累及胸壁的胸部肿瘤的外科治疗——胸壁切除与重建(附12例报告)

背景与目的胸部肿瘤累及胸壁是临床常见事件,若无远处转移,完整切除受累胸壁仍可获得良好疗效。本文结合12例肿瘤患者胸壁切除与重建(chest wall resection and reconstruction,CWRR)的经验就重建人工材料、软组织覆盖等方面作一介绍,并强调切除外科与重建外科合作的重要性。方法总结2005年10月-2011年4月北京大学肿瘤医院胸外一科和重建外科共同参与的CWRR 12例,详细复习自确诊至今的诊治全过程,包括术前治疗、手术方式、切除范围、重建方式,主要的局部及全身并发症及生存情况。结果 12例均为根治性手术,均行骨性胸壁切除,切除后骨性胸壁缺损为25 cm~2-700 cm~2,胸壁软组织缺损为56 cm~2-400 cm~2。骨性胸壁修补材料采用聚丙烯单丝网片(polypropylene mesh),软组织修复采用转移肌瓣、转移肌皮瓣及大网膜瓣。术后1例发生呼吸衰竭,呼吸机辅助通气1个月后痊愈,余例均无并发症,全组12例至今全部存活。结论只有切除外科和重建外科同时参与才能完成符合肿瘤原则的复杂CWRR。由切除外科主导、重建外科协助、了解并熟悉重建材料及胸壁软组织重建,是达到手术根治性及保证远期生存的关键。     

肺癌侵犯胸壁的外科治疗

目的探讨肺癌侵犯胸壁的手术切除方式及影响患者生存的因素.方法对30例侵犯胸壁的肺癌患者的外科治疗结果进行综合分析.结果全组中肺叶切除26例,双肺叶切除2例,全肺切除2例;壁层胸膜外切除6例,胸壁肌肉和肋骨切除(整块切除)24例.根治性切除25例,根治切除率83.3%(25/30).手术并发症发生率6.7%(2/30),手术死亡率3.3%(1/30).鳞癌18例,腺鳞癌8例,腺癌3例,大细胞未分化癌1例.T3N0M0 20例,T3N1M0 5例,T3N2M0 5例.采用寿命表法(life table)计算生存率,用对数秩和检验(Logrank test)其显著性.1、3、5年生存率分别为40.2%、10.8%和10.8%.根治性切除患者5年生存率为13.2%,姑息性切除者中无5年生存者(P＞0.05).根治性切除无淋巴结转移者5年生存率为15.5%,有淋巴结转移者中无5年生存者(P＞0.05).不考虑淋巴结转移情况,根治性切除患者中,肿瘤侵犯胸壁局限于壁层胸膜者的5年生存率为15.0%,而侵犯胸壁肌肉和肋骨者中则无5年生存者(P＞0.05).结论胸膜外切除或胸壁整块切除是外科治疗肺癌侵犯胸壁的主要手段.能否根治切除、有无淋巴结转移以及胸壁受侵程度是影响患者术后生存的重要因素.     

原发性肺癌侵犯胸壁的外科治疗

本文报告了１０７例原发性肺癌侵犯胸壁的外科疗效，术后１年，３年，５年生存率分别为７３．８％，４５．５％，３０．７％。文章着重讨论了术前诊断与估计，手术方式的选择及胸壁重建原则和方法，认为这类病变大都为周围型肺癌，只要无远处转移，即使肿块巨大，伴有或不伴有助骨破坏仍可行根治性手术切除。文章分析了影响预后的主要因素：淋巴结有无转移，肺和胸壁切除有无肿瘤残留，尤其强调了根治性胸壁切除，区域淋巴结清除和综     

