Department of Radiation Oncology, University of Massachusetts Medical Center, Worcester, Massachusetts.
Department of Healthcare Policy and Research, Virginia Commonwealth University, Richmond, Virginia.
Int J Radiat Oncol Biol Phys. 2015 Mar 15;91(4):765-73. doi: 10.1016/j.ijrobp.2014.12.028.
Current National Comprehensive Cancer Network guidelines recommend postoperative radiation therapy (PORT) for patients with resected non-small cell lung cancer (NSCLC) with N2 involvement. We investigated the relationship between nodal stage and local-regional recurrence (LR), distant recurrence (DR) and overall survival (OS) for patients having an R0 resection.
A multi-institutional database of consecutive patients undergoing R0 resection for stage I-IIIA NSCLC from 1995 to 2008 was used. Patients receiving any radiation therapy before relapse were excluded. A total of 1241, 202, and 125 patients were identified with N0, N1, and N2 involvement, respectively; 161 patients received chemotherapy. Cumulative incidence rates were calculated for LR and DR as first sites of failure, and Kaplan-Meier estimates were made for OS. Competing risk analysis and proportional hazards models were used to examine LR, DR, and OS. Independent variables included age, sex, surgical procedure, extent of lymph node sampling, histology, lymphatic or vascular invasion, tumor size, tumor grade, chemotherapy, nodal stage, and visceral pleural invasion.
The median follow-up time was 28.7 months. Patients with N1 or N2 nodal stage had rates of LR similar to those of patients with N0 disease, but were at significantly increased risk for both DR (N1, hazard ratio [HR] = 1.84, 95% confidence interval [CI]: 1.30-2.59; P=.001; N2, HR = 2.32, 95% CI: 1.55-3.48; P<.001) and death (N1, HR = 1.46, 95% CI: 1.18-1.81; P<.001; N2, HR = 2.33, 95% CI: 1.78-3.04; P<.001). LR was associated with squamous histology, visceral pleural involvement, tumor size, age, wedge resection, and segmentectomy. The most frequent site of LR was the mediastinum.
Our investigation demonstrated that nodal stage is directly associated with DR and OS but not with LR. Thus, even some patients with, N0-N1 disease are at relatively high risk of local recurrence. Prospective identification of risk factors for local recurrence may aid in selecting an appropriate population for further study of postoperative radiation therapy.
目前，美国国家综合癌症网络指南建议对接受手术切除的非小细胞肺癌（NSCLC）伴 N2 受累患者进行术后放疗（PORT）。我们研究了 N 分期与局部-区域复发（LR）、远处复发（DR）和总生存（OS）之间的关系，以评估接受 R0 切除的患者。
使用了一个多机构数据库，其中包括 1995 年至 2008 年间接受 I 期-IIIA 期 NSCLC 根治性切除术的连续患者。排除了在复发前接受任何放疗的患者。分别确定了 1241、202 和 125 例 N0、N1 和 N2 受累患者；161 例患者接受了化疗。作为首次失败部位，计算 LR 和 DR 的累积发生率，并使用 Kaplan-Meier 估计 OS。使用竞争风险分析和比例风险模型来检查 LR、DR 和 OS。独立变量包括年龄、性别、手术方式、淋巴结取样范围、组织学、淋巴血管侵犯、肿瘤大小、肿瘤分级、化疗、淋巴结分期和脏层胸膜侵犯。
中位随访时间为 28.7 个月。N1 或 N2 淋巴结分期的患者 LR 率与 N0 疾病患者相似，但 DR 风险显著增加（N1，风险比[HR] = 1.84，95%置信区间[CI]：1.30-2.59；P<.001；N2，HR = 2.32，95% CI：1.55-3.48；P<.001）和死亡（N1，HR = 1.46，95% CI：1.18-1.81；P<.001；N2，HR = 2.33，95% CI：1.78-3.04；P<.001）。LR 与鳞癌组织学、脏层胸膜受累、肿瘤大小、年龄、楔形切除术和节段切除术有关。LR 最常见的部位是纵隔。
我们的研究表明，淋巴结分期与 DR 和 OS 直接相关，但与 LR 无关。因此，即使是 N0-N1 疾病的一些患者也存在相对较高的局部复发风险。对局部复发危险因素的前瞻性识别可能有助于选择合适的人群进行术后放疗的进一步研究。
