原发性腹膜恶性肿瘤的治疗及预后分析

Clinical management and prognostic analysis of primary peritoneal neoplasms

目的探讨原发性腹膜恶性肿瘤的临床治疗方案及预后相关因素。方法对1995年5月—2004年4月在北京大学人民医院治疗的24例原发性腹膜恶性肿瘤患者的临床病理资料进行回顾性分析。结果24例患者中,腹膜浆液性乳头状腺癌15例(中、高分化9例,低分化6例),腹膜混合型上皮性癌6例,腹膜恶性苗勒管混合瘤3例。全部患者均施行肿瘤细胞减灭术,其中满意的肿瘤细胞减灭术(残留灶直径<2cm)3例,不满意的肿瘤细胞减灭术(残留灶直径≥2cm)21例。术后给予以铂类为主的联合化疗,其中13例行紫杉醇+顺铂或卡铂(TP)方案化疗,9例行顺铂+阿霉素+环磷酰胺(PAC)方案化疗。初次化疗缓解率为80%,其中完全缓解率为55%,部分缓解率为25%。患者的中位数生存时间为42个月(22～62个月),其中腹膜浆液性乳头状腺癌、恶性苗勒管混合瘤、混合型上皮性癌患者的中位数生存时间分别为44、13和19个月,前两者比较,差异有统计学意义(P<0.05),而后者分别与前两者比较,差异均无统计学意义(P>0.05);接受TP和PAC方案化疗患者的平均生存时间分别为75、28个月,两者比较,差异有统计学意义(P<0.05)。结论原发性腹膜恶性肿瘤的治疗,应尽量首选恰当的肿瘤细胞减灭术,基本术式为双侧附件及大网膜切除术,过分强调减瘤的彻底性可能不利于患者的预后;术后应给予以铂类为主的联合化疗,TP方案可能优于PAC方案。病理类型及化疗方案是预后的影响因素。

Objective To investigate the clinical management strategies and prognostic factors of primary peritoneal neoplasms. Methods We retrospectively reviewed the clinical and pathological records of 24 cases with primary peritoneal neoplasms treated in the People′s Hospital, Peking University during May 1995 and April 2004. Results Among 24 cases, 15 patients were diagnosed as serous papillary adenocarcinoma (9 highly and intermediately differentiated, and 6 lowly differentiated), 6 as mixed epithelial carcinoma and 3 as mixed malignant Mullerian tumor (MMMT). All patients underwent cytoreductive surgery, 21 cases having, suboptimal debulking one. Then they received a platinum-based chemotherapy. Thirteen cases received paclitaxel + cisplatin (TP) and 9 received cisplatin+doxorubicin+ cyclophosphamide (PAC) combination chemotherapy. The primary response reached 80% (complete response 55% and partial response 25%). The median survival of all patients was 42 months (95% CI=22-62 months). Survival for patients with primary peritoneal serous papillary carcinoma (PPSPC), mixed epithelial carcinoma and MMMT was 44, 19 and 13 months respectively, with a significant difference between PPSPC and MMMT (P<0.05). Patients receiving TP combination also exhibited longer survival than those receiving PAC regimen (mean survival 75 vs 28 months, P<0.05). Conclusions Patients with primary peritoneal neoplasms should be treated with appropriate cytoreductive surgery. A primary surgical protocol is bilateral salpingo-oophorectomy and omentectomy. Overestimating an optimal debulking surgery may have no benefit on the survival. TP combination therapy may bring longer survival than PAC regimen. Histopathologic types and chemotherapy regimens are the essential factors of the prognosis.