Graeter Thomas P, Sebastian Benni, Bischof Marc, Kugler Gudrun, Fischer Juergen R, Schneider Thomas
Department of Thoracic and Vascular Surgery, Klinik Loewenstein, Löwenstein, Germany.
Institute for Radiation Therapy, SLK-Kliniken Heilbronn, Heilbronn, Germany.
Thorac Cardiovasc Surg. 2016 Sep;64(6):501-6. doi: 10.1055/s-0035-1562940. Epub 2015 Aug 31.
Objectives The role of postoperative mediastinal radiotherapy in completely resected non-small cell lung cancer (NSCLC) and pathological N2 disease is controversial. In clinical practice, not all lung cancer patients with histologically confirmed N2 disease and a high risk for local recurrence are able to undergo postoperative concurrent radio/chemotherapy due to their physical condition or postoperative morbidities. Mediastinal radiotherapy is less compromising than a combination of radio/chemotherapy and seems likely to be tolerable for limited patients to achieve better local tumor control. Materials and Methods All patients included in this retrospective analysis were excluded from postoperative adjuvant combination chemo/radiotherapy due to their comorbidity, advanced age, or a complicated postoperative course. Three-dimensional conformal radiotherapy of the mediastinal lymph node stations (mean dose: 50 Gy; range: 50-54 Gy) in patients with R0 resection, additional boost of 10 Gy in patients with R1 or R2 resection, was performed postoperatively. Results A total of 110 patients were included in this analysis. Mean survival was 25.5 ± 19.2 months. The 1-, 3-, and 5-year survival was 75.4, 38.7, and 26.2%, respectively. Postoperative complications and the development of distant metastases did not correlate (p = 0.7). Distant metastases proved to be a significant prognostic factor of survival (p < 0.0001). Local recurrence was seen in a total of three patients (2.7%). Five-year survival of patients developing major postoperative complications was significantly inferior (p = 0.04) to those without postoperative complications. The extent of surgery had a significant impact on survival-5-year survival after lobectomy was significantly longer than after pneumonectomy (p = 0.029). R1 resection had no significant impact on the survival rates (p = 0.67). Discussion Stage III-N2 NSCLC patients with multiple comorbidities or a complicated postoperative course after surgery may benefit from modern mediastinal radiotherapy. Surgery and postoperative mediastinal radiotherapy can achieve local tumor control. Distant metastases have the highest impact on the prognosis. Pneumonectomy, however, should be avoided in stage III NSCLC, when possible.
目的 术后纵隔放疗在完全切除的非小细胞肺癌（NSCLC）及病理N2期疾病中的作用存在争议。在临床实践中，并非所有经组织学证实为N2期疾病且局部复发风险高的肺癌患者都能因身体状况或术后并发症而接受术后同步放化疗。纵隔放疗相比放化疗联合的耐受性更好，似乎有限的患者能够耐受以实现更好的局部肿瘤控制。
材料与方法 纳入本回顾性分析的所有患者因合并症、高龄或术后病程复杂而被排除在术后辅助放化疗联合治疗之外。对R0切除患者的纵隔淋巴结区域进行三维适形放疗（平均剂量：50 Gy；范围：50 - 54 Gy），对R1或R2切除患者额外追加10 Gy，均在术后进行。
结果 本分析共纳入110例患者。平均生存期为25.5±19.2个月。1年、3年和5年生存率分别为75.4%、38.7%和26.2%。术后并发症与远处转移的发生无相关性（p = 0.7）。远处转移被证明是生存的一个重要预后因素（p < 0.0001）。总共3例患者（2.7%）出现局部复发。发生主要术后并发症患者的5年生存率显著低于无术后并发症患者（p = 0.04）。手术范围对生存率有显著影响——肺叶切除术后的5年生存率显著长于全肺切除术后（p = 0.029）。R1切除对生存率无显著影响（p = 0.67）。
讨论 患有多种合并症或术后病程复杂的Ⅲ期N2 NSCLC患者可能从现代纵隔放疗中获益。手术及术后纵隔放疗可实现局部肿瘤控制。远处转移对预后影响最大。然而，Ⅲ期NSCLC患者尽可能应避免行全肺切除术。
