胸膜全肺切除治疗肺癌胸膜转移伴恶性胸腔积液

Pleuro-pneumonectomy in the treatment of pulmonary carcinoma complicated with diffuse pleural metastasis and malignant pleural effusion

背景与目的按肺癌TNM国际分期标准,肺癌胸膜转移伴癌性胸水属于ⅢB期,既往一般采取非手术疗法,但疗效较差,患者的生活质量不高。本研究通过观察胸膜全肺切除的临床应用,来评估治疗ⅢB期肺癌伴胸膜转移和癌性胸水的注意事项和远期效果。方法对1978年12月至2003年2月间采用该术式治疗的55例肺癌伴有胸膜转移、癌性胸水的患者进行总结,定期随访,了解患者生活质量、复发情况和生存时间。计算术后生存率和中位生存时间。结果本组患者中手术死亡2例。患者术后胸闷、呼吸困难、胸腹壁疼痛症状明显缓解,恶病质迅速消失,未见胸水复发,但后期绝大部分患者发生远处脏器转移。随访至2003年8月,出院患者中已死亡48例,生存时间5～40月,平均生存期15个月,中位生存期14个月,仍健在的5例患者术后时间均未超过1年。结论①要严格掌握手术适应证;②手术中要注意肿瘤切除的彻底性;③术中要重视对切口的保护;④手术打破免疫封闭状态,为后续治疗创造条件;⑤患者通过手术可以提高生活质量和中位生存期;⑥患者术后远期生存还不尽如人意。

Background and objective According to the international standard in TNM staging of pulmonary carcinoma, pulmonary carcinoma complicated with diffuse pleural metastasis and malignant pleural effusion belongs to Ⅲ B stage. In the past, non-operative therapy was employed, but both the therapeutic efficacy and the quality of life of patients were poor. The purpose of this study is to find out a complex treatment for this disease. Methods Total pleuro-pneumonectomy was performed in 55 cases of patients with pulmonary carcinoma complicated with diffuse pleural metastasis and malignant pleural effusion from December 1978 to February 2003. The patients were followed up postoperatively, and the quality of life and survival period of them were observed. Results In all the cases, only 2 patients died of operation. Satisfactory recovery and remarkable relief of symptoms such as short breath, dyspnea and chest pain were found in all the other patients. After a follow-up period of 1--25 years, local recurrence was found in 6 cases （11.3%）, and distant metastasis in 42 cases （79.2%）. A total of 48 patients died of tumor, with survival period ranging from 5--40 months （average survival period： 15 months; median survival period： 14 months）, and 5 patients were still alive in good health. Conclusion ① Patients appropriated for operation should be carefully selected in case that postoperative complications influence their smooth recovery; ② Tumor tissues should be removed as clear as possible; ③During the operation, close attention should be paid to the protection of incisions;④ Removal of the tumor tissues can reduce the tumor load, effectively clean the immunosuppressive factors in malignant pleural effusion, and break the immunity block status, which provides basis for the following comprehensive therapy; ⑤The quality of life of the patients can be improved and the median survival period can be prolonged by the operation;⑥The long-term survival rate of patients is still unsatisfactory.