M E D iC A L
JO U R N A L
B e n e d ito M a u ro R o ssi, A d e m a r L o p e s, L u iz P a u lo K o w a lski, R o sa n a C a rd o so d e O live ira R e g a zzin i
P r o g n o s tic f a c to r s in 2 9 1 p a tie n ts w ith p u lm o n a r y
m e ta s ta s e s s u b m itte d to th o r a c o to m y
Department of Pelvic Surgery - Hospital A.
C .Camargo,
Fundaflio Antonio Prudente - Slio Paulo, Brazil
P u lm o n a r y m e ta s ta s e s a r e a m o n g th e m o s t c o m m o n s ite s fo r th e s p r e a d o f c a n c e r , p a r tic u la r ly w ith m e s e n c h y m a l tu m o r s . D e s p ite im p r o v e m e n ts in c a n c e r th e r a p y , th e p r o g n o s is r e m a in s p o o r , e x c e p t fo r th e h ig h ly s e le c tiv e g r o u p o f p a tie n ts w h o a r e c o n s id e r e d e lig ib le fo r s u r g ic a l tr e a tm e n t a n d th o s e w ith c h e m o s e n s itiv e tu m o r s . T h e m a in o b je c tiv e o f th is s tu d y w a s to e v a lu a te s u r v iv a l r e s u lts o f 2 9 1 p a tie n ts w h o u n d e r w e n t th o r a c to m y d u e to p u lm o n a r y m e ta s ta s e s b e tw e e n 1 9 5 3 a n d 1 9 8 6 . T h e n u m b e r o f m e ta s ta s e s r a n g e d fr o m a m in im u m o f 1 to a s m a n y a s 3 0 . T h e ty p e o f r e s e c tio n d e p e n d e d o n s ite , s iz e , a n d n u m b e r o f p u lm o n a r y le s io n s : 1 5 4 w e d g e r e s e c tio n s , 4 9 lo b e c to m ie s , a n d 9 p n e u m e c to m ie s . T h e tu m o r w a s n o t r e s e c ta b le in th e r e m a in in g 7 9 p a tie n ts . O f th e p r o g n o s tic fa c to r s a n a ly z e d , o n ly ty p e o f p u lm o n a r y r e s e c tio n ( w e d g e v s . lo b e c to m y v s . p n e u m e c to m y v s . u n r e s e c ta b le ) a n d d is e a s e fr e e in te r v a l ( D F I) b e tw e e n p r im a r y tr e a tm e n t a n d p u lm o n a r y m e ta s ta s e s d ia g n o s is « = 6 m o n th s v s . 7 - 1 2 m o n th s v s . > 1 2 m o n th s ) w e r e s e le c te d a s in d e p e n d e n t p r e d ic to r s o f th e r is k o f d e a th in m u ltiv a r ia te a n a ly s is . A r e d u c e d m o d e l fo r b o n e tu m o r s in c lu d e d d is e a s e fr e e in te r v a l, s e x a n d h is to lo g y .
U N IT E R M S : S u r v iv a l. S u r g e r y . P r o g n o s tic fa c to r s . M e ta s ta s e s . L u n g .
