49例老年小细胞肺癌综合治疗的临床观察

Clinical observation of multidisciplinary therapy for small-cell lung cancer in elderly patients

目的探讨应用密集周化疗及多学科综合治疗方案治疗老年小细胞肺癌（small—celllungcancer，SCLC）的疗效、耐受性及生存预后因素。方法对1995年3月至2005年12月入组的49例老年（≥60岁）SCLC患者采取CODE（顺铂、长春新碱、多柔比星及依托泊苷）密集周化疗，总疗程9周。首次化疗方案完成后，根据患者的KPS评分和心肺功能确定是否接受胸部放射治疗（radiotherapy，RT）和（或）维持治疗（maintenancechemotherapy，MCT）以及最佳支持治疗（bestsupportivecare，BSC）。符合手术条件的病例于CODE前或后行胸部手术。按WHO实体瘤通用标准进行疗效评定，应用Kaplan—Meier法绘制生存曲线，寿命表法计算生存率，COX多因素回归比例风险模型分析生存预后因素。并与同期同方案治疗的SCLC轻年组（〈60岁）69例进行比较。结果老年组患者占同期人组病例41．5％（49／118例），可进行CODE疗效评定的患者为45例。评价结果为CR13例（28．9％），PR30例（66．7％），PD2例（4．4％）。随后完成的综合治疗有CODE＋RT＋MCT（34例）、OP＋CODE＋RT＋MCT（5例）、CODE＋RT或CODE＋MCT（8例）、CODE＋BSC（2例）。综合疗效分别为CR38．8％、PR53．1％和PD8．2％。老年组中位生存时间（mediansurvivaltime，MST）23个月（95％CI：16～30），其中局限期（LD）为37个月（95％CI：16～58），广泛期（ED）为18个月（95％CI：12～24），P=0．027。1年、5年生存率LD为92．3％和30．8％，ED为80．6％和11．1％（P值分别为0．308、0．116）。单因素分析显示KPS评分、疾病分期、治疗模式、CODE疗效和综合治疗疗效可影响老年患者生存（P〈0．05）。多因素分析显示疾病分期和综合治疗疗效是影响患者生存的独立预后因素（P〈0．05）。老年组与轻年组MST及1年、5年生存率无明显统计学差异（P〉0．05）。结论CODE密集周化疗及选择性个体化综合治疗，可提高老年SCLC患者的疗效，有更好的安全性，明显延长生存期。

Objective To assess the effect, tolerance and survival prognosis of the intensive weekly ehemotherapy and multidisciplinary therapy of small-cell lung cancer （SCLC） in elderly patients. Method Forty-nine elderly patients （≥60 years） with SCLC enrolled during March 1995 to December 2005 received CODE （cisplatin, vincristine, doxorubi-cin and etoposide） intensive weekly chemotherapy for 9 weeks, followed by additional chest radiotherapy （RT） and/or ma- intenance chemotherapy （MCT）, or best supportive care （BSC） based on patients＇ KPS score and cardio-pulmonary func- tion after the primary chemotherapy. The patients who were eligible for surgery accepted chest surgery before or after CODE. WHO RESICT criteria was referenced for clinical effect, and survival was plotted by Kaplan-Meier, while survival rates were calculated using life table, besides, COX multivariate regression proportional hazard model was applied for survival prognostic factors. A group of 69 young patients （〈60 years） with SCLC of the same period was taken as control. Result Elderly patients accounted for 41.5% （49/118） in all, in which there were only 45 cases that were evaluable for efficacy. Complete response （CR）, partial response （PR） and progressive disease （PD） were observed in 13 （28.9%）, 30 （66. 7%） and 2 （4. 4%） patients, respectively. The ensuing multidisciplinary therapy included CODE＋RT＋MCT （34 ca- ses）, OP＋CODE＋RT＋MCT （5 cases）, CODE＋MCT or CODE＋RT （8 cases）, and CODE＋BSC （2 cases）. The compre- hensive clinic effects for multidisciplinary therapy were 38.8% in CR, 53.1% in PR, and 8.2% in PD, respectively. The median survival time （MST） of elderly patients group was 23 months （95% CI： 16-30）. MST for patients of LD was 37 months （95% CI： 16-58）, ED was 18 months （95% CI： 12-24） （P=0. 027）. One- and five-year survival rate was 92.3% ＆ 30. 8% （P=0. 308） for LD, and 80. 6% ＆ 11.1% （0. 116） for ED. Univariate analysis showed that the surviv- al of elderly patients was related to KPS, disease stage, therapy mode, effect of CODE and multidisciplinary therapy （P 〈 0. 05）. While multivariate analysis showed that disease stage and effect of multidisciplinary were independent prognosis fac- tors （P 〈 0. 05）. No significant difference was observed between elderly and young patients in terms of MST, 1- and 5-year survival rates （P 〈 0. 05）. Conclusion Intensive weekly chemotherapy （CODE） and individualized muhidisciplinary therapy shows satisfactory effect, better safety, and longer survival for elderly SCLC patients.