王大权　庞青松　章文成　赵路军　徐利明　陈曦　陈秀丽　刘宁波　王平



淋巴结降期对ⅢA～N2期非小细胞肺癌患者术后远期疗效的影响

王大权庞青松章文成赵路军徐利明陈曦陈秀丽刘宁波王平

摘要目的：观察ⅢA～N2期非小细胞肺癌（NSCLC）诱导化疗加手术患者的术后复发及生存情况，分析淋巴结降期对预后的影响，探索术后放疗的必要性。方法：回顾性选取天津医科大学肿瘤医院2009年1月至2014年6月116例接受诱导化疗加手术的ⅢA～N2期NSCLC患者116例，全组均为R0切除。Kaplan-Meier法计算局部无复发生存期（local-recurrence free survival，LRFS）、无远处转移生存期（distant-metastasis free survival，DMFS）和生存期（overall survival，OS），Log-rank法比较组间差异，Cox模型多因素预后分析。结果：全组中位随访时间24.42个月。pN0、pN1、pN2期患者分别为40例（34.5%）、16例（13.8%）和60例（51.7%），3年复发率分别为27.5%、56.2%和51.7%。77例患者接受了辅助化疗，其中pN0、pN1、pN2患者3年复发率分别为26.9%、58.3%和46.2%。多因素分析中，pN0是影响LRFS的因素。pN1组的LRFS短于pN0组（P=0.048），pN1组和pN2组的LRFS差异无统计学意义（P=0.314）。全组5年生存率为46.6%，多因素分析显示pT1、pN0～1、诱导化疗疗效是影响OS的因素。pN2组的OS短于pN1组和pN0组（P<0.05），pN1组和pN0组的OS差异无统计学意义（P=0.412）。结论：淋巴结降期虽然是ⅢA～N2期NSCLC诱导化疗加手术患者的良好预后因素，但是淋巴结降期的pN0和pN1患者，即使接受了辅助化疗，仍有较高复发风险，有必要探索诱导化疗+手术+术后放疗的新模式。

关键词非小细胞肺癌诱导化疗ⅢA期降期局部复发

The effect of nodal downstage on long-term outcome for patients of non-small-cell lung cancer withⅢA-N2stage

Daquan WANG, Qingsong PANG, Wencheng ZHANG, Lujun ZHAO, Liming XU, Xi CHEN, Xiuli CHEN, Ningbo LIU, Ping WANG
Correspondence to: Ping WANG; E-mail: tjdoctorwang@163.com
Radiotherapy Department, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

Abstract Objective: To observe the locoregional recurrence and survival of stageⅢA-N2non-small cell lung cancer（NSCLC）after induction chemotherapy and surgery, to analyze the prognosis influenced by nodal downstaging, and to explore the necessity for postoperative radiotherapy.Methods: A total of 116 cases of stageⅢA-N2NSCLC were treated with induction chemotherapy and surgery between January 2009 and June 2014.These cases underwent R0 resection.Kaplan-Meier method was employed to calculate the local recurrence-free survival（LRFS）, distant metastasis-free survival（DMFS）, and overall survival（OS）of the patients.Log-rank test was conducted to compare the differences between groups.Cox models were used to perform multivariate analysis.Results: The median follow-up of the patients was 24.42 months.The numbers of patients with pN0, pN1, and pN2were 40（34.5%）, 16（13.8%）, and 60 （51.7%）, respectively.The 3-year local recurrence rates of patients with pN0, pN1, and pN2were 27.5%, 56.2%, and 51.7%, respectively.In the group treated with adjuvant chemotherapy, the 3-year local-recurrence rates of patients with pN0, pN1, and pN2were 26.9%, 58.3%, and 46.2%, respectively.Multivariate analysis revealed that the significant predictor of LRFS was pN0during the surgery.The LRFS of patients with pN0was greater than that of the patients with pN1（P=0.048）.The LRFS of patients with pN1was not significantly associated with that of patients with pN2（P=0.314）.The 5-year OS rate of the groups was 46.6%.The multivariate analysis also demonstrated that pT1, pN0-1, and induction chemotherapy effects were associated with OS.The patients with pN2yielded a poorer OS than those with pN0and pN1（P<0.05）.The patients with pN0did not significantly differ from those with pN1in terms of OS（P=0.412）.Conclusion: Although the occurrence of pathologic downstaging is a well-known positive prognostic indicator after stageⅢ-N2NSCLC is subjected to chemotherapy, the local-recurrence rate of nodal-downstaged patients remains high, even when they receive adjuvant chemotherapy.Therefore, new postoperative strategies after induction chemotherapy and surgery should be developed.

Keywords:non-small cell lung cancer, induction chemotherapy, stageⅢA, downstaging, locoregional recurrence

综合治疗是Ⅲ期非小细胞肺癌的标准治疗模式［1］。对于ⅢA～N2期非小细胞肺癌（NSCLC）患者，诱导化疗加手术与单纯手术相比可达到淋巴结降期、提高完全切除率，进而延长患者生存［2-4］。虽然诱导化疗可以使部分患者明显获益，但是也有研究显示，即使对于诱导化疗后淋巴结状态降期的患者，术后5年复发率也高达30.8%［1］。对于这部分患者是否需要引入放疗，仍是值得探索的问题［5-6］。本文对116例诱导化疗加手术的ⅢA～N2期NSCLC患者的术后复发及生存情况进行分析，从而探索淋巴结降期患者术后放疗的必要性。……