88例早期乳腺癌术后胸壁复发的多因素分析

目的 探讨影响早期乳腺癌根治术和改良根治术后胸壁复发及其预后的相关因素.方法 对本院1995～2005年收治的88例早期乳腺癌术后胸壁复发患者进行回顾性分析.其中Ⅰ期12例,Ⅱa期33例,Ⅱb期43例（不包括T3N0M0和T1N1M0、T2N1M0中淋巴结阳性4个以上者）,术后均未接受胸壁放疗,复发后均采用以局部放疗和全身化疗为主的综合治疗.结果 中位发病年龄为47岁,中位复发年龄为49岁,中位复发时间为24个月,中位生存时间为59.5个月.总的5、10年生存率为85.5%、44.9%.3、5年无瘤生存率为36.6%、21.2%.复发后的3、5年生存率为59.6%、41.8%.行根治术者胸壁复发时间显著长于行改良根治术者（P＜0.002）;术后行化疗者胸壁复发时间显著长于术后未行化疗者（P＜0.002）;术后行内分泌治疗者胸壁复发时间显著长于术后未行内分泌治疗者（P＜0.032）.单纯胸壁复发者生存率显著高于伴有区域性淋巴结转移或远处转移者（P＜0.02）;2年以上复发者生存率显著高于2年以内复发者（P＜0.003）;ER（＋）者生存率显著高于ER（-）者（P＜0.026）.结论 手术方式、术后有无全身化疗及内分泌治疗是影响早期乳腺癌术后胸壁复发的相关因素.术后胸壁复发时间、有无出现区域性淋巴结转移或远处转移、ER表达情况等是影响早期乳腺癌胸壁复发后预后的相关因素.     

乳腺癌患者术后胸壁复发及预后相关因素分析

目的 乳腺癌出现胸壁复发通常被认为是乳腺癌治疗失败的第一征象,是发生远处转移的先兆.本研究回顾性分析乳腺癌术后胸壁复发患者病例资料,分析影响乳腺癌患者术后胸壁复发及预后的相关因素,为规范的临床治疗提供有用的依据.方法 收集湖南省肿瘤医院2008-01-01-2009 12-31收治的130例乳腺癌术后胸壁复发患者的临床、病理及预后资料,其中Ⅰ期42例,Ⅱ期60例,Ⅲ期28例,分析其临床特点和胸壁复发时间,Kaplan-Meier法计算患者无瘤生存率,采用二元Logistic回归分析复发的影响因素,OR及95％ CI为评价指标,采用Cox回归分析生存期的影响因素,HR及95％CI为评价指标.结果 3、5年无瘤生存率分别为58.4％和33.7％,3、5年总体生存率为91.4％和83.9％,中位发病年龄为45岁,中位复发时间为25个月,中位生存时间为56个月.胸壁复发二元Logistic回归分析显示,肿瘤分期、肿瘤大小及细胞分化程度、雌激素受体(estrogen receptor,ER)、孕激素受体(progesterone receptor,PR)和Ki-67表达、淋巴结转移是影响乳腺癌患者术后胸壁复发的相关因素,均P＜o.05. Cox分析显示,肿瘤分期、肿瘤细胞分化程度、肿瘤病理类型及C-erbB-2表达是影响患者5年总体生存率的因素,均P＜0.05.结论 肿瘤分期晚、肿瘤偏大,肿瘤细胞分化程度低、存在4枚及以上腋窝淋巴结转移、ER和PR低表达及Ki-67高表达是乳腺癌术后胸壁复发的危险因素,而临床分期Ⅲ期、肿瘤细胞低分化、肿瘤病理类型为浸润型癌、C-erbB-2阳性表达是总生存的独立预后因素,对存在上述危险因素的患者,应根据患者情况选择个体化的综合治疗方案,加强随访改善患者预后.     

侵犯胸壁的原发性肺癌的外科治疗

目的　探讨侵犯胸壁的原发性肺癌的外科治疗经验。方法　对35例侵犯胸壁的原发性肺癌患者,按照肿瘤外侵程度及采取的手术方式不同分组,肺叶及壁层胸膜切除16例为1组,肺胸壁整块切除19例为2组。结果　全组无手术死亡。1组3和5年生存率分别为38.5%和18.2%,2组3和5年生存率分别为41.2%和35.7%。全组N0患者3、5年生存率分别为63.2%(12/19)和42.9%(6/14),N12患者中仅1例生存5年以上。结论　手术切除范围和淋巴结转移是影响侵犯胸壁肺癌预后的重要因素。行术后胸壁缺损的重建时,采取20Prolene线网状固定,胸背部肌肉覆盖,效果良好     

24例直肠间质瘤的临床特点与外科治疗分析

[目的]探讨直肠间质瘤的临床特点及外科治疗。[方法]回顾性分析1986～2007年间收治的24例直肠间质瘤患者的临床资料。[结果]24例患者中男性14例，女性10例。中位年龄50岁。手术切除23例，其中局部切除16例，根治性切除7例，9例术后复发（39．1％），两种术式的术后复发率差异无显著性（X^2=1．371，P〉0．05）。5年生存率为92．0％，3年、5年无病生存率分别为72．0％和57．6％，中位无病生存时间为61个月。[结论]对于最大径〈5cm的低位直肠间质瘤，局部切除是一种安全可行的手术方式。     

