Ⅲa(N_2)期非小细胞肺癌术后放疗疗效分析

An analysis of postoperative radiotherapy for patients with completely resected stage Ⅲa(N_2)non-small cell lung cancer

目的:回顾性分析Ⅲa(N2)期非小细胞肺癌术后放疗的治疗结果,同时探讨其治疗策略。方法:1987～2004年本院收治的Ⅲa(N2)期非小细胞肺癌92例,所有病人都接受根治性手术,术后放疗46例(S+R组),单纯手术46例(S组),39例接受化疗;放疗中位剂量56 Gy(40～64 Gy)。用Kaplan-Meier及Log-rank法计算和比较两组病人的生存率。结果:(1)全组病人5年及10年总生存率(Overall survival,OS)分别为44.5%和30.4%。(2)术后放疗组与单纯手术组相比,5年及10年总生存率分别为49.1%、36.5%,36.3%、25.4%;两组间差异无统计学意义(χ2=0.83,P=0.65)。(3)纵隔单站转移N2病人,术后放疗组有提高无病生存率(Diseaes-free survival,DFS)的趋势;而多站转移N2病人,术后放疗组与单纯手术组相比,5年及10年无病生存率明显提高,分别为:40.6%、4.5%,21.2%、4.1%,差异有显著性(χ2=4.35,P=0.03),且有提高总生存率的趋势。(4)1996～2004年术后放疗病人的生存率优于1987～1995年。(χ2=4.28,P=0.04)。(5)治疗失败率63.0%,术后放疗组总复发率及局部区域复发率低于单纯手术组,差异具显著性,分别为50.0%、76.1%,(χ2=6.72,P=0.001);及8.7%、32.6%,(χ2=8.03,P=0.001)。两组失败的首位原因均为远处转移。(6)多变量分析结果显示,年龄和纵隔淋巴结受累的站数影响Ⅲa(N2)期非小细胞肺癌的生存。结论:(1)Ⅲa(N2)期非小细胞肺癌术后放疗有延长生存期的趋势,纵隔多站转移N2病人术后放疗可提高无病生存期。纵隔单站转移N2病人术后放疗价值不确切,有待于进一步的随机临床研究加以证实。(2)年龄和纵隔淋巴结受累的站数影响病人的生存期。(3)治疗设备和治疗技术可以影响术后放疗的价值。(4)无论是否放疗,失败的首位原因均为远处转移,提示这类病人可能从化疗获益,建议Ⅲa(N2)期非小细胞肺癌术后常规辅以化疗。

Objective： This paper will retrospectively analyze the long-term results of PORT for Completely Resected Stage m a （N2） NSCLC. The strategies of treatment are also to be discussed. Methods：92 cases with Completely Resected Stage Ⅲa（N2） NSCLC treated in our hospital from 1987 to 2004 were analyzed. Among them, 46 patients received PORT（Group S＋R）, 46 no PORT （Group S）. 39 of the entire patients. received chemotherapy. Median radiation dose was 56 Gy（40 - 64 Gy）. The survival rates were analyzed and compared by Kaplan-Meier and Log-rank. Results： （1） The 5 and 10-year overall survival （OS） for all patients was 44.5% and 30.4%, respectively. （2） The 5 and 10-year OS of group S＋R and S was 49.1% vs 36.5% and 36.3% vs 25.4%, respectively, with no significant difference （X2=0.83, P=0.65 ）. （ 3 ） For the patients with single station involved N2, PORT tends to improve the disease-free survival （ DFS ） but no reach significant difference. As for patients with multiple stations involved N2, PORT could improve the DFS, the 5 and 10-year DFS of group S＋R and S was 40.6% vs.4.5% ; 21.2% vs.4.1%, respectively, （χ^2=4.35, P=-0.03 ）, meanwhile, it might increase the OS.（4） The survival rate treated with PORT from 1996 to 2004 was higher than that from 1987 to 1995, （χ^2=4.28, P=-0.04 ）. （5） Recurrence was seen in 63% of patients. The total （both local/regional recurrence and distant metastasis） and local/regional recurrenc rate of group S＋R was lower than that of group S, i.e. 50.0% vs76.1% （χ^2=6.72,P=-0.001 ） and 8.7% vs 32.6% （χ^2=8.03 ,P=-0.001 ）, respectively. Distant metastasis was found to be the main failure cause for both group S＋R and S. Multivariate analyses showed that age and number of mediastinal lymph node station involved have influence on the survival of patients with Completely Resected Stage m a （N2） NSCLC. Conclusions： （ 1 ） PORT tends to yield a survival advantage for patients with Completely Resected Stage Ⅲa（N2） NSCLC. For patients with multiple stations involved N2, PORT could improve the DFS. But its value for patients with single station involved N2 was unclear and a further randomized clinical trail is still warrant. （2） Age and the number of mediastinal lymph node station involved are the two significant prognosis factors for patients with Completely Resected Stage Ⅲa（N2） NSCLC. （3）Condition of equipment and radiation technology used could have some influence on the result of PORT. （4）The fact that distant metastasis was the main failure cause for both group S＋R and S might imply that patients with Completely Resected Stage Ⅲa（N2） NSCLC might benefit from chemotherapy. It suggests thus that chemotherapy should be considered for these patients.