心包内全肺切除术83例报告

目的 探讨心包内全肺切除术的适应证，手术技术，心包缺损修补和心脏疝预防，术后心律失常的处理等问题。方法 回顾性分析自１９９３年１月至１９９９年３月施行的心包内全肺切除术８３例的７病例资料。结果 全部病例均术中修补心包，其中术中直接间断缝合心包缺损６５例，自体壁层胸膜修补心包１７例，涤纶片修补１例。术后无心脏疝发生。术后并发心律失常８例，均发生在术后１周内。结论 术中探查才能决定是否行心包内全肺切除     

毁损肺一侧全肺切除治疗

由各种原因引起肺叶或一侧全肺功能完全丧失,体积缩小,已造成不可逆病理性改变称毁损肺.对于一侧肺毁损的患者,适时采取手术切除病侧全肺.不但可以迅速缓解呼吸系统症状,而且可以显著提高患者生存质量,甚至对部分良性疾病可达到治愈目的.由于肺组织的广泛纤维化患侧肺功能丧失.患者均有不同程度的气促及反复出现的咳嗽、咳脓痰、咯血.而且由于壁层胸膜的增厚,内科治疗效果差.大多需外科治疗,但该手术对患者围术期的生理状况干扰大,手术过程创伤大,出血多,术后并发症多且严重,对手术技术的要求较高.文章总结毁损肺的全肺外科治疗方法和进展进行综述.     

Proposed adjustments to pathologic staging of epithelial malignant pleural mesothelioma based on analysis of 354 cases

BACKGROUND:

Several pathologic staging systems for malignant pleural mesothelioma (MPM) have been published, but none of them provide optimal survival stratification or stage distribution among patients treated with surgery. Interpretation of prior studies that correlate pathologic factors with outcome has been confounded by the inclusion of patients undergoing differing surgical procedures and with varied tumor histology.

METHODS:

We examined pathologic characteristics, previously included in published studies, and explored correlations with outcome among patients with epithelioid MPM who underwent extrapleural pneumonectomy (EPP) at Brigham and Women's Hospital (BWH). Comparisons of survival among patients with and without each tumor or lymph node feature guided adjustments to the American Joint Commission on Cancer (AJCC)/International Union Against Cancer (UICC) classification criteria. Proportional hazards modeling of TN combinations guided adjustments to stage groupings.

RESULTS:

Three hundred fifty‐four patients were resectable by EPP and had complete pathologic data. Overall median survival was 18 months from surgery. By AJCC/UICC criteria, 233 (66%) patients were stage III, whereas by BWH criteria, 194 (55%) patients were stage III. T classification criteria were adjusted based on prevalence and relation to survival. N status correlated significantly with survival. Regrouping of TN combinations based on relative hazard and Kaplan‐Meier survival analysis resulted in improved stage distribution (stage I‐IV: 8%, 43%, 33%, 16%, respectively) and survival stratification (51, 26, 15, 8 months, respectively).

CONCLUSIONS:

Proposed adjustments to TNM staging criteria improved outcome stratification of patients with epithelial tumor histology who received surgical therapy by EPP and complete pathologic assessment. Determining relevance to other treatment or staging modalities will require verification in additional cohorts. Cancer 2010. © 2010 American Cancer Society.     

Long-term follow-up in a patient after pneumonectomy and SILASTIC prosthetic placement for unilateral pulmonary artery agenesis

Unilateral pulmonary artery agenesis is an exceedingly rare condition. The authors report the case of a 9-year-old girl with unilateral pulmonary artery agenesis who presented with exertional hemoptysis. The patient underwent a right pneumonectomy with placement of an expandable. SILASTIC® (Dow Corning, Midland, MI) prosthesis in the right thorax. A 13-year follow-up is reported, and management of this condition is discussed.     

