[摘要] 目的 探讨胸膜恶性间皮瘤的临床特点与治疗经验。 方法 回顾性分析中国医科大学附属第一医院1998年6月~2015年10月收治的35例胸膜恶性间皮瘤患者的临床资料。 结果 全部35例患者中,15例术前曾存在不同程度的误诊,误诊率为42.8%,1年生存率为60%,3年生存率为5.7%。大多数患者在术后3个月~1年复发,1年复发率为71.4%。 结论 胸膜恶性间皮瘤发病率低、恶性程度高、预后差,应根据患者疾病分期、病理分型、心肺功能等因素综合考虑,制订个体化治疗策略。
[关键词] 恶性间皮瘤;诊断;治疗
[Abstract] Objective To explore the clinical characteristics and treatment experience of malignant pleural mesothelioma. Methods The data of 35 cases of MPM were analyzed retrospectively in the First Hospital of China Medical University from June 1998 to October 2015. Results In all the patients, 15 cases was misdiagnosised, and the misdianosis rate was 42.8%. The 1-year-survival rate was 60% and the 3-year-survival rate was 5.7%. Most of the patients was recurrence during 3 months to 1 year after surgery, and the 1-year-recurrence rate was 71.4%. Conclusion MPM has low incidence, high grade malignance and bad prognosis. It should work out individualized treatment strategies considering the staging of disease, pathological type and cardiopulmonary function of each patient.
[Key words] malignant pleural mesothelioma; Dianosis; Treatment恶性胸膜间皮瘤(malignant pleural mesothelioma,MPM)是一种少见的起源于胸膜间皮细胞的原发肿瘤,其发病率较低,仅占全部恶性肿瘤的0.02%~0.04%[1-2],在我国恶性胸膜间皮瘤的发病率为0.3/10万~0.5/10万[3],云南楚雄州大姚县最高。MPM早期临床症状不明显,影像缺乏特征性表现,容易误诊,且MPM恶性度高、侵袭性强、预后差,治疗方法选择存在争议,总体中位生存期仅为 9~17个月[4]。本文通过对中国医科大学附属第一医院(以下简称“我院”)胸外科收治的MPM患者的临床资料进行回顾性分析,结合国内外文献,探讨胸膜恶性间皮瘤的治疗方法及预后。
1 资料与方法
1.1 一般资料
1998年6月~2015年10月我院收治MPM患者35例,其中男22例,女13例;年龄22~85岁,中位年龄51岁。有石棉接触史9例,石棉接触时间为3个月~11年,吸烟史17例,吸烟时间为5个月~33年。全部患者中,单纯胸痛12例,胸闷气短10例,自发性液气胸5例,不明原因长期体热4例,其余均为体检发现。
1.2 影像学表现
所有患者术前均行胸部CT检查,30例患者提示胸膜存在不同程度增厚,5例因胸腔积液较多,CT分辨率不足,无法准确显示评估胸膜。14例患者患侧单侧胸腔积液,4例双侧胸腔积液,4例伴发肺内病变,4例伴胸膜钙化,6例伴纵隔及肺门淋巴结肿大,1例与心包分界不清,1例侵及同侧部分胸壁及肋骨。完成增强CT的28例患者中,22例胸膜存在不同程度的强化效应。
1.3 实验室及辅助检查
3例患者术前检查存在贫血,1例患者存在较重的低蛋白血症,蛋白为25 g/L,3例合并凝血异常,肿瘤系列诸如癌胚抗原(CEA)、神经元特异性烯醇化酶(NSE)、CA199等均可有不同程度的升高,因年代久远,部分患者未能完善该项检查,故未予确切统计。18例合并胸腔积液患者,14例行胸腔积液穿刺引流,所得胸水均行胸水常规及脱落细胞学检查。所有胸腔积液患者均为渗出液,4例血性,9例淡黄色。胸腔积液中乳酸脱氢酶有不同程度的升高。脱落细胞学检查2例发现轻度异性细胞,2例发现可疑肿瘤细胞。
1.4 手术及治疗方法
8例患者行胸膜切除术,5例行胸膜外全肺切除术,3例行肺叶切除术,1例位于前纵隔行纵隔肿物切除术,1例因肿瘤与心包关系密切行胸膜及部分心包切除术,1例因肿瘤侵及肋骨而行胸膜肺叶及部分肋骨切除术,5例行胸腔镜活检,3例行开胸探查活检,其余患者依靠CT引导下穿刺明确诊断,确诊后行放化疗。
2 结果
全部35例患者中,15例曾存在不同程度的误诊,误诊率为42.8%,误诊为结核性胸膜炎7例,胸膜转移瘤3例,肺癌2例,肺炎1例,纵隔肿瘤1例,孤立性纤维瘤1例。14例在外院误诊,1例在我院误诊,确诊依据病理。术后病理示上皮型11例,肉瘤型1例,混合型4例,其余患者未分型。根据Butchart分期法,Ⅰ期8例,Ⅱ期16例,Ⅲ期7例,Ⅳ期4例。全组患者围术期无死亡,术后无致命并发症。术中术后输血量0~3000 mL,术后住院时间7~52 d。术后开胸再止血1例,术后出现脓胸1例,术后心律失常4例,术后出现顽固性胸腔积液3例,均经积极治疗后康复出院。术后定期复查肺CT,通过门诊或电话随访,观察有无复发及生存期,规定确诊日期为随访零时。全部35例患者,失访2例,随访时间3个月~3年。1年生存率为60%,3年生存率为5.7%。大多数患者在术后3个月~1年复发,1年复发率为71.4%。 [8] Hansen J,de Kler NH,Musk AW,et al. Environmental exposure to crocidolite and mesothelioma.Exposure-response relationships [J]. Am J Respir Crit Care Med,1998,157(1):69-75.