IN T R O D U C T IO N
O
n l yp u l m o n a r ya s m a l lm e t a s t a s e sn u m b e r r e s e c t i o no f c a s e s b e f o r et h a t u n d e r w e n t1 9 5 0 w e r e p u b l i s h e d , a n d m o s t o f t h o s e w e r e l a c k i n g d e t a i l e d i n f o r m a t i o n o n s u r v i v a l r a t e s a n d p r o g n o s t i c f a c t o r s . I n 1 8 8 4 , K r o n l e i n ( 1 3 ) p r e s e n t e d t h e f i r s t c a s e o f p u l m o n a r yA d d re ss fo r co rre sp o n d e n ce : B e n e d ito M . R o ssi
H o sp ita l A . C .C a m a rg o - F u n d a 9 a o A n to n io P ru d e n te R u a P ro fe sso r A n to n io P ru d e n te , 2 1 1
S a o P a u lo - S P - B ra sil- C E P 0 1 5 0 9 -0 1 0
m e t a s t a s e s r e s e c t i o n f r o m a c h e s t w a l l s a r c o m a t h a t w a s o p e r a t e d s i m u l t a n e o u s l y . I n 1 9 2 6 , D i v i s ( 8 ) p e r f o r m e d a m e t a c h r o n o u s p u l m o n a r y m e t a s t a s e s r e s e c t i o n . I n 1 9 3 9 , B a r n e y a n d C h u r c h i l l ( 3 ) r e s e c t e d o n e p u l m o n a r y m e t a s t a s e s f r o m a k i d n e y c a r c i n o m a . T h i s p a t i e n t s u r v i v e d 2 3 y e a r s a f t e r n e f r e c t o m y . I n 1 9 4 7 , A l e x a n d e r a n d H a i g h t ( 1 ) r e p o r t e d g o o d s l ; l r v i v a l r e s u l t s i n 3 o f 6 p a t i e n t s t h a t u n d e r w e n t p u l m o n a r y m e t a s t a s e s r e s e c t i o n .
O n l y i n t h e 5 0 's a n d 6 0 's w i t h t h e d e v e l o p m e n t o f s u r g i c a l a n d a n e s t h e t i c t e c h n i q u e s d i d p u l m o n a r y r e s e c t i o n s b e g i n t o b e p e r f o r m e d w i t h m o r e f r e q u e n c y . I n s p i t e o f t h e f a c t t h a t t h e n u m b e r o f p u b l i s h e d c a s e s n o w e x c e e d s 2 , 0 0 0 , v a r i o u s c o n t r o v e r s i e s a b o u t i n d i c a t i o n s a n d p r o g n o s t i c f a c t o r s r e m a i n ( 1 2 ) .
S o m e i m p o r t a n t i n d i c a t i o n f a c t o r s h a v e t o b e c o n s i d e r e d ( 1 6 ) : ( I ) T h e p r i m a r y t u m o r m u s t b e u n d e r c o n t r o l o r a b l e t o b e c o n t r o l l e d ; ( I I ) p u l m o n a r y m e t a s t a s e s
911
resection m ust be technically possible; (III) the patient m ust
not have another site of m etastatic lesions; (IV ) surgery
should be considered only in the absence of a m ore efficient
therapy; (V ) the patient m ust have adequate clinical
conditions and pulm onary function to be operated on.
T he m ain objectives of this paper w ere to evaluate
survival results and identify prognostic factors related to
pulm onary m etastases resection. T hese results can be used
to im prove accuracy w hen evaluating cases eligible for
this kind of treatm ent.
C A S E W O R K A N D M E T H O D O L O G Y
T he authors review ed the records of 291 patients w ho
underw ent pulm onary m etastases resection at the
D epartm ent of Pelvic Surgery of A . C . C am argo H ospital,
Foundation A ntonio Prudente, in Sao Paulo, B razil, from
January 1953 to D ecem ber 1986. T hese patients represent
only a portion of a larger group w ith clinical diagnosis of
pulm onary m etastases. O nly patients eligible for surgical
treatm ent w ere considered for this study. T he criteria for
the indication of surgical treatm ent w as rather uniform
during the period of this investigation, specifically: good
perform ance status, no evidence of pleural effusion or
m ediastinum invasion and absence of a m ore efficient
therapy. Patients w ere operated on independent of num ber,
size, and location of pulm onary m etastases. T he
histological type of prim ary tum or w as not taken into
consideration for treatm ent. W hen there w as any plausible
doubt w hether or not the pulm onary lesion w as in fact
m etastatic, the case w as excluded from this study.
T here w ere 150 (51.5% ) m ale patients and 141
(48.5% ) fem ale patients. A ges ranged from Ito 79 years
old, w ith a m edian age of 30.5. T he prim ary tum or
locations w ere: 107 bone (36.8% ), 78 soft parts (26.8% ),
46 urogenital (15.8% ), and 45 m iscellaneous (15.5% ). T w o
cases had pulm onary recurrence of H odgkin's disease after
chem otherapy and 13 w ere patients w ith pulm onary
m etastases from unknow n prim ary tum ors.
