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胸外科手术结果研究协会 (ThORN) 关于早期肺癌高质量楔形切除术定义的共识文件

SCI天天读 · 公众号 · · 2025-01-15 21:36

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SCI

15 December 2025

_{Thoracic Surgery Outcomes Research Network (ThORN) Consensus Document on Defining a High Quality Wedge Resection for Early Stage Lung Cancer}

_{(The Annals of Thoracic Surgery, IF: 3.7)}

Seth B. Krantz, MD, Brian Mitzman, MD, MS, Mara B. Antonoff, MD, Leah Backhus, MD, MPH, Stephen R. Broderick, MD, MPHS, Lisa M. Brown, MD, MAS, Jennifer M.Burg, MD, MS, Elizabeth Colwell, MD, Alberto de Hoyos, MD, Kathryn Engelhardt, MD, MS, Rian M. Hasson, MD, MPH, Hari B. Keshava, MD, MS, Onkar V. Khullar, MD, MSc, Biniam Kidane, MD, MSc, Shari L. Meyerson, MD, MEd, Gita N. Mody, MD, MPH, Clinton Morgan, MD, PhD, Joseph D. Phillips, MD, David D. Odell, MD, MMSc, Uma M. Sachdeva, MD, PhD, Elliot L. Servais, MD, Christina M. Stuart, MD, Kei Suzuki, MD, MS, Brooks V. Udelsman, MD, MHS, Thomas K. Varghese, Jr., MD,MS, MBA, Elliot Wakeam, MD, MPH, Chi-Fu J. Yang, MD, Robert A. Meguid, MD,MPH, David T. Cooke, MD, on behalf of ThORN
CORRESPONDENCE TO: [email protected]

Abstract 摘要

With the publication of CALGB 140503, an increase in wedge resections for small, peripheral non-small cell lung cancer is expected; however, a relative paucity of data exists as to what defines a high quality oncologic wedge resection. The Thoracic Surgery Outcomes Research Network (ThORN), through expert discussion, guided by review of what limited data does exist, and through use of a modified Delphi process, provides these consensus statements defining an oncologically sound, high quality wedge resection. The statements are classified into five categories: 1) Preoperative Considerations 2) Technical Aspects 3) Lymph Node Assessment 4) Margin Assessment and 5) Tissue Handling by Pathology.

随着CALGB 140503研究的发表，针对小的、外周型非小细胞肺癌的楔形切除术的使用预期将增加。然而，目前关于高质量肿瘤学楔形切除术定义的数据仍相对缺乏。胸外科手术结果研究协会（ThORN）通过专家讨论、对现有有限数据的审查以及修订后的Delphi法，制定了这些共识声明，以定义符合肿瘤学标准的高质量楔形切除术。这些声明被分为五个类别：1）术前考虑；2）技术要点；3）淋巴结评估；4）切缘评估；5）病理组织处理。

Wedge Resection for Early Stage Lung Cancer Expert Consensus Statements

早期肺癌楔形切除术专家共识声明

1.When considering the adequacy of margin and quality of resection, the surgeon should assess tumor location beyond “peripheral” or “central”, paying attention to considerations such as location near a visceral pleural reflection, which lobe, and which segment within a lobe is involved.

2.The wedge should be planned with respect to understanding all of the various margins and which margin will be the closest.

3.Preoperative consent discussions should include informing patients about the evidence base for selecting wedge resection in their case and opportunity to decline this in favor of lobectomy.

4.In tumors that are likely not to be visible or palpable when utilizing a minimally invasive approach, preoperative localization should be used, to both localize the tumor and help ensure adequate margins.

5.Risk of defunctionalizing adjacent lung parenchyma should be considered when planning a wedge resection.

6.If there is intraoperative concern as to the adequacy of the margin (prior to resection) and the surgeon has decided that wedge resection is the optimal/preferred operation, the following maneuvers are recommended to improve the geometry of the wedge and the adequacy of the margin: completing the fissure, dissecting the inferior pulmonary ligament (in a lower lobe), and/or lengthening the hilum (i.e., clearing lymphovascular tissue but not circumferentially dissecting or dividing hilar structures).

7.If there is intraoperative concern as to the adequacy of the margin and maneuvers to achieve an appropriate margin are insufficient, then formal anatomic resection is recommended, when possible, instead of proceeding with wedge resection.

8.Sampling at least three N2 stations in the appropriate lymph node basin and one surgically excised N1 station is necessary for adequate intraoperative lymph node staging, similar as one would perform for any anatomic resection.

9.Concerning lymph nodes should be sent for frozen pathologic evaluation, and if positive for cancer, conversion to anatomic resection is recommended.

10.The surgeon should assess margins for adequacy prior to completion of the operation.

11.If intraoperative frozen pathologic evaluation of the staple line margin is positive, re-excision of the staple line, if an adequate margin can be obtained, is acceptable.

