在2025年欧洲肺癌大会（ELCC）争议专场上，国际肺癌研究协会（IASLC）主席、比利时安特卫普大学医院胸外科/血管外科教授Paul van Schil就“非小细胞肺癌患者新辅助化疗-免疫治疗后是否需行侵入性纵隔再分期”这一争议性问题展开了深入探讨。会议期间，Van Schil教授特别接受本刊专访，不仅就该议题分享了权威观点，还就间皮瘤治疗领域的最新突破作了专业解读。

 

Dr.van Schil：过去，我们通常使用纵隔镜进行纵膈再分期，甚至在仅诱导化疗后重复进行纵隔镜检查。我们知道纵隔内持续存在淋巴结转移或残留N2病变的患者预后较差，2025 ELCC争议专场针对“对于cN2期患者，在新辅助化疗免疫治疗后，是否应常规进行侵入性纵隔再分期以决定是否实施手术”进行投票，这个问题尚存在争议，但争议讨论专场的大多数肿瘤学家认为无需有创纵隔再分期。

 

我认为，考虑到淋巴结病变持续存在的患者预后仍可能不佳，尽管尚无生存数据支持侵入性纵隔再分期，我所在中心对新辅助化疗免疫治疗前通过EBUS（超声支气管镜）确诊N2病变的患者，仍会在临床试验之外使用纵隔镜进行纵膈再分期。大多数持续性N2患者将接受放疗。

 

尽管缺乏确切数据，我认为在新辅助化疗免疫治疗后，纵隔镜再分期仍然有益。在2025 ELCC争议专场，外科医生与肿瘤内科医生对此观点常存在分歧。

 

Dr.van Schil:In the past，we used to do mediastinal re-staging by mediastinoscopy or even repeat mediastinoscopy after induction chemotherapy only.We know that those patients with persisting nodal disease in the mediastinum，or residual N2 disease，have a poor prognosis.There is now discussion about chemoimmunotherapy as neoadjuvant therapy and whether we should do re-staging or not.As you just heard during the session，most of the oncologists don’t think we need to do it，although we are not quite convinced yet.Those patients with persisting nodal disease I suppose will still have a poor prognosis although we don’t have the survival data yet.So，in our center，we are performing mediastinal re-staging by mediastinoscopy outside of a clinical trial if we have proven N2 disease by EBUS before the neoadjuvant chemoimmunotherapy.Most of those patients with persisting N2 disease will be treated by radiotherapy.I think invasive restaging is still useful to perform，even though we don’t have any definitive data yet.You just heard that there is a lot of discussion about it–the surgeons sometimes think differently from medical oncologists.

 

Dr.van Schil：如果通过EBUS或EUS（食管超声）进行再分期，风险会较低，因二者属于微创穿刺。进行纵隔镜检查的风险更高，因为患者必须接受全身麻醉，且需解剖淋巴结，可能导致淋巴结粘连到奇静脉或肺动脉，进而增加出血风险；左侧是食管和喉返神经，纵膈镜检查可能导致声音嘶哑或食管撕裂等严重并发症。

 

因为纵隔镜检查能为后续治疗方案提供更多信息，针对年轻医生和研究员进行纵隔镜规范操作很重要。此外，病理学家也更希望我们使用纵隔镜，因为他们可以获得更大的活检样本，以便进行更多检测（如二代测序[NGS]和免疫组化[IHC]染色）。

 

Dr.van Schil:When we do the re-staging by EBUS(endobronchial ultrasound)or by EUS(esophageal ultrasound)，I think the risk is very low because it is a minimally invasive procedure with puncture.When you do mediastinoscopy，the risk is higher，because patients have to undergo general anesthesia and we have to dissect the lymph nodes，which sometimes can be adherent，for example，to the azygous vein or the pulmonary artery.In this way，bleeding is a concern.On the left side we encounter the esophagus and recurrent laryngeal nerve，so hoarseness or esophageal tears are also possible.Those are severe complications.We have to teach our younger colleagues and fellows how to do mediastinoscopy in the correct way，because it provides additional information to decide on further treatment.Also，pathologists like us to do mediastinoscopies because they obtain larger biopsy samples in order to do more tests including next-generation sequencing(NGS)and immunohistochemical(IHC)staining on those biopsies.