A ll cases w ere evaluated w ith chest X -rays. C hest
planigraphy w as done in 157 cases (55% ). T here w ere
unilateral m etastases in 259 cases (89% ), and 32 (1 1% )
w ere bilateral. T he exact num ber of m etastases w as
obtained post-surgically. O f the thoractom ies there w ere:
259 cases of posterolateral (15 bilateral), 9 bi lateral
horizontal, 7 trans sternal, and in 16 other types. T he
resections w ere one or m ultiple w edge resections in 154
cases (52.9% ), lobectom y in 34 cases (11.7% ), w edge
resection plus lobectom y in 15 cases (5.2% ), and
pneum ectom y in 9 (3.1 % ). In 79 cases (27.1 % ) the
m etastases w ere not resectable.
T he histology of the m etastases w as the sam e as the
prim ary tum or in 247 (84.9% ), different in 23 (7.9% ), not
conclusive in 10 (3.4% ), and in 11 (3.8% ) there w as no
inform ation on the chart.
Statistical A nalysis: product lim it estim ates of the
survival function w ere used for the com putation of
cum ulative survival rates (11), using the K M SU R V
program (5). O verall survival w as com puted on the basis
ofthe dates and events abstracted from the original patient
records. T his w as defined as the interval betw een the date
of the thoractom y and the date of death for uncensored
observations.
C ox's regression m odel w as used to estim ate the
hazard ratio (H R ) of death due to the com bined effects of
tw o or m ore study factors (4). T his m odel w as also used
to build m odels containing the m ost restricted subset of
variables w ith independent predictive properties w ith
respect to the risk of death. A stepw ise forw ard algorithm
w as used for variable selection. Inferences w ere based on
the partial likelihood ratio (deviance) statistic betw een
nested m odels (10% significance level). Finally, risk
groups w ere determ ined on the basis of distribution of
com bined effects of significant variables, and split into
three levels: low risk (R R < 0.5 I ) , interm ediate risk
(0.51< R R < 1.51) and high risk (R R > 1.5 I ) .
R E S U L T S
T he num ber of pulm onary m etastases ranged from a
m inim um of I (102 cases, 35% ) to as m any as 30. T he
exact num ber of m etastases w as not reported in 9 cases,
(3% ). A t the closing date of the study, there w as a total of
6,193 patient-m onths of cum ulative follow -up experience
w ith a 10 m onth m edian. D uring the follow -up period, 74
patients (25.4% ) w ere re-operated w ith further
thoractom ies: a second thoractom y in 58 cases and a third
in 16 cases. O ne hundred and ninety-six (196) patients
died (67.4% ) due to residual or recurrent cancer or
treatm ent com plications (5.8% post-operative m ortality
rate 30 days after first thoractom y) and 5 deaths (1.7% )
due to causes not related to cancer. N ineteen (19) patients
w ere alive (6.5% ) w ith recent follow -up inform ation
R O S S I , B . M . ; L O P E S , A . ; K O W A L S K I , L . P . & R E G A Z Z I N I , R . C . O . - P r o g n o s t ic f a c t o r s in 2 9 1 p a t ie n t s w it h p u lm o n a r y m e t a s t a s e s s u b m it t e d t o t h o r a c o t o m y
