Mineo Tommaso Claudio, Ambrogi Vincenzo, Pompeo Eugenio, Baldi Alfonso, Stella Franco, Aurea Paolo, Marino Mario
Department of Thoracic Surgery, Policlinico Tor Vergata University, Rome, Italy.
Ann Thorac Surg. 2008 May;85(5):1740-6. doi: 10.1016/j.athoracsur.2008.01.088.
The purpose of this study was to examine the prognostic impact of occult disease after extrapleural pneumonectomy for malignant mesothelioma.
We reviewed the resection margin and node specimens from 41 consecutive patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma in different institutions between 1985 and 2004. The specimens were reassessed by immunohistochemical staining with anticalretinin and antimesothelin monoclonal antibodies, and results were used to draw Kaplan-Meier survival curves and perform Cox regression analyses.
Histologic examination showed 34 epithelioid, 4 biphasic, and 3 sarcomatoid subtypes. Results of postoperative TNM staging were that 14 patients were in stage I, 6 were in stage II, and 21 were in stage III. One patient died during the early postoperative period. Median survival was 13 months. Survival was affected by nonepithelial histologic type (p = 0.001), TNM stage (p = 0.007), positive resection margins (p = 0.002), and N disease (p = 0.01). Immunohistochemistry revealed occult positive resection margins in 6 patients, not correlated with T stage. Microscopic N disease was discovered in 5 patients, of whom 2 had their nodes retrieved through cervical mediastinoscopy. No correlation with nodal diameter was found. In all patients microscopic N disease could have been accessible through mediastinoscopy. Overall, the presence of occult disease was diagnosed in 5 new patients and influenced survival more than any other variable, both at univariate (p < 0.001) and multivariate Cox regression analysis (p < 0.0001; odds ratio, 5.4; 95% confidence interval, 3 to 15).
In malignant pleural mesothelioma, the presence of occult disease in resection margins and lymph nodes can be identified by immunohistochemistry and significantly influences the prognosis. Cervical mediastinoscopy is useful in all patients considered for radical resection, but all specimens should be processed with immunohistochemical staining.
本研究旨在探讨恶性间皮瘤胸膜外肺切除术后隐匿性疾病的预后影响。
我们回顾了1985年至2004年间不同机构连续41例行胸膜外肺切除术治疗恶性胸膜间皮瘤患者的手术切缘和淋巴结标本。用抗钙视网膜蛋白和抗间皮素单克隆抗体进行免疫组化染色对标本进行重新评估，结果用于绘制Kaplan-Meier生存曲线并进行Cox回归分析。
组织学检查显示34例上皮样、4例双向性和3例肉瘤样亚型。术后TNM分期结果为14例患者为I期，6例为II期，21例为III期。1例患者在术后早期死亡。中位生存期为13个月。生存受非上皮组织学类型（p = 0.001）、TNM分期（p = 0.007）、手术切缘阳性（p = 0.002）和N期疾病（p = 0.01）影响。免疫组化显示6例患者手术切缘隐匿性阳性，与T分期无关。5例患者发现微小N期疾病，其中2例通过颈部纵隔镜检获取淋巴结。未发现与淋巴结直径相关。在所有患者中，微小N期疾病均可通过纵隔镜检发现。总体而言，5例新患者被诊断为隐匿性疾病，在单因素（p < 0.001）和多因素Cox回归分析中，隐匿性疾病对生存的影响均超过其他任何变量（p < 0.0001；比值比，5.4；95%置信区间，3至15）。
在恶性胸膜间皮瘤中，手术切缘和淋巴结隐匿性疾病可通过免疫组化识别，并显著影响预后。颈部纵隔镜检对所有考虑行根治性切除的患者有用，但所有标本均应进行免疫组化染色处理。
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