106例进展期胃癌术后复发的诊治经验

目的：探讨进展期胃癌根治术后复发的早期诊断及治疗的相关问题。方法：回顾性分析我院1997年12月至2004年12月收治的106例进展期胃癌根治术后复发病例．按治疗方法进行分组，采用Kaplan-Meier方法绘制生存曲线．进行累积生存率的比较结果：全组106例患者平均复发时间为术后18.3个月，2年内复发占81．1％。复发癌根治性切除组17例．姑息性切除组19例，非手术切除组21例。3组中位生存时间分别为≥24．0、9．0和3．0个月．两两之间存在显著差异（P〈0.05）。非手术治疗组49例，中位生存时间2.0个月，与手术各组相比，存在显著性差异（P〈0．05）．结论：进展期胃癌术后复发患者预后较差．早期发现和积极治疗有助于延长患者生存时间。     

进展期直肠癌侵犯邻近脏器手术治疗184例分析

目的：探讨直肠癌侵犯邻近脏器手术切除的疗效。方法：回顾性分析我院1974年至1998手术治疗184例直肠癌侵犯邻近脏器临床资料,根治性切除124例,姑息性切除42例,单纯结肠造瘘18例。结果：术后总的1、3和5年生存率分别为85．9％、64．4％和47．9％。其中根治性切除组1、3和5年生存率分别为93．4％、80．7％和63．7％;姑息性切除组为71．7％、42．8％和25．0％;单纯造瘘组为62．5％、30．0％和12．0％。根治性切除组5年生存率显高于姑息性切除和造瘘组（P＜0．05）。结论：对直肠癌侵犯邻脏器的患,只要没有肝脏弥漫性转移、腹膜肿植和淋巴结广泛转移等不能治愈的因素,都应将直肠癌和受侵犯脏器一并切除,以达到根治的目的;对有不能治愈因素存在,则应急取切除直肠癌原发灶,术后辅以化疗和放疗,以提高生存质量和延长生存期。     

胸壁肿瘤切除和重建

胸壁肿瘤临床上较为少见，其发生率占胸部肿瘤的5％，胸壁肿瘤几乎一半以上为良性，报道为21％～67％。胸壁恶性肿瘤的治疗对胸外科医师是一种挑战。过去，由于错误诊断，不能完全切除，对大的缺损不能成功修复，使术后并发症发生率和死亡率较高，能够长期生存较少。随着麻醉技术的提高，重建技术发展和各种重建材料发现，使胸壁恶性肿瘤根治性切除得以实施，大大提高了长期生存率。现对胸壁肿瘤的治疗综述如下：     

Chest wall reconstruction after full thickness resection: an experience with 22 patients

The authors present their experience of chest wall reconstruction after full thickness resection in 22 patients. The patients are from a series of 80 patients treated by chest wall resection from 1967 to 1989. Whether performed on breasts still in place, for recurrent disease, or for radiation-induced lesions (which are often associated), the defect created by complete resection of the chest wall layers causes difficulties. Large cutaneous flaps, often including the opposite breast were used at the beginning of the series. Then came omentum associated to Mersilene mesh and myocutaneous flaps. The results, in terms of comfort and local control are acceptable, even though surgery is only palliative for cancer patients. We feel that full thickness chest wall resection is the only effective treatment for some primary and recurrent malignant tumors and for extensive thoracic radionecroses. Such procedures are designed to improve the patient's quality of life even if they do not actually prolong survival. The goals guiding the reconstruction programme are: (1) the restoration of a stable parietal rigidity; and (2) the reconstruction of long lasting superficial layers.     

Chest wall resection in the treatment of local recurrence of breast cancer

Chest wall resection has been carried out in 30 patients with chest wall recurrences of breast cancer after previous mastectomy and irradiation. Patients were carefully selected. Twenty-eight patients were treated with curative intent, two patients underwent palliative resections for extremely painful ulcerating recurrences. The operation consists of a full thickness chest wall resection and immediate reconstruction. A variety of reconstructive techniques have been used. Based on this experience we prefer reconstruction of rigidity by means of a vicryl mesh and of soft tissue coverage by omentum transposition and split skin grafting. Using this technique post operative complications have been acceptable. Long term results have been encouraging with 50% disease free survival at 5 years. A disease free interval after mastectomy longer than 5 years correlates with a long disease free survival after chest wall resection. Chest wall resection is very effective in the palliation of pain caused by ulcerating chest wall recurrence.     

