Weiser M R, Downey R J, Leung D H, Brennan M F
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
J Am Coll Surg. 2000 Aug;191(2):184-90; discussion 190-1. doi: 10.1016/s1072-7515(00)00306-9.
Even after an apparent complete resection of sarcomatous pulmonary metastases, 40% to 80% of patients will re-recur in the lung. The benefit of subsequent re-resection is poorly defined. This study examines patient survival after repeat pulmonary exploration for re-recurrent metastatic sarcoma at a single institution.
Between July 1982 and December 1997, data on 3,149 adult in-patients with soft tissue sarcoma were prospectively gathered. Of these, pulmonary metastases were present or developed in 719 patients and 248 underwent at least one resection. Of the patients relapsing in the lung after an apparently complete resection, 86 underwent reexploration. Disease-specific survival (DSS) after re-resection was the end point of the study. Time to death was modeled using the method of Kaplan and Meier. The association of factors to time-to-event end points was analyzed using the log-rank test for univariate analysis and the Cox proportional hazards model for multivariate analysis. Clinicopathologic factors were analyzed with the Pearson chi-square or Fisher's exact test when appropriate.
The median DSS after re-resection for all patients undergoing at least two pulmonary resections was 42.8 months with an estimated 5-year survival of 36%. The median DSS in patients with complete reresection was 51 months (n = 68) compared with 6 months in patients with an incomplete re-resection (n = 16, p<0.0001). Patients with one or two nodules at re-resection (n = 39) had a median DSS of 51 months compared with 20 months in patients with three or more nodules (n = 40, p = 0.003). Patients in whom the largest metastasis re-resected was less than or equal to 2 cm (n = 33) had a median DSS of 44 months compared with 20 months in patients with metastasis greater than 2 cm (n = 43, p = 0.033). Patients with primary tumor high-grade histology (n = 75) had a median DSS of 32 months and patients with low-grade histology (n = 11) had a median DSS that was not reached (p = 0.041). Three independent prognostic factors associated with poor outcomes may be determined preoperatively: > or =3 nodules, largest metastases > 2 cm, and high-grade primary tumor histology. Patients with either zero or one poor prognostic factor had a median DSS > 65 months and patients with three poor prognostic factors had a median DSS of 10 months.
Reexploration for recurrent sarcomatous pulmonary metastases appears beneficial for patients who can be completely re-resected. Outcomes are described by factors that may be determined preoperatively, including metastasis size, metastasis number, and primary tumor histologic grade. Patients who cannot be completely re-resected or those with numerous, large metastasis and high-grade primary tumor pathology have poor outcomes and should be considered for investigational therapy.
即使肉瘤肺转移灶看似已完全切除，仍有40%至80%的患者会在肺部再次复发。后续再次切除的益处尚不明确。本研究探讨了在单一机构中，复发性转移性肉瘤患者再次进行肺探查后的生存情况。
1982年7月至1997年12月，前瞻性收集了3149例成年软组织肉瘤住院患者的数据。其中，719例患者出现或发生了肺转移，248例接受了至少一次切除。在看似完全切除后肺部复发的患者中，86例接受了再次探查。再次切除后的疾病特异性生存（DSS）是本研究的终点。采用Kaplan-Meier方法对死亡时间进行建模。使用对数秩检验进行单因素分析，使用Cox比例风险模型进行多因素分析，以分析各因素与事件发生时间终点的关联。在适当情况下，使用Pearson卡方检验或Fisher精确检验对临床病理因素进行分析。
所有接受至少两次肺切除的患者再次切除后的中位DSS为42.8个月，估计5年生存率为36%。完全再次切除的患者中位DSS为51个月（n = 68），不完全再次切除的患者为6个月（n = 16，p<0.0001）。再次切除时出现1个或2个结节的患者（n = 39）中位DSS为51个月，出现3个或更多结节的患者为20个月（n = 40，p = 0.003）。再次切除的最大转移灶小于或等于2 cm的患者（n = 33）中位DSS为44个月，转移灶大于2 cm的患者为20个月（n = 43，p = 0.033）。原发性肿瘤组织学分级为高级别的患者（n = 75）中位DSS为32个月，低级别组织学患者（n = 11）的中位DSS未达到（p = 0.041）。术前可确定与不良预后相关的三个独立预后因素：≥3个结节、最大转移灶>2 cm和原发性肿瘤组织学高级别。预后不良因素为0个或1个的患者中位DSS>65个月，有3个不良预后因素的患者中位DSS为10个月。
对于能够完全再次切除的复发性肉瘤肺转移患者，再次探查似乎有益。预后情况可通过术前确定的因素来描述，包括转移灶大小、转移灶数量和原发性肿瘤组织学分级。无法完全再次切除或有大量、大转移灶及原发性肿瘤病理高级别的患者预后不良，应考虑进行试验性治疗。
