Concurrent cisplatin/etoposide plus 3D-conformal radiotherapy followed by surgery for stage IIB (superior sulcus T3N0)/III non-small cell lung cancer yields a high rate of pathological complete response
Concurrent cisplatin/etoposide plus 3D-conformal radiotherapy followed by surgery for stage IIB (superior sulcus T3N0)/III non-small cell lung cancer yields a high rate of pathological complete response
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DOI：
10.1016/j.ejcts.2008.01.063
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发表时间：
2008-05-01
影响因子：
3.4
通讯作者：
Reboul, Francois
中科院分区：
文献类型：
--
作者：
Pourel, Nicolas;Santelmo, Nicola;Reboul, Francois
简介：IIB期（Pancoast）/III期非小细胞肺癌（NSCLC）的最佳术前治疗仍不确定，并且是一个有争议的主题。我们研究的目的是确认在我们的社区治疗中心进行诱导放化疗（CRT）后的可行性和病理反应率。患者和方法：根据功能和可切除性标准选择患者。诱导治疗包括3D适形放射治疗，4500 cGy，在CT扫描上对原发肿瘤和病理性肺门和/或纵隔淋巴结进行放射治疗，外切缘1-1.5 cm。同期化疗方案为顺铂20 mg/m2，d1 ~ d5;依托泊苷50 mg/m2，d1 ~ d5，d1- 5d29 ~ 33。在CRT完成后3-4周内，相应地重新评估可操作性。在CRT完成后4-6周对认为可切除的患者（pts）进行手术。不能手术的患者接受20-25戈伊加强+/- 1个额外周期的顺铂+依托泊苷。结果如下：从1996年到2005年，最初选择了107名患者进行治疗并接受了诱导放化疗（IIB-Pancoast期18名，IIIA期58名和IIIB期31名，鳞状细胞癌48%，腺癌44%，大细胞未分化癌14%）。术前评估后，72例患者（67%）进行了开胸术（肺切除术21例，肺叶切除术45例，双叶切除术5例），除1例（不可切除的肿瘤）外，所有患者均进行了肉眼完全切除。在术后3个月内，5例患者（6.9%）死亡，4例肺切除术后（右3例，左1例）。肿瘤样本的分析显示病理学完全缓解率或显微镜下残留病灶为39.5%。中位随访时间为22.3个月（幸存者：36.8个月），2年和3年总生存率分别为55%和40%所有意向治疗人群（n = 107）中，62%和51%（中位数= 26.7个月）（中位数= 36.5个月），41%和16%的36例非切除患者（中位数= 19.1个月）。在多变量分析中，手术切除和肿瘤坏死>50%（或病理完全缓解）是死亡风险最相关的预测因素（风险比分别为0.50和0.48，p = 0.006和0.038）。结论：诱导放化疗后手术是可行的，特别是PS 0-1、IIB期（Pancoast）/III期NSCLC患者的肺叶切除术，但全肺切除术术后死亡风险较高（特别是右肺切除术）。39.5%的患者对诱导放化疗的病理反应是完全的，是总生存率的重要预测因素。(C)2008年欧洲胸外科协会。Elsevier B. V.出版，保留所有权利。
Introduction: Optimal preoperative treatment of stage IIB (Pancoast)/III non-small cell lung cancer (NSCLC) remains undetermined and a subject of controversy. The goat of our study is to confirm feasibility and pathological response rates after induction chemoradiation (CRT) in our community-based treatment center. Patients and methods: Patients were selected according to functional and resectability criteria. Induction treatment comprised 3D conformal 4500 cGy radiotherapy delivered to the primary tumor and pathologic hilar and/or mediastinal lymph nodes on CTscan with an extra-margin of 1-1.5 cm. Concurrent chemotherapy regimen was cisplatinum 20 mg/m(2) d1-d5 and etoposide 50 mg/m(2) d1-d5, d1-5 d29-33. Within 3-4 weeks after CRT completion, operability was re-assessed accordingly. Surgery was performed 4-6 weeks after CRT completion in patients (pts) deemed resectable. Inoperable pts were referred for a 20-25 Gy boost +/- 1 extra-cycle of cisplatinum + etoposide. Results: From 1996 to 2005, 107 pts were initially selected for treatment and received induction chemoradiation (stage IIB-Pancoast 18, IIIA 58 and IIIB 31, squamous cell carcinoma 48%, adenocarcinoma 44%, large-cell undifferentiated carcinoma 14%). After preoperative evaluation, 72 pts (67%) had a thoracotomy (pneumonectomy 21, lobectomy 45, bilobectomy 5) and all but one (unresectable tumor) had a macroscopic complete resection. During the 3-month postoperative time, five patients (6.9%) died, four after pneumonectomy (right 3, left 1). The analysis of tumoral samples showed a pathological complete response rate or microscopic residual foci of 39.5%. Median follow-up time was 22.3 months (survivors: 36.8 months), 2-year and 3-year overall survival rates were 55% and 40%, respectively (median = 26.7 months) for all the intention-to-treat population (n = 107), 62% and 51% (median = 36.5 months) for 71 resected pts, 41% and 16% for 36 non-resected pts (median = 19.1 months). On multivariate analysis, surgical resection and tumoral necrosis >50% (or pathological complete response) were the most pertinent predictive factors of the risk of death (hazard ratio = 0.50 and 0.48, p = 0.006 and 0.038, respectively). Conclusion: Surgery was feasible after induction chemoradiation, particularly lobectomy in PS 0-1, stage IIB (Pancoast)/III NSCLC pts but pneumonectomy carries a high risk of postoperative death (particularly, right pneumonectomy). Pathological response to induction chemoradiation was complete in 39.5% of patients and was a significant predictive factor of overall survival. (C) 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.