Han Kook Nam, Kang Chang Hyun, Park In Kyu, Kim Young Tae
Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
Interact Cardiovasc Thorac Surg. 2014 May;18(5):615-20. doi: 10.1093/icvts/ivt514. Epub 2014 Feb 4.
There are few reports on optimal surgical approaches to bilateral pulmonary metastasis and the sequences used in the operation. The aim of this study was to evaluate the feasibility of the thoracoscopic bilateral approach to pulmonary metastasis.
From June 2006 to February 2013, 61 patients underwent a planned bilateral pulmonary metastasectomy with one- (n = 52) or two-stage (n = 9) thoracoscopic surgery. We retrospectively analysed the outcomes of this group of patients to define the role and limitation of thoracoscopic surgery in bilateral disease.
In 17 patients with bilateral single lesions on the computed tomography (CT) scans, we were able to resect more nodules than initially imaged in 7 patients (41.2%), and there were 2 patients (11.8%) who had more true metastatic lesions than expected. Among 44 patients who showed more than two bilateral multiple lesions on the CT scan, we were able to resect more than 10 nodules in 2 patients (4.5%). The overall accuracy rate for resected malignant nodules was 76.6%, and 9 patients (14.8%) actually had the disease confined to the unilateral thorax, with solitary (n = 8) and multiple (n = 1) metastases after bilateral exploration. The prognostic factors for unilateral disease were unilateral lesion on the positron emission tomography (PET) scan (P = 0.024). The values of FVC and FEV1 were, respectively, 14.4 and 15.4% reduction at 6 months postoperatively in patients who had three or more nodules resected. Sarcomatous histology (P = 0.039), a diameter larger than 3 cm (P = 0.042) and bilateral lesion on PET (P = 0.035) were the prognostic factors for intrathoracic recurrences.
Bilateral pulmonary metastasectomy was performed safely with thoracoscopy in patients with bilateral oligo-metastatic sub-pleural lesions and the one-stage approach was a feasible option in bilateral single lesions. Preoperative PET scan could help predict intrathoracic recurrence after thoracoscopic metastasectomy.
关于双侧肺转移瘤的最佳手术方式及手术顺序的报道较少。本研究旨在评估胸腔镜双侧入路治疗肺转移瘤的可行性。
2006年6月至2013年2月，61例患者接受了计划性双侧肺转移瘤切除术，其中52例采用一期胸腔镜手术，9例采用二期胸腔镜手术。我们回顾性分析了这组患者的手术结果，以明确胸腔镜手术在双侧病变中的作用及局限性。
在17例CT扫描显示双侧单发结节的患者中，7例（41.2%）切除的结节数多于最初影像显示的结节数，2例（11.8%）的真正转移病灶比预期的多。在44例CT扫描显示双侧多发结节超过两个的患者中，2例（4.5%）切除的结节数超过10个。切除恶性结节的总体准确率为76.6%，9例（14.8%）患者实际病变局限于单侧胸腔，双侧探查后为孤立性转移（8例）和多发性转移（1例）。单侧病变的预后因素为正电子发射断层扫描（PET）显示单侧病灶（P = 0.024）。切除三个或更多结节的患者术后6个月时，用力肺活量（FVC）和第一秒用力呼气容积（FEV1）的值分别降低了14.4%和15.4%。肉瘤组织学类型（P = 0.039）、直径大于3 cm（P = 0.042）和PET显示双侧病灶（P = 0.035）是胸腔内复发的预后因素。
对于双侧寡转移的胸膜下病变患者，胸腔镜下双侧肺转移瘤切除术可安全进行，一期手术对于双侧单发结节是一种可行的选择。术前PET扫描有助于预测胸腔镜转移瘤切除术后的胸腔内复发。
