Rusch V W, Piantadosi S, Holmes E C
Memorial Sloan-Kettering Cancer Center, New York, N.Y.
J Thorac Cardiovasc Surg. 1991 Jul;102(1):1-9.
Malignant pleural mesothelioma is usually a fatal cancer for which operation has been the mainstay of treatment because chemotherapy and radiation are relatively ineffective. The choice of operation for malignant pleural mesothelioma remains controversial. Extrapleural pneumonectomy has been advocated because it allows complete removal of gross tumor and can be associated with long-term survival. To evaluate extrapleural pneumonectomy, we conducted a prospective multiinstitutional trial in patients with biopsy-proved previously untreated malignant pleural mesothelioma. Criteria for extrapleural pneumonectomy were (1) potentially completely resectable unilateral disease by computed tomography scan, (2) predicted postresection forced expiratory volume in 1 second greater than 1 L/sec, and (3) no other major medical problems. Patients who were not candidates for extrapleural pneumonectomy had a more limited operation with or without adjuvant therapy or had nonsurgical treatment. From September 1985 to June 1988 83 eligible patients (64 male, 19 female) were entered. The mean age for all patients was 59.7 years. Only 20 of the 83 patients (24%) underwent extrapleural pneumonectomy. Three of these 20 patients (15%) died postoperatively. The recurrence-free survival was significantly longer for the patients undergoing extrapleural pneumonectomy than for the other two groups (p = 0.03), but there was no difference in overall survival among the three groups. In univariate analyses, epithelial versus sarcomatoid and mixed histologic findings and platelet count less than 400,000 were associated with a better overall survival (p = 0.02), and performance status (Karnofsky less than 80) was predictive of recurrence (p = 0.02). In a multivariate analysis, histologic findings, sex, age, extrapleural pneumonectomy, weight loss, and performance status all had no significant impact on survival. Extrapleural pneumonectomy was associated with a greater likelihood of relapse in distant sites than were limited operation and nonsurgical treatment. We conclude that (1) only a small proportion of all patients with malignant pleural mesothelioma are candidates for extrapleural pneumonectomy, (2) extrapleural pneumonectomy carries a significant operative mortality and does not seem to improve overall survival compared with more conservative forms of treatment, (3) extrapleural pneumonectomy alters the patterns of relapse, and (4) factors previously thought to have an impact on survival in other series did not affect outcome in this trial.
恶性胸膜间皮瘤通常是一种致命的癌症，由于化疗和放疗相对无效，手术一直是主要的治疗手段。恶性胸膜间皮瘤的手术选择仍存在争议。提倡进行胸膜外全肺切除术，因为它能完全切除肉眼可见的肿瘤，且可能带来长期生存。为评估胸膜外全肺切除术，我们对经活检证实为先前未接受过治疗的恶性胸膜间皮瘤患者进行了一项前瞻性多机构试验。胸膜外全肺切除术的标准为：（1）计算机断层扫描显示潜在可完全切除的单侧病变；（2）预计切除术后第1秒用力呼气量大于1升/秒；（3）无其他重大内科问题。不符合胸膜外全肺切除术条件的患者接受了范围更有限的手术，可伴有或不伴有辅助治疗，或接受非手术治疗。从1985年9月至1988年6月，共纳入83例符合条件的患者（64例男性，19例女性）。所有患者的平均年龄为59.7岁。83例患者中仅20例（24%）接受了胸膜外全肺切除术。这20例患者中有3例（15%）术后死亡。接受胸膜外全肺切除术的患者无复发生存期明显长于其他两组（p = ？03），但三组的总生存期无差异。在单因素分析中，上皮样与肉瘤样及混合组织学表现以及血小板计数低于400,000与较好的总生存期相关（p = ？02），而体能状态（卡诺夫斯基评分低于80）可预测复发（p = ？02）。在多因素分析中，组织学表现、性别、年龄、胸膜外全肺切除术、体重减轻和体能状态对生存均无显著影响。与有限手术和非手术治疗相比，胸膜外全肺切除术远处复发的可能性更大。我们得出以下结论：（1）所有恶性胸膜间皮瘤患者中只有一小部分适合胸膜外全肺切除术；（2）胸膜外全肺切除术手术死亡率高，与更保守的治疗方式相比，似乎并未改善总生存期；（3）胸膜外全肺切除术改变了复发模式；（4）先前在其他系列研究中认为对生存有影响的因素在本试验中并未影响结果。
原文中“p = 0.03”和“p = 0.02”处的“？”为原英文文档中可能的格式问题，实际应是正常数字，这里保留原文格式疑问供你参考。
