Department of Surgery, Surgical Outcomes and Quality Improvement Center, Northwestern University, Feinberg School of Medicine, Chicago, Ill; Department of Surgery, Canning Thoracic Institute, Northwestern University, Feinberg School of Medicine, Chicago, Ill.
Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Ill.
J Thorac Cardiovasc Surg. 2023 Jan;165(1):351-363.e20. doi: 10.1016/j.jtcvs.2022.05.050. Epub 2022 Aug 5.
Segmentectomy has become an accepted procedure for the treatment of non-small cell lung cancer. Adequate lymph node sampling, sufficient margins, and proper tumor size selection are factors vital for achieving outcomes comparable to lobectomy. Previous studies have demonstrated poor adherence to lymph node sampling guidelines. However, national trends in the quality of segmentectomy and implications on survival are unknown.
The National Cancer Database was used to identify patients with clinical stage I to IIA non-small cell lung cancer surgically treated between 2004 and 2018. Facility-level trends in extent of resection and segmentectomy odds of adherence to (1) 2014 Commission on Cancer guidelines of sampling 10 or more lymph nodes, (2) negative (R0) resection margins, and (3) tumor size 2 cm or less were determined. Propensity score matching was based on segmentectomy adherence to (4) a composite of all measures, and survival was evaluated with Cox models and Kaplan-Meier survival estimates.
The study included 249,391 patients with 4.4% (n = 11,006) treated with segmentectomy. The proportion of segmentectomies performed annually increased from 3.3% in 2004 to 6.1% in 2018 (P < .001). Overall, 12.6% (n = 1385) of patients who underwent segmentectomy between 2004 and 2018 were adherent to all measures, and adherence was more likely at academic programs (odds ratio, 1.56; 95% confidence interval, 1.14-2.15) than nonacademic programs (P < .001, reference). Adherence to all measures was associated with improved survival (hazard ratio, 0.67; 95% confidence interval, 0.56-0.79).
As segmentectomy is increasingly established as a valid oncological option for the treatment of non-small cell lung cancer, it is important that quality remains high. This study demonstrates that continued improvement is needed.
肺段切除术已成为治疗非小细胞肺癌的一种可接受的方法。充分的淋巴结取样、足够的切缘和适当的肿瘤大小选择是达到与肺叶切除术相当的结果的关键因素。先前的研究表明，对淋巴结取样指南的遵循情况不佳。然而，目前尚不清楚全国范围内肺段切除术质量的趋势及其对生存率的影响。
本研究使用国家癌症数据库，对 2004 年至 2018 年间接受手术治疗的临床 I 期至 IIA 期非小细胞肺癌患者进行了分析。确定了机构层面在切除范围和肺段切除术的可能性方面的趋势，包括（1）遵循 2014 年肿瘤委员会指南，取样 10 个或更多淋巴结；（2）达到阴性（R0）切缘；（3）肿瘤大小为 2cm 或更小。基于肺段切除术对（4）所有措施的综合遵守情况进行了倾向评分匹配，并使用 Cox 模型和 Kaplan-Meier 生存估计值评估了生存情况。
本研究共纳入了 249391 例患者，其中 4.4%（n=11006）接受了肺段切除术。每年进行肺段切除术的比例从 2004 年的 3.3%增加到 2018 年的 6.1%（P<.001）。总体而言，2004 年至 2018 年间，接受肺段切除术的患者中，有 12.6%（n=1385）符合所有措施，在学术项目中比非学术项目更有可能符合所有措施（比值比，1.56；95%置信区间，1.14-2.15；P<.001，参考）。符合所有措施与生存改善相关（风险比，0.67；95%置信区间，0.56-0.79）。
随着肺段切除术作为治疗非小细胞肺癌的一种有效的肿瘤学选择方法的地位日益确立，确保其质量仍然很高是很重要的。本研究表明，需要继续改进。
