Chapelier A, Fadel E, Macchiarini P, Lenot B, Le Roy Ladurie F, Cerrina J, Dartevelle P
Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hopital Marie-Lannelongue (Paris-Sud University), 92350 Le Plessis Robinson, Paris, France.
Eur J Cardiothorac Surg. 2000 Nov;18(5):513-8. doi: 10.1016/s1010-7940(00)00537-6.
Several reports emphasize the importance of en-bloc resection as the optimal surgical treatment of lung cancer with chest wall invasion. We investigated possible factors which could affect long-term survival following radical resection of these tumors.
Between 1981 and 1998, 100 patients (90 male; ten female), with a median age of 60 years (36-84), underwent radical en-bloc resection of non-small cell lung cancer (NSCLC) with chest wall involvement. Patients with superior sulcus tumors invading the thoracic inlet were excluded from this series. There were 43 squamous and 57 non-squamous tumors. The median number of resected ribs was three (1-5). Lung resection included 73 lobectomies, two bilobectomies, 18 pneumonectomies and seven segmentectomies. Chest wall resection also extended to the sternum in one patient, the transverse process in one, the costotransverse foramen and hemivertebrae in two. All patients had a complete resection. Sixty-three patients received postoperative radiotherapy and 12 received chemotherapy. Histological data, including differentiation and depth of chest wall invasion, were carefully reviewed. The effect of various factors on survival were studied.
There were four in-hospital deaths. Lymph node involvement was negative on surgical specimens in 65 patients, and 28 patients had positive N1 nodes; the final histology revealed seven N2 diseases. Chest wall invasion was limited to the parietal pleura in 29 patients and included intercostal muscles, bones and extrathoracic muscles in 67, 24 and seven cases, respectively. The overall 2-year survival rate was 41%. The 5-year survival for patients with N0, N1 and N2 disease was 22, 9 and 0%, respectively. A local recurrence occurred in 13 patients, with four having a new resection and 45 patients developing systemic metastases. The nodal status (N0-1 vs. N2; P=0. 026) and the number of resected ribs(<2 vs. >2; P=0.03) were survival predictors in univariate analysis. By multivariate analysis, the two independent factors affecting long-term survival were the histological differentiation (well vs. poorly differentiated; P=0. 01) and the depth of chest wall invasion (parietal pleura vs. others; P=0.024).
Histological differentiation and depth of chest wall involvement were the main factors affecting long-term survival in this series. The role of induction chemotherapy for tumors with poor prognosis should be investigated.
多篇报告强调整块切除作为胸壁受侵肺癌最佳手术治疗方式的重要性。我们研究了可能影响这些肿瘤根治性切除术后长期生存的因素。
1981年至1998年间，100例患者（90例男性；10例女性）接受了非小细胞肺癌（NSCLC）合并胸壁受累的根治性整块切除术，中位年龄60岁（36 - 84岁）。侵犯胸廓入口的肺上沟瘤患者被排除在本系列之外。有43例鳞癌和57例非鳞癌肿瘤。切除肋骨的中位数为3根（1 - 5根）。肺切除包括73例肺叶切除术、2例双肺叶切除术、18例全肺切除术和7例肺段切除术。1例患者的胸壁切除还延伸至胸骨，1例至横突，2例至肋横突孔和半椎体。所有患者均实现完全切除。63例患者接受了术后放疗，12例接受了化疗。仔细复查了组织学数据，包括分化程度和胸壁侵犯深度。研究了各种因素对生存的影响。
有4例住院死亡。手术标本中65例患者淋巴结受累为阴性，28例患者N1淋巴结阳性；最终组织学检查发现7例N2期病变。29例患者胸壁侵犯局限于壁层胸膜，67例、24例和7例患者分别累及肋间肌、骨骼和胸外肌肉。总体2年生存率为41%。N0、N1和N2期疾病患者的5年生存率分别为22%、9%和0%。13例患者发生局部复发，4例再次手术，45例患者发生全身转移。单因素分析中，淋巴结状态（N0 - 1与N2；P = 0.026）和切除肋骨数量（<2根与>2根；P = 0.03）是生存预测因素。多因素分析显示，影响长期生存的两个独立因素是组织学分化程度（高分化与低分化；P = 0.01）和胸壁侵犯深度（壁层胸膜与其他；P = 0.024）。
组织学分化程度和胸壁受累深度是本系列中影响长期生存的主要因素。对于预后不良的肿瘤，应研究诱导化疗的作用。
