Kesler Kenneth A, Brooks Jo Ann, Rieger Karen M, Fineberg Naomi S, Einhorn Lawrence H, Brown John W
Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind, USA.
J Thorac Cardiovasc Surg. 2003 Apr;125(4):913-23. doi: 10.1067/mtc.2003.407.
The purpose of this study was to determine the pattern of mediastinal dissemination of nonseminomatous germ cell tumors of testicular origin and evaluate variables that may influence survival with mediastinal dissection in patients with metastatic nonseminomatous germ cell tumors.
From 1981 to 2000, a total of 421 patients were seen at our institution for extirpation of residual lung or mediastinal disease after cisplatin-based chemotherapy for metastatic testicular nonseminomatous germ cell tumors. We reviewed 268 of these patients, with a mean age of 26.8 years, who required at least one surgical procedure to remove residual mediastinal disease. Pathologic types of resected residual mediastinal disease were necrosis (15%), teratoma (59%), persistent nonseminomatous germ cell cancer (15%), and non-germ cell carcinomatous degeneration (11%). Twelve variables were evaluated by univariate analyses, and four variables potentially statistically significant at P <.10 were subsequently entered into a Cox regression model.
All patients demonstrated metastases to the visceral mediastinum. Fewer patients also demonstrated metastases to the paravertebral sulcus or anterior compartments (16% and 7%, respectively). Overall 5- and 10-year survivals were 86% +/- 2% and 74% +/- 4%, respectively. According to multivariate analysis, disease-related survival was negatively influenced by an elevated preoperative beta-human chorionic gonadotropin level (P =.028) and adverse pathologic characteristics of residual mediastinal disease (P =.006).
Testicular nonseminomatous germ cell tumors follow a predictable pattern of mediastinal dissemination, primarily following the course of the thoracic duct and its major tributaries. Patients who require surgery to remove residual mediastinal disease after cisplatin-based chemotherapy for metastatic nonseminomatous germ cell tumors have good to excellent long-term survivals. These results justify an aggressive surgical approach, including multiple surgical procedures if clinically indicated.
本研究旨在确定睾丸源性非精原细胞瘤纵隔播散的模式，并评估影响转移性非精原细胞瘤患者行纵隔清扫术后生存的相关变量。
1981年至2000年期间，共有421例患者因转移性睾丸非精原细胞瘤接受以顺铂为基础的化疗后，在我院接受残留肺部或纵隔疾病的切除手术。我们回顾了其中268例患者，平均年龄26.8岁，这些患者至少需要一次手术来切除残留的纵隔疾病。切除的残留纵隔疾病的病理类型为坏死（15%）、畸胎瘤（59%）、持续性非精原细胞瘤（15%）和非生殖细胞癌性退变（11%）。通过单因素分析评估了12个变量，随后将4个在P<0.10时有潜在统计学意义的变量纳入Cox回归模型。
所有患者均表现为内脏纵隔转移。较少患者也表现为椎旁沟或前纵隔转移（分别为16%和7%）。总体5年和10年生存率分别为86%±2%和74%±4%。多因素分析显示，术前β-人绒毛膜促性腺激素水平升高（P=0.028）和残留纵隔疾病的不良病理特征（P=0.006）对疾病相关生存有负面影响。
睾丸非精原细胞瘤遵循可预测的纵隔播散模式，主要沿胸导管及其主要分支走行。对于转移性非精原细胞瘤患者，在以顺铂为基础的化疗后需要手术切除残留纵隔疾病的患者，长期生存率良好至优秀。这些结果证明了积极的手术方法是合理的，包括在临床指征明确时进行多次手术。