Correlation between first disease-free interval from mastectomy to second disease-free interval from chest wall resection.

Between 24 November 1977 and 16 September 1988, 18 consecutive chest wall resections for recurrent breast cancer after failure of radiotherapy, were evaluated as of 1 January 1990. Chest wall involvement was the only site of recurrence in 14 patients (Group I), and the most painful of the multiple recurrences in the remaining four (Group II). Of Group I, chest wall recurrence was local in eight patients (four with necrosis after radiotherapy), regional in four, and distant in two. Chest wall reconstruction was effected by contralateral breast flap in six, by random cutaneous flap in seven and by myocutaneous flap in the remaining five. Cosmetic results were better if both marlex mesh and myocutaneous flap were used. Of Group I, at surgical/pathological staging, one recurrence with sarcomatous findings, two multiple recurrences and residual cancer in all necrosed local recurrences were found: in three of these cases radionecrosis was prominent. Mortality was 0% and surgical morbidity 5%. For Group I, median disease-free interval from mastectomy was extended from 1611 days to 3220 by recurrence resection, and disease-free interval from chest wall resection was 28% cancer-free at 1657 days, without any difference between the local vs regional-distant recurrence. Correlation factor between first and second disease interval was 0.99 and R2 was 0.98. For Group II, survival was 0% at 635 days. Chest wall resection must be considered as an important part of palliative treatment in breast cancer, but the results reflects the biology of the disease more than the chest wall surgery.     

根治术后盆腔复发直肠癌疗效及预后因素分析

目的 分析直肠癌根治术后盆腔复发规律以及放疗疗效和影响预后的因素.方法 回顾分析2000-2006年直肠癌根治术后盆腔复发接受放疗患者93例,分别为单纯放疗21例、放化疗56例、放疗结合手术和(或)化疗16例.放疗采用60Co或加速器X线,中位剂量59.4Gy,其中90例采用常规分割技术.68例患者放疗后接受了1～8个(中位数3个)疗程化疗,42例行同步放化疗,多为氟尿嘧啶为主的化疗方案.16例患者在放疗后接受了复发灶切除术,其中RO切除7例,姑息性肿块切除9例.结果 全组共132处复发,常见复发部位为直肠周围(31.8%)和骶前区(30.3%),髂外淋巴结和腹股沟淋巴结少见(1.5%和3.0%).总随访率为92%,随访满2、5年者分别为39、4例.有局部症状的84例患者中83%(70例)放疗后症状缓解.全组2、5年局部无进展率分别为49%、22%,2、5年生存率分别为46%、14%.多因素分析结果显示复发后治疗方法是影响直肠癌根治术后复发的局部无进展率的独立预后因素,复发灶最大径、无病间期、放疗后有无远处转移是影响直肠癌根治术后复发患者生存率的独立顶后因素.结论 直肠周围区、骶前区、髂内淋巴结区是直肠癌主要复发部位;放疗可明显改善直肠癌根治术后盆腔复发患者的症状和提高生存质量,放疗联合手术和(或)化疗可提高直肠癌根治术后复发的局部无进展率,复发灶直径＞5 cm、无病间期＜2年、放疗后有远处转移是影响预后的因素.     

External beam radiotherapy in the treatment of male breast carcinoma: patterns of failure in a single institute experience

AIMS AND BACKGROUND: We analyzed our own results in the treatment of male breast cancer patients with respect to local control, overall survival and possible prognostic factors for local and distant control. METHODS: Thirty-one patients with 32 carcinomas of the male breast were treated with radiotherapy. Twenty-five patients received radiotherapy to the chest wall including or not regional lymphatics after initial mastectomy (n = 23) or after surgery for local recurrence (n = 2). Median total dose was 60 Gy to the chest wall and 46 Gy to regional lymphatics. Seven patients with metastatic disease were referred for palliative radiotherapy. RESULTS: Overall survival after postoperative radiotherapy was 40% after a median follow-up of 4.3 years. Actuarial 3-, 5- and 10-year survival was 82.6%, 56.5% and 43.5%, respectively. Five-year progression-free survival was 62.5%. Survival was significantly affected by the presence of lymph node metastases (P <0.001). Local recurrence was seen in one patient after 29 months. CONCLUSIONS: Postoperative radiotherapy is important in the management of male breast cancer to improve local control and progression-free survival, resulting in one local failure in our analysis. The presence of lymph node metastases significantly impairs survival.     

