T4肺癌侵及心脏大血管的外科治疗

Surgical results of T4 lung cancer invading left atrium and great vessels

目的探讨T4肺癌侵及心脏大血管的外科治疗适应证及影响预后的因素。方法回顾性分析中国医学科学院肿瘤医院1981年9月至2007年1月间T4肺癌侵及心脏大血管接受外科治疗的136例患者临床资料，全组男114例，女22例。年龄28～76岁，中位年龄58岁。根据肿瘤侵犯部位分为侵犯心房组，侵犯上腔静脉组和侵犯肺动脉组。根据手术性质分为完全性切除组和不完全性切除组。根据术后病理淋巴结转移分为N0、N1、N2组。结果全组136例患者，均接受原发肿瘤切除术，其中83例同期实行肺动脉成形术，21例同期实行上腔静脉成形术，32例同期实行心房切除术。完全性切除120例，不完全性切除16例。全组5年生存率43．0％，肺动脉成形组5年生存率52．8％，上腔静脉成形组5年生存率18．2％，心房切除组5年生存率18．4％。术后病理N0组5年生存率74％，N1组5年生存率44．9％，N2组5年生存率15．1％。3组之间生存率差异有统计学意义（P=0．028）。完全性切除组5年生存率37．5％，不完全性切除组5年生存率24．4％，两组之间有差异有统计学意义（P=0．042）多因素分析发现，淋巴结转移是独立预后因素（P=0．01，RR=1．923，95％可信区间：1．172-3．157），而组织学类型（P=0．421）和切除性质（P=0．051）不是独立预后因素。结论淋巴结转移是影响T4肺癌的独立预后因素。提高T4肺癌术后生存率的关键在于手术适应证的选择，即病理N0-1的病例。对于T4肺癌，手术前应该尽可能明确纵隔淋巴结的转移状况。肿瘤完全性切除可以明显改善T4肺癌的预后。肺癌侵犯心包外肺动脉应定义为T2。

Objective To analyzed the indication and prognostic factors of surgical treatment of lung cancer invading left atrium and great vessels （T4）. Methods We retrospectively reviewed the database of 136 T4 lung cancer （tumors invading left atrium and great vessels） patients who received surgical treatment in Cancer Hospital of Chinese Academy of Medical Science （CAMS） from Setember 1981 to January 2007. There are 114 men and 22 women, the median age was 58 years （range 28 -76 ）. All patients were divided into three subgroups according to the invading site： tumor invading left atrium group, tumor invading superior vena cavagroup and tumor invading pulmonary artery group. All patients were divided into two subgroups according to the character of operation ： complete resection group and incomplete resection group. Patients were divided into three subgroups according to pathological lymph node status ： N0, N1 and N2 group. Results One hundred and thirty six lung cancer patients received resection of primary lesions plus arterioplasty of pulmonary artery （PA） （ n = 83 ） and/or angioplasty of superior vena cava （SVC） （n = 21 ） and/or partial resection of left atrium （LA） （n = 32）. Complete resection was possible in 120 patients and 16 patients underwent incomplete resection. Five-year survival was 43.0% for entire group, 52. 8% for PA group, 18. 2% for SVC group and 18.4% for LA group. Factors significantly influencing the overall 5-year survival were the pathologic N status （5-year survival 15. 1% for N2 , 5-year survival 44. 9% for N1 , 5-year survival 74% for No group; N2 versus Nl versus N0, P = 0. 028） and the completeness of resection （5-year survival 37. 5% for complete resection, 5-year survival 22.4% for incomplete resection group ; complete versus incomplete, P = 0. 042 ）. Pathological lymph node status but not histology and character of operation was an independent prognostic factor using Cox regression analysis （ P = 0. 01, RR = 1. 923,95% CI： 1. 172 -3. 157）. Conclusion Pathological lymph node status is an independent prognostic factor for T4 lung cancer. Patients with pathological N0-1 lung cancer invading left atrium and great vessels （T4） may benefit from surgical treatment. In the preoperative workup, every possible effort should be made to achieve a careful evaluation of mediastinal lymph noda status. Compared with incomplete resection group, complete resection group may have a better prognosis. Tumor invading extrapericardial PA may be defined as T2.