III期非小细胞肺癌手术是否有价值

Value of Surgery for Stage IIIa Non-small Cell Lung Cancer

背景与目的对于III期非小细胞肺癌(non-smallcelllungcancer,NSCLC),目前普遍倡导手术、化疗、放疗的多学科综合治疗,但许多研究者对是否应该手术提出了质疑。该研究探讨了手术对于III期NSCLC患者的价值。方法回顾性分析2002年3月-2012年10月北京协和医院收治的经病理学确诊的III期NSCLC患者310例。根据最初确诊时是否手术可分为手术组和非手术组。IIIa期根据N分期的不同可分为T4N0/T3-4N1M0期和T1-3N2M0期。采用χ2检验比较计数资料,Kaplan-Meier方法比较总生存期(overall survival,OS)和无进展生存期(progression free survival,PFS),并绘制生存曲线。结果 ECOG评分0分和IIIa期NSCLC患者更倾向于手术治疗。IIIa期手术与非手术组的中位OS分别为38.9个月和21.8个月,中位PFS分别为19.2个月和11.9个月。两组OS的差异有统计学意义(P=0.041),PFS的差异无统计学意义(P=0.209)。IIIa期中的T4N0/T3-4N1M0期手术与非手术组的中位OS分别为48.7个月和20.1个月,中位PFS分别为14.6个月和10.5个月,两组OS和PFS的差异均无统计学意义(P>0.05);T1-3N2M0期手术与非手术组中位OS分别为38.9和30.8月,中位PFS分别为19.8个月和12.7个月,两组OS和PFS的差异亦无统计学意义(P>0.05)。肿瘤最大径和辅助化疗对IIIa-N2期患者的OS和PFS的影响有统计学意义,而肿瘤的病理类型仅影响患者的OS(P<0.05)。结论 ECOG评分0分和IIIa期NSCLC患者更适于手术治疗。手术可延长IIIa期尤其是T4N0/T3-4N1M0期NSCLC患者的OS,但对PFS无改善作用。肿瘤最大径和辅助化疗对IIIa-N2期患者的OS和PFS均有明显影响,而肿瘤的病理类型只影响其OS。

Background and objective Nowadays, comprehensive treatment, induding surgery, chemotherapy and radiotherapy is advocated for stageⅢ non-small cell lung cancer （NSCLC）. However, many researchers have questioned the effectiveness of surgery, The aim of this study is to evaluate the effect of surgery for stage Ⅲ NSCLC. Methods Between March 2002 and October 2012, 310 cases that have completed foUowed-up data with stage LII NSCLC were received in the Peking Union Medical College Hospital. They were divided into surgical and non-surgical groups according to whether received sur- gery when diagnosed. In TNM staging, stage Ⅲ NSCLC includes stageⅢa and ILib, and stage Ⅲa NSCLC can be grouped into stage T4N0/T3-4N1M0 and T1-3N2M0 according to different N stages. Analyzed the enumeration data by Chi-Square test. Kaplan-Meier survival method was used to calculate the overall survival （OS） and progression-free survival （PFS）, and to draw the survival curves. A P value less than 0.0S was evaluated as statistically significant. Results Three hundred and ten stage LII NSCLC patients include surgical group 189 cases and non-surgical group 121 cases. One hundred and eighty-eight stage Ⅲa NSCLC patients include surgical group 152 cases and non-surgical group 36 cases. In stage ILia, stage T4N0/T3-4NIM0 had 57 patients with 44 surgical and 13 non-surgical patients, and stage TI-3N2M0 had 131 patients with 108 surgical and 23 non-surgical patients. Thirty-seven out of 121 stage IIIb NSCLC patients received surgery. They had 22 stage T4N2M0 cases and 15 stage T1-4N3M0 cases.The patient whose performance status was 0 and staging was stage LiIa was more inclined to un- dergo surgery. For stage ILia NSCLC patients, the median OS of surgical and non-surgical groups were 38.9 and 21.8 months, and the median PFS of them were 19.2 and 11.9 months respectively.The difference of OS between the two groups was signifi- cant （P=0.041）, but the PFS of them had no significant difference （P=0.209）. For stage T4NO/T3-4NIMO which belongs to stage Ⅲa, the median OS of surgical and non-surgical groups were 48.7 and 20.1 months, and the median PFS of them were14.6 and 10.5 months respectively. There were no significant differences of OS and PFS between the two groups （P〉0.05）. For stage T 1-3N2M0 which also belongs to stageⅢa, the median OS of surgical and non-surgical groups were 38.9 and 30.8 months, and the median PFS of them were 19.8 and 12.7 months respectively. There were also no significant differences of OS and PFS between the two groups （P〉0.05）. The maximum diameter of tumor and auxiliary chemotherapy had significant influ- ences on OS and PFS of stage Ⅲa-N2 NSCLC patients, while the histology of tumor only influenced the OS of them （P〈0.05）. Conclusion The patient whose performance status is 0 and staging is stageⅢa is more inclined to undergo surgery. Surgery can prolong OS of patients with stage Ⅲa, especially for stage T4N0/T3-4N1M0. However, it has no benefit on PFS. The maximum diameter of tumor and auxiliary chemotherapy have significant influences on OS and PFS of stage Ⅲa-N2 NSCLC patients, while the histology of tumor only influence the O S of them.