Bakir Mohammed, Fraser Stephanie, Routledge Tom, Scarci Marco
King's College London School of Medicine, First Floor, Hodgkin Building, Guy's Campus, London, SE1 1UL, UK.
Interact Cardiovasc Thorac Surg. 2011 Sep;13(3):303-10. doi: 10.1510/icvts.2011.267872. Epub 2011 Jun 17.
The role of surgery in the treatment of patients with stage IIIa non-small cell lung cancer (NSCLC) and mediastinal node involvement is examined in this best evidence topic according to a structured protocol. A total of 579 papers were identified using the outlined search, 12 of which were deemed to represent the best available evidence. From the data summarized, we conclude that surgery, as part of a multimodality therapeutic approach, offers a survival benefit for patients with resectable N2 NSCLC. Overall five-year survival rates following primary resection ranged from 17% to 20% (four studies). Improved five-year survival was demonstrated with multimodality therapy (19-45%; 13 studies). Subgroup analysis demonstrates a five-year survival of 30.5% with postoperative chemo-radiotherapy, 22.2% with chemotherapy alone, and 27% with radiotherapy alone. In our review, we address three major issues regarding the management of stage IIIa NSCLC, the first of which is primary vs. postinduction surgery. The largest cohort series to date is the International Association for the Study of Lung Cancer Staging Committee paper on nodal disease, which reports that patients with single-zone N2 disease had the same survival outcome as patients with multizone N1 disease. The second issue is that of randomized vs. cohort studies: there have been five randomized trials reporting similar outcomes and hence equipoise. The third issue is postinduction staging. All studies evaluated reported a better outcome in patients with ypN0 (i.e. postinduction N0 disease). However, surgery should not be denied to patients with ypN1-N2, as there is evidence to demonstrate a significant improvement in survival time in all patients able to undergo surgery after induction chemo-radiotherapy. In conclusion, although some of the evidence available is equivocal regarding the survival benefit of resection for stage IIIa N2 disease, the authors believe surgery should be considered as part of a multimodality therapeutic strategy for patients with advanced nodal disease.
本最佳证据专题依据结构化方案，探讨了手术在治疗Ⅲa期非小细胞肺癌（NSCLC）并伴有纵隔淋巴结受累患者中的作用。通过概述的检索方法共识别出579篇论文，其中12篇被视为代表了现有最佳证据。根据汇总数据，我们得出结论，手术作为多模式治疗方法的一部分，可为可切除的N2期NSCLC患者带来生存获益。初次切除后的总体五年生存率在17%至20%之间（四项研究）。多模式治疗显示五年生存率有所提高（19% - 45%；13项研究）。亚组分析表明，术后放化疗的五年生存率为30.5%，单纯化疗为22.2%，单纯放疗为27%。在我们的综述中，我们讨论了关于Ⅲa期NSCLC治疗的三个主要问题，第一个问题是初次手术与诱导术后手术。迄今为止最大的队列系列是国际肺癌研究协会分期委员会关于淋巴结疾病的论文，该论文报告单区域N2疾病患者与多区域N1疾病患者的生存结果相同。第二个问题是随机对照试验与队列研究的问题：有五项随机试验报告了相似的结果，因此存在 equipoise（暂不明确如何准确翻译该术语，可保留英文）。第三个问题是诱导术后分期。所有评估的研究均报告ypN0（即诱导术后N0疾病）患者的预后更好。然而，对于ypN1 - N2患者不应拒绝手术，因为有证据表明，所有诱导放化疗后能够接受手术的患者，其生存时间都有显著改善。总之，尽管现有一些证据对于Ⅲa期N2疾病切除的生存获益并不明确，但作者认为手术应被视为晚期淋巴结疾病患者多模式治疗策略的一部分。
