Cox Morgan L, Yang Chi-Fu Jeffrey, Speicher Paul J, Anderson Kevin L, Fitch Zachary W, Gu Lin, Davis Robert Patrick, Wang Xiaofei, D'Amico Thomas A, Hartwig Matthew G, Harpole David H, Berry Mark F
Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina.
J Thorac Oncol. 2017 Apr;12(4):689-696. doi: 10.1016/j.jtho.2017.01.003. Epub 2017 Jan 8.
This study examined the association of extent of lung resection, pathologic nodal evaluation, and survival for patients with clinical stage I (cT1-2N0M0) adenocarcinoma with lepidic histologic features in the National Cancer Data Base.
The association between extent of surgical resection and long-term survival for patients in the National Cancer Data Base with clinical stage I lepidic adenocarcinoma who underwent lobectomy or sublobar resection was evaluated using Kaplan-Meier and Cox proportional hazards regression analyses.
Of the 1991 patients with cT1-2N0M0 lepidic adenocarcinoma who met the study criteria, 1544 underwent lobectomy and 447 underwent sublobar resection. Patients treated with sublobar resection were older, more likely to be female, and had higher Charlson/Deyo comorbidity scores, but they had smaller tumors and lower T status. Of the patients treated with lobectomy, 6% (n = 92) were upstaged because of positive nodal disease, with a median of seven lymph nodes sampled (interquartile range 4-10). In an analysis of the entire cohort, lobectomy was associated with a significant survival advantage over sublobar resection in univariate analysis (median survival 9.2 versus 7.5 years, p = 0.022, 5-year survival 70.5% versus 67.8%) and after multivariable adjustment (hazard ratio = 0.81, 95% confidence interval: 0.68-0.95, p = 0.011). However, lobectomy was no longer independently associated with improved survival when compared with sublobar resection (hazard ratio = 0.99, 95% confidence interval: 0.77-1.27, p = 0.905) in a multivariable analysis of a subset of patients in which only those patients who had undergone a sublobar resection including lymph node sampling were compared with patients treated with lobectomy.
Surgeons treating patients with stage I lung adenocarcinoma with lepidic features should cautiously utilize sublobar resection rather than lobectomy, and they must always perform adequate pathologic lymph node evaluation.
本研究在国家癌症数据库中，调查了临床I期（cT1-2N0M0）具有鳞屑状组织学特征的腺癌患者的肺切除范围、病理淋巴结评估与生存之间的关联。
使用Kaplan-Meier法和Cox比例风险回归分析，评估国家癌症数据库中接受肺叶切除术或肺段以下切除术的临床I期鳞屑状腺癌患者的手术切除范围与长期生存之间的关联。
在1991例符合研究标准的cT1-2N0M0鳞屑状腺癌患者中，1544例行肺叶切除术，447例行肺段以下切除术。接受肺段以下切除术的患者年龄更大，更可能为女性，Charlson/Deyo合并症评分更高，但肿瘤更小，T分期更低。在接受肺叶切除术的患者中，6%（n = 92）因淋巴结疾病阳性而分期上调，中位取样淋巴结数为7个（四分位间距4-10）。在对整个队列的分析中，在单因素分析中肺叶切除术与肺段以下切除术相比具有显著的生存优势（中位生存期9.2年对7.5年，p = 0.022，5年生存率70.5%对67.8%），且在多变量调整后（风险比=0.81，95%置信区间：0.68-0.95，p = 0.011）。然而，在仅将接受包括淋巴结取样的肺段以下切除术的患者与接受肺叶切除术的患者进行比较的亚组患者的多变量分析中，与肺段以下切除术相比，肺叶切除术不再与生存改善独立相关（风险比=0.99，95%置信区间：0.77-1.27，p = 0.905）。
治疗具有鳞屑状特征的I期肺腺癌患者的外科医生应谨慎采用肺段以下切除术而非肺叶切除术，并且必须始终进行充分的病理淋巴结评估。