A case of chest wall recurrence of breast cancer treated with paclitaxel weekly, 5’-deoxy-5’-fluorouridine,arterial embolization and chest wall resection

Chest wall resection and reconstruction has proved to be a safe surgical procedure for local recurrence of breast cancer. Recently, as second- or third-line chemotherapy for the patients with recurrent breast cancer or ovarian cancer, weekly paclitaxel has provided a significant response rate in those patients, and generated much clinical interest. We report here a case of chest wall recurrence of breast cancer successfully treated by a combination of weekly paclitaxel, 5'-deoxy-5-fluorouridine, arterial embolization, and chest wall resection. A 56-year-old woman presented with a large mass in the left anterior chest. A recurrent tumor developed and enlarged one-and-half years after undergoing modified radical mastectomy for advanced breast cancer (T4N2M0, stage III B) at another hospital. The mass had enlarged while the patient underwent chemotherapy with cyclophosphamide, doxorubicin, 5-fluorouracil, and anastozole, followed by low-dose cisplatin, 5-fluorouracil, and goserelin. To reduce the mass and inflammatory changes of the skin, weekly paclitaxel and 5'-deoxy-5-fluorouridine was given. Furthermore, to obtain hemostasis and promote the mass reduction, arterial embolization of the supply arteries was performed. Chest wall resection, reconstruction of the bony chest wall with polypropylene mesh folded 8 times, and soft tissue reconstruction with a contralateral myocutaneous flap were carried out successfully. The patient was discharged from the hospital ten weeks after the operation without any major morbidity, and remained well for ten months. A multimodal approach with chemotherapy and arterial embolization was effective in this case in treating chest wall recurrence of breast cancer. Reconstruction of the chest wall bone with polypropylene mesh folded 8 times and soft tissue reconstruction with a contralateral myocutaneous flap was a useful procedure after chest wall resection, even after chemotherapy and arterial embolization.     

乳腺癌术后胸壁复发的放射治疗

目的探讨放射治疗在乳腺癌根治术或改良根治术后胸壁复发患者中的合理应用及影响生存率的预后因素。方法接受放射治疗的乳腺癌术后胸壁复发患者共86例。中位随访时间为77.4个月。51例复发灶为单结节,19例为多结节,16例为弥散。67例为单纯胸壁复发,19例同时合并区域淋巴结复发。30例在放射治疗前接受手术切除。27例照射野为全胸壁,59例为局部小野。中位照射剂量为58Gy。结果①近期疗效65例(76%)病灶达到临床完全消退(CR)。单因素分析显示复发灶数目、直径和有无手术切除与临床CR率有关。②胸壁再次复发47例(55%)出现胸壁再次复发。采用小野照射发生野外复发的几率明显高于全胸壁照射(58%∶15%)。③生存率中位生存时间为6.3年,2、5和8年生存率分别为88%、62%和34%。62%的患者在随访期内出现远地转移。多因素分析发现无病间期长短和有无区域淋巴结累及是影响生存率的独立因素。结论照射野必须包括完整的胸壁以避免小野照射带来的高比例胸壁再次复发率。直径3cm以上或弥散的病灶需要综合治疗的配合以提高局部控制率。生存率预后良好的因素包括无病间期>2年,无区域淋巴结累及和复发灶表现为单结节。     

Results of irradiation in the treatment of locoregional breast cancer recurrence

A retrospective review is presented of 255 patients with chest wall and/or regional nodal recurrent breast cancer treated between January 1956 through December 1981 at the University of Texas M. D. Anderson Hospital; 61 patients had such massive or diffuse disease that only palliative irradiation was given, and 194 patients were treated with curative intent and form the basis of this report. All patients treated with radical irradiation received greater than or equal to 4500 rad, and 65% of the patients received boost therapy through reduced fields. Thirty-two percent of patients were treated only to a single recurrent site, 11% of two sites, and 57% to the chest wall and regional nodes. Failure to control recurrent disease within or on the border of the irradiated field occurred in 27% of patients. Of 62 patients treated to the local recurrence site, 27% had further recurrences in adjacent unirradiated sites. The patients with the greatest success for tumor control (78%) and survival at 5 years (48% disease-free) are those patients with histologically negative nodes at time of mastectomy and a single chest wall recurrence. Possible prognostic factors are discussed: initial clinical stage, age of the patient, axillary histology at the time of mastectomy, disease-free interval between mastectomy and recurrence, number and size of recurrences, and prior chest wall recurrence.