Ehrlich Peter F, Hamilton Thomas E, Grundy Paul, Ritchey Michael, Haase Gerald, Shamberger Robert C
Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI 48104, USA.
J Pediatr Surg. 2006 Jan;41(1):162-7; discussion 162-7. doi: 10.1016/j.jpedsurg.2005.10.020.
BACKGROUND/PURPOSE: Computed tomography (CT) of the chest with its increased sensitivity frequently identifies lesions not visible on chest radiograph. Treatment of such lesions is controversial. A recent review suggests that patients with Wilms' tumor with pulmonary lesions detected only by CT, who were treated with dactinomycin and vincristine, have an inferior outcome compared with those who also received pulmonary radiation therapy (RT) and doxorubicin. It is important to determine if these small lesions seen only on CT represent metastatic disease and whether patients with these lesions require RT and/or doxorubicin for optimal outcome.
Patients with Wilms' tumor with lung metastasis, registered on National Wilms' Tumor Study 5, were reviewed, and those with CT-only lesions who had a radiology and surgical checklist submitted were identified. The treatment regimens of these patients and the histological findings of the pulmonary lesions are presented. We analyzed the pathological findings by whether the patients had single or multiple lesions.
Of 2498 patients registered on National Wilms' Tumor Study 5, 252 had pulmonary metastases. Of these patients, 129 (5.2%) had CT-only lesions (<1 cm). Forty-two of these patients (20 boys and 22 girls) underwent lung biopsy at the discretion of the attending physicians. The local tumor stages in these patients were stage I (7%), II (34%), and III (59%). The treatment stages in these patients were stage I (n = 3, 2 drugs), II (n = 3, 2 drugs), III (n = 12, 3 drugs); and IV (n = 24, 3 drugs + RT). There were 16 patients with isolated lung lesions and 26 with multiple lesions, average size 5.8 +/- 0.5 mm. Of 16 isolated lesions, 13 patients (82%) and 69% (18/26) with multiple lesions had tumor on biopsy. Of the 24 who received RT, 8 had a negative biopsy and, thus, may not have needed the RT. Five of 6 treated with just 2 drugs may have been undertreated. Nine of 12 treated with 3 drugs had tumor on biopsy.
Computed tomography-only pulmonary lesions are not invariably tumor, demonstrating the need for histopathological confirmation. Biopsy remains critical until radiographic techniques allow differentiation between benign and malignant lesions to optimally direct therapy.
背景/目的：胸部计算机断层扫描（CT）敏感度提高，常能发现胸部X光片上不可见的病变。此类病变的治疗存在争议。最近一项综述表明，仅通过CT检测出肺部病变的肾母细胞瘤患者，若仅接受放线菌素D和长春新碱治疗，其预后比同时接受肺部放射治疗（RT）和阿霉素治疗的患者要差。确定这些仅在CT上可见的小病变是否代表转移性疾病，以及患有这些病变的患者是否需要RT和/或阿霉素以获得最佳预后非常重要。
对参加国家肾母细胞瘤研究5的肾母细胞瘤肺转移患者进行回顾，识别出提交了放射学和手术清单的仅通过CT发现病变的患者。介绍了这些患者的治疗方案以及肺部病变的组织学检查结果。我们根据患者是单发还是多发病变分析了病理结果。
在参加国家肾母细胞瘤研究5的2498例患者中，252例有肺转移。在这些患者中，129例（5.2%）仅有CT可见病变（<1 cm）。其中42例患者（20名男孩和22名女孩）由主治医生酌情进行了肺活检。这些患者的局部肿瘤分期为I期（7%）、II期（34%）和III期（59%）。治疗分期为I期（n = 3，2种药物）、II期（n = 3，2种药物）、III期（n = 12，3种药物）和IV期（n = 24，3种药物 + RT）。有16例患者为孤立性肺部病变，26例为多发性病变，平均大小为5.8 +/- 0.5 mm。在16例孤立性病变中，13例患者（82%）活检发现肿瘤，多发性病变患者中有69%（18/26）活检发现肿瘤。在接受RT的24例患者中，8例活检为阴性，因此可能不需要RT。仅接受2种药物治疗的6例患者中有5例可能治疗不足。接受3种药物治疗的12例患者中有9例活检发现肿瘤。
仅通过CT发现的肺部病变并非总是肿瘤，这表明需要进行组织病理学确认。在放射学技术能够区分良性和恶性病变以优化指导治疗之前，活检仍然至关重要。
