恶性胸膜间皮瘤术后预后因素分析

目的:分析恶性胸膜间皮瘤(MPM)的临床病理特征、生存时间及手术方式并探讨影响术后生存的因素.方法:回顾性总结我院1998-2005 年手术治疗的MPM患者51例,分析胸膜外全肺切除和胸膜切除两种不同手术方式和不同分期对预后的影响,对性别、年龄、手术方式、病理分型和分期等多个预后因素进行探讨.结果:总中位生存期为22个月,1、3和5年生存率分别为68.1%、25.2%和14.5%.胸膜外全肺切除术38例,胸膜切除术13例,不同手术方式之间术后生存期差异无统计学意义.不同TNM分期之间1、3和5年生存率差异有统计学意义,P=0.004.多因素分析结果显示,原发瘤侵袭程度(T)不是影响预后的因素,上皮型肿瘤(P=0.019)、临床分期(P=0.016)和淋巴结转移(N)情况(P=0.002),尤其是N2组淋巴结是影响预后的独立因素.结论:胸膜外全肺切除及胸膜切除两种手术方式对预后的影响差异无显著性,早期肿瘤预后较好;淋巴结转移,尤其是纵隔淋巴结转移是影响预后的的主要因素.早期诊断和尽早手术治疗是取得良好效果的关键.     

恶性胸膜间皮瘤29例分析

目的：探讨恶性胸膜间皮瘤诊断和治疗的临床特点。方法：回顾性分析手术治疗29例恶性胸膜间皮瘤患者的临床资料。结果：术后2年生存率为51．7％(15／29)，5年生存率为31．0％(9/29)。手术并发症发生率为24．1％(7／29)，无手术死亡者。接受根治术、姑息手术、探查术的患者5年生存率存在明显差异；局限型患者5年生存率高于弥漫型患者。患者生存率与TNM分期明显相关。结论：手术治疗恶性胸膜间皮瘤有效。国际间皮瘤研究组提出的新的恶性胸膜间皮瘤TNM分期标准客观且可行。Ⅰ、Ⅱ期患者适行手术治疗；Ⅳ期患者不适行手术治疗；对局限型、上皮型、估计手术能达到肉眼根治的Ⅲ期患者应考虑手术治疗。     

胸膜剥脱或胸膜全肺切除术治疗弥漫型胸膜恶性间皮瘤

胸膜剥脱或胸膜全肺切除术治疗弥漫型胸膜恶性间皮瘤杨永珠，陈世谋，苏云峰，姜君威，魏万胜兰州医学院第二附属医院胸外科（兰州市７３００３０）弥漫型胸膜恶性间皮瘤往往伴有大量胸水。采用非手术方法治疗，胸水难以消失，疗效不佳。作者用外科手术治疗２例，效果良好...     

心包内处理肺血管全肺切除治疗中心型肺癌

目的 总结心包内处理肺血管全肺切除治疗中心型肺癌的临床结果。方法 回顾性分析1978－1999年间91例接受心包内处理肺血管全肺切除治疗中心型肺癌的临床资料。结果 91例中心型肺癌患者采取心包内处理肺血管全肺切除,占同期肺癌手术的5．6％。全组1、3、5年生存率分别为79．0％、37．3％、23．8％。本文讨论了该术式的适应证、操作体会、并发症处理和预后评价等。结论 心包内处理肺血管全肺切除是一种安全可靠的手术方式,可以提高手术切除率及术后生存期。肿瘤TNM分期、病理类型、切除部位及术后放、化疗对预后有显著影响。     

