonography for Mediastinal Nodal Staging of Lung Cancer
Jouke T. Annema, MD, PhD; Jan P. van Meerbeeck, MD, PhD; Robert C. Rintoul, FRCP, PhD; Christophe Dooms, MD, PhD; Ellen Deschepper, PhD; Olaf M. Dekkers, MA, MD, PhD; Paul De Leyn, MD, PhD; Jerry Braun, MD; Nicholas R. Carroll, FRCP, FRCR; Marleen Praet, MD, PhD; Frederick de Ryck, MD; Johan Vansteenkiste, MD, PhD; Frank Vermassen, MD, PhD; Michel I. Versteegh, MD; Maud Veseli?, MD; Andrew G. Nicholson, FRCPath, DM; Klaus F. Rabe, MD, PhD; Kurt G. Tournoy, MD, PhD
Context Mediastinal nodal staging is recommended for patients with resectable non–small cell lung cancer (NSCLC). Surgical staging has limitations, which results in the performance of unnecessary thoracotomies. Current guidelines acknowledge minimally invasive endosonography followed by surgical staging (if no nodal metastases are found by endosonography) as an alternative to immediate surgical staging.
Objective To compare the 2 recommended lung cancer staging strategies.
Design, Setting, and Patients Randomized controlled multicenter trial (Ghent, Leiden, Leuven, Papworth) conducted between February 2007 and April 2009 in 241 patients with resectable (suspected) NSCLC in whom mediastinal staging was indicated based on computed or positron emission tomography.
Intervention Either surgical staging or endosonography (combined transesophageal and endobronchial ultrasound [EUS-FNA and EBUS-TBNA]) followed by surgical staging in case no nodal metastases were found at endosonography. Thoracotomy with lymph node dissection was performed when there was no evidence of mediastinal tumor spread.
Main Outcome Measures The primary outcome was sensitivity for mediastinal nodal (N2/N3) metastases. The reference standard was surgical pathological staging. Secondary outcomes were rates of unnecessary thoracotomy and complications.
Results Two hundred forty-one patients were randomized, 118 to surgical staging and 123 to endosonography, of whom 65 also underwent surgical staging. Nodal metastases were found in 41 patients (35%; 95% confidence interval [CI], 27%-44%) by surgical staging vs 56 patients (46%; 95% CI, 37%-54%) by endosonography (P = .11) and in 62 patients (50%; 95% CI, 42%-59%) by endosonography followed by surgical staging (P = .02). This corresponded to sensitivities of 79% (41/52; 95% CI, 66%-88%) vs 85% (56/66; 95% CI, 74%-92%) (P = .47) and 94% (62/66; 95% CI, 85%-98%) (P = .02). Thoracotomy was unnecessary in 21 patients (18%; 95% CI, 12%-26%) in the mediastinoscopy group vs 9 (7%; 95% CI, 4%-13%) in the endosonography group (P = .02). The complication rate was similar in both groups.
Conclusions Among patients with (suspected) NSCLC, a staging strategy combining endosonography and surgical staging compared with surgical staging alone resulted in greater sensitivity for mediastinal nodal metastases and fewer unnecessary thoracotomies.
