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。

Clinical characteristics and diagnostic analysis of 120 cases with malignant pleural mesothelioma

Objective:To investigate the clinical characteristics of patients with pleural mesothelioma,including the history,symptoms,lymph node metastasis and the rule of distant metastasis,to analyze the survival of patients with different stages,pathological types and treatment methods,so as to provide ideas for the diagnosis and treatment of this disease.Methods:The clinical data of 120 patients with pleural mesothelioma admitted to Tangdu Hospital of Air Force Medical University from April 2009 to September 2016 were analyzed,and the staging was conducted according the eighth TNM staging standard.For the different clinical stages,pathological types and treatment methods,the median survival of patients in each group was calculated and analyzed by Kaplan-Meier method.Results:Among the 120 patients,3 cases(2.5%)had a history of occupational exposure.There were 56 cases(46.7%)of left pleural mesothelioma,63 cases(52.5%)of right pleural mesothelioma,and 1 case of bilateral concurrent lesion.The total misdiagnosis rate of the patients was 30%(36/120),among which 32 cases(26.7%)were misdiagnosed as tuberculosis.In terms of symptoms,55 cases(45.8%)suffered from chest pain,107 cases(89.2%)suffered from pleural effusion,and 49 cases(40.8%)suffered from both symptoms.Fifty-three cases(44.2%)were diagnosed by pleural puncture,41 cases(34.2%)by thoracoscopy,and 26 cases(21.6%)by exploratory thoracotomy.There were 43 cases(35.8%)of lymph node metastasis(N1 and N2).There were 54 sites of lymph node metastasis,including 42 cases(77.8%)of metastasis in mediastinal lymph node areas and 12 cases(22.2%)of metastasis in other areas.Seventy-eight patients were followed up successfully.The overall median survival was 15.0 months,and the 1-year,2-year,3-year,and 5-year survival rates were 67.9%,27.7%,16.0%,and 4.2%,respectively.The median survival of patients in stageⅠ/Ⅱwas 17.0 months,which was longer than that of patients in stageⅢ/Ⅳ(13.0 months)(P<0.05).The median survival time of patients with epithelial type of pleural mesothelioma was 17.0 months,which was better than those of patients with mixed type and sarcoma type of pleural mesothelioma(both P<0.05).The median survival time of patients in the combination group of surgery and chemotherapy was 30.0 months,which was better than those of patients in surgery,chemotherapy alone and supportive treatment groups(all P<0.05).Conclusion:The misdiagnosis rate of pleural mesothelioma is high,most of patients are misdiagnosed as tuberculosis.The incidence of malignant pleural effusion is high,and the pattern of lymph node metastasis is different from lung cancer.Therefore,for the diagnosis and treatment of pleural mesothelioma,these clinical features should be paid great attention to minimize misdiagnosis and improve the treatment efficiency.However,the prognosis of patients with early clinical stage and epithelial type of pleural mesothelioma is relatively better.Relatively long survival can be achieved by a combination of surgery and chemotherapy.