Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK.
Eur J Cardiothorac Surg. 2012 Jul;42(1):72-6; discussion 76. doi: 10.1093/ejcts/ezr251. Epub 2012 Jan 26.
Selection criteria for radical surgery in malignant pleural mesothelioma (MPM) and related clinical trials remain controversial. The relative importance of nodal metastases and the need for pre-operative nodal staging are undetermined.
From a prospective database, we identified 212 patients with non-sarcomatoid MPM (160 epithelioid and 52 biphasic). A total of 127 patients underwent extrapleural pneumonectoctomy (EPP) and 85 lung-sparing total pleurectomy (LSTP) with lymphadenectomy. We investigated the effect of nodal burden and distribution in survival by testing for differences between N0, N1 and N2 disease and constructing a theoretical model dividing the patients into four groups according to diseased nodes identified in the surgical specimen: Group 0, no nodal disease; Group CM, nodes accessible by cervical mediastinoscopy (CM): Stations 2, 3a, 4 and 7; Group EBUS/EUS, nodes accessible by endobronchial (EBUS) or endoscopic (EUS) ultrasound: Stations 2, 3a, 4 and 7-11. Group EM, extramediastinal nodes not accessible by CM or EBUS/EUS: Stations 5, 6, internal mammary, pericardial and diaphragmatic lymph nodes.
There was no difference in overall median survival between EPP and LSTP [15.6, SE 1.8, 95% confidence interval (CI) 12-19 months versus 13.4, SE 2.3, 95% CI 9-18 months, P=0.41]. Patients with N0 disease (n=94) had the best prognosis: median survival was 19.6 months (SE 3, 95% CI 13.2-26) versus 12 months for the 19 patients with N1 (SE 1.5, 95% CI 9-15) and 13.6 months for 99 patients with N2 (SE 1.7, 95% CI 10-17), P=0.015. Subgroup analysis of patients with nodal metastases revealed no significant survival difference between group CM and group EBUS/EUS: achieving maximum theoretical diagnostic yield CM could detect 63 (54%) of patients with nodal disease and the median survival of this group was 13.6 months (SE 2, 95% CI 9.6-17.6). EBUS/EUS could detect an additional 30 cases (26%) with survival of 11.3 months (SE 1, 95% CI 9-13.6). The survival in group EM (25 cases, 21%, median survival 18.7 months, SE 6, 95% CI 7-30) was significantly better than groups CM or EBUS/EUS, P=0.002.
There is a strong case for routine CM as a method of prognostic staging in all patients undergoing radical surgery for MPM. The addition of EUS staging and the detection of nodal metastases inaccessible to mediastinoscopy had no prognostic benefit.
恶性胸膜间皮瘤（MPM）根治性手术的选择标准和相关临床试验仍存在争议。淋巴结转移的相对重要性和术前淋巴结分期的必要性尚未确定。
从前瞻性数据库中，我们确定了 212 例非肉瘤样 MPM 患者（160 例上皮样和 52 例双相型）。127 例患者接受了胸膜外全肺切除术（EPP）和 85 例肺保留性全胸膜切除术（LSTP）伴淋巴结切除术。我们通过检测 N0、N1 和 N2 疾病之间的生存差异，并根据手术标本中发现的患病淋巴结构建一个理论模型，将患者分为四组：0 组，无淋巴结疾病；CM 组，可通过颈纵隔镜（CM）检测到的淋巴结：站 2、3a、4 和 7；EBUS/EUS 组，可通过支气管内（EBUS）或内镜（EUS）超声检测到的淋巴结：站 2、3a、4 和 7-11。EM 组，CM 或 EBUS/EUS 无法检测到的纵隔外淋巴结：站 5、6、内乳、心包和膈肌淋巴结。
EPP 和 LSTP 的总中位生存期无差异[15.6，SE 1.8，95%置信区间（CI）12-19 个月与 13.4，SE 2.3，95%CI 9-18 个月，P=0.41]。无淋巴结疾病的患者（n=94）预后最好：中位生存期为 19.6 个月（SE 3，95%CI 13.2-26），而 19 例 N1 患者的中位生存期为 12 个月（SE 1.5，95%CI 9-15），99 例 N2 患者的中位生存期为 13.6 个月（SE 1.7，95%CI 10-17），P=0.015。对有淋巴结转移的患者进行亚组分析显示，CM 组和 EBUS/EUS 组的生存无显著差异：CM 可检测到 63 例（54%）有淋巴结疾病的患者，该组的中位生存期为 13.6 个月（SE 2，95%CI 9.6-17.6）。EBUS/EUS 可检测到另外 30 例（26%）生存时间为 11.3 个月（SE 1，95%CI 9-13.6）。EM 组（25 例，21%，中位生存期 18.7 个月，SE 6，95%CI 7-30）的生存明显优于 CM 组或 EBUS/EUS 组，P=0.002。
在所有接受 MPM 根治性手术的患者中，常规进行 CM 作为预后分期方法具有很强的理由。EUS 分期和检测纵隔镜无法检测到的淋巴结转移没有预后获益。
