289例局部晚期非小细胞肺癌放疗和放化综合治疗结果

Outcome of 289 locally advanced non-small cell lung cancer treated with radiotherapy alone and radiotherapy combined with chemotherapy

目的回顾性分析局部晚期非小细胞肺癌放疗和放化综合治疗结果。方法对随诊资料完整的289例局部晚期非小细胞肺癌患者纳入分析。其中鳞癌152例，腺癌74例，腺鳞癌2例，其他类型2例，分类不明癌24例，临床诊断35例；分期ⅢA 74例、ⅢB 215例；治疗方法包括单纯放疗（168例）、综合治疗（121例），综合治疗中同步放化疗24例、序贯化放疗78例（序贯或同步放化疗后巩固化疗38例）、放疗后化疗19例。结果1、3、5年总生存率、中位生存时间全组为45%、16%、8%、16．2个月，ⅢA期为57%、27%、11%、21．7个月，ⅢB期为41%、12%、7%、15．3个月。Logrank检验显示临床分期、KPS评分、肿瘤总体积、疗前血红蛋白水平、巩固化疗、放疗剂量、近期疗效等显著影响5年生存率和中位生存时间；放化综合组疗效略好于单纯放疗组，但差别无统计学意义。Cox多因素回归分析显示分期、巩固化疗为独立预后因素，KPS评分、近期疗效和放疗剂量对预后的影响处于统计学边沿水平。2级以上放射性食管炎和放射性肺炎发生率分别为24%和8%。失败原因包括胸腔内占41%、胸腔外占48%、胸内＋胸外占11%，不同治疗组之间无差别。结论分期为ⅢA期、KPS〉80、巩固化疗、较小肿瘤总体积、近期疗效（CR＋PR）的患者生存率较好。放化疗联合诱导治疗后巩固化疗的治疗模式可能是进一步改善疗效的方向。

Objective To retrospectively analyze the outcome of locally advanced non-small cell lung cancer patients treated with radiotherapy and chemoradiotherapy. Methods 289 patients who were treated either by radiotherapy alone （ 168 patients ） or radiotherapy plus chemotherapy （ 121 patients ） from Dec. 1999 to Dec. 2002 were entered into the database for analysis. Pathological types： squamous cancer （152）, adenecarcinoma（74）, squamoadenocarcinoma （ 2 ） and other types （ 2 ）. 24 showed cancer unclassificable and 35 were diagnosed without pathological proof. Stages： 74 had Ⅲ A and 215 Ⅲ B stage disease. Among the 121 patients treated with combined modality, 24 were treated with concurrent chemoradiotherapy, 78 radiotherapy after chemotherapy（ C ＋ R） , and 19 radiotherapy followed by chemotherapy（ R ＋ C ）. In patients treated by concurrent chemoradiotherapy or C ＋ R, 38 received consolidation chemotherapy after induction treatment. Results The 1-, 3-, 5-year overall survival, and the median survival were： 45% , 16% , 8%, and 16.2 months for all patients; 57% , 27%, 11% , and 21.7 months for stage ⅢA; 41% , 12% , 7% , and 15.3 months for ⅢB. By logrank test, clinical stage, KPS performance, tumor volume, hemoglobin level before treatment, consolidation chemotherapy, radiation dose, and response to treatment showed statistically dramatic impact on overall survival. The overall survival rate and median survival time were slightly higher in the combined group than in the radiotherapy alone group, but the difference is statistically insignificant. In Cox muhivariable regression, stage and consolidation chemotherapy were independent prognostic factors ; KPS performance, radiation dose, and response to treatment were at the margin of statistical significance. Esophagitis and pneumonitis of Grade Ⅱ or higher were 24% and 8%, respectively. Failure sites included in the thorax（41% ）, outside of thorax（48% ）, and both in and outside the thorax（ 11% ）. There was no difference between the treatment modalities for failure sites. Conclusions For locally advanced non-small cell lung cancer patients with stage Ⅲ A lesion, good KPS performance, and smaller total tumor volume, who were treated with chemoradiotherapy and consolidation chemotherapy, giving good response to the treatment, do show encouraging survival rate. Induction treatment combined with chemotherapy and radiotherapy plus consolidation chemotherapy may be a reasonable treatment modality.