912
Table 1
Cumulative survival rates according to selected characteristics
V ariable C ategories # of cases M ean survival S tandard error 5-years survival p
A ge (years) < = 16 72 33.5 5.8 20.7 0.9738
17-50 142 31.1 4.0 19.0
> = 51 77 32.4 5.7 18.2
S ex M ale 150 38.1 5.4 16.8 0.6776
F em ale 141 40.0 7.5 22.1
O F I (1) prior < = 6 m o. 58 15.4 2.9 5.8 0.0007
to lung 7-12 m o. 50 20.8 5.9 15.2
m etastases > = 13 m o. 183 28.6 2.3 23.8
T um or location
a) B one N o 184 35.35 4.1 21.2 0.6242
Y es 107 31.6 5.0 15.6
b) S oft N o 213 45.9 6.1 20.1 0.8560
parts Y es 78 38.8 9.5 17.0
c) U re- N o 245 47.0 6.6 17.1 0.6271
genital Y es 46 63.1 14.4 30.1
d) O ther N o 246 34.2 3.3 20.3 0.3428
Y es 45 26.0 6.2 13.4
T ype of W edge 154 46.9 0.8 27.7 < 0.0001
resection Lobectom y 49 15.0 2.3 16.3
P neum ectom y 9 6.0 2.9 0.0
U nresec. 79 11.5 1.1 4.3
N um ber of 1 102 38.8 5.3 24.5 0.0719
m etastases 2 51 30.1 6.2 17.1
> = 3 138 26.6 3.7 15.8
P re/postop. N o 159 37.1 6.6 14.6 0.0361
chem otherapy Y es 132 57.3 9.2 23.3
(1) O F I = disease free interval
a v a i l a b l e ( t h r e e o f t h e m w i t h r e c u r r e n t d i s e a s e ) . A n
a d d i t i o n a l 7 6 p a t i e n t s ( 2 6 .1 % ) w e r e c o n s i d e r e d l o s t t o
f o l l o w - u p , b u t c o n t r i b u t e d s u f f i c i e n t i n f o r m a t i o n b e f o r e
t h e n t o b e i n c l u d e d i n t h e s u r v i v a l a n a l y s i s .
P o s t - o p e r a t i v e c o m p l i c a t i o n s i n c l u d e d : r e s p i r a t o r y
a l t e r a t i o n s ( 7 .4 % ) , m e t a b o l i c a l t e r a t i o n s ( 4 .7 % ) , c a r d i o
-v a s c u l a r a l t e r a t i o n s a n d i n f e c t i o n ( 4 .1 % ) , f i s t u l a ( 1 .4 % )
a n d s e p s i s ( 1 % ) .
T a b l e 1 s h o w s a s u m m a r y o f c u m u l a t i v e s u r v i v a l d a t a
f o r s e l e c t e d c h a r a c t e r i s t i c s . D e m o g r a p h i c v a r i a b l e s h a d
n o i m p a c t o n p r o g n o s i s . D i s e a s e f r e e i n t e r v a l ( D F I ) p r i o r
t o t h e d e t e c t i o n o f p u l m o n a r y m e t a s t a s e s w a s s i g n i f i c a n t l y
a s s o c i a t e d w i t h p a t i e n t 's o u t c o m e . P a t i e n t s w i t h D F l s
l o n g e r t h a n 6 a n d 1 2 m o n t h s e x p e r i e n c e d b e t t e r s u r v i v a l
r a t e s , ( 1 5 .2 % a n d 2 3 .8 % r e s p e c t i v e l y f o r f i v e y e a r o v e r a l l
s u r v i v a l ) . T h e s i t e o f t h e p r i m a r y t u m o r d i d n o t h a v e
s i g n i f i c a n t e f f e c t o n s u r v i v a l r e s u l t s . T h e n u m b e r o f
m e t a s t a s e s a n d t r e a t m e n t - r e l a t e d f a c t o r s h a d a s i g n i f i c a n t
i m p a c t o n s u r v i v a l r a t e s . R a t e s w e r e b e t t e r f o r p a t i e n t s
w i t h s o l i t a r y m e t a s t a s e s a n d t h o s e w h o u n d e r w e n t w e d g e
r e s e c t i o n s . T h e p o s i t i v e p r o g n o s t i c e f f e c t o f p r e - a n d / o r
p o s t - o p e r a t i v e c h e m o t h e r a p y w a s a p p a r e n t l y s u b s t a n t i a l .
