不同影像学表现的多原发肺癌的临床特点及诊疗效果分析

Clinical features and treatment outcome of multiple primary lung cancer patients with different imaging performance

目的 探讨研究不同类型同时性多原发肺癌患者的临床特征及长期生存.方法 对北京大学人民医院胸外科2007年1月至2014年12月因肺癌接受手术治疗的1 868例患者中,通过Martini及美国胸科医师协会的诊断标准确诊的103例同时性多原发肺癌的患者资料进行回顾性分析.男性34例,女性69例,年龄39 ～ 84岁,平均年龄60.5岁.根据影像学实性成分最大径与肿瘤最大径的比值分为3组.A组：全部病灶均为磨玻璃样成分为主（实性成分比例≤50％）;B组：1个病灶为实性成分为主（实性成分比例＞50％）;C组：2个及以上病灶为实性成分为主.综合评估患者病变特点及肺功能后确定手术方式.采用Kaplan-Meier法计算无复发生存率和总体生存率,Log-rank检验比较各组生存曲线的差异,Cox风险比例回归模型进行预后多因素分析.结果 A组38例,B组40例,C组25例.A组与C组患者相比,女性比例高（73.7％比48.0％,x2=4.291,P=0.038）、吸烟比例偏低（21.1％比44.0％,x2=3.770,P=0.052）、更年轻（56.2岁比65.9岁,t=-4.172,P=0.000）且肿瘤最大径更小（1.24 cm比2.31 cm,t=-4.573,P=0.000）.全部患者的3、5年无复发生存率分别为80.3％、64.9％,3、5年总体生存率分别为87.3％、68.6％.A组无复发或死亡,B组3、5年无复发生存率分别为77.7％、51.8％,C组3、5年无复发生存率分别为59.6％、44.7％,3组间差异有统计学意义（P =0.029）.3组总体生存率差异无统计学意义（P =0.214）.多因素分析结果显示,肿瘤最大径＞2 cm（HR =4.475,95％ CI：1.138 ～ 17.604,P=0.032）是影响无复发生存率的独立风险因素.结论 磨玻璃样多原发肺癌与实性多原发肺癌的临床特点及预后不同.病灶大小是多原发肺癌无复发生存率的独立风险因素.手术切除的疗效满意,应针对不同类型的多原发肺癌患者选择相应的手术方式.

Objective To analyze the clinical characteristics and follow up record of patients with synchronous multiple lung cancers （SMLC）.Methods The medical records of 1 868 lung cancer patients who underwent surgical treatments From January 2007 to December 2014 were reviewed,in which 103 patients were diagnosed SMLC by Martini and American College of Chest Physicians modified guideline.The average age was 60.5 years,including 34 male and 69 female patients.According to consolidation/ tumor ratio （CTR） on thin-section computed tomography,103 cases were classified into three groups：group A （multiple ground-glass opacities,CTR ≤ 50%）,group B （with one solid dominant nodules,CTR 〉 50%）,group C （with two solid dominant nodules）.The surgical procedure was determined according to CT findings and respiratory function.The Kaplan-Meier method was used to analyze the duration of recurrencefree survival （RFS） and over-all survival （OS）,and differences were assessed using the Log-rank test.Multivariate analysis using the Cox proportional hazards models was used to assess the potential independent effects on RFS or OS.Results There were 38 patients in group A （36.9%）,40 patients in group B （38.8%） and 25 patients （24.3%） in group C.More female （73.7% vs.48.0%,x2 =4.291,P=0.038）,less smoker （21.1% vs.44.0%,2 =3.770,P =0.052）,younger （56.2 years old vs.65.9 years old,t=-4.172,P=0.000） and less tumor size （1.24 cm vs.2.31 cm,t=-4.573,P=0.000） patients in group A than in group C.The 3,5-year RFS were 80.3% and 64.9% for all patients,respectively.The 3,5-year OS were 87.3% and 68.6% for all patients,respectively.The 3,5-year RFS were 100% and 100% in group A,77.7% and 51.8% in group B,59.6% and 44.7% in group C （P=0.029）.No significance were found in OS between the three groups （P =0.214）.Multivariate Cox analysis demonstrated that size of dominant nodule larger than 2 cm （HR =4.475,95% CI：1.138 to 17.604,P =0.032） is associated with poor prognosis,whereas postoperative chemotherapy did not affect RFS.Conclusions Multifocal ground-glass opacities and multiple solid lung cancers are different in nature.RFS of patients with SMLC is strongly affected tumor size.Surgical resection is effective and should be performed specifically to patients.