Комбинированное лечение больных немелкоклеточным раком легкого

Summary. The combined treatment of non-small cell lung cancer, combining the use of pre- and postoperative chemoradiotherapy and plastic resection, allows for a full-fledged treatment of patients and provides for immediate and long-term results of patient treatment comparable with pneumonectomy.Objective. To evaluate the effectiveness of combined treatment in patients with IA-IIIA stages of NSCLC.Materials and methods. The results of meta-analyzes and randomized studies in recent years indicate that postoperative radiation therapy increases the overall and disease-free survival in stage III (T1–3N2) of NSCLC. At the same time, chemo-radiotherapy with combined treatment reduces the frequency of local recurrence and distant metastasis, increases the median survival rate in stage III of operable NSCLC. This allows us to recommend pre- and postoperative chemo-radiotherapy for the treatment of stage III A NSCLC. At stages I–II (N0 and N1), the effectiveness of pre- and postoperative chemoradiotherapy has not yet been proved and the question of the expediency of it carrying out is solved individually, proceeding from the positions of the clinic.From 2000 to 2016 in Donetsk Regional Cancer Center and Professor G. V. Bondar Republican Cancer Center of health ministry of the DPR, for non-small cell lung cancer 112 plastic resections of the lungs (PRL) and 218 pneumonectomies (PE) were performed. At stage I (T1a, b-T2aN0M0), 50 (45%) PRL and 45 (21%) PE, stage II (T2a, b-N1M0, T3N0M0) — 31 (28%) PRL and 74 (40%) PE, Stage III (T1a, b-T2a, bN2M0, T3N1–2M0, T4N0–1M0) — 31 (28%) PRL and 99 (45%) PE. Squamous cell carcinoma was diagnosed in 91 (81.3%) patients in the group of PRL and 167 (77%) in the PE group; adenocarcinoma in 9 (8%) patients in the group of PRL and in 40 (18.3%) patients in the PE group, non-differentiated cancer in 12 (10.6%) patients in the group of PRL and in 11 (5%) patients in PE group. Plastic upper lobectomy on the right was performed in 52 (46%) patients, the lower lobectomy — 10 (9%), the upper bylobectomy — 5 (4.5%), the lower bylobectomy — 5 (4.5%), the middle lobectomy — 2 (1, 8%). Upper lobectomy on the left was performed in 30 (27%) patients, the lower lobectomy — 8 (7%) patients. 10 (9%) patients underwent angyobronchoplastic surgery. A total of 74 (66%) PRLs were performed on the right and 38 (34%) respectively on the left. Wedge-shaped resections 68 (61%), circular resections 44 (39%). On the right, PE was performed 74 (34%), on the left 144 (66%). Combined PRL were performed in 6 (5.3%) patients, in the PE group 18 (8.3%) patients. By sex and age, the groups are identical and comparable: the average age in the PRL group was 58.9±7.5, in the PE group it was 58.2±7.8. There were 106 males in the PRL group (94.6%) and 203 (93.1%) in the PE group. There were 6 women in the PRL group (5.4%) and 15 (6.9%) in the PE group.Results and discussion. After plastic resection of the lung two (1.8%) patients died: in the first case, after pleural empyema as a result of alveolar fistula; in the second case from myocardial infarction. Postoperative complications developed after PRL in 35 (31%) patients, almost all of them were treated conservatively, only in one case was a retoracotomy for intrapleural bleeding. The results of our studies showed, with combined treatment, forced indentation is less than 7 mm. from the visible edge of the tumor does not necessarily predetermine the development of tumor recurrence. In 8 (7%) patients after the operation, tumor cells were histologically identified along the bronchus (R1) line — these patients necessarily received adjuvant chemoradiation therapy. The frequency (R1) in the PE group was 3 (1.3%).Relapse in the zone of interbronchial anastomosis was detected after 6 and 8 months in 2 patients, after primary R0-operations. These patients were re-operated, pneumonectomy was performed. One of the patients died on the 7th day after the operation from an acute myocardial infarction, the second suffered empyema of the pleura and lived for 97 months, after which it fell out of our observation.In 2 (1.5%) patients, after the operation, the insufficiency of the seams of the interbronchial anastomosis was established, in both cases ended with healing, and the patients were soon discharged with recovery.The maximum mortality after combined therapy with lung resection and pneumonectomy was noted in the first 20 months, then the indices were leveled, always remaining higher after PLR as a component of combination therapy. 3-year survival after combined treatment and PLR was 54.2%, after PE — 32.0% (p <0.05). 5-year survival after combined treatment and PLR — 47,9%, after PE –27,5% (р <0,05). It should be noted that significantly higher survival rates were noted only at stage I of the tumor process (T1a, b-T2aN0M0), in stage II (T2a, b-N1M0, T3N0M0), significantly higher survival results relate only to 5-year survival, more common tumor process IIIA stage (T1a, b-T2a, bN2M0, T3N1–2M0, T4N0–1M0) survival differed in favor of patients after PE, but the difference is mathematically unreliable.Conclusions and practical recommendations. The lung cancer remains an unsolved medical problem, operative is 15–20% of all the newly diagnosed patients. For 40 years, despite the constant search for methods of surgical and combined treatment, the definition of screening methods, the situation with the effectiveness of diagnosis, treatment and prevention of lung cancer have practically not changed.Pre- and postoperative chemo-radiotherapy, as components of combined therapy, allows performing organ-preserving resection of the lungs in those cases when PE is not an offer in connection with a high risk of complications in the postoperative period. At the same time, as many authors note, direct and long-term results and the «quality of life» of patients do not deteriorate.Combined chemo-radiotherapy in combination with radical PRL in lung cancer can be a method of choice in the program of combined therapy of patients with I–IIIA disease stages.Treatment order of pre- and postoperative chemo-radiotherapy in this group of patients should be determined collectively on the basis of an assessment of additional prognostic factors, including: N +, a small indentation from the line of resection of the bronchus to the edge of the tumor, low differentiation of the tumor, etc.