Triplet chemotherapy with cisplatin, gemcitabine and vinorelbine for malignant pleural mesothelioma

BACKGROUND: The incidence of malignant pleural mesothelioma (MPM) is expected to increase due to delayed control of occupational exposure to asbestos in Japan. We investigated the use of triplet combination chemotherapy with cisplatin (CDDP), gemcitabine (GEM) and vinorelbine (VNR) for the treatment of Japanese patients with MPM. METHODS: From December 2000 to August 2003, 12 patients received the following regimen: CDDP 40 mg/m(2), GEM 800 mg/m(2) and VNR 20 mg/m(2) on days 1 and 8 every 4 weeks. Among the 12 patients, six selected patients underwent an extrapleural pneumonectomy (EP) after a median of three cycles of triplet chemotherapy. RESULTS: The overall response rate for all patients and the response rate for chemotherapy-naive cases were 58 and 67%, respectively. The median survival time and survival rate at 2 years for all patients were 11 months and 50%, respectively. The 2-year survival rates for the patients with and without EP were 83.3 and 16.7%, respectively. CONCLUSIONS: Triplet chemotherapy with CDDP, GEM and VNR was thus found to be highly effective for patients with MPM and its toxicity was manageable. A multi-institutional phase II trial is now being planned to establish the effectiveness of this new regimen in chemotherapy-naive patients with MPM.     

心包内全肺及部分左心房切除治疗Ⅲ期肺癌53例

为了探讨心包内全肺度部分左心房切除治疗Ⅲ期肺癌的疗效和价值，1988年2月～2001年12月对53例Ⅲ期肺癌行心包内全肺切除32例，合并部分左心房切除治疗17例，剖胸撂查或单纯心包开窗4例。手术并发症发生率为17．0％（9／53），死亡2例（3．8％），随访率为96．1％，术后1、3和5年生存率分别为73．6％（39／53）、34．0％（18／53）和20．8％（11／53），其中2例生存超过7年。初步研究结果提示，Ⅲ期肺癌采用扩大切除能提高根治性手术切除率，延长患者生存期，改善生活质量，在临床上有应用价值。     

Hemithoracic radiation after extrapleural pneumonectomy for malignant pleural mesothelioma

PURPOSE: The treatment of malignant pleural mesothelioma remains a therapeutic challenge, with median survival rates of about 12 months and local failure rates of up to 80%. Our institution recently published results showing that extrapleural pneumonectomy (EPP) followed by hemithoracic radiation yielded excellent local control. This paper reports our technique for high-dose hemithoracic radiation after EPP. METHODS: Between 1990 and 2001, 35 patients with malignant pleural mesothelioma were treated with EPP followed by hemithoracic radiation therapy (median dose: 54 Gy, range: 45-54 Gy) at Memorial Sloan-Kettering Cancer Center. EPP was defined as en bloc resection of the entire pleura, lung, and diaphragm with or without resection of the pericardium. The radiation therapy target volume was the entire hemithorax, including the pleural folds and the thoracotomy and chest tube incision sites. Patients were treated with a total dose of 5400 cGy delivered in 30 fractions of 180 cGy. Radiation therapy was well tolerated, and toxicity data are described. RESULTS: Of the 35 patients analyzed, 29 patients were male, and 18 had right-sided tumors. Twenty-six had epithelioid histologies. UICC stage was I in 4, II in 11, III in 19, and IV in 1 patient. As shown by axial and sagittal isodose distributions, we were able to deliver adequate doses to the target volume while limiting dose to critical structures such as heart, spinal cord, liver, and stomach. The most common toxicities were RTOG Grades 1 and 2 nausea and vomiting, as well as lung, esophageal, and skin toxicities. CONCLUSION: Extrapleural pneumonectomy followed by high-dose hemithoracic radiation therapy is a feasible treatment regimen that is well tolerated for patients with malignant mesothelioma. We have demonstrated adequate dose distributions, using a combined photon and electron technique with blocking of critical normal structures.     

Experiment study and clinical observation with ligation method for closing bronchial stump following lobectomy for lung neoplasms

Objective: Traditional method of closing bronchial stumps after lobectomy was whole layer suture by hand or by stapler. Little is known about the ligated bronchial stump following lobectomy. To evaluate the characteristics of ligation method for closing bronchial stumps. Methods: In this study 90 lobectomies on 15 mongrel dogs and 75 bronchial stump models on fresh cadaver bronchus were performed. Multivariables comparison experimental studies were made on the results of three different closing methods: simple ligation, manual suture and stapling. Results: In the ligation group, the operation time was significantly shortened (P<0.01). The depth of stump cavity between ligation group and suture group was of no difference significantly (P>0.05). The resistance against intrabronchial pressure was greater in the ligation group than in the suture group (P<0.01). Pathological studies illustrated earlier healing of mucosal membrane with milder inflammatory reactions. In clinical practice, 121 lobectomies were successfully performed with simple ligation of the stumps. Conclusion: Simple ligation is a safe, reliable, simple, and applicable method for closing bronchial stump following lobectomies.