H o w e v e r , i t s i n d i c a t i o n w a s r e m a r k a b l y b i a s e d b y p a t i e n t s
p e r f o r m a n c e s t a t u s a n d s u p p o s e d c h e m o s e n s i t i v i t y t o t h e
9 1 3
tu m o r . T h e r e f o r e th is v a r ia b le w a s o m itte d f r o m th e p o o l
o f c a n d id a te p r o g n o s tic f a c to r s u s e d to b u ild th e C o x
m o d e ls f o r s u r v iv a l p r e d ic tio n p u r p o s e s .
P a tie n ts w ith c h o n d r o s a r c o m a a n d b o n e tu m o r s o th e r
th a n o s te o s a r c o m a h a d th e h ig h e s t s u r v iv a l r a te s in th is
s e r ie s , w ith 5 0 % o f 5 - y e a r o v e r a ll s u r v iv a l r a te s . O n th e
o th e r h a n d , th e w o r s t r e s u lts w e r e s e e n a m o n g p r im a r y
liv e r c a n c e r a n d m a lig n a n t m e la n o m a p a tie n ts , b o th g r o u p s
h a v in g n o s u r v iv o r s a f te r f iv e y e a r s . ( T a b le 2 ) .
O n ly tw o o f th e p r o g n o s tic f a c to r s w e r e s e le c te d in
th e s ta tis tic a l m o d e l a s in d e p e n d e n t p r e d ic to r s o f th e r is k
o f d e a th : th e ty p e o f p u lm o n a r y r e s e c tio n a n d D F I . T h e
m o d e l f o r b o n e tu m o r s in c lu d e d D F I , s e x a n d h is to lo g y .
T h e r is k o f d e a th d u e to s o f t p a r ts tu m o r s w a s o n ly a f f e c te d
b y th e n u m b e r o f m e ta s ta s e s a n d D F I ( T a b le 3 ) .
A s y n th e tic v a r ia b le r e p r e s e n tin g th e r is k o f d e a th w a s
c a lc u la te d u s in g r e g r e s s io n c o e f f ic ie n ts f r o m th e m u ltiv a r ia te
m o d e ls s h o w n in T a b le 3 . P a tie n ts w e r e s u b s e q u e n tly
g r o u p e d in to th r e e e m p ir ic a l r is k g r o u p s ( lo w , in te r m e d ia te
a n d h ig h ) b a s e d o n th e d is tr ib u tio n o f th e s y n th e tic lin e a r
p r e d ic to r s . T h e c u m u la tiv e s u r v iv a l d is tr ib u tio n f o r e a c h o f
th e s e r is k g r o u p s is s h o w n in f ig u r e 1 .
D IS C U S S IO N
T h e im p a c t o f v a r io u s p r o g n o s tic f a c to r s o n s u r v iv a l
r a te s o f p a tie n ts w h o u n d e r w e n t p u lm o n a r y m e ta s ta s e s
r e s e c tio n h a s b e e n r e c o g n iz e d in th e lite r a tu r e .
T h o u g h D F I h a s b e e n s h o w n b y v a r io u s a u th o r s
( 6 ,7 ,9 , I7 ,2 3 ,2 4 ,2 5 ,2 6 ,2 7 ) s p e c if ic a lly to b e th e m o s t
im p o r ta n t p r o g n o s tic f a c to r , o th e r in v e s tig a tio n s h a v e n o t
c o n f ir m e d th is f a c t ( 1 0 ,1 8 ,2 I).I n th is s tu d y , h o w e v e r , D F I
e m e r g e d a s o n e o f th e m o s t s ig n if ic a n t p r o g n o s tic f a c to r s .
