述评:胸腺瘤TNM分期是进步吗?

已有 634 次阅读2023-6-2 10:28 |个人分类:TET学习|系统分类:医学科学| 胸腺瘤

Commentary: Progress, or just movement, on thymoma staging?:胸腺瘤TNM分期是进步吗?

Despite the fact that virtually all other malignancies have had a tumor, node, metastasis (TNM) staging system for decades, one for thymic epithelial malignancies (TEMs) was introduced only in 2014.1 Before this project of the International Association for the Study of Lung Cancer and International Thymic Malignancy Interest Group, which evaluated more than 10,000 cases, several conflicting TEM staging systems existed. The lack of consistent staging has clearly hampered research allowing advancements in this disease, as without a shared “language,” investigators and physicians could not join together their cases for wellpowered studies.
尽管几十年来几乎所有其他恶性肿瘤都有肿瘤、淋巴结、转移(TNM)分期系统,但胸腺上皮性恶性肿瘤(TEM)分期系统仅在2014年引入。在国际癌症研究协会和国际胸腺恶性肿瘤兴趣小组(International thymic Magnancy Interest Group)的这一项目评估了10000多个病例之前,存在若干相互冲突的TEM分级系统。缺乏一致的分期显然阻碍了这一疾病的研究进展,因为如果没有共同的“语言”,研究人员和医生就无法将他们的病例结合起来进行有力的研究。

Adoption of the recently introduced TNM system for TEM has been sporadic. Many recent publications still use the older systems. More telling, even in our tumor boards, we often continue to fall back on the old terminologies.
近期很少研究者或研究采用了新的用于TEM的TNM系统。许多最近的文献或出版物仍然使用旧的系统。更能说明问题的是,即使在我们的肿瘤委员会中,我们也经常继续使用旧的术语。

Ahmad’s article is both a plea for adoption of the new system and a targeted education in what surgeons should remember about it. He argues convincingly that adoption of the system will advance management of TEM. He highlights what in my opinion is the major change with the new system—that even macroscopic invasion into the fat/ thymus and/or mediastinal pleura is stage I in the TNM system. Other important changes are moving pericardial invasion from stage III to II, and the separation of nodal disease into N1 (IVA) and N2 (IVB). These changes will frequently stage tumors lower (eg, many Masaoka–Koga stage II will be TNM stage I), which will—appropriately, in my opinion—reduce recommendations for adjuvant radiotherapy when it is unlikely to provide benefit.
Ahmad的文章既是对采用新系统的呼吁,也是对外科医生应该记住的有针对性的教育。他令人信服地认为,采用该系统将促进TEM的管理。他强调了我认为新系统的主要变化,即即使是对脂肪/胸腺和/或纵隔胸膜的大体侵犯也是TNM系统的I期。其他重要变化是将心包侵犯从III期转移到II期,以及将淋巴结疾病分离为N1(IVA)和N2(IVB)。这些变化通常会使肿瘤分期降低(例如,许多Masaoka–Koga II期将为TNM I期),在我看来,这将适当地减少辅助放疗的建议,因为辅助放疗不太可能带来益处。

The author, however, shows perhaps insufficient recognition that there are points of conflict between the new TNM system and the way thymoma resections are actually performed today. For example, should surgeons really alter their current thoracoscopic approaches to stage I/II TEMs to allow N2 (middle mediastinal) lymph node dissection, when only 2% of thymomas have involved nodes? Anterior port sites used for thymectomy do not allow good access to level 7; unilateral video-assisted thoracoscopic surgery (VATS)/robotic approaches will always leave contralateral lymph node stations unexplored. It would be more appropriate to suggest an aggressive search for lymph nodes only with frankly invasive tumors and known thymic carcinomas. 然而,作者可能没有充分认识到新的TNM系统与当今胸腺瘤切除术的实际方式之间存在冲突。例如,当只有2%的胸腺瘤累及淋巴结时,外科医生真的应该改变目前的胸腔镜方法,将其改为I/II期TEMs,以允许N2(中纵隔)淋巴结清扫吗?用于胸腺切除术的前端口部位不能很好地进入7级;单侧电视胸腔镜手术(VATS)/机器人技术总是会遗漏对侧淋巴结区。建议只对侵袭性肿瘤和已知胸腺癌进行积极的淋巴结干预更为合适。

Finally, I do have concern that since the majority of tumors used to create the TNM system were resected “open,” before the wide adoption of thoracoscopy for TEMs, that the system may only be appropriately applied to “open” resections. For example, if one performs a VATS/robotic “thymomectomy”rather than the “total thymectomy/thymomectomy” typically performed “open,”one may be more likely to have a recurrence with a Masaoka stage II tumor invading extracapsular fat. That risk may not be reflected, however, in a staging system developed from data derived from “open” operations. Might the aforedescribed stage-shift downward from Masaoka stage II to TNM stage I tumors be inappropriate for VATS/robotic resections? 最后,我确实担心的是,由于用于创建TNM系统的大多数肿瘤都是在胸腔镜广泛应用于TEMs之前“开放式”切除的,因此该系统可能仅适用于“开放性”切除。例如,如果进行VATS/机器人“胸腺切除术”,而不是通常“开放式”进行的“全胸腺切除术/胸腺切除术“,则Masaoka II期肿瘤侵犯瘤周脂肪的复发可能性更大。然而,这种风险可能不会反映在根据“开放”行动的数据开发的分期系统中。上述阶段从Masaoka II期向下转移到TNM I期肿瘤是否不适合VATS/机器人切除?

Overall, using a shared, worldwide staging system for TEMs will certainly accelerate progress in this disease, and thus surgeons should embrace it despite a few specific concerns about its current iteration. As cases are accumulated using the new system, including more minimally invasive cases, the staging will be progressively refined. 总的来说,使用一个共享的全球TEMs分期系统肯定会加速这种疾病诊疗的进步,因此外科医生应该接受它,尽管目前对它的迭代有一些具体的担忧。随着使用新系统积累病例,包括更多的微创病例,分期将逐步完善。

Shrager JB. Commentary: Progress, or just movement, on thymoma staging? J Thorac Cardiovasc Surg. 2021 Apr;161(4):1530-1531. doi: 10.1016/j.jtcvs.2020.11.009. Epub 2020 Nov 6. PMID: 33293061.


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