Mitzman Brian, Varghese Thomas K, Kuchta Kristine, Krantz Seth B
Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, UT, USA.
Department of Surgery, NorthShore University Health System, Evanston, IL, USA.
J Thorac Dis. 2022 May;14(5):1360-1373. doi: 10.21037/jtd-21-1845.
Real-world treatment practices for positive mediastinal nodal disease in non-small cell lung cancer (NSCLC) continues to vary despite guidelines. We aim to assess national trends in the treatment of pathologic-N2 disease, and evaluate the association with clinical nodal staging and timing of systemic therapy.
The National Cancer Database was queried for patients with NSCLC who underwent lobectomy and had pathologic-N2 disease from 2010-2017. National Comprehensive Cancer Network (NCCN) guideline concordance was evaluated. cN2 patients were analyzed based on timing of systemic therapy and response. Multivariable logistic regression evaluated outcomes by type of systemic therapy. Survival analysis utilized Cox proportional hazards regression and Kaplan-Meier methods.
10,225 patients met inclusion criteria. Fifty-four percent of patients were understaged prior to surgery as either cN0 or cN1. Of clinically staged N2 patients, 56% received NCCN recommended neoadjuvant therapy. Annual guideline concordance increased until 2016 to a max of 62.9%. Neoadjuvant and adjuvant systemic therapy showed an overall survival benefit compared with no systemic therapy (HR 0.54 & 0.57), but no difference when compared against each other. Complete response after neoadjuvant therapy was associated with improved survival (5-year OS 56.1%, P<0.001), while partial response, no-response, and adjuvant therapy were similar. All systemic treatment strategies improved survival compared with no systemic therapy (5-year OS 24.5%).
Guideline concordance for treatment of cN2 disease has been increasing, but still not followed in over 1/3 of patients. Responsiveness to neoadjuvant therapy appears to be a predictor of survival, and may become a prognostic adjunct for determining which patients would benefit from additional systemic therapy.
尽管有相关指南，但非小细胞肺癌（NSCLC）纵隔淋巴结阳性疾病的实际治疗方法仍存在差异。我们旨在评估病理性N2疾病治疗的全国趋势，并评估其与临床淋巴结分期及全身治疗时机的相关性。
查询国家癌症数据库中2010 - 2017年间接受肺叶切除术且患有病理性N2疾病的NSCLC患者。评估其与美国国立综合癌症网络（NCCN）指南的一致性。根据全身治疗时机和反应对cN2患者进行分析。多变量逻辑回归按全身治疗类型评估结果。生存分析采用Cox比例风险回归和Kaplan - Meier方法。
10225例患者符合纳入标准。54%的患者在手术前被低估为cN0或cN1。在临床分期为N2的患者中，56%接受了NCCN推荐的新辅助治疗。到2016年年度指南一致性不断提高，最高达到62.9%。与未进行全身治疗相比，新辅助和辅助全身治疗均显示出总生存获益（HR分别为0.54和0.57），但两者之间无差异。新辅助治疗后的完全缓解与生存改善相关（5年总生存率56.1%，P<0.001），而部分缓解、无反应和辅助治疗情况相似。与未进行全身治疗相比，所有全身治疗策略均改善了生存（5年总生存率24.5%）。
cN2疾病治疗的指南一致性一直在提高，但仍有超过1/3的患者未遵循。对新辅助治疗的反应似乎是生存的一个预测因素，可能成为确定哪些患者将从额外全身治疗中获益的预后辅助指标。