12.If intraoperative frozen pathologic evaluation of the staple line margin is positive, conversion to anatomic resection is acceptable.

13.A margin of ≥2 cm is recommended; a minimum adequate resection margin is considered ≥ diameter of the solid component of the tumor.

14.Consistent handling by pathology team members across specimens is critical for consistency in margin determination.

15.Margins should be measured grossly by the pathology team prior to freezing or fixation for permanent pathologic evaluation.

16.The staple line should be excised, measured separately, and saved for possible further examination.

1.在评估切缘充分性和切除质量时，外科医生除了引用“外周型”或“中央型”的简单位置描述，还应注意肿瘤位置的具体细节，如是否靠近脏层胸膜反折、所属的肺叶及肺叶内的具体肺段。

2. 楔形切除术应基于对所有切缘的了解进行规划，并明确哪个切缘可能是最接近的。

3. 术前同意书讨论应包括向患者说明选择楔形切除术的证据基础，并给予患者拒绝楔形切除术而选择肺叶切除术的机会。

4. 对于可能无法通过微创手术看到或触及的肿瘤，术前定位应用于定位肿瘤并确保足够的切缘。

5. 在规划楔形切除术时，应考虑到可能导致周围肺实质功能丧失的风险。

6. 如果术中对切缘的充分性存在疑虑（切除前），并且外科医生认为楔形切除术是最佳或首选手术方式，建议采取以下措施以改善楔形切除的几何形状和切缘充分性：完成叶间裂的分离、分离下叶的肺韧带（针对下叶）、和/或延长肺门（即清除淋巴血管组织，但不对肺门结构进行环形分离或切除）。

7. 如果术中对切缘充分性的疑虑无法通过上述措施解决，则推荐尽可能进行正式的解剖切除术，而不是继续楔形切除术。

8. 为了进行充分的术中淋巴结分期，需对适当的淋巴结引流区域至少采样3个N2淋巴结站点及1个经手术切除的N1淋巴结站点，与解剖切除术的分期要求一致。

9. 如果有可疑的淋巴结，建议送检快速病理分析，若确诊为癌，则推荐转换为解剖切除术。

10. 外科医生在完成手术前应对切缘充分性进行评估。

11. 如果术中对切缘进行快速病理分析的结果为阳性，且可以获得足够的切缘，再次切除切缘是可接受的。

12. 如果术中对切缘的快速病理分析结果为阳性，转换为解剖切除术也是可接受的。

13. 推荐的切缘为≥2 cm；最低切缘充分性应为≥肿瘤实性成分的直径。

14. 病理团队成员对标本的一致性处理对于切缘评估的一致性至关重要。

15. 病理团队应在冷冻或固定标本进行永久病理评估之前，进行大体切缘测量。

16.应切下并单独测量切割吻合器钉缘，并妥善保存以备进一步检查。

AI全文解析

这篇文章是《早期肺癌高质量楔形切除的专家共识文件》，由胸外科结果研究网络（ ThORN）制定，旨在定义高质量肿瘤楔形切除的标准，为外科医生提供操作指导。以下是文章重点总结：

背景

• 随着新影像技术和小型周边非小细胞肺癌（NSCLC）病例的增加，楔形切除术逐渐受到关注。

• 历史上，楔形切除被认为是肿瘤学上不充分的手术，缺乏关于其高质量操作的明确指导。

目的

文章通过文献回顾、专家讨论和修订后的德尔菲共识流程，制定了 16条专家共识声明，重点包括术前准备、技术操作、淋巴结评估、切缘评估和病理处理五大方面。

主要内容

1. 术前考虑

• 评估肿瘤位置，分析可能导致切缘不充分的解剖因素。

• 术前规划需考虑切缘与肿瘤直径的比例，确保≥2 cm的切缘距离。

• 与患者讨论楔形切除的科学依据，并提供选择其他手术方式的机会。

2. 手术技术

• 对于不可见或难以触及的肿瘤，需使用术前标记技术以确保切缘充分。

• 如术中发现切缘不足，可通过调整手术几何或改为解剖性切除（如肺叶切除）来优化切缘。

3. 淋巴结评估

• 至少采样3个N2区域和1个N1区域的淋巴结以进行充分的分期评估。

• 对可疑淋巴结进行术中快速冰冻病理评估，若发现肿瘤累及，建议改为解剖性切除。

4. 切缘评估

• 推荐≥2 cm或至少与肿瘤直径相等的切缘。

• 如快速病理切缘阳性，可选择重新切除或改为解剖性切除。

5. 病理处理

• 病理团队需保持一致性，准确测量并记录切缘。

• 手术切缘应单独保存，以备进一步检查。

结论

• 高质量楔形切除的关键在于术前规划、术中技术优化以及病理团队的协调合作。

• 文章旨在为外科医生提供指导，填补楔形切除操作标准的空白。

• 未来需要更多研究来补充数据和进一步优化这些指导原则。

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