Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY 10065, USA.
J Thorac Cardiovasc Surg. 2011 Jan;141(1):48-58. doi: 10.1016/j.jtcvs.2010.07.092. Epub 2010 Nov 18.
In clinical stage IIIA non-small cell lung cancer, the role of surgical resection, particularly pneumonectomy, after induction therapy remains controversial. Our objective was to determine factors predictive of survival after postinduction surgical resection.
We retrospectively reviewed a prospectively collected database of 136 patients who underwent surgical resection after induction chemotherapy (n = 119) or chemoradiation (n = 17) from June 1990 to January 2010.
One hundred five lobectomies or bilobectomies and 31 pneumonectomies were performed. There was 1 perioperative death (pneumonectomy). Seventy-one patients had downstaging to N0 or N1 nodal status (52%). There were 2 complete pathologic responses. Median follow-up was 42 months (range, 0.69-136 months). Overall 5-year survival for entire cohort was 33% (36% lobectomy, 22% pneumonectomy, P = .001). Patients with pathologic downstaging to pN0 or pN1 had improved 5-year survival (45% vs 20%, P = .003). For patients with pN0 or pN1 disease, survival after lobectomy was better than after pneumonectomy (48% vs 27%, P = .011). In patients with residual N2 disease, there was no statistically significant survival difference between lobectomy and pneumonectomy (5-year survival, 21% vs 19%; P = .136). Multivariate analysis showed as independent predictors of survival age (hazard ratio, 1.05; P = .002), extent of resection (hazard ratio, 2.01; P = .026), and presence of residual pN2 (hazard ratio, 1.60; P = .047).
After induction therapy for patients with clinical stage IIIA disease, both pneumonectomy and lobectomy can be safely performed. Although survival after lobectomy is better, long-term survival can be accomplished after pneumonectomy for appropriately selected patients. Nodal downstaging is important determinant of survival, particularly after lobectomy.
在临床 IIIA 期非小细胞肺癌中，诱导治疗后手术切除的作用，尤其是全肺切除术，仍然存在争议。我们的目的是确定诱导治疗后手术切除患者生存的预测因素。
我们回顾性分析了 1990 年 6 月至 2010 年 1 月期间接受诱导化疗（n=119）或放化疗（n=17）后手术切除的 136 例患者的前瞻性数据库。
105 例患者行肺叶切除术或双肺叶切除术，31 例患者行全肺切除术。围手术期死亡 1 例（全肺切除术）。71 例患者降期至 N0 或 N1 淋巴结状态（52%）。2 例患者病理完全缓解。中位随访时间为 42 个月（0.69-136 个月）。整个队列的 5 年生存率为 33%（肺叶切除术 36%，全肺切除术 22%，P=0.001）。降期至 pN0 或 pN1 的患者 5 年生存率提高（45%比 20%，P=0.003）。对于 pN0 或 pN1 疾病的患者，肺叶切除术的生存优于全肺切除术（48%比 27%，P=0.011）。对于残留 N2 疾病的患者，肺叶切除术和全肺切除术的生存无统计学差异（5 年生存率，21%比 19%；P=0.136）。多因素分析显示，生存的独立预测因素包括年龄（风险比，1.05；P=0.002）、切除范围（风险比，2.01；P=0.026）和残留 pN2（风险比，1.60；P=0.047）。
对于临床 IIIA 期疾病患者，在诱导治疗后可安全地进行全肺切除术和肺叶切除术。虽然肺叶切除术的生存更好，但对于适当选择的患者，全肺切除术也可获得长期生存。淋巴结降期是生存的重要决定因素，尤其是在肺叶切除术后。
