经活检证实为ⅢA期pN2非小细胞肺癌患者，其选择及治疗策略对肺叶切除术后结局的影响
Impact of patient selection and treatment strategies on outcomes after lobectomy for biopsy-proven stage IIIA pN2 non-small cell lung cancer.
作者信息
Yang Chi-Fu Jeffrey, Adil Syed M, Anderson Kevin L, Meyerhoff Robert Ryan, Turley Ryan S, Hartwig Matthew G, Harpole David H, Tong Betty C, Onaitis Mark W, D'Amico Thomas A, Berry Mark F
机构信息
Duke University, Durham, NC, USA.
Stanford University, Stanford, CA, USA
出版信息
Eur J Cardiothorac Surg. 2016 Jun;49(6):1607-13. doi: 10.1093/ejcts/ezv431. Epub 2015 Dec 30.
OBJECTIVES
We evaluated the impact of patient selection and treatment strategies on long-term outcomes of patients who had lobectomy after induction therapy for stage IIIA pN2 non-small cell lung cancer (NSCLC).
METHODS
The impact of various patient selection, induction therapy and operative strategies on survival of patients with biopsy-proven stage IIIA pN2 NSCLC who received induction chemotherapy ± radiation followed by lobectomy from 1995 to 2012 was assessed using Cox proportional hazards analysis.
RESULTS
From 1995 to 2012, 111 patients had lobectomy for stage IIIA pN2 NSCLC after chemotherapy ± radiation with an overall 5-year survival of 39%. The use of induction chemoradiation decreased over time; from 1996 to 2007, 46/65 (71%) patients underwent induction chemoradiation, whereas from 2007 to 2012, 36/46 (78%) patients underwent induction chemotherapy. The use of video-assisted thoracoscopic surgery (VATS) increased over the time period of the study, from 0/26 (0%) in 1996-2001, to 4/39 (10%) in 2002-07 to 33/46 (72%) in 2008-12. Compared with patients given induction chemotherapy alone, patients given additional induction radiation were more likely to have complete pathologic response (30 vs 11%, P = 0.01) but had worse 5-year survival in univariable analysis (31 vs 48%, log-rank P = 0.021). Patients who underwent pathologic mediastinal restaging following induction therapy but prior to resection had an improved overall survival compared with patients who did not undergo pathologic mediastinal restaging {5-year survival: 45.2 [95% confidence interval (CI): 33.9-55.9] vs 13.9% (95% CI: 2.5-34.7); log-rank, P = 0.004}. In multivariable analysis, the particular induction therapy strategy and the surgical approach used, as well as the extent of mediastinal disease were not important predictors of survival. However, pathologic mediastinal restaging was associated with improved survival (HR 0.39; 95% CI: 0.21-0.72; P = 0.003).
CONCLUSIONS
For patients with stage IIIA pN2 NSCLC, the VATS approach or the addition of radiation to induction therapy can be selectively employed without compromising survival. The strategy of assessing response to induction therapy with pathologic mediastinal restaging allows one to select appropriate patients for complete resection and is associated with a 5-year overall survival of 39% in this population.
目的
我们评估了患者选择和治疗策略对IIIA期pN2非小细胞肺癌（NSCLC）诱导治疗后接受肺叶切除术患者长期预后的影响。
方法
采用Cox比例风险分析评估1995年至2012年间，各种患者选择、诱导治疗和手术策略对经活检证实为IIIA期pN2 NSCLC且接受诱导化疗±放疗后行肺叶切除术患者生存情况的影响。
结果
1995年至2012年，111例IIIA期pN2 NSCLC患者在化疗±放疗后接受了肺叶切除术，总体5年生存率为39%。诱导放化疗的使用随时间减少；1996年至2007年，46/65（71%）例患者接受了诱导放化疗，而2007年至2012年，36/46（78%）例患者接受了诱导化疗。在研究期间，电视辅助胸腔镜手术（VATS）的使用增加，从1996 - 2001年的0/26（0%），到2002 - 2007年的4/39（10%），再到2008 - 2012年的33/46（72%）。与仅接受诱导化疗的患者相比，接受额外诱导放疗的患者更有可能获得完全病理缓解（30%对11%，P = 0.01），但在单因素分析中5年生存率更差（31%对48%，log秩检验P = 0.021）。诱导治疗后但在切除术前接受病理纵隔再分期的患者与未接受病理纵隔再分期的患者相比，总生存期有所改善{5年生存率：45.2 [95%置信区间（CI）：33.9 - 55.9]%对13.9%（95% CI：2.5 - 34.7）；log秩检验，P = 0.004}。在多因素分析中，特定的诱导治疗策略、使用的手术方法以及纵隔疾病范围并非生存的重要预测因素。然而，病理纵隔再分期与生存改善相关（风险比0.39；95% CI：0.21 - 0.72；P = 0.003）。
结论
对于IIIA期pN2 NSCLC患者，可选择性采用VATS方法或在诱导治疗中加用放疗，而不影响生存率。通过病理纵隔再分期评估诱导治疗反应的策略可使人们选择合适的患者进行完全切除，该人群的5年总生存率为39%。
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