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

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。%Objective:To observe the locoregional recurrence and survival of stageⅢA-N2 non-small cell lung cancer (NSCLC) after in-duction chemotherapy and surgery, to analyze the prognosis influenced by nodal downstaging, and to explore the necessity for postop-erative radiotherapy. Methods:A total of 116 cases of stageⅢA-N2 NSCLC were treated with induction chemotherapy and surgery be-tween 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 con-ducted to compare the differences between groups. Cox models were used to perform multivariate analysis. Results:The median fol-low-up of the patients was 24.42 months. The numbers of patients with pN0, pN1, and pN2 were 40 (34.5%), 16 (13.8%), and 60 (51.7%), respectively. The 3-year local recurrence rates of patients with pN0, pN1, and pN2 were 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 pN2 were 26.9%, 58.3%, and 46.2%, respectively. Multivariate analysis revealed that the significant predictor of LRFS was pN0 during the surgery. The LRFS of patients with pN0 was greater than that of the patients with pN1 (P=0.048). The LRFS of patients with pN1 was 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 demon-strated that pT1, pN0-1, and induction chemotherapy effects were associated with OS. The patients with pN2 yielded a poorer OS than those with pN0 and pN1 (P<0.05). The patients with pN0 did not significantly differ from those with pN1 in terms of OS (P=0.412). Conclu-sion:Although the occurrence of pathologic downstaging is a well-known positive prognostic indicator after stageⅢ-N2 NSCLC is sub-jected to chemotherapy, the local-recurrence rate of nodal-downstaged patients remains high, even when they receive adjuvant che-motherapy. Therefore, new postoperative strategies after induction chemotherapy and surgery should be developed.