A n o th e r s ig n if ic a n t p r e d ic to r o f o u tc o m e is th e ty p e
o f p u lm o n a r y r e s e c tio n , a v a r ia b le b a s e d o n s ite , s iz e a n d
n u m b e r o f m e ta s ta s e s ( 1 9 ,2 6 ) . I n s u m m a r y , th e la r g e r th e
s iz e o f p u lm o n a r y m e ta s ta s e s , th e w o r s e th e p r o g n o s is ,
b u t o n th e o th e r h a n d , to ta l c u r a tiv e p n e u m e c to m y is s till
d e f e n d e d b y s e v e r a l a u th o r s ( 6 ,9 ,1 4 ,1 6 ,1 7 ) . O u r r e s u lts
in d ic a te th a t th e ty p e o f r e s e c tio n w a s th e m o s t im p o r ta n t
p r e d ic to r o f s u r v iv a l. P a tie n ts s u b m itte d to w e d g e
r e s e c tio n s h a d a b e tte r p r o g n o s is .
R e g a r d le s s o f th e ty p e o f th o r a c to m y ,.w e f o u n d th a t
th e b e s t a c c e s s f o r th e w h o le lu n g is p o s te r o la te r a l, e v e n
S ite o f tu m o r
B o n e
S o ft p a rts
U ro g e n ita l a ) K id n e y b ) U te ru s c) B re a st d ) O th e r
O th e r a ) C o lo re cta l b ) L ive r c) S kin d ) H e a d /n e ck
T a b le 2
C u m u la tive su rviva l ra te s a cco rd in g to h isto p a to lo g y o f p rim a ry tu m o r
H isto lo g y # o f ca se s M e a n su rviva l S ta n d a rd e rro r 5 -ye a rs su rviva l p
O ste o sa rco m a 9 6 2 1 .5 3 .1 1 2 .9 0 .1 5 2 2
C h o n d ro sa rco m a 7 5 1 .0 2 1 .1 5 0 .0
O th e r 4 6 9 .9 4 1 .1 5 0 .0
R h a b d o m io sa . 9 2 6 .2 9 .0 2 0 .8 0 .9 6 4 9
O th e r 6 9 2 2 .7 2 .9 1 5 .7
A d e n o ca . 1 1 2 2 .0 1 4 .7 3 1 .2 0 .7 5 2 7
S q u a m o u s-ce ll ca . 1 3 2 1 .6 6 .9 2 9 .2
A d e n o ca . 8 2 9 .2 2 9 .1 1 4 .6
V a rio u s 1 4 2 8 .0 7 .5 4 2 .2
A d e n o ca . 1 6 1 2 .0 1 .7 2 2 .9 0 .1 3 8 1
C a rcin o m a 5 8 .8 2 .9 0 .0
M e la n o m a 7 1 0 .6 2 .5 0 .0
C a rcin o m a 1 7 8 .8 1 .7 1 0 .2
R O S S I, 8 .M .; L O P E S , A .; K O W A L S K I, L .P . & R E G A Z Z IN I, R .C .O . - P ro g n o stic fa cto rs in 2 9 1 p a tie n ts w ith p u lm o n a ry m e ta sta se s su b m itte d to th o ra co to m y
9 1 4
T a b l e 3
S t a t i s t i c a l m o d e l s f o r t h e r i s k o f d e a t h a f t e r s u r g i c a l t r e a t m e n t o f p u l m o n a r y m e t a s t a s e s
V ariable in the m odel T erm s R egression coefficient S tandard error
a) C om plete m odel (all sites and histologies):
T ype of resection Lobectom y 0.4274 0.2040
P neum ectom y 1.8516 0.3596
U nresectable 0.8041 0.1783
O F I 6-12 -0.0584 0.2392
> 12 -0.6639 0.1875
b) B one tum ors m odel:
O F I (m onths) 6-12 -0.5404 0.3078
> 12 -1.0752 0.3182
S ex F em ale 0.6820 0.2746
H istology C hondrosarcom a -1.0748 0.7244
O ther -0.9409 0.7396
c) S oft parts tum ors m odel:
N um ber de m etastases 2 -0.0833 0.3037
> = 3 0.4746 0.2295
O F I (m onths) 6-12 -0.0460 0.3198
> 12 -0.5301 0.2746
100
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TIME (MONTHS)
F i g u r e 1 -C um ulative survival distribution for low , interm ediate and high risk of death.
sao P aulo M edical Journal/R P M 113(3): 910-916,1995 R O S S I, 8.M .; LO P E S , A .; K O W A LS K I, L.P . & R E G A Z Z IN I. R .C .O . - P rognostic factors
9 1 5
in b ila te ra l le sio n s. In th e se c a se s a se q u e n tia l b ila te ra l
p o ste ro la te ra l th o ra c to m y is in d ic a te d .
