Chambers Anthony, Routledge Tom, Billè Andrea, Scarci Marco
Brighton and Sussex Medical School, University of Sussex, Brighton, East Sussex BN1 9PX, UK.
Interact Cardiovasc Thorac Surg. 2010 Oct;11(4):473-9. doi: 10.1510/icvts.2010.235119. Epub 2010 Jul 9.
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether [surgery] has a role in [treatment of T4N0 and T4N1 lung cancer]. Altogether more than 151 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that upfront surgery for locally invasive T4 tumours without mediastinal lymph node involvement (T4N0 and T4N1 non-small cell lung cancer) is of benefit in terms of survival rates in carefully selected patients. Overall five-year survival rates following resection of T4N0-N2 tumours vary from 19.1% to 57% (from six studies), within which, involvement of certain structures were found to greatly affect prognosis. Pulmonary artery invasion has a good prognosis (five-year survival; 52.8%) relative to other mediastinal structures [five-year survival: left atrium; N0; 28.94%, N1; 27.92%, N2; 17.95% (three-year survival), aorta; N0; 100%, N1; 37.1%, N2; 0%, superior vena cava (SVC); 11%, -29.4% (from four studies), carina; 28-42.5% (two studies), veterbral bodies; 16%, oesophagus; 12%, pleural dissemination; 0%]. When considering isolated invasion of the pulmonary great vessels there are mixed outcomes, one study reporting reduced mortality (reduced risk -0.483, P=0.004) in contrast to another that found five-year survival of 35.7% with great vessel invasion vs. 58.3% for invasion of all other structures excluding the pulmonary great vessels. The prognostic variables found to be of greatest determinacy were; first, the completeness of resection, wherein five-year survival rates ranged from 37.5 to 46.2% (from three studies) with complete tumour removal, and 15.9-22.4% (from three studies) with incomplete resection, and second, nodal status of the patients, N0/N1 having five-year survival of 43-74% and N2 of 15.1-17.5% (P=0.022 and P=0.007, for two studies). Multiple intralobar lesions represent either multilobar metastasis or NSCLC with multifocal origin and have been found to behave differently to invasive T4 tumours. Reported five-year survival in NSCLC with satellite nodules is 48.2-57% compared with 18-30% from T4 invasive tumours (three studies), respectively (P=0.011) corroborating the change in TNM ipsilobar multifocal T4 disease to be recoded as T3.
根据结构化方案撰写了一篇胸外科最佳证据主题文章。该问题探讨了[手术]在[T4N0和T4N1肺癌治疗]中是否具有作用。通过报告的检索共找到151多篇论文，其中15篇代表了回答该临床问题的最佳证据。现将这些论文的作者、期刊、发表日期、国家、研究的患者组、研究类型、相关结局及结果制成表格。我们得出结论，对于局部侵犯性T4肿瘤且无纵隔淋巴结受累（T4N0和T4N1非小细胞肺癌）的患者，在经过精心挑选后， upfront手术对生存率有益。T4N0 - N2肿瘤切除后的总体五年生存率在19.1%至57%之间（来自六项研究），其中发现某些结构受累会极大影响预后。相对于其他纵隔结构，肺动脉侵犯的预后较好（五年生存率；52.8%）[五年生存率：左心房；N0；28.94%，N1；27.92%，N2；17.95%（三年生存率），主动脉；N0；100%，N1；37.1%，N2；0%，上腔静脉（SVC）；11%，-29.4%（来自四项研究），隆突；28 - 42.5%（两项研究），椎体；16%，食管；12%，胸膜播散；0%]。在考虑孤立的肺大血管侵犯时，结果不一，一项研究报告死亡率降低（风险降低 -0.483，P = 0.004），而另一项研究发现肺大血管侵犯的五年生存率为35.7%，相比之下，除肺大血管外所有其他结构侵犯的五年生存率为58.3%。发现最具决定性的预后变量为：首先，切除的完整性，其中肿瘤完全切除的五年生存率在37.5%至46.2%之间（来自三项研究），不完全切除的五年生存率在15.9 - 22.4%之间（来自三项研究）；其次，患者的淋巴结状态，N0/N1的五年生存率为43 - 74%，N2的五年生存率为15.1 - 17.5%（两项研究中P = 0.022和P = 0.007）。多个叶内病变代表多叶转移或多灶起源的非小细胞肺癌，并且已发现其行为与侵袭性T4肿瘤不同。报告的伴有卫星结节的非小细胞肺癌的五年生存率为48.2 - 57%，而T4侵袭性肿瘤的五年生存率为18 - 30%（三项研究），分别（P = 0.011），这证实了TNM同侧叶多灶性T4疾病应重新分类为T3。
