手术在局限期小细胞肺癌中的作用：一项国家退伍军人事务部数据库分析。
The Role of Surgery in Stage I Small Cell Lung Cancer: A National VA Database Analysis.
机构信息
Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI.
Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL.
出版信息
Clin Lung Cancer. 2023 Jul;24(5):e179-e186. doi: 10.1016/j.cllc.2023.04.002. Epub 2023 Apr 15.
BACKGROUND
Historically, limited stage Small Cell Lung Cancer (SCLC) has been treated with concurrent chemoradiation (CRT). While current NCCN guidelines recommend consideration of lobectomy in node-negative cT1-T2 SCLC, data regarding the role of surgery in very limited SCLC is lacking.
METHODS
Data from the National VA Cancer Cube were compiled. A total of 1,028 patients with pathologically confirmed stage I SCLC were studied. Only 661 patients that either received surgery or CRT were included. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median overall survival (OS) and hazard ratio (HR), respectively. Two survival curves were compared by a Wald test. Subset analysis was performed based on the location of the tumor in the upper vs. lower lobe as delineated by ICD-10 codes C34.1 and C34.3.
RESULTS
Four-hundred and forty-six patients received concurrent CRT; while 223 underwent treatment that contained surgery (93 surgery only, 87 surgery/chemo, 39 surgery/chemo/radiation and 4 surgery/radiation). The median OS for the surgery-inclusive treatment was 3.87 years (95% CI 3.21-4.48) while median OS for the CRT cohort was 2.45 years (95% CI 2.17-2.74). HR of death for surgery-inclusive treatment when compared to CRT is 0.67 (95% CI 0.55-0.81; P < .001). Subset analysis based on the location of the tumor in both the upper or lower lobes showed improved survival with surgery as compared to CRT regardless of the location. HR for the upper lobe was 0.63 (95% CI 0.50-0.80; P < .001) and lower lobe 0.61 (95% CI 0.42-0.87; P = .006). Multivariable regression analysis accounting for age and ECOG-PS shows a HR 0.60 (95% CI 0.43-0.83; P = .002) favoring surgery.
CONCLUSIONS
Surgery was used in less than a third of patients with stage I SCLC who received treatment. Surgery-inclusive multimodality treatment was associated with a longer overall survival as compared to chemoradiation, independent of age, performance status or tumor location. Our study suggests a more expansive role for surgery in stage I SCLC.
背景
历史上，局限期小细胞肺癌（SCLC）采用同步放化疗（CRT）治疗。目前 NCCN 指南建议考虑对淋巴结阴性 cT1-T2 SCLC 行肺叶切除术，但在非常局限的 SCLC 中，手术的作用尚缺乏数据。
方法
从国家退伍军人事务部癌症数据库中收集数据。共纳入 1028 例经病理证实为 I 期 SCLC 的患者。仅纳入了 661 例接受手术或 CRT 的患者。采用区间删失 Weibull 分布和 Cox 比例风险回归模型分别估计中位总生存期（OS）和风险比（HR）。采用 Wald 检验比较两条生存曲线。根据 ICD-10 编码 C34.1 和 C34.3 界定的肿瘤在上叶或下叶的位置进行亚组分析。
结果
446 例患者接受同步 CRT；223 例患者接受包含手术的治疗（93 例仅手术，87 例手术/化疗，39 例手术/化疗/放疗，4 例手术/放疗）。手术联合治疗的中位 OS 为 3.87 年（95%CI 3.21-4.48），而 CRT 组的中位 OS 为 2.45 年（95%CI 2.17-2.74）。与 CRT 相比，手术联合治疗的死亡风险 HR 为 0.67（95%CI 0.55-0.81；P<0.001）。根据肿瘤在上叶或下叶的位置进行的亚组分析显示，无论肿瘤位置如何，与 CRT 相比，手术治疗均能改善生存。上叶 HR 为 0.63（95%CI 0.50-0.80；P<0.001），下叶 HR 为 0.61（95%CI 0.42-0.87；P=0.006）。多变量回归分析考虑年龄和 ECOG-PS 后显示，手术的 HR 为 0.60（95%CI 0.43-0.83；P=0.002），有利于手术。
结论
在接受治疗的 I 期 SCLC 患者中，不到三分之一的患者接受了手术。与 CRT 相比，手术联合多模态治疗可显著提高总生存率，与年龄、体能状态或肿瘤位置无关。我们的研究表明，在 I 期 SCLC 中，手术的作用可能更为广泛。
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