T h e n u m b e r o f p u lm o n a ry m e ta sta se s is c o n sid e re d
a n im p o rta n t p ro g n o stic fa c to rs b y m a n y a u th o rs
(6 ,7 ,9 ,1 6 ,1 7 ,1 9 ,2 0 ,2 3 ,2 4 ,2 5 ,2 6 ,2 7 ). O th e r p a p e rs d e a lin g
w ith sq u a m o u s c a rc in o m a o f th e h e a d a n d n e c k (1 5 ,2 1 ,2 5 )
d o n o t c o n firm th o se re su lts. In th is stu d y th e n u m b e r o f
re se c te d p u lm o n a ry m e ta sta se s w a s a sig n ific a n t p ro g n o stic
fa c to r w h e n so lita ry le sio n s w e re c o m p a re d w ith tw o a n d
th re e o r m o re . H o w e v e r, p a tie n ts w ith g o o d p e rfo rm a n c e
sta tu s c a n re a c h th e lo n g te rm su rv iv a l c a te g o ry in sp ite o f
m u ltip le p u lm o n a ry m e ta sta se s. In o u r o p in io n , th e to ta l
n u m b e r o f m e ta sta se s sh o u ld n o t b e c o n sid e re d a s a n
a b so lu te lim itin g fa c to r fo r su rg e ry , e x c e p t w h e n w id e
p le u ra l d isse m in a tio n o c c u rs. T h e sa m e is v a lid fo r
re c u rre n t le sio n s, w h e n d ia g n o se d b y c o m p u te riz e d
to m o g ra p h y .
C h e m o th e ra p y w a s a sig n ific a n t p ro g n o stic fa c to r in
p re lim in a ry a n a ly sis; h o w e v e r w e m u st b e a r in m in d o th e r
p o ssib ly c o n fu sin g v a ria b le s su c h a s th e v a rie ty o f ty p e s
o f p rim a ry tu m o rs a n d v a rio u s stra te g ie s o f c h e m o th e ra p y
u se d o v e r th e 3 3 y e a r ra n g e o f th e . stu d y . In th e c a se o f
o ste o sa rc o m a , fo r e x a m p le , c h e m o th e ra p y h a s b e e n th e
first o p tio n a s a n e o -a d ju v a n t th e ra p y fo r p u lm o n a ry
m e ta sta se s fo r th e la st 2 0 y e a rs (1 5 ,1 9 ). N e o -a d ju v a n t a n d
a d ju v a n t c h e m o th e ra p y h a v e a lso b e e n u se d o n W ilm s'
tu m o rs, o v a ry a n d te stic u la r c a rc in o m a (2 ,7 ). T h e p a tie n ts
c la ssifie d a s h a v in g u n re se c ta b le p u lm o n a ry d ise a se in th is
stu d y w h o su rv iv e d m o re th a n 5 y e a rs h a d , in fa c t,
c h e m o se n sitiv e tu m o rs.
H isto lo g y a n d site o f p rim a ry tu m o r d o n o t sh o w a n y
sig n ific a n t e ffe c t o n su rv iv a l re su lts a fte r p u lm o n a ry
m e ta sta se s re se c tio n . H o w e v e r, tu m o rs lik e
c h o n d ro sa rc o m a , k id n e y a d e n o c a rc in o m a , W ilm s' tu m o r,
c o lo re c ta l c a rc in o m a a n d u te rin e c e rv ix c a rc in o m a te n d e d
to h a v e a b e tte r p ro g n o sis. O n th e o th e r h a n d , th e re w e re
n o su rv iv o rs o f m a lig n a n t sk in m e la n o m a o r p rim a ry liv e r
c a n c e r.
