Lauk Olivia, Hoda Mir Alireza, de Perrot Marc, Friess Martina, Klikovits Thomas, Klepetko Walter, Keshavjee Shaf, Weder Walter, Opitz Isabelle
Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland.
Division of Thoracic Surgery, Medical University Vienna, Vienna, Austria.
Ann Thorac Surg. 2014 Nov;98(5):1748-54. doi: 10.1016/j.athoracsur.2014.05.071. Epub 2014 Aug 7.
Several publications have suggested that induction chemotherapy followed by extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma (MPM) patients is associated with exceedingly high morbidity and mortality, and the role of EPP is controversially debated. The present retrospective study analyzed the perioperative outcome in 251 consecutively treated patients at three high-volume mesothelioma centers.
251 MPM patients completed EPP after platinum-based induction chemotherapy at three institutions for thoracic surgery over more than 10 years. The rates of 30-day and 90-day mortality and of major morbidities (pulmonary embolism, postoperative bleeding, acute respiratory distress syndrome, empyema, bronchopleural fistula (BPF), chylothorax, patch failure) were recorded. Perioperative outcome was correlated to risk factors such as smoking history (pack years), age at operation, body mass index, spirometry results, C-reactive protein, American Society of Anesthesiologists classification, chemotherapy regimen used, blood loss during operation, duration of operation, and characteristics of the tumor (laterality, histologic subtype, pT and pN stage) to find factors predicting 30-day and 90-day mortality or major morbidity.
The overall 30-day mortality was 5%. Within 90 days after operation, 8% of the patients died. The rates of 30-day and 90-day mortality were significantly higher in patients with high preoperative C-reactive protein values (p=0.001 and p<0.0005). The spirometry values forced expiratory volume in 1 second and forced vital capacity exhaled (FVCex) were both associated with 30-day and 90-day mortality (p=0.001 and p<0.0005; and p=0.002 and p<0.0005). Major morbidity occurred in 30% of the patients, significantly more often after right-sided EPP (p=0.01) and after longer operations (p<0.0005). Empyema (p<0.0005) and acute respiratory distress syndrome (p=0.02) were associated with longer duration of operation.
EPP after induction chemotherapy is a demanding procedure but can be performed with acceptable morbidity and mortality if patients are well selected and treated at dedicated high-volume MPM centers.
多项研究表明，恶性胸膜间皮瘤（MPM）患者先进行诱导化疗再行胸膜外全肺切除术（EPP），其发病率和死亡率极高，EPP的作用存在争议。本回顾性研究分析了三个大型间皮瘤中心连续治疗的251例患者的围手术期结果。
251例MPM患者在三家胸外科机构接受了基于铂类的诱导化疗后完成了EPP，治疗时间超过10年。记录30天和90天死亡率以及主要并发症（肺栓塞、术后出血、急性呼吸窘迫综合征、脓胸、支气管胸膜瘘（BPF）、乳糜胸、修补失败）的发生率。将围手术期结果与危险因素进行关联分析，这些危险因素包括吸烟史（包年数）、手术年龄、体重指数、肺功能检查结果、C反应蛋白、美国麻醉医师协会分级、所用化疗方案、术中失血量、手术时长以及肿瘤特征（侧别、组织学亚型、pT和pN分期），以找出预测30天和90天死亡率或主要并发症的因素。
总体30天死亡率为5%。术后90天内，8%的患者死亡。术前C反应蛋白值高的患者30天和90天死亡率显著更高（p = 0.001和p < 0.0005）。一秒用力呼气量和呼出用力肺活量（FVCex）的肺功能检查值均与30天和90天死亡率相关（p = 0.001和p < 0.0005；以及p = 0.002和p < 0.0005）。30%的患者发生了主要并发症，右侧EPP后（p = 0.01）和手术时间较长后（p < 0.0005）发生的频率明显更高。脓胸（p < 0.0005）和急性呼吸窘迫综合征（p = 0.02）与手术时间延长有关。
诱导化疗后行EPP是一项要求较高的手术，但如果患者经过精心挑选并在专门的大型MPM中心接受治疗，其发病率和死亡率是可以接受的。