[9] Butchart EG,Gibbs AR. Pleural mesothelioma [J]. Curr Opin Oncol,1990,2:352-358.
[10] Rohren EM,Turkington TG,Coleman RE. Clinical applications of PET in oncology [J]. Radiology,2004,231(2):305-332.
[11] Liu F,Zhao B,Krug LM,et al. Assessment of therapy responses and prediction of survival in malignant pleural mesothelioma through computer-aided volumetric measurement on computed tomography scans [J]. J Thorac Oncol,2010,5(6):879-884.
[12] 王景贵,高文萍,张晓轩,等.恶性胸膜间皮瘤的临床特点及病理学改变[J].中国当代医药,2010,17(33):83.
[13] Schexpereel A,Astoul P,Baas P,et al. Guidelines of the European Respiratory Society and the European Society of Thoracic Surgeons for the management of malignant pleural mesothelioma [J]. Eur Respir J,2010,35(3):479-495.
[14] King JE,Thatcher N,Pickering CA,et al. Sensitivity andspecificity of immunohistochemical markers used in the diagnosis of epithelioidmesothelioma:a detailed systematic analysis using published data [J]. Histopathology,2006,48(3):223-232.
[15] Takeshima Y,Amatya VJ,Kushitani K,et al. Value of immunohistochemistry in the differential diagnosis of pleural sarcomatoid mesothelioma from lung sarcomatoid carcinoma [J]. Histopathology,2009,54(6):667-676.
[16] Husain AN,Colby T,Ordonez N,et al. Guidelines for pathologic diagnosis of malignant mesothelioma:2012 update of the consensus statement from the International Mesothelioma Interest Group [J]. Arch Pathol Lab Med,2013,137(5):647-667.
[17] Helland A,Solberg S,Brustugun OT. Incidence and survival of malignant pleural mesothelioma in norway:a population-based study of 1686 cases [J]. J Thorac Oncol,2012,7(12):1858-1861.
[18] Zucali PA,Glaccone G. Biology and management of malignant pleural mesolioma [J]. Eur J Cancer,2006,42(16):2706-2714.
[19] Higashiguchi M,Suzuki H,Hirashima T,et al.A retrospective study of chemotherapy with and without pemetrexed in malignant pleural mesothelioma [J]. Anticancer Research,2012,32(2):609-613.
[20] Shukuya T,Takahashi T,Imai H,et al. Comparison of cisplatin plus pemetrexed and cisplatin plus gemcitabine for the treatment of malignant pleural mesothelioma in Japanese patients [J]. Respir Investig,2014,52(2):101-106.
[21] Vogelzang NJ,Rusthoven JJ,Symanowski J,et al. Phase Ⅲ study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma [J]. Journal of Clinical Oncology,2003,21(14):2636-2644.
[22] Opitz I. Management of malignant pleural mesothelioma-The European experience [J]. J Thorac Dis,2014,6(Suppl 2):S238-S252.
发表评论