O u r stu d y c o n firm e d th a t se x a n d a g e d o n o t h a v e a
sig n ific a n t e ffe c t o n su rv iv a l re su lts (1 0 ,2 0 ).
In c o n c lu sio n , p a tie n ts w h o h a v e a D F I th a t is
g re a te r th a n 6 m o n th s, a n d a sin g le le sio n th a t is
re se c ta b le w ith w e d g e su rg e ry h a v e th e b e st p ro g n o sis.
H isto lo g y a n d site o f p rim a ry tu m o r m u st b e a n a ly z e d
c a se b y c a se , b u t w e th in k th a t su rg e ry is still th e o n ly
w a y to o ffe r a la st c h a n c e o f p ro lo n g e d a n d c o m fo rta b le
su rv iv a l fo r m a n y p a tie n ts.
RESUMO
O b je tiv o s : A d is s e m in a y a o n e o p la s ic a p a ra o s p u lm o e s e m u ito c o m u m , p rin c ip a l m e n te n o s tu m o re s p rim a rio s d e o rig e m m e s e n q u im a l. A p e s a r d o d e s e n v o lv im e n to d o tra ta m e n to d o c a n c e r, 0p ro g n 6 s tic o d e p a c ie n te s c o m m e ta s ta s e s p u lm o n a re s c o n tin u a p o b re , e x c e to p a ra u m g ru p o s e le to d e p a c ie n te s , q u e s a o e le ito s p a ra 0 tra ta m e n to c iru rg ic o , e a q u e le s c o m m a io r s e n s ib ilid a d e
a
q u im io te ra p ia . M a te ria l e M e to d o s : 0 p rin c ip a l objetivo d e s te e s tu d o e avaliar re s u lta d o s d e tra ta m e n to e m u m a s e rie d e 2 9 1 p a c ie n te s s u b m e tid o s c o n s e c u tiv a m e n tea
to ra c o to m ia p o r m e ta s ta s e s p u lm o n a re s , e n tre 1 9 5 3 e 1 9 8 6 . 0 n u m e ro d e m e ta s ta s e s v a rio u d e 1 a 3 0 , s e n d o q u e 0 tip o d e re s s e c y a o d e p e n d e u d a lo c a liz a y a o , ta m a n h o e n u m e ro d e le s o e s p u lm o n a re s . F o ra m re a liz a d a s 1 5 4 re s s e c y o e s e m c u n h a , 4 9 lo b e c to m ia s e 9 p n e u m o n e c to m ia s . 0 tu m o r fo i irre s s e c a v e l e m 7 9 c a s o s . R e s u lta d o s e c o n c lu s a o : D o s fa to re s p ro g n 6 s tic o s a n a lis a d o s , s o m e n te 0 tip o d e re s s e c y a o p u lm o n a r (c u n h avs lo b e c to m ia vs p n e u m o n e 'c to m ia vs irre s s e c a v e l) e0 in te rv a lo livre d e d o e n y a (O F I) e n tre 0tra ta m e n to d o tu m o r p rim a rio e
o d ia g n 6 s tic o d a m e ta s ta s e p u lm o n a r (m e n o r q u e 6 m e s e s VS.e n tre 7 e 1 2 m e s e s VS.m a io r q u e 1 2 m e s e s ) fo ra m fa to re s in d e p e n d e n te s s e le c io n a d o s c o m o d e ris c o p a ra 6 b ito e m a n a lis e m u ltiv a ria d a . U m a a n a lis e d e m o d e lo re d u z id o p a ra tu m o re s 6 s s e o s in c lu iu in te rv a lo liv re d e d o e n y a , s e x o e h is to lo g ia .
R O S S I, 8 .M .; L O P E S , A ;K O W A L S K I, L .P . & R E G A Z Z IN I, R .C .O . - P ro g n o s tic fa c to rs in 2 9 1 p a tie n ts w ith p u lm o n a ry m e ta s ta s e s s u b m itte d to th o ra c o to m y
916
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