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先离断静脉还是动脉的肺叶切除手术方式对非小细胞肺癌患者的生存影响

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先离断静脉还是动脉的肺叶切除手术方式对非小细胞肺癌患者的生存影响
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来自华西医院,大坪医院等单位开展的随机临床试验,目的是比较肺叶切除时,首先离断静脉,是否会减少非小细胞肺癌患者肿瘤细胞的传播。

方法:主要通过检测术后患者循环肿瘤细胞 (FR+CTCs) 以及 5年总生存,无疾病生存和肺癌特异性生存 。

结果 共有86人随机分组; 22例患者(25.6%)年龄较小,46岁(74.4%)年龄大于60岁。对其中78名患者进行了分析。动脉先断组40例患者中有26例(65.0%)观察到FR + CTC 的增量变化,静脉先断组38例(31.6%)中有12例(P  =.003) 。多变量分析证实,动脉先断的手术方式是手术中FR + CTC增加的危险因素。倾向性匹配分析包括420名患者(210名患者采用静脉先断手术,210名采用动脉第先断)。静脉先断的结果显著优于动脉先断5年总生存率(73.6% vs 57.6%; P  = .002),无病生存率(63.6%对48.4%; P  = .001)和肺癌特异性生存率(76.4% vs 59.9%; P  = .002)。多变量分析显示,动脉先断的手术方式是5年总生存率,无病生存率和肺癌特异性存活的不良因素。

结论: 手术期间首先切断血静脉可以减少肿瘤细胞的传播,并改善非小细胞肺癌患者的生存结果。

Importance  It is important to develop a surgical technique to reduce dissemination of tumor cells into the blood during surgery.

Objective  To compare the outcomes of different sequences of vessel ligation during surgery on the dissemination of tumor cells and survival in patients with non–small cell lung cancer.

Design, Setting, and Participants  This multicenter, randomized clinical trial was conducted from December 2016 to March 2018 with patients with non–small cell lung cancer who received thoracoscopic lobectomy in West China Hospital, Daping Hospital, and Sichuan Cancer Hospital. To further compare survival outcomes of the 2 procedures, we reviewed the Western China Lung Cancer database (2005-2017) using the same inclusion criteria.

Interventions  Vein-first procedure vs artery-first procedure.

Main Outcomes and Measures  Changes in folate receptor–positive circulating tumor cells (FR+CTCs) after surgery and 5-year overall, disease-free, and lung cancer–specific survival.

Results  A total of 86 individuals were randomized; 22 patients (25.6%) were younger and 46 (74.4%) older than 60 years. Of these, 78 patients were analyzed. After surgery, an incremental change in FR+CTCs was observed in 26 of 40 patients (65.0%) in the artery-first group and 12 of 38 (31.6%) in the vein-first group (P = .003) (median change, 0.73 [interquartile range (IQR), −0.86 to 1.58] FU per 3 mL vs −0.50 [IQR, −2.53 to 0.79] FU per 3 mL; P = .006). Multivariate analysis confirmed that the artery-first procedure was a risk factor for FR+CTC increase during surgery (hazard ratio [HR], 4.03 [95% CI, 1.53-10.63]; P = .005). The propensity-matched analysis included 420 patients (210 with vein-first procedures and 210 with artery-first procedures). The vein-first group had significantly better outcomes than the artery-first group for 5-year overall survival (73.6% [95% CI, 64.4%-82.8%] vs 57.6% [95% CI, 48.4%-66.8%]; P = .002), disease-free survival (63.6% [95% CI, 55.4%-73.8%] vs 48.4% [95% CI, 40.0%-56.8%]; P = .001), and lung cancer–specific survival (76.4% [95% CI, 67.6%-85.2%] vs 59.9% [95% CI, 50.5%-69.3%]; P = .002). Multivariate analyses revealed that the artery-first procedure was a prognostic factor of poorer 5-year overall survival (HR, 1.65 [95% CI, 1.07-2.56]; P = .03), disease-free survival (HR, 1.43 [95% CI, 1.01-2.04]; P = .05) and lung cancer–specific survival (HR = 1.65 [95% CI, 1.04-2.61]; P = .03).

Conclusions and Relevance  Ligating effluent veins first during surgery may reduce tumor cell dissemination and improve survival outcomes in patients with non–small cell lung cancer.

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