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目的总结对胸腺上皮肿瘤(TET)的外科治疗结果以改进现有的治疗方法。方法回顾对204例TET的外科治疗,方法为手术探查切除结合术后辅助治疗。根据WHO胸腺上皮肿瘤组织分型和改良Masaoka分期进行疗效分析。结果全组外科整体切除180例占88.2%(其中根治切除139例占68.1%,大体切除41例占20.1%),部分切除17例占8.3%,单纯活检7例占3.4%;MasaokaⅠ/Ⅱ期肿瘤的外科整体切除率显著高于Ⅲ/Ⅳ期肿瘤(100%和75%,P<0.001),其根治性切除率则更明显地高于后者(94.5N和37.2%,P<0.001)。外科整体切除病例的术中出血量显著少于部分切除或单纯活检病例(524.7ml和1955.4ml,P<0.001)。24例(11.8%)患者术后发生严重并发症29人次,其中肌无力危象11人次,合并重症肌无力、部分切除或单纯活检、Ⅲ/Ⅳ期肿瘤、年龄<45岁为术后发生严重并发症的独立预测因素。术后死亡15例(7.4%),其中6例死于肌无力危象。部分切除或单纯活检以及合并重症肌无力为手术死亡的独立预测因素。术前行激素化疗的术后肌无力危象的发生率及其死亡率均显著降低。WHO组织分型A/AB/B1型TET中Ⅰ/Ⅱ期肿瘤明显多于B2/B3/C型(87.6%和26.4%,P<0.001);其外科整体切除率显著高于B2/B3/C型(98.9%和78.3%,P<0.001)。全组术后5年和10年生存率为63.2%和50.4%。WHO组织分型B2/B3/C型、MasaokaⅢ/Ⅳ期肿瘤及部分切除或单纯活检是预后不良的独立预测因素。结论根治性切除仍然是治癒TET的主要手段,术前激素化治疗有利于降低重症肌无力患者的手术风险;TET的治疗原则应以WHO组织分型和改良Masaoka分期为依据,Ⅰ/Ⅱ期、A-B1型TET切除率高、手术安全、远期预后好,手术治疗应列为首选,术后放疗并无必要;Ⅲ期以上、B2-C型TET切除率低、手术困难且风险较大,传统的“手术探查切除+术后辅助治疗”策略效果不理想,应通过诱导治疗提高切除率以改善疗效。
Objective To summarize the results of surgical treatment of thymic epithelial tumors (TETs) to improve the current treatment. Methods The surgical treatment of 204 cases of TET was reviewed. The surgical resection and postoperative adjuvant therapy were performed. According to WHO thymus epithelial tumor tissue classification and modified Masaoka staging for the efficacy analysis. Results The overall surgical resection in 180 cases accounted for 88.2% (radical resection in 139 cases accounted for 68.1%, 41 cases of gross resection accounted for 20.1%), partial resection in 17 cases accounted for 8.3%, biopsy in 7 cases accounted for 3.4%; Masaoka Ⅰ / Ⅱ The surgical resection rate of tumors was significantly higher than that of stage Ⅲ / Ⅳ tumors (100% and 75%, P <0.001), and the radical resection rate was significantly higher than that of the latter (94.5N and 37.2%, P <0.001) . Surgical total removal of cases of intraoperative bleeding was significantly less than the partial resection or simple biopsy cases (524.7ml and 1955.4ml, P <0.001). Twenty-four patients (11.8%) experienced 29 serious postoperative complications, of which 11 were myasthenic crisis, with myasthenia gravis, partial or simple biopsy, stage III / IV tumors, and those under 45 years old had severe postoperative complications Independent predictors of complications. Postoperative death occurred in 15 cases (7.4%), of which 6 died of myasthenic crisis. Partial resection or biopsy alone and myasthenia gravis combined with surgical predictors of mortality. Preoperative hormonal chemotherapy postoperative myasthenic crisis and the mortality rate were significantly lower. The WHO Ⅰ / Ⅱ tumors in type A / AB / B1 tumors were significantly more than those in type B2 / B3 / C tumors (87.6% and 26.4%, P <0.001) Type C (98.9% and 78.3%, P <0.001). The 5-year and 10-year survival rates of the whole group were 63.2% and 50.4% respectively. WHO classification of B2 / B3 / C tissue, Masaoka Ⅲ / Ⅳ tumor and partial resection or simple biopsy is an independent prognostic factor for poor prognosis. Conclusions Radical resection is still the main method to cure TET. Preoperative hormone therapy can reduce the surgical risk in patients with myasthenia gravis. The treatment principle of TET should be based on WHO histological classification and modified Masaoka staging, stage Ⅰ / Ⅱ, A-B1 type TET high removal rate, safe operation, good long-term prognosis, surgical treatment should be listed as the first choice, postoperative radiotherapy is not necessary; Ⅲ stage, B2-C TET resection rate is low, difficult and risky surgery , The traditional “Surgical exploration excision + postoperative adjuvant therapy” strategy is not effective, should be induced by treatment to improve the resection rate in order to improve the curative effect.