Jaklitsch M T, Mery C M, Lukanich J M, Richards W G, Bueno R, Swanson S J, Mentzer S J, Davis B D, Allred E N, Sugarbaker D J
Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
J Thorac Cardiovasc Surg. 2001 Apr;121(4):657-67. doi: 10.1067/mtc.2001.112822.
The value of sequential thoracic metastasectomies is unknown. We evaluate repeat metastasectomy for limited recurrences within the thorax.
From July 1988 to September 1998, 54 patients underwent 2 to 6 separate sequential procedures to excise metastases after recurrence isolated to the thorax. Kaplan-Meier survival and Cox modeling determined prognostic variables.
Thirty-three men and 21 women, 22 to 76 years underwent 2 (100%, n = 54), 3 (50%), 4 (22%), or 5 to 6 (11%) metastasectomies. Fifty-four percent of patients had carcinoma, 35% sarcoma, 9% germ cell, and 2% melanoma. There were no operative deaths; all late deaths occurred from cancer. Median follow-up was 48 months. Cumulative 5-year survival from the second procedure was 57%. After the second, third, fourth, and fifth procedures, respectively, permanent control was achieved in 15 (27%) of 54 patients, 5 (19%) of 27, 1 (8%) of 12, and 0 of 7. Recurrence amenable to additional surgery occurred in 27 (50%) of 54, 12 (44%) of 27, 6 (50%) of 12, and 1 (17%) of 6. Mean hazard for the development of unresectable recurrence increased from 0.21 after the second procedure to 0.91 after the fifth procedure. The 5-year survival for the 27 patients undergoing only 2 metastasectomies was 60% (median not yet reached), 33% for the 15 patients undergoing only 3 metastasectomies (median 34.7 months), and 38% for the 12 patients undergoing 4 or more (median 45.6 months). From the time a recurrence was declared unresectable, patients had a 19% 2-year survival (median 8 months).
Multiple attempts to re-establish intrathoracic control of metastatic disease is justified in carefully selected patients, but the magnitude of benefit decays with each subsequent attempt.
序贯性胸内转移瘤切除术的价值尚不清楚。我们评估了针对胸内局限性复发进行的重复转移瘤切除术。
1988年7月至1998年9月，54例患者接受了2至6次单独的序贯手术，以切除仅局限于胸部复发后的转移瘤。采用Kaplan-Meier生存分析和Cox模型确定预后变量。
33例男性和21例女性，年龄22至76岁，接受了2次（100%，n = 54）、3次（50%）、4次（22%）或5至6次（11%）转移瘤切除术。54%的患者为癌，35%为肉瘤，9%为生殖细胞肿瘤，2%为黑色素瘤。无手术死亡；所有晚期死亡均因癌症所致。中位随访时间为48个月。第二次手术后的累积5年生存率为57%。在第二次、第三次、第四次和第五次手术后，54例患者中有15例（27%）、27例中有5例（19%）、12例中有1例（8%）以及7例中有0例实现了永久性控制。54例患者中有27例（50%）、27例中有12例（44%）、12例中有6例（50%）以及6例中有1例（17%）出现了适合再次手术的复发。不可切除性复发发生的平均风险从第二次手术后的0.21增加到第五次手术后的0.91。仅接受2次转移瘤切除术的27例患者的5年生存率为60%（中位生存时间未达到），仅接受3次转移瘤切除术的15例患者为33%（中位生存时间34.7个月），接受4次或更多次转移瘤切除术的12例患者为38%（中位生存时间45.6个月）。从复发被判定为不可切除之时起，患者的2年生存率为19%（中位生存时间8个月）。
对于经过精心挑选的患者，多次尝试重新建立对胸内转移性疾病的控制是合理的，但每次后续尝试的获益程度都会降低。
