{"title":"肺亚实性结节：早期手术还是观察等待？","authors":"Fenglan Li, Linlin Qi, Changfa Xia, Jianing Liu, Jiaqi Chen, Shulei Cui, Liyan Xue, Sainan Cheng, Xu Jiang, Jianwei Wang","doi":"10.1016/j.chest.2024.12.028","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Patients with pulmonary subsolid nodules (SSNs) of ≤ 2 cm in diameter and a consolidation to tumor ratio (CTR) of ≤ 0.25 have good postoperative prognoses, but their management remains controversial.</p><p><strong>Research question: </strong>Does upfront surgical intervention lead to higher survival than watchful waiting in patients with SSNs with diameter of ≤ 2 cm and CTR of ≤ 0.25?</p><p><strong>Study design and methods: </strong>Patients with SSNs who underwent thin-section CT scan examination between February 2005 and December 2018 were followed up retrospectively until December 2023 or until all-cause death or lung cancer recurrence or metastases. Patients were divided into observation and surgery groups and categorized further by the diameter and CTR of these SSNs. Event-free survival (EFS) was evaluated using Kaplan-Meier analysis, multivariable-adjusted Cox proportional hazards modeling, propensity score matching, and a noninferiority trial.</p><p><strong>Results: </strong>Data from 1,676 patients were included (surgery group, n = 1,122 [66.9%]; observation group, n = 554 [33.1%]), with a median EFS of 70.2 months (range, 0.3-213.6 months). Comparing the observation group with the surgery group, the 5-year EFS rates in category A (diameter ≤ 2 cm and CTR ≤ 0.25), category A1 (diameter ≤ 1 cm and CTR ≤ 0.25), category A2 (1 cm < diameter ≤ 2 cm and CTR ≤ 0.25), and the combined category (diameter ≤ 3 cm and CTR ≤ 0.5) were 100% vs 99.0%, 100% vs 99.6%, 100% vs 98.6%, and 100% vs 97.4%, respectively. In the above categories of SSNs, the EFS of the observation group was noninferior to that of the surgery group (P < .001 for noninferiority), and the results remained consistent after propensity score matching. Category A2 achieved the maximum hazard ratio of 0.0668, with corresponding 5-year EFS rates for the observation and surgery groups being 100% vs 93.3%, respectively.</p><p><strong>Interpretation: </strong>In patients with SSNs of ≤ 2 cm in diameter and CTR of ≤ 0.25, watchful waiting could be more appropriate than upfront surgical intervention.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":"1764-1777"},"PeriodicalIF":8.6000,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Pulmonary Subsolid Nodules: Upfront Surgery or Watchful Waiting?\",\"authors\":\"Fenglan Li, Linlin Qi, Changfa Xia, Jianing Liu, Jiaqi Chen, Shulei Cui, Liyan Xue, Sainan Cheng, Xu Jiang, Jianwei Wang\",\"doi\":\"10.1016/j.chest.2024.12.028\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Patients with pulmonary subsolid nodules (SSNs) of ≤ 2 cm in diameter and a consolidation to tumor ratio (CTR) of ≤ 0.25 have good postoperative prognoses, but their management remains controversial.</p><p><strong>Research question: </strong>Does upfront surgical intervention lead to higher survival than watchful waiting in patients with SSNs with diameter of ≤ 2 cm and CTR of ≤ 0.25?</p><p><strong>Study design and methods: </strong>Patients with SSNs who underwent thin-section CT scan examination between February 2005 and December 2018 were followed up retrospectively until December 2023 or until all-cause death or lung cancer recurrence or metastases. 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引用次数: 0
摘要
背景：直径≤2cm、实变肿瘤比(CTR)≤0.25的肺亚实性结节（SSNs）患者术后预后良好，但其处理仍存在争议。研究问题：对于直径≤2cm、CTR≤0.25的ssn患者，术前手术干预是否比观察等待生存率更高？研究设计和方法：回顾性随访2005年2月至2018年12月期间接受薄层CT扫描检查的ssn患者，直至2023年12月或直到全因死亡或肺癌复发或转移。将患者分为观察组和手术组，并根据ssn的直径和CTR进一步分类。使用Kaplan-Meier分析、多变量校正Cox比例风险模型、