Radiation Oncology Journal

The Korean Society for Radiation Oncology (대한방사선종양학회)
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Division of the N2 Stage According to the Multiplicity of the Involved Nodal Stations May be Necessary in the N2-NSCLC Patients Who are Treated with Postoperative Radiotherapy

비소세포성 폐암으로 수술 후 방사선치료가 시행된 N2병기 환자들에서 다발 부위 종격동 림프절 전이 여부에 따른 N2병기 구분의 임상적 의미

  • Yoon, Hong-In (Departments of Radiation Oncology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Kim, Yong-Bae (Departments of Radiation Oncology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Lee, Chang-Geol (Departments of Radiation Oncology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Lee, Ik-Jae (Departments of Radiation Oncology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Kim, Song-Yih (Departments of Radiation Oncology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Kim, Jun-Won (Departments of Radiation Oncology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Kim, Joo-Hang (Departments of Medical Oncology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Cho, Byung-Chul (Departments of Medical Oncology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Lee, Jin-Gu (Departments of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Chung, Kyung-Young (Departments of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Yonsei University Health System)
  • 윤홍인 (연세대학교 의과대학 방사선종양학교실) ;
  • 김용배 (연세대학교 의과대학 방사선종양학교실) ;
  • 이창걸 (연세대학교 의과대학 방사선종양학교실) ;
  • 이익재 (연세대학교 의과대학 방사선종양학교실) ;
  • 김송이 (연세대학교 의과대학 방사선종양학교실) ;
  • 김준원 (연세대학교 의과대학 방사선종양학교실) ;
  • 김주항 (연세대학교 의과대학 종양내과학교실) ;
  • 조병철 (연세대학교 의과대학 종양내과학교실) ;
  • 이진구 (연세대학교 의과대학 흉부외과학교실) ;
  • 정경영 (연세대학교 의과대학 흉부외과학교실)
  • Received : 2009.04.21
  • Accepted : 2009.08.06
  • Published : 2009.09.30
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Abstract

Purpose: We wanted to evaluate the prognostic factors for the pathologic N2 non-small cell lung cancer (NSCLC) patients who were treated by postoperative radiotherapy. Materials and Methods: We retrospectively reviewed 112 pN2 NSCLC patients who underwent surgery and postoperative radiotherapy (PORT) From January 1999 to February 2008. Seventy-five (67%) patients received segmentectomy or lobectomy and 37 (33%) patients received pneumonectomy. The resection margin was negative in 94 patients, and it was positive or close in 18 patients. Chemotherapy was administered to 103 (92%) patients. Nine (8%) patients received PORT alone. The median radiation dose was 54 Gy (range, 45 to 66), and the fraction size was 1.8~2 Gy. Results: The 2-year overall survival (OS) rate was 60.2% and the disease free survival (DFS) rate was 44.7% for all the patients. Univariate analysis showed that the patients with multiple-station N2 disease had significantly reduced OS and DFS (p=0.047, p=0.007) and the patients with an advanced T stage ($\geq$T3) had significantly reduced OS and DFS (p<0.001, p=0.025). A large tumor size ($\geq$5 cm) and positive lymphovascular invasion reduced the OS (p=0.035, 0.034). Using multivariate analysis, we found that multiple-station N2 disease and an advanced T stage ($\geq$T3) significantly reduced the OS and DFS. Seventy one patients (63.4%) had recurrence of disease. The patterns of failure were loco-regional in 23 (20.5%) patients, distant failure in 62 (55.4%) and combined loco-regional and distant failure in 14 (12.5%) patients. Conclusion: Multiple involvement of mediastinal nodal stations for the pN2 NSCLC patients with PORT was a poor prognostic factor in this study. A prospective study is necessary to evaluate the N2 subclassification and to optimize the adjuvant treatment.

목 적: 비소세포성 폐암 림프절 병기 N2 환자에서 수술 후 방사선치료의 결과와 예후에 영향을 주는 인자에 대해 알아보고자 하였다. 대상 및 방법: 1999년부터 2008년 2월까지 비소세포성 폐암으로 진단받고 수술 후 병기 N2로 방사선치료를 시행받은 112명의 환자를 대상으로 하였다. 폐구간절제술(segmentectomy) 및 폐엽절제술(lobectomy)를 시행받은 환자는 75명(67%), 전폐절제술(pneumonectomy)을 시행 받은 환자는 37명(33%)였다. 절제연 음성인 환자는 94명(83.9%)이었고, 근접절제연 및 절제연 양성인 환자는 모두 18명(16.1%)이었다. 수술 후 보조적 요법으로 103명(92%)의 환자에서 항암치료가 시행되었다. 방사선치료의 분할선량은 1.8에서 2 Gy로 총선량은 45에서 66 Gy가(중앙값, 54 Gy) 시행되었다. 결 과: 전체환자의 2년 생존율과 무병생존율은 각각 60.2%와 44.7%였다. 예후 인자에 대한 단변량 분석을 하였을 때 종격동 림프절 부위(nodal station)의 전이가 단일 부위(single-station)인 환자에 비해 다발 부위(multiple-station)일 때 생존율과 무병생존율이 통계학적으로 의미 있게 감소하였다(p=0.047, p=0.007). T병기가 3기 이상일 때 생존율과 무병생존율이 의미 있게 감소하였다(p<0.001, p=0.025). 종양크기가 5 cm 이상이거나 림프혈관침윤이 양성인 경우 의미 있는 생존율의 감소를 보였고(p=0.035, p=0.034), 무병생존율은 통계학적으로 의미 있는 차이가 없었다. Cox-regression을 이용한 다변량 분석상 전이된 종격동 림프절 부위의 다발 부위 여부와 T병기가($\geq$T3) 생존율(p=0.046, p<0.001)과 무병생존율(p=0.005, p=0.033)에 통계학적으로 의미 있는 인자들이었다. 치료후 재발한 환자는 71명(63.4%)이었고, 국소재발은 23명(20.5%), 원격전이는 62명(55.4%), 그리고 국소재발과 원격전이가 동시에 진단된 환자는 14명(12.5%)이었다. 결 론: 수술 후 방사선치료를 시행받은 절제된 N2 병기 비소세포성 폐암에서 전이된 종격동 림프절 부위의 수가 다발 부위인 경우는 중요한 예후 인자로 향후 N2 병기와 관련된 하위 분류 연구와 그에 적절한 보조 요법에 대한 임상 연구가 필요할 것으로 생각한다.

Keywords

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