Grunenwald D H
Thoracic Department, Institut Mutualiste Montsouris, Paris, France.
Semin Surg Oncol. 2000 Mar;18(2):137-42. doi: 10.1002/(sici)1098-2388(200003)18:2<137::aid-ssu7>3.0.co;2-a.
Therapeutic strategy in advanced stage disease remains controversial. Theoretically resectable, Stage IIIa disease includes a high proportion of non-resectable nodal diseases. Overall 5-year survival after surgery remains lower than 15%. Randomized trials comparing the results of surgery alone with induction chemotherapy followed by surgery showed a significant benefit to induction therapy. Currently, Stage IIIb diseases are considered unresectable; nevertheless, selected patients are able to undergo an extended resection after induction treatments. In highly selected cases, a surgical resection can be performed in T4 tumors. Surgical resection must be included in a combined multidisciplinary strategy of treatment, and is proposed only for responders. Resectability criteria have to be defined with clinical trials designed to increase the local control by surgery. Thus, so-called Stage IIIb tumors can be divided in two subcategories: potentially resectable and definitively non-resectable. Some locally advanced, initially unresectable tumors (Stage IIIb) can become operable after induction chemoradiotherapy. The French staging system, based upon prognostic and therapeutic subcategories, splits N2 involvement into two subcategories: mN2 (minimal), found at the thoracotomy; and cN2 (clinical), histologically proven at the pre-treatment staging. T4 tumors are divided in potentially resectable T4(1) (invasion of superior vena cava, carina, lower trachea, left atrium), and definitively non-resectable T4(2) (malignant pleural or pericardial effusion, invasion of oesophagus, and vertebrae). Thus, Stage III can be separated into three subcategories, A, B, and C, instead of the two current substages. Stage IIIA includes T3 N1 M0 and T1-T3mN2M0 tumors. Stage IIIB includes T1-T3cN2M0 and T4(1)N0-N2MO tumors. Stage IIIC includes T4(2)N0-N3M0 and T1-T4(1)N3M0 tumors. In this way, the therapeutic options in non-small-cell lung cancer (NSCLC) will be clarified with 1) a "primary surgery" subgroup, including Stages I, II, and IIIA, 2) an "induction treatment" subgroup, including Stage IIIB, and 3) a "non-surgical" subgroup, including Stages IIIC and IV.
晚期疾病的治疗策略仍存在争议。理论上可切除的Ⅲa期疾病包含高比例的不可切除的淋巴结疾病。手术后总体5年生存率仍低于15%。比较单纯手术结果与诱导化疗后手术结果的随机试验显示诱导治疗有显著益处。目前，Ⅲb期疾病被认为不可切除；然而，部分患者在诱导治疗后能够接受扩大切除术。在经过严格筛选的病例中，T4肿瘤可进行手术切除。手术切除必须纳入多学科综合治疗策略，且仅建议用于有反应的患者。必须通过旨在提高手术局部控制率的临床试验来确定可切除性标准。因此，所谓的Ⅲb期肿瘤可分为两个亚类：潜在可切除和明确不可切除。一些局部晚期、最初不可切除的肿瘤（Ⅲb期）在诱导放化疗后可变为可手术切除。基于预后和治疗亚类的法国分期系统将N2受累分为两个亚类：mN2（微小），在开胸手术时发现；以及cN2（临床），在治疗前分期时经组织学证实。T4肿瘤分为潜在可切除的T4(1)（侵犯上腔静脉、隆突、下气管、左心房）和明确不可切除的T4(2)（恶性胸腔或心包积液、侵犯食管和椎体）。因此，Ⅲ期可分为三个亚类，A、B和C，而非目前的两个亚期。ⅢA期包括T3 N1 M0和T1-T3 mN2 M0肿瘤。ⅢB期包括T1-T3 cN2 M0和T4(1) N0-N2 M0肿瘤。ⅢC期包括T4(2) N0-N3 M0和T1-T4(1) N3 M0肿瘤。通过这种方式，非小细胞肺癌（NSCLC）的治疗选择将得以明确，包括1）“一期手术”亚组，包括Ⅰ期、Ⅱ期和ⅢA期；2）“诱导治疗”亚组，包括ⅢB期；3）“非手术”亚组，包括ⅢC期和Ⅳ期。
