肺转移瘤外科治疗策略和影响预后因素分析

Surgical therapeutic strategy and prognostic factors analysis for pulmonary metastasis

目的探讨肺转移瘤的手术适应症,手术方式及影响预后的因素。方法对154例行手术治疗的肺转移瘤患者的临床资料进行回顾性分析。结果本组患者的1,3,5年生存率分别为87.7%、55.3%、37.8%,其中3例生存时间超过20年,中位生存期为38.9个月。术后死亡率和发生并发症率分别为3.2%(5/154)和5.8%(9/154)。肺转移灶是否完全切除、肺内结节个数、有无肺外转移、开胸与胸腔镜(VATS)手术方式是影响预后的独立因素。术前肺功能正常与否是影响行肺叶切除和一侧全肺切除患者预后的一个重要因素(P<0.05)。肺转移灶完全切除、单个结节、无肺外转移和行开胸手术者预后较好,行一侧全肺切除者术后生存期明显低于行部分切除和肺叶切除者,行肺叶切除和一侧全肺切除患者术前肺功能正常者预后较好。而无瘤间期时间、转移瘤部位、转移瘤大小、纵膈淋巴结清扫情况、年龄、性别、症状以及原发肿瘤病理类型对预后均无明显影响(P>0.05)。结论有手术适应证的肺转移瘤患者应积极采取手术治疗,且应以开胸手术为主,手术方式以楔形切除为主,尽量避免行肺叶切除和一侧全肺切除术,对术前肺功能不正常的肺转移瘤患者如需行肺叶切除或一侧全肺切除手术应衡量权重。

Objective To investigate the indications of resection for lung metastasis and the surgical procedure and factors affecting the survival.Methods The clinical data of 154 patients of pulmonary metastases after surgical intervention were analyseds retrospectively.Results After surgery,the cumulative 1-,3- and 5-year survival rates were 87.7%,55.3%,37.8%,respectively in our clinical data,of which 3 patients survived for more than 20 years,with an overall median survival of 38.9 months.Mortality and complication rates after surgery were 3.2% (5/154) and 5.8% (9/154).Whether complete resection of lung metastases or not,the number of lung nodules,whether other organs metastasis besides the lung or not,operative modus (thoracotomy and VATS) are prognostic factors.The patients with one latus total pneumonectomy have a shorter survival than the ones with pneumectomy or pulmonary lobectomy.Preoperative pulmonary function is a prognostic factor for the patients with pulmonary lobectomy or one latus total pneumonectomy.Complete resection of pulmonary metastases,a single nodule,no other organs metastasis except the lung and thoracotomy predicts a longer survival whereas disease-free interval (DFI),metastatic locus,pulmonary metastasis size,the status of mediastinal lymph node removal,age,gender,symptom and pathology of the primary tumor were found statistically insignificant prognostic factors.Conclusion Surgical intervention should be undertaken for the indication patients who fit these criteria and thoracotomy is a better choice.For the patients with abnormal preoperative pulmonary function,pulmonary lobectomy or one lateral total pneumonectomy should be attempted with prudence.