120例恶性胸膜间皮瘤的临床特征及诊断分析

目的:回顾性分析胸膜间皮瘤患者的临床资料,包括病史、症状、淋巴结及远处脏器转移的规律,并分析不同分期、病理类型及治疗方式的患者生存情况,为该疾病的诊断和治疗提供思路。方法:分析空军军医大学唐都医院2009年4月-2016年9月收治的120例胸膜间皮瘤患者资料,基于第8版TNM分期标准进行肿瘤分期。对不同临床分期、病理类型及治疗方式的患者生存期进行统计分析,应用Kaplan-Meier法进行生存分析。结果:120例患者中有职业暴露史3例(占2.5%)。发病部位为左侧胸膜56例(占46.7%),右侧胸膜63例(占52.5%),双侧胸膜1例。总体的误诊率为30%(36/120),其中误诊为结核32例(26.7%)。以胸痛症状发病55例(占45.8%),胸腔积液107例(占89.2%),两者合并为49例(占40.8%)。确诊方法包括胸膜穿刺诊断53例(占44.2%),胸腔镜诊断41例(占34.2%),开胸探查诊断26例(占21.6%)。所有患者中淋巴结转移(N1~N2)共43例(占35.8%),涉及54个淋巴区;纵隔淋巴结转移42例(占77.8%),纵隔外淋巴区转移12例(占22.2%)。成功随访78例患者,总体中位生存期为15.0个月,1、2、3及5年生存率分别为67.9%、27.7%、16.0%及4.2%。Ⅰ/Ⅱ期患者中位生存期为17.0个月,明显长于Ⅲ/Ⅳ期患者的13.0个月(P<0.05)。上皮型肿瘤患者的中位生存期为17.0个月,与混合型及肉瘤型患者比较有生存优势(P值均<0.05)。手术联合化疗组的患者中位生存期为30.0个月,优于单纯手术、单纯化疗及支持治疗的患者(P值均<0.05)。结论:胸膜间皮瘤的误诊率高,其中大多被误诊为肺结核。恶性胸膜间皮瘤患者主要以胸腔积液症状发病,而且淋巴结转移规律与肺癌有所不同。所以在胸膜间皮瘤的诊断和治疗中,应高度重视这些临床特征,尽量减少误诊,以提高治疗效果。另外,临床分期较早及上皮型病理类型的患者预后相对较好,而且采用手术联合化疗的综合治疗模式可以使胸膜间皮瘤患者获得相对较长的生存期。     

肺癌袖状切除术与全肺切除术疗效比较分析

背景与目的 肺癌袖状切除术可以达到与全肺切除相似的肿瘤和淋巴结切除率，而且，同全肺切除相比，可以减少肺功能的丧失，改善患者生存质量。该研究旨在比较肺癌患者肺癌袖状切除术和全肺切除术的5年生存率和术后并发症。方法 选取我院自1990年1月～2000年12月收治的173例肺癌袖状切除术和435例全肺切除术患者，回顾性分析两种手术方式的5年生存率，并比较其并发症发生率及围手术期死亡率的差别。结果 肺癌袖状切除术患者总的5年生存率为42．3％，全肺切除术为30．9％，前者生存期明显长于后者（P-0．007）；其中右侧肺癌行袖状切除术的患者5年生存率优于右全肺切除术[p-0．004（N0），0．025（N1），0．042（N0）]；左侧N0期肺癌袖状切除术后生存期明显优于左全肺切除（P=0．018），N1及N2期肺癌两种术式的5年生存率无差异；支气管肺动脉成形术与全肺切除术的生存期亦无显著性差异；肺癌袖状切除术后肺感染和心律失常并发症发生率低于全肺切除术（P-0．019），围手术期死亡率无显著性差异。结论 在可以选择袖状切除术或全肺切除术的肺癌患者中，右侧病变适合进行癌袖状切除术，而左侧病变无淋巴结转移者应首选癌袖状切除术，支气管肺动脉成形术与全肺切除术相比并未延长生存期。     

恶性胸膜间皮瘤新辅助化疗后胸膜厚度对预后的潜在预测价值

目的:探讨新辅助化疗后胸膜厚度对恶性胸膜间皮瘤预后的潜在预测价值。方法:选择2013年5月至2017年12月在我院接受新辅助化疗和手术治疗的患者作为研究对象，采用单因素和多因素分析患者新辅助化疗前最大胸膜厚度（pre-max）、新辅助化疗后最大胸膜厚度（post-max）、新辅助化疗前3个区pre-max之和（pre-sum）、新辅助化疗后3个区post-max之和（post-sum）与患者无复发生存期（RFS）和总生存期（OS）的相关性。结果:不同性别、年龄、pre-max、部位、PS评分、T分期、病理T分期患者mRFS相比较差异均无统计学意义（P＞0.05），不同pre-sum、post-max、post-sum、组织学类型、mRECIST和淋巴结转移患者mRFS存在统计学差异（P＜0.05）；不同性别、pre-max、pre-sum、部位、T分期患者mOS相比较差异均无统计学意义（P＞0.05），不同年龄、post-max、post-sum、PS评分、组织学类型、病理T分期、mRECIST、淋巴结转移患者mOS相比较差异存在统计学意义（P＜0.05）。Cox风险模型结果显示，年龄≥65岁、组织类型为非上皮型、淋巴结转移阳性、post-sum≥13 mm是影响OS的风险因素（P＜0.05）。结论:新辅助化疗后post-sum与RFS和OS显著相关，虽然本研究存在一定局限性，但为胸膜厚度与恶性胸膜间皮瘤预后的相关性研究做出有益的探讨。     

