Tsitsias Thomas, Boulemden Anas, Ang Keng, Nakas Apostolos, Waller David A
Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK.
Eur J Cardiothorac Surg. 2014 May;45(5):882-7. doi: 10.1093/ejcts/ezt478. Epub 2013 Sep 29.
Resection of N2a non-small-cell lung cancer (NSCLC) diagnosed preoperatively is controversial but there is support for resection of unexpected N2 disease discovered at surgery. Since the seventh TNM edition, we have intentionally resected clinical N2a disease. To validate this policy, we determined prognostic factors associated with all resected N2 disease.
From a prospective database of 1131 consecutive patients undergoing elective resection for primary lung cancer over a period of 8 years, we identified 68 patients (35 females (51.4%), mean age 66 years, standard deviation (SD) 9 years) who had pathological N2 disease. All patients had positron emission computed tomography (CT-PET) staging and selective mediastinoscopy. A Cox-regression analysis was performed to identify prognostic factors.
At a median follow-up of 38.7 months (standard error 10, 95% confidence interval (CI) 19.0-58.4), the overall median survival was 22.2 months (95% CI 14.6-29.8) with 1-, 2- and 5-year survival rates of 63.3, 46.6 and 13.2%, respectively. Survival after resection of pN2 disease is adversely affected by the need for pneumonectomy, multizone pN2b involvement and by non-compliance with adjuvant chemotherapy. Pathological involvement of the subcarinal zone but no other zone appears to be associated with an adverse prognosis (hazard ratio (HR) 1.87, P = 0.063). Importantly, long-term survival is not different between those patients who have a negative preoperative PET-CT scan and yet are found to have pN2 after resection, and those who are single-zone cN2a positive before resection on PET-CT scan (HR 1.37, P = 0.335).
Our results support a policy of intentionally resecting single-zone N2a NSCLC identified preoperatively as part of a multimodality therapy.
术前诊断为N2a期的非小细胞肺癌（NSCLC）是否进行手术切除存在争议，但对于手术中意外发现的N2期病变进行切除有一定支持依据。自第7版TNM分期以来，我们一直有意对临床N2a期病变进行手术切除。为验证这一策略，我们确定了与所有切除的N2期病变相关的预后因素。
从一个前瞻性数据库中，该数据库涵盖了8年间连续1131例行原发性肺癌择期切除术的患者，我们识别出68例有病理N2期病变的患者（35例女性（51.4%），平均年龄66岁，标准差（SD）9岁）。所有患者均接受了正电子发射计算机断层扫描（CT-PET）分期及选择性纵隔镜检查。进行Cox回归分析以确定预后因素。
中位随访38.7个月（标准误10，9５%置信区间（CI）19.0 - 58.4），总体中位生存期为22.2个月（95%CI 14.6 - 29.8），1年、2年和5年生存率分别为63.3%、46.6%和13.2%。肺叶切除术的需求、多区域pN2b受累以及未接受辅助化疗对pN2期病变切除后的生存产生不利影响。隆突下区域的病理受累但无其他区域受累似乎与不良预后相关（风险比（HR）1.87，P = 0.063）。重要的是，术前PET-CT扫描为阴性但切除后发现为pN2的患者与术前PET-CT扫描为单区域cN2a阳性但切除前的患者相比，长期生存率无差异（HR 1.37，P = 0.335）。
我们的结果支持将术前识别的单区域N2a期NSCLC作为多模式治疗的一部分进行有意切除的策略。
