Samual Francis, Andrew Orton, Randa Tao, Ying J. Hitchcock, Wallace Akerley, and Kristine E. Kokeny, University of Utah Huntsman Cancer Institute; Greg Stoddard, University of Utah, Salt Lake City, UT.
J Clin Oncol. 2018 Feb 1;36(4):333-341. doi: 10.1200/JCO.2017.74.4771. Epub 2017 Dec 13.
Purpose Although several feasibility studies have demonstrated the safety of adjuvant concurrent chemoradiotherapy (CRT) for locally advanced or incompletely resected non-small-cell lung cancer (NSCLC), it remains uncertain whether this approach is superior to sequential chemotherapy followed by postoperative radiotherapy (C→PORT). We sought to determine the most effective treatment sequence. Patients and Methods Using the National Cancer Database, we selected two cohorts of patients with nonmetastatic NSCLC who had received at least a lobectomy followed by multiagent chemotherapy and radiotherapy; cohort one included patients with R0 resection and pN2 disease, whereas cohort two included patients with R1-2 resection regardless of nodal status. Overall survival (OS) was examined using a propensity score-matched analysis with a shared frailty Cox regression. Results A total of 747 patients in cohort one and 277 patients in cohort two were included, with a median follow-up of 32.8 and 27.9 months, respectively. The median OS was 58.8 months for patients who received C→PORT versus 40.4 months for patients who received CRT in cohort one (log-rank P < .001). For cohort two, the median OS was 42.6 months for patients who received C→PORT versus 38.5 months for patients who received CRT (log-rank P = .42). After propensity score matching, C→PORT remained associated with improved OS compared with CRT in cohort one (hazard ratio, 1.35; P = .019), and there was no statistical difference in OS between the sequencing groups for cohort two (hazard ratio, 1.35; P = .19). Conclusion Patients with NSCLC who undergo R0 resection and are found to have pN2 disease have improved outcomes when adjuvant chemotherapy is administered before, rather than concurrently with, radiotherapy. For patients with positive margins after surgery, there is not a clear association between treatment sequencing and survival.
尽管几项可行性研究已经证明辅助同步放化疗（CRT）治疗局部晚期或不完全切除的非小细胞肺癌（NSCLC）的安全性，但辅助 CRT 是否优于序贯化疗后行术后放疗（C→PORT）仍不确定。我们试图确定最有效的治疗顺序。
我们使用国家癌症数据库选择了至少接受肺叶切除术加多药化疗和放疗的非转移性 NSCLC 患者的两个队列；队列 1 包括 R0 切除和 pN2 疾病患者，而队列 2 包括无论淋巴结状态如何的 R1-2 切除患者。使用倾向评分匹配分析和共享脆弱 Cox 回归分析检查总生存期（OS）。
队列 1 中共有 747 例患者，队列 2 中有 277 例患者，中位随访时间分别为 32.8 个月和 27.9 个月。队列 1 中接受 C→PORT 的患者中位 OS 为 58.8 个月，而接受 CRT 的患者中位 OS 为 40.4 个月（对数秩 P<0.001）。对于队列 2，接受 C→PORT 的患者中位 OS 为 42.6 个月，而接受 CRT 的患者中位 OS 为 38.5 个月（对数秩 P=0.42）。经过倾向评分匹配后，与 CRT 相比，队列 1 中 C→PORT 仍与 OS 改善相关（风险比，1.35；P=0.019），而队列 2 中 OS 在两组之间无统计学差异（风险比，1.35；P=0.19）。
接受 R0 切除且发现 pN2 疾病的 NSCLC 患者，在接受辅助化疗之前而不是同时接受放疗时，可获得更好的结局。对于手术后切缘阳性的患者，治疗顺序与生存之间没有明确的关联。