 

Dr.van Schil：间皮瘤是一种致命疾病。不幸的是，我所居住的比利时安特卫普拥有大型港口，处理着大量石棉。间皮瘤仍是这类大型港口地区的重大健康问题，在法国和荷兰也是如此。

 

几年前，我们仅使用化疗治疗间皮瘤患者，但疗效有限。近年来，针对不可切除胸膜间皮瘤患者（占90%以上），免疫治疗及双免疫疗法已开始应用。由于该疾病确诊时多已晚期，多数患者失去手术机会。对于可手术者，我们现采用扩大胸膜剥脱术以最大程度减瘤。

 

在最近的EORTC（欧洲癌症研究与治疗组织）1205试验中，我们在所有接受扩大胸膜剥脱术的患者中对比了诱导化疗与辅助化疗，结果显示诱导化疗后病理缓解并不十分显著，多数患者仍存有持续性病灶。我们目前正在进行一项诱导化疗联合免疫治疗的随访方案，该试验将于2025年6月开始。这是一种难度更大的治疗方法，但我们希望能够更好地降低病理分期，以便能够通过扩大胸膜剥脱术来治疗这些患者，从而提高他们的无病生存率。

 

Dr.van Schil:Mesothelioma is a deadly disease.Unfortunately，I am living in Antwerp in Belgium，where we have a big port where a lot of asbestos has been handled.Mesothelioma is still a concern in those large port areas，also in France and the Netherlands.Years ago，we only had chemotherapy to treat those patients，with rather poor outcomes.Recently，immunotherapy and even dual immunotherapy have been given to those patients with unresectable disease，which is actually a majority–up to 90%of the patients we see.Diagnosis is usually made late in the course of the disease，so 90%are inoperable.For those who are resectable，nowadays we try to perform an extended pleurectomy decortication to get maximum debulking of the whole area where the mesothelioma is present.In the recent EORTC(European Organisation for Research and Treatment of Cancer)1205 trial，we evaluated induction versus adjuvant chemotherapy with all patients having an extended pleurectomy decortication.What we noticed was that after induction chemotherapy，the pathological response is not very pronounced.Most of those patients still had a lot of persisting disease.We are currently starting a follow-up trial in June 2025 of induction chemotherapy combined with immunotherapy，which is a tougher treatment，but we hope to have a better pathological downstaging to be able to treat those patients by extended pleurectomy decortication in order to increase their disease-free survival.

 

Dr.van Schil：作为胸外科医生，我尤其关注肺癌及其他胸部肿瘤的多学科治疗模式，例如新辅助治疗与围手术期治疗模式，这一领域有许多问题仍待解答：若新辅助免疫治疗后患者达到病理完全缓解（pCR）或主要病理缓解（MPR），是否需在术后继续辅助免疫治疗？我期待着几项试验的最新进展，并基于最新进展与业内同道探讨如何推进下一步治疗。

 

我们还将讨论一项新的ETOP试验（即ADOPT研究），该研究的患者接受新辅助免疫治疗联合化疗，随后进行肺切除术，术后随机分配接受进一步免疫治疗或术后不进行免疫治疗。我认为这是一项非常有趣的试验，可以确认哪些类别的患者能在术后辅助免疫治疗中获益。2025 ELCC会议也发布了很多令人兴奋的新信息。

 

Dr.van Schil:As a thoracic surgeon，I am especially interested in multimodality therapy of lung cancer and other thoracic oncologies，for example，neoadjuvant versus perioperative treatment.We still have a lot of questions that remain.When you have given neoadjuvant therapy and the patient has a pathological complete response or a major pathologic response，do we have to continue treatment or not?I am looking forward to updates of several trials that will be presented here，and to discuss with my colleagues how we should further advance.We will also be discussing a new ETOP trial，the so-called ADOPT study in which patients get neoadjuvant immunotherapy with chemotherapy followed by lung resection，and after the operation，they are randomized between further immunotherapy or not.I think that is a very interesting trial to determine which patient categories will benefit from further adjuvant treatment after neoadjuvant therapy combined with surgery.At this meeting a lot of new exciting information will become available!

 

《肿瘤瞭望》在ELCC现场报道