全胸壁整块切除的肺切除术：是否值得？来自两家机构的34例患者报告。
Pneumonectomy with en bloc chest wall resection: is it worthwhile? Report on 34 patients from two institutions.
作者信息
Cardillo Giuseppe, Spaggiari Lorenzo, Galetta Domenico, Carleo Francesco, Carbone Luigi, Morrone Aldo, Ricci Alberto, Facciolo Francesco, Martelli Massimo
机构信息
Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy.
出版信息
Interact Cardiovasc Thorac Surg. 2013 Jul;17(1):54-8. doi: 10.1093/icvts/ivt091. Epub 2013 Mar 25.
OBJECTIVES
Pneumonectomy with en bloc chest wall resection is often denied because of the procedure-related high risk. We evaluated the short- and long-term outcome of this procedure.
METHODS
From January 1995 to October 2011, 34 patients (30 males and 4 females; mean age: 61.8 years) underwent pneumonectomy with en bloc chest wall resection for 33 non-small-cell lung cancer and 1 metastatic osteosarcoma in two institutions. Data were retrospectively reviewed.
RESULTS
Operative (30-day) mortality was 2.9% (1 of 34), and morbidity was 38.2% (13 of 34). There were 14 (41.1%) right-side procedures and 20 (58.8%) left-side procedures. Three (8.8%) patients developed bronchopleural fistulas. The mean number of resected ribs per patient was 2.7 ± 1.1. In 13 (38.2%) patients, a prosthetic reconstruction of the chest wall was needed. In 3 (8.8%) cases, the bronchial step was buttressed. Preoperative pain was statistically significantly related to the depth of chest wall invasion (P = 0.026). The N status was N0 in 18 (52.9%) cases, N1 in 9 (26.4%), N2 in 6 (17.6%) and Nx in 1 (metastatic osteosarcoma). Patients were followed-up for a total of 979 months. The median survival was 40 months. The overall 5-year survival was 46.8% (± 95% confidence interval [CI]: 0.2-0.6): 45.2 (± 95% CI: 0.03-0.8) for right-side and 48.4% (± 95% CI: 0.2-0.7) for left-side procedures, respectively. According to the N status, the 5-year survival was 59.7 (± 95% CI: 0.3-0.8) in N0, 55.5 (± 95% CI: 0.06-1) in N1 and 16.6% (± 95% CI: 0-0.4) in N2. The subgroup N0 plus N1 (27 patients) showed a 58.08% (± 95% CI: 0.3-0.8) 5-year survival compared with 16.6% (± 95% CI: 0-0.4) in N2 (χ(2): 3.7; P = 0.053).
CONCLUSIONS
Pneumonectomy with en bloc chest wall reconstruction can be safely offered to selected patients. The addition of en bloc chest wall resection to pneumonectomy does not affect operative mortality and morbidity compared with standard pneumonectomy. The pivotal additional effect of the chest wall resection should not be considered a contraindication for such procedures. Survival showed a clinically relevant difference by comparing N0 plus N1 with N2 (58.1 vs 16.6%), not confirmed by the statistical analysis (P = 0.053).
目的
由于与手术相关的高风险，全胸壁整块切除的肺切除术常不被采用。我们评估了该手术的短期和长期结果。
方法
1995年1月至2011年10月，在两家机构中，34例患者（30例男性和4例女性；平均年龄：61.8岁）因33例非小细胞肺癌和1例转移性骨肉瘤接受了全胸壁整块切除的肺切除术。对数据进行回顾性分析。
结果
手术（30天）死亡率为2.9%（34例中的1例），发病率为38.2%（34例中的13例）。右侧手术14例（41.1%），左侧手术20例（58.8%）。3例（8.8%）患者发生支气管胸膜瘘。每位患者切除肋骨的平均数量为2.7±1.1根。13例（38.2%）患者需要进行胸壁假体重建。3例（8.8%）病例对支气管断端进行了加固。术前疼痛与胸壁侵犯深度在统计学上显著相关（P = 0.026）。N分期为N0的有18例（52.9%），N1的有9例（26.4%），N2的有6例（17.6%），Nx的有1例（转移性骨肉瘤）。患者总共随访979个月。中位生存期为40个月。总体5年生存率为46.8%（±95%置信区间[CI]：0.2 - 0.6）：右侧手术为45.2%（±95% CI：0.03 - 0.8），左侧手术为48.4%（±95% CI：0.2 - 0.7）。根据N分期，N0的5年生存率为59.7%（±95% CI：0.3 - 0.8），N1的为55.5%（±95% CI：0.06 - 1），N2的为16.6%（±95% CI：0 - 0.4）。N0加N1亚组（27例患者）的5年生存率为58.08%（±95% CI：0.3 - 0.8），而N2组为16.6%（±95% CI：0 - 0.4）（χ(2)：3.7；P = 0.053）。
结论
对于选定的患者，可安全地进行全胸壁整块切除的肺切除术。与标准肺切除术相比，在肺切除术中增加全胸壁整块切除并不影响手术死亡率和发病率。胸壁切除的关键附加作用不应被视为此类手术的禁忌证。通过比较N0加N1与N2，生存率显示出临床相关差异（58.1%对16.6%），但未得到统计学分析的证实（P = 0.053）。
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