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手术是作为胸膜孤立性纤维瘤的最佳治疗方法

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手术是作为胸膜孤立性纤维瘤的最佳治疗方法
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因胸膜孤立性纤维瘤 ( solitary fibrous tumors of the pleura ,SFTP) 发病率低,占胸膜源性肿瘤的5%,约80%来自脏层胸膜,20%来自壁层胸膜。临床中偶有碰到,且国内外对SFTP 的研究多为个案报道或是单中心的数据分析。 最近一期Annals of Thoracic Surgery有篇文章关于胸膜孤立性纤维瘤 治疗的回顾性分析, 借此文章,我们来复习下胸膜孤立性纤维瘤相关知识。

首先来介绍这篇文章:

背景
本研究的目的是确定胸膜孤立性纤维性肿瘤( solitary fibrous tumors of the pleura ,SFTP)患者的最有效的治疗方法。
方法
经国家癌症数据库查询恶性SFTP数据。患者分为两组,即接受手术治疗的患者和未接受手术治疗的患者。主要研究终点是5年总生存期,通过Kaplan-Meier方法评估并使用对数秩检验进行比较。

数据来源


结果
在2004年至2014年期间,共有204名SFTP患者被确诊。其中65%的患者(133名)进行了外科手术,18%(37名)没有手术干预,17%(34名)未获得治疗信息。在接受切除术的患者中,42%(56)进行亚肺叶切除术,45%(60例)进行了肺叶切除术,13%(17例)进行了全肺切除术。SFTP患者的总体5年生存率为56%。手术治疗的患者存活率64%,相比无手术干预的患者为22(p <0.001)。
行亚肺叶切除的患者的5年生存率与合并肺叶或全肺切除的患者相比,没有明显差异(65%对64%,p  = 0.823)。

Five-year survival of patients with solitary fibrous tumors of
the pleura who underwent surgical treatment (broken line) versus
patients who did not undergo surgical treatment (solid line), including
alternative or no therapy.
Five-year survival of patients with solitary fibrous tumors of
the pleura who underwent sublobar resections (broken line) versus
patients who underwent greater anatomic resections (solid line),
including lobectomy and pneumonectomy


结论
通过外科手术治疗的SFTP患者的总体生存率高于未通过手术治疗的患者。此外,合并亚肺叶切除患者的5年生存率与 合并肺叶或全肺切除的患者相似,这表明在可能的情况下,亚肺叶切除已经足够达到手术范围。

Optimal Treatment for Solitary Fibrous Tumors of the Pleura (英文摘要,点击打开)

Background
The objective of this study was to identify the most effective treatment for survival in patients with solitary fibrous tumors of the pleura (SFTP).
Methods
The National Cancer Database was queried for patients with malignant SFTPs. Patients were divided into two groups, those who had surgical treatment and those who did not. The primary outcome was 5-year overall survival, which was assessed by the Kaplan-Meier method and compared using the log rank test.
Results
There were 204 patients with SFTPs identified between 2004 and 2014. Of those, 65% of patients (133) had surgical intervention, whereas 18% (37) had no surgical intervention, and 17% (34) had unknown treatment information. Among patients who underwent resection, 42% (56) had sublobar resections, 45% (60) had lobectomies, and 13% (17) had pneumonectomies. The overall 5-year survival for SFTP patients was 56%. Patients who had surgical intervention had a relative survival of 64%, and patients with no surgical intervention had 22% (p < 0.001). There was no difference in 5-year survival among patients who had sublobar resections compared with patients who had greater anatomic resections (65% versus 64%, p = 0.823).
Conclusions
Patients with SFTP who were managed with surgical intervention have better overall survival than patients who are not managed with surgery. Furthermore, similar 5-year survival for sublobar resections compared with greater anatomic resections suggested that the former, when possible, is sufficient.

SFTPs 多见于50~70 岁患者,无性别差异。随着病理学水平的发展,SFTPs被证实是一种起源于CD34阳性的树突间叶细胞的肿瘤,并具有向纤维母细胞、肌纤维母细胞分化的特征,可发生在全身各部位。免疫组织化学法常提示CD34和Bcl-2呈阳性。外科完整切除并切缘阴性是目前SFTP的主要治疗方式,恶性SFTPs术后有一定的复发率,约30%。

对于直径>20 cm的SFTP,常因肿瘤巨大,术前无法明确评估其与周边脏器的关系,而使得手术难度增加。因胸部巨大SFTP的特殊性围术期应注意如下几点:1)术中肿瘤的血运及瘤蒂的情况;2)术中肿瘤对纵隔的压迫引起循环不稳定;3)肿瘤切除术后肺复张的问题,应评估肺复张的能力和避免术后复张性的肺水肿。

对于巨大肿瘤压迫导致一侧肺失去功能的患者,可考虑一并切除患肺;对于直径10 cm以下的肺内SFTP推荐行胸腔镜下肺叶切除;肿瘤巨大广泛侵袭或者气管源性SFTs无法根治性切除时,姑息性切除仍具有重要的治疗价值。

大多数SFTP呈良性特性,仅10%~15%的胸部SFTP可复发和或出现转移,因此,大多数学者认为SFTP是一种低度恶性, 极少发生转移的肿瘤。

也有学者认为胸膜孤立性纤维瘤是定义不明确的恶性肿瘤,即使病理区分了SFTP的良恶性,但总体5年和10年生存率在良性和恶性肿瘤之间没有差异。


The Annals of Thoracic Surgery Volume 99, Issue 3, March 2015, Pages 1025-1031

因此,手术是作为胸膜孤立性纤维瘤的最佳治疗方法。

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