肺癌胸膜全肺切除手术技术探讨

[目的]探讨肺癌伴胸膜转移恶性胸水行胸膜全肺切除术手术技术和术中处理体会。[方法]1988年1月至2003年1月对21例肺癌伴胸膜转移恶性胸水患者行胸膜全肺切除术。肺部原发病灶位于左肺8例，右肺13例。其中鳞癌1例，腺癌12例，腺鳞癌2例，肺泡细胞癌6例。采用胸膜外径路整块切除病变，低能混切电刀分离壁层胸膜，尤其注重心包、纵隔大血管表面胸膜、膈胸膜的切除；对确无法彻底切除的少量残余癌灶，局部反复电刀烧灼；心包表面有转移病灶未行心包切除者常规行心包开窗；关胸前以大量蒸馏水反复冲洗胸腔及切口，氮芥留置胸腔。[结果]无围手术期死亡，无支气管胸膜瘘、脓胸、大出血等严重并发症。随访已死亡16例，生存期为5～34年月，其余5例患者随访24～29个月仍生存，全组中位生存时间18个月，死亡原因均为远处转移，无局部肿瘤复发。[结论]Ⅲb期肺癌病人有选择地行胸膜全肺切除术是安全可行的，改良手术技术可以减少手术并发症、降低肿瘤局部复发机会，采用该术式再结合综合治疗，能获得明显延长生存时间的良好效果。     

恶性胸膜间皮瘤45例临床分析

背景与目的恶性胸膜间皮瘤是一种罕见疾病,其发病率在逐年上升,早期诊断和治疗非常困难。本文旨在探讨恶性胸膜间皮瘤的临床特点、诊断及治疗,为临床提供参考。方法回顾性分析解放军总医院1997年1月-2010年12月收治的45例恶性胸膜间皮瘤患者的临床资料。结果恶性胸膜间皮瘤患者的主要临床症状为胸痛(53.33%)、胸闷气促(48.89%)和咳嗽(37.78%);CT表现主要为胸膜增厚(71.11%)、胸腔积液(60%)和肺部阴影(40%);胸水以渗出液为主,有核细胞数明显增多,以单核细胞的增多为主,乳酸脱氢酶明显增高;大部分患者临床分期为Ⅲ期和Ⅳ期;确诊的方式主要是胸腔镜,病理类型以上皮型多见,且常易被误诊为结核性胸膜炎。早期患者以手术治疗为主,而晚期患者以化疗为主,病理类型为上皮型的疾病控制率高于肉瘤型。结论恶性胸膜间皮瘤误诊率较高,其临床症状无特异性,胸部CT可提供诊断依据,组织病理学检查结合免疫组化才能确诊,治疗方式包括化疗、手术、放疗和支持治疗,普遍疗效欠佳。     

肺癌胸膜全肺切除术的围术期处理

目的：总结对于肺癌伴胸膜转移和恶性胸水行胸膜全肺切除手术的围术期处理经验。方法：1988年1月～2003年1月对21例肺癌伴胸膜转移和恶性胸水患者行胸膜全肺切除术。肺部原发病灶位于左肺8例,右肺13例。病理分类：鳞状细胞癌1例,腺癌12例,腺鳞癌2例,肺泡细胞癌6例。结果：术后呼吸机机械通气支持12例,平均支持时间4．5小时。无围手术期死亡,无支气管胸膜瘘、脓胸、大出血等严重并发症。随访已死亡16例,生存期为5～34个月,其余5例患者随访24～29个月仍生存,全组中位生存时间18个月。结论：加强围术期处理,对常见并发症重点防范、早期治疗,是降低手术风险、促进此类患者康复的关键。     

Malignant pleural mesothelioma: a survival study.

Ninety-four patients with malignant pleural mesothelioma were treated at Southern California Permanente Medical Group Facilities between 1965 and 1988. This retrospective analysis of survival in these patients is compared according to surgical and/or supportive management. Group I patients received supportive care only, including pleurodesis as needed. This group included the majority of patients. Group II patients were managed largely with debulking procedures including decortication and pleurectomy. Group III patients received extrapleural pneumonectomy. This group included the two long-term survivors of the entire group. This study of survival points out the need for a cooperative protocol as well as the consistent use of proper modern preoperative staging in an attempt to select patients who benefit from extrapleural pneumonectomy.     

