Boffa Daniel, Fernandez Felix G, Kim Sunghee, Kosinski Andrzej, Onaitis Mark W, Cowper Patricia, Jacobs Jeffrey P, Wright Cameron D, Putnam Joe B, Furnary Anthony P
Department of Thoracic Surgery, Yale New Haven Hospital, New Haven, Connecticut.
Department of Thoracic Surgery, Emory University, Atlanta, Georgia.
Ann Thorac Surg. 2017 Aug;104(2):395-403. doi: 10.1016/j.athoracsur.2017.02.031. Epub 2017 May 17.
The role of surgical resection in patients with clinical stage IIIA-N2 positive (cIIIA-N2) lung cancer is controversial, partly because of the variability in short- and long-term outcomes. The objective of this study was to characterize the management of cIIIA-N2 lung cancer in The Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD).
The STS-GTSD was queried for patients who underwent operations for cIIIA-N2 lung cancer between 2002 and 2012. A subset of patients aged older than 65 years was linked to Medicare data.
Identified were 3,319 surgically managed, cIIIA-N2 patients, including 1,784 (54%) treated with upfront resection (treatment naïve upfront surgery group, and 1,535 (46%) with induction therapy. A positron emission tomography scan was documented in 93% of patients, and 51% of patients were coded in STS-GTSD as having undergone invasive mediastinal staging. Nodal overstaging (cN2→pN0/N1) was observed in 43% of upfront surgery patients. Lobectomy was performed in 69% of patients and pneumonectomy in 11%. Operative mortality was similar between patients treated with upfront surgery (1.9%) and induction therapy (2.5%, p = .2583). The unadjusted Kaplan-Meier estimate of 5-year survival of cIII-N2 patients treated with induction therapy then resection was 35%.
STS surgeons achieve excellent short- and long-term results treating predominantly lobectomy-amenable cIIIA-N2 lung cancer. However, prevalent overstaging and abstention from induction therapy suggest "overcoding" of false positives on imaging or variable compliance with current guidelines for cIIIA-N2 lung cancer. Efforts are needed to improve clinical stage determination and guideline compliance in the GTSD for this cohort.
手术切除在临床 IIIA 期 N2 阳性（cIIIA-N2）肺癌患者中的作用存在争议，部分原因是短期和长期结果存在差异。本研究的目的是描述胸外科医师协会普通胸外科数据库（STS-GTSD）中 cIIIA-N2 肺癌的治疗情况。
查询 STS-GTSD 中 2002 年至 2012 年间接受 cIIIA-N2 肺癌手术的患者。年龄大于 65 岁的患者子集与医疗保险数据相关联。
共识别出 3319 例接受手术治疗的 cIIIA-N2 患者，其中 1784 例（54%）接受 upfront 切除（初治 upfront 手术组），1535 例（46%）接受诱导治疗。93%的患者进行了正电子发射断层扫描，51%的患者在 STS-GTSD 中编码为接受了侵入性纵隔分期。43%的 upfront 手术患者观察到淋巴结分期过度（cN2→pN0/N1）。69%的患者进行了肺叶切除术，11%的患者进行了全肺切除术。接受 upfront 手术的患者与接受诱导治疗的患者手术死亡率相似（分别为 1.9%和 2.5%，p = 0.2583）。接受诱导治疗后再切除的 cIII-N2 患者未调整的 Kaplan-Meier 5 年生存率估计为 35%。
STS 外科医生在治疗主要适合肺叶切除的 cIIIA-N2 肺癌方面取得了优异的短期和长期结果。然而，普遍存在的分期过度和未进行诱导治疗表明影像学上假阳性的“过度编码”或对 cIIIA-N2 肺癌当前指南的依从性存在差异。需要努力改善该队列在 GTSD 中的临床分期确定和指南依从性。
