Attaran Saina, Acharya Metesh, Anderson Jon R, Punjabi Prakash P
Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College, London, UK.
Interact Cardiovasc Thorac Surg. 2012 Sep;15(3):494-7. doi: 10.1093/icvts/ivs263. Epub 2012 Jun 14.
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Does surgical debulking for advanced stages of thymoma improve survival?' Altogether, only 17 papers were found using the reported search, of which only 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated; these studies have mainly reported the survival and recurrence rates after total vs subtotal resection of thymic tumours in patients receiving or not receiving adjuvant chemoradiotherapy. These studies confirmed that complete resection is the best prognostic factor in thymomas. With regard to subtotal tumour resection/debulking, we did not find any randomized controlled trials. The evidence on this topic is scarce and these 10 reported were retrospective reviews of the operative, histology and survival data of patients with thymoma who had subtotal vs partial resection for advanced stages of thymoma. Although debulking surgery for thymoma had positively affected survival, in six studies, the difference failed to reach statistical significance. Three of the studies, on the other hand, showed a higher survival rate in thymomas in which maximum debulking was performed and the treatment was followed by high-dose irradiation. None of these studies showed any benefit in debulking surgery for thymic carcinoma. Besides histology and tumour cell-type, other factors influencing survival included the tumour stage and the presence of symptoms such as myasthenia gravis as a warning sign at an early stage. Current evidence in the literature on the survival after debulking surgery for thymoma is contradictory, and most of the studies do not show any survival benefit after debulking for thymoma. However, debulking surgery minimizes the tumour size and area for irradiation postoperatively, hence it can result in less damage to the adjacent tissue during radiotherapy and may be considered for patients in advanced stages of thymoma in whom extensive radiotherapy will be required. In these cases, however, the risks of surgery followed by radiotherapy or radiotherapy alone should carefully be assessed prior to the initiation of treatment.
一篇心胸外科的最佳证据主题文章是根据结构化方案撰写的。所探讨的问题是“晚期胸腺瘤的减瘤手术是否能提高生存率？”通过报告的检索方式，总共仅找到17篇论文，其中只有10篇代表了回答该临床问题的最佳证据。将这些论文的作者、期刊、发表日期和国家、所研究的患者群体、研究类型、相关结局和结果制成表格；这些研究主要报告了接受或未接受辅助放化疗的患者在胸腺肿瘤全切除与次全切除后的生存率和复发率。这些研究证实，完整切除是胸腺瘤最佳的预后因素。关于肿瘤次全切除/减瘤手术，我们未找到任何随机对照试验。关于该主题的证据稀少，这10篇报告均为对晚期胸腺瘤行次全切除与部分切除的患者的手术、组织学和生存数据的回顾性分析。尽管胸腺瘤减瘤手术对生存有积极影响，但在6项研究中，差异未达到统计学意义。另一方面，其中3项研究显示，在进行最大程度减瘤并随后接受高剂量放疗的胸腺瘤患者中，生存率更高。这些研究均未显示减瘤手术对胸腺癌有任何益处。除了组织学和肿瘤细胞类型外，影响生存的其他因素包括肿瘤分期以及诸如重症肌无力等症状的存在，重症肌无力是早期的一个警示信号。目前文献中关于胸腺瘤减瘤手术后生存情况的证据相互矛盾，且大多数研究未显示胸腺瘤减瘤手术后有任何生存获益。然而，减瘤手术可使肿瘤大小和术后放疗面积最小化，因此在放疗期间对相邻组织的损伤可能较小，对于需要广泛放疗的晚期胸腺瘤患者可考虑采用。然而，在这些情况下，放疗后手术或单纯放疗的风险在开始治疗前应仔细评估。
