Wakeam E, Acuna S A, Leighl N B, Giuliani M E, Finlayson S R G, Varghese T K, Darling G E
Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
Lung Cancer. 2017 Jul;109:78-88. doi: 10.1016/j.lungcan.2017.04.021. Epub 2017 May 1.
The role of surgery in small cell lung cancer (SCLC) is controversial. Survival outcomes for resection of stage I-IIIA SCLC compared to chemotherapy-based non-surgical treatment (NST) were examined using propensity matching.
29,994 clinical stage I-IIIA SCLC patients, including 2,619 undergoing surgery, were identified in the National Cancer Database. Stage-specific propensity scores for receipt of surgery were created. Resected patients were matched 1:1 to those undergoing NST. Overall survival (OS) was assessed using Kaplan-Meier and multivariable Cox models. A separate match was performed comparing Stage I/II patients aged <85 with a Charlson score of 0 who underwent lobectomy with adjuvant chemotherapy (and radiotherapy if node positive) to those treated with multiagent chemotherapy and concurrent chest radiotherapy (CRT) of at least 40 gray.
2,089 patients were matched, and cohorts were well balanced. Surgery was associated with longer survival for Stage I (median OS 38.6 months vs. 22.9 months, HR 0.62 95%CI 0.57-0.69, p<0.0001), but survival differences were attenuated for Stage II (median OS 23.4 months vs. 20.7 months, HR 0.84 95%CI 0.70-1.01, p=0.06) and IIIA (median OS 21.7 vs. 16.0 months, HR 0.71 95%CI 0.60-0.83, p <0.0001). In analyses by T and N stage, longer OS was observed in resected patients with stage T3/T4 N0 (median OS 33.0 vs. 16.8 months, p=0.008) and node positivity(N1+ 24.4 vs. 18.3 months p=0.03; N2+ 20.1 vs. 14.6 months p=0.007). In the subgroup analysis, 507 stage I/II patients receiving lobectomy and adjuvant chemotherapy were matched to patients receiving concurrent CRT. In this cohort, lobectomy with adjuvant chemotherapy was associated with significantly longer survival (median OS 48.6 vs. 28.7 months, p<0.0001).
Surgical resection is associated with significantly longer survival for early SCLC. New randomized trials should assess trimodality therapy in stages I/II, and in node negative disease.
手术在小细胞肺癌（SCLC）中的作用存在争议。使用倾向评分匹配法比较了I-IIIA期SCLC手术切除与基于化疗的非手术治疗（NST）的生存结果。
在国家癌症数据库中识别出29994例临床I-IIIA期SCLC患者，其中2619例接受了手术。创建了接受手术的特定阶段倾向评分。将接受手术的患者与接受NST的患者按1:1进行匹配。使用Kaplan-Meier法和多变量Cox模型评估总生存期（OS）。进行了一项单独的匹配，比较年龄<85岁、Charlson评分为0且接受肺叶切除术加辅助化疗（如果淋巴结阳性则加放疗）的I/II期患者与接受多药化疗和至少40格雷同步胸部放疗（CRT）的患者。
匹配了2089例患者，队列均衡性良好。手术与I期患者更长的生存期相关（中位OS 38.6个月对22.9个月，HR 0.62，95%CI 0.57-0.69，p<0.0001），但II期（中位OS 23.4个月对20.7个月，HR 0.84，95%CI 0.70-1.01，p=0.06）和IIIA期（中位OS 21.7个月对16.0个月，HR 0.71，95%CI 0.60-0.83，p<0.0001）患者的生存差异有所减弱。在按T和N分期的分析中，T3/T4 N0期（中位OS 33.0个月对16.8个月，p=0.008）和淋巴结阳性（N1+ 24.4个月对18.3个月，p=0.03；N2+ 20.1个月对14.6个月，p=0.007）的手术切除患者观察到更长的OS。在亚组分析中，507例接受肺叶切除术和辅助化疗的I/II期患者与接受同步CRT的患者进行了匹配。在该队列中，肺叶切除术加辅助化疗与显著更长的生存期相关（中位OS 48.6个月对28.7个月，p<0.0001）。
手术切除与早期SCLC患者显著更长的生存期相关。新的随机试验应评估I/II期以及淋巴结阴性疾病的三联疗法。
