Komaki R, Roth J A, Walsh G L, Putnam J B, Vaporciyan A, Lee J S, Fossella F V, Chasen M, Delclos M E, Cox J D
Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
Int J Radiat Oncol Biol Phys. 2000 Sep 1;48(2):347-54. doi: 10.1016/s0360-3016(00)00736-7.
Superior sulcus tumors (SST) of the lung are uncommon and constitute approximately 3% of non-small cell lung cancer (NSCLC). These tumors cause specific symptoms and signs, and are associated with patterns of failure that differ from those seen for NSCLC tumors in other nonapical locations. Prognostic factors and most effective treatments are controversial. We conducted a retrospective study at The University of Texas M. D. Anderson Cancer Center to identify outcome predictors for patients with SST treated by a multidisciplinary approach.
This retrospective review of 143 patients without distant metastasis at presentation is a continuation of a previous M. D. Anderson study now updated to 1994. In this study, we examine the 5-year survival rate by pretreatment tumor and patient characteristics and by the treatments received. Strict criteria were used to define SST. Actuarial life-table analyses and Cox proportional hazard models were used to compare survival rates.
Overall predictors of 5-year survival were weight loss (p < 0.01), supraclavicular fossa (p = 0. 03), or vertebral body (p = 0.05) involvement, stage of the disease (p < 0.01), and surgical treatment (p < 0.01). Five-year survival for patients with Stage IIB disease was 47% compared to 14% for Stage IIIA, and 16% for Stage IIIB. For patients with Stage IIB disease, surgical treatment (p < 0.01) and weight loss (p = 0.01) were significant independent predictors of 5-year survival. Among patients with Stage IIIA disease, the only predictor of survival was Karnofsky performance score (KPS) (p = 0.02). For patients with Stage IIIB disease, the only independent predictor of survival was a right superior sulcus location, which was associated with a worse 5-year survival rate than that for patients with tumors in the left superior sulcus (p = 0.02). More patients with adenocarcinoma than with squamous cell tumors experienced cerebral metastases within 5 years (p < 0.01). Patients without gross residual disease after surgical resection who received postoperative radiation therapy with total doses of 55 to 64 Gy had a 5-year survival rate of 82% as compared with the 5-year survival rate of 56% in patients who received 50 to 54 Gy. Twenty-three patients survived for longer than 3 years. Of these, 4 patients (17%) received radiation therapy alone or in combination with chemotherapy without surgical resection. The other 19 patients (83%) had resection combined with radiation therapy and/or chemotherapy.
The findings from this study confirm the importance of the new staging system, separating T3 N0 M0 (Stage IIB) from Stage IIIA, since there was a significant difference in the 5-year survival (p < 0.01). Interestingly, there was no significant 5-year survival difference between Stage IIIA (N2) and Stage IIIB (T4 or N3). This study also suggests that surgery is an important component of the multidisciplinary approach to patients with SST if their nodes were negative. Disease that is minimally invading surrounding normal structures can be resected followed by radiation therapy in doses of 55 to 64 Gy. Further investigation of treatment strategies combining high-dose radiation therapy (>/=66 Gy) with chemotherapy is indicated for patients with unresectable and/or node-positive (N2) SST.
肺上沟瘤（SST）并不常见，约占非小细胞肺癌（NSCLC）的3%。这些肿瘤会引发特定的症状和体征，且其失败模式与其他非肺尖部位的NSCLC肿瘤不同。预后因素和最有效的治疗方法存在争议。我们在德克萨斯大学MD安德森癌症中心进行了一项回顾性研究，以确定采用多学科方法治疗的SST患者的预后预测因素。
本回顾性研究对143例初诊时无远处转移的患者进行，是MD安德森之前一项研究的延续，现更新至1994年。在本研究中，我们根据治疗前肿瘤和患者特征以及所接受的治疗来检查5年生存率。采用严格标准定义SST。使用精算生命表分析和Cox比例风险模型比较生存率。
5年生存的总体预测因素为体重减轻（p < 0.01）、锁骨上窝受累（p = 0.03）或椎体受累（p = 0.05）、疾病分期（p < 0.01）以及手术治疗（p < 0.01）。IIB期疾病患者的5年生存率为47%，而IIIA期为14%，IIIB期为16%。对于IIB期疾病患者，手术治疗（p < 0.01）和体重减轻（p = 0.01）是5年生存的显著独立预测因素。在IIIA期疾病患者中，生存的唯一预测因素是卡诺夫斯基性能评分（KPS）（p = 0.02）。对于IIIB期疾病患者，生存的唯一独立预测因素是右上沟位置，与左上沟肿瘤患者相比，其5年生存率更差（p = 0.02）。腺癌患者比鳞状细胞肿瘤患者在5年内发生脑转移的更多（p < 0.01）。手术切除后无大体残留疾病且接受总剂量为55至64 Gy术后放疗的患者5年生存率为82%，而接受50至54 Gy放疗的患者5年生存率为56%。23例患者存活超过3年。其中，4例患者（17%）单独接受放疗或放疗联合化疗而未进行手术切除。其他19例患者（83%）进行了手术切除联合放疗和/或化疗。
本研究结果证实了新分期系统的重要性，即将T3 N0 M0（IIB期）与IIIA期区分开来，因为5年生存率存在显著差异（p < 0.01）。有趣的是，IIIA期（N2）和IIIB期（T4或N3）之间5年生存率无显著差异。本研究还表明，如果患者淋巴结阴性，手术是SST患者多学科治疗方法的重要组成部分。对周围正常结构侵犯最小的疾病可进行切除，随后给予55至64 Gy的放疗。对于不可切除和/或淋巴结阳性（N2）的SST患者，建议进一步研究高剂量放疗（≥66 Gy）与化疗联合的治疗策略。
