伴有肺内转移细支气管肺泡癌的外科治疗

Surgical treatment for bronchioloalveolar carcinoma with ipsilateral intrapulmonary metastatic nodules

目的探讨外科手术对伴有肺内转移的细支气管肺泡癌（BAC）的治疗作用。方法回顾性分析67例行完全性手术切除并存在肺内转移的非小细胞肺癌（NSCLC）患者的临床病理特征和生存资料，比较含BAC成分的患者（研究组）与其他病理类型患者（对照组）的手术效果和预后差异。结果研究组28例，对照组39例。研究组患者的术后中位生存时间为58．0个月，明显高于对照组患者（27．0个月，P〈0．01）。无纵隔淋巴结转移患者的术后中位生存时间为39．0个月，明显高于有纵隔淋巴结转移的患者（14．0个月，P〈0．01）。同一肺叶内转移和不同肺叶内转移患者的术后生存时间分别为36．0个月和24．0个月，差异尤统计学意义（P〉0．05）。结论外科手术可有效治疗伴有肺内转移的BAC，尤其是对无纵隔淋巴结转移的患者，手术可取得与早期NSCLC患者类似的效果。目前的TNM分期对伴有肺内转移的NSCLC患者的预后判断不够准确，需要进一步修正。

Objective The staging and treatment of bronchioloalveolar carcinoma （BAC） with pulmonary metastasis are still controversial. This study aimed at evaluating the current staging of BAC with ipsilateral intrapulmonary metastatic nodules and the therapeutic effectiveness of surgical resection. Methods The clinicopathologieal data of 729 completely and surgically resected patients with non-small cell lung cancer （NSCLC） from December 1999 to December 2006 were retrospectively reviewed. Prognostic factors affecting the overall survival were analyzed by the Kaplan-Meier method and compared by the log rank test. Results Among 67 NSCLC patients with ipsilateral intrapulmonary metastatic nodules, 54 had multiple nodules in the lobe with primary lesion （T4, PM1 ） and 13 had additional nodules in the other ipsilateral lobes （M1, PM2）. This series consisted of 40 males and 27 females, with a median age of 60.0 years. Of those, 28 had the lesions containing pure or some bronchioloalveolar carcinoma component, while the other 39 had a NSCLC lesions containing non-bronchioloalveolar carcinoma components. The median overall survival time of this series was 24.0 months. Prognostic study demonstrated that bronchioloalveolar carcinoma histology and mediastinal lymph node metastasis had significant adverse impact on the overall survival. The median survival time of the patients with bronchioloalveolar carcinoma was 58.0 months versus 27.0 months in patients with other subtypes of NSCLC （ P 〈 0.01 ）. The median survival times were 39.0 months for the patients with NO or N1 versus 14.0 months for patients with N2, with a significant difference between the two groups （P 〈 0.01 ）. There was no significant difference in the survival time between the patients with PM1 （36 months） and those with PM2 （ 24 months） （ P 〉 0.05 ）. Conclusion Surgical resection is effective for NSCLC patients with ipsilateral intra-pulmonary metastasis, especially for those with bronchioloalveolar carcinoma components. Our results suggest that the current TNM classification system may be inappropriate for the NSCLC patients with ipsilateral intrapulmonary metastatic noduals, and may need a modification.