Diagnosis, Staging, and Surgical Treatment of Malignant Pleural Mesothelioma

OPINION STATEMENT: The clinical presentation of malignant pleural mesothelioma (MPM) is nonspecific. The process to obtain the correct diagnosis can be challenging and requires a high index of suspicion. Once the diagnosis is made, there is no universally accepted standard of care and treatment decisions are strongly influenced by physician bias. Physicians who see few numbers of patients tend to treat based on symptoms alone by drainage of the pleural effusion and talc pleurodesis, while physicians at several tertiary referral centers tend to take an aggressive multimodality approach incorporating surgical resection, chemotherapy, and radiation. The primary goal of surgery in this setting is the resection of all gross disease. The choice of operation, extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D), depends on disease stage, pulmonary function, philosophy of the treating physician, and type of planned adjuvant therapy.     

Safety and efficacy of trimodality therapy in patients undergoing extrapleural pneumonectomy

Malignant pleural mesothelioma (MPM) is a rare but rapidly deadly disease (1).Macroscopic complete resection (MCR) is the goal of surgery (2).MCR seems to have the most significant impact on survival in patients undergoing multimodality treatment for MPM.The role of surgical resection in the management of MPM remains controversial.The selection criterion to perform either extrapleural pneumonectomy (EPP) or extended/radical pleurectomy/decortication (PD) rely not only on the cardio-pulmonary status of the patient,tumor stage and intraoperative findings but is strongly dependent also on surgeons' decision and philosophy.This is reflected by a recent survey of opinions and beliefs among 802 thoracic surgeons,in which EPP was believed to be more effective than PD (3).Nonetheless,either surgery might achieve MCR.     

Nationwide prospective registry database of patients with newly diagnosed untreated pleural mesothelioma in Japan

Due to the scarcity of large-sized prospective databases, the Japanese Joint Committee for Lung Cancer Registry conducted a nationwide prospective registry for newly diagnosed and untreated pleural mesothelioma. All new cases diagnosed pathologically as any subtype of pleural mesothelioma in Japan during the period between April 1, 2017, to March 31, 2019, were included before treatment. Data on survival were collected in April 2021. The eligible 346 patients (285 men [82.3%]; 61 women [17.7%]; median age, 71.0 years [range, 44–88]) were included for analysis. Among these patients, 138 (39.9%) underwent surgery, 164 (47.4%) underwent non-surgical therapy, and the remaining 44 (12.7%) underwent best supportive care. The median overall survival for all 346 patients was 19.0 months. Survival rates at 1, 2, and 3 years for all patients were, 62.8%, 42.3%, and 26.5%, respectively. Median overall survival was significantly different among patients undergoing surgery, non-surgical treatment, and best supportive care (32.2 months vs. 14.0 months vs. 3.8 months, p < 0.001). The median overall survival of patients undergoing pleurectomy/decortication and extrapleural pneumonectomy was 41.8 months and 25.0 months, respectively. Macroscopic complete resection resulted in longer overall survival than R2 resection and partial pleurectomy/exploratory thoracotomy (41.8 months vs. 32.2 months vs. 16.8 months, p < 0.001). Tumor shape, maximum tumor thickness, and sum of three level thickness were significant prognostic factors. The data in the prospective database would serve as a valuable reference for clinical practice and further studies for pleural mesothelioma.     

Surgery in Malignant Pleural Mesothelioma

Surgical intervention plays an important role in the diagnosis, staging, and treatment of malignant pleural mesothelioma (MPM) and can be applied with curative or palliative intent. The overall aim of surgery should be, as in any oncologic surgery, the macroscopic complete resection (MCR) of the tumor. Most importantly, the majority of patients with the diagnosis of MPM should be appropriately staged and initially evaluated in a multidisciplinary setting, including medical oncology, radiation oncology, and surgery after histologic diagnosis. Surgical staging, including determination of the histologic subtype and lymph node status, as well as clinical staging with positron-emission tomography–computer tomography scan and determination of cardiopulmonary reserve are crucial. Herein, we summarize the role of surgical resection, specifically macroscopic complete resection, performed as extrapleural pneumonectomy or extended pleurectomy/decortication in multimodality treatment settings and advocate for optimal patient selection for one or the other procedure. In addition, the roles of surgery in diagnosis of MPM and in palliative care are discussed.     

Radiation therapy for malignant pleural mesothelioma

The treatment of malignant pleural mesothelioma with radiation has always been a technical challenge. For many years, conventional radiation therapy was delivered after extrapleural pneumonectomy with acceptable results. Novel radiation treatment techniques, such as intensity modulated radiation therapy (IMRT) were introduced, but the early experience with IMRT demonstrated troubling toxicity. Recent reports from institutions have demonstrated that with greater experience, IMRT, both in the setting of extrapleural pneumonectomy or pleurectomy, can be delivered safely. A recent study, SAKK 17/04, questions the role of using radiation after extrapleural pneumonectomy.     

Establishing locoregional control of malignant pleural mesothelioma using high-dose radiotherapy and (18) F-FDG PET/CT scan correlation

Introduction: The management of malignant pleural mesothelioma represents one of the most challenging issues in oncology, as there is no proven long‐term benefit from surgery, radiotherapy or chemotherapy alone or in combination. Locoregional progression remains the major cause of death, but radical surgical resection may produce major postoperative morbidity. While radical or postoperative radiotherapy using conventional techniques has resulted in severe toxicity with no impact on survival, recent advances in radiotherapy delivery may be more effective. Methods: We treated patients with locally advanced mesothelioma whose tumours had been sub optimally resected with high‐dose three‐dimensional conformal radiotherapy (3DCRT) or intensity‐modulated radiotherapy (IMRT) to large volumes of one hemithorax, using CT and positron emission tomography (PET) scan‐based treatment planning. Clinical outcomes were assessed by determining patterns of failure and metabolic changes in total glycolytic volume (TGV) between pre‐ and post‐irradiation ¹⁸F‐FDG PET/CT scans and by recording acute and late toxicity grades. Results: Fourteen patients were analysed with 40 PET scans performed before and up to 4.5 years after radiotherapy. Eleven patients had pleurectomy/decortications, one had an extrapleural pneumonectomy and two had no surgery. Four patients who received chemotherapy had all progressed prior to radiotherapy. After radiotherapy, the in‐field local control rate was 71%. No progression occurred in two patients, one was salvaged with further radiotherapy to a new site, four recurred inside the irradiated volume all with concurrent distant metastases and the other seven had distant metastases only. The TGVs were reduced by an average of 67% (range 12–100%) after doses of 45 to 60 Gy to part or all of one hemithorax. There were no serious treatment‐related toxicities. Median survival was 25 months from diagnosis and 17 months after starting radiotherapy. Conclusions: We have established that mesothelioma can be locally controlled with high radiation doses using 3DCRT or IMRT, and that strict normal tissue dose constraints have limited radiation toxicities. Radiotherapy should be considered to prevent or delay the local manifestations of progressive disease in suitable patients after surgery including extrapleural pneumonectomy and pleurectomy/decortication. Higher radiation doses may allow more effective palliation.     

Surgery for malignant pleural mesothelioma: Why,when and what?

Malignant pleural mesothelioma is a fatal cancer developing in the pleural cavity, linked to asbestos exposure. Various therapies have been tried in the past 50 years including surgery, radiotherapy, chemotherapy, immunotherapy and more recently, targeted therapy. Radical surgery remains controversial in malignant pleural mesothelioma and two procedures have been offered in the past to obtain maximal cytoreduction: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). Despite growing evidence that EPP might be detrimental, many believe that radical surgery should still be part of multimodality therapy in patients with malignant pleural mesothelioma. Recent evidence suggests that P/D is well tolerated and produces low mortality and morbidity. The role of adjuvant intrapleural therapies remains to be determined and evaluated in large prospective trials. Pleurectomy/decortication does not jeopardize the chance of having chemotherapy, or chemoradiotherapy either. Many now believe that it should be the default procedure in multimodality regimens. However, this remains to be proven in a large randomized trial. Palliative surgery still has an important role to play in mesothelioma, in establishing or refining diagnosis and in controlling symptoms and improving quality of life in many patients whose life expectancy is limited. Recent progress in molecular analyses and biomarkers should help with patient selection for surgery, immunotherapy and systemic therapies in the near future.     

Treatment of malignant pleural mesothelioma

In Japan, it is predicted that mesothelioma will rapidly increase in the future. Malignant pleural mesothelioma that accounts for approximately 90% of mesothelioma as a whole has a median survival time of approximately nine months which is considered a poor prognosis. As for the treatment of this disease,extrapleural pneumonectomy or pleurectomy/decortication are available for those patients who can be surgically operated on. However, since a complete cure rate is low when only surgical treatment is performed, generally a multimodality treatment is performed wherein chemotherapy and/or radiotherapy are combined. For chemotherapy, a large-scale randomized phase III study demonstrated that a treatment using two agents: pemetrexed, which is a new multitargeted antifolate, and cisplatin is effective. Pemetrexed will be the drug of first choice for mesothelioma in the future. As other treatment methods, chemohyperthermia, treatments using various kinds of cytokines and angiogenesis inhibitors, genetic treatment and photodynamic therapy have been attempted. The current treatment results for this disease are very poor, and there has been a strong demand for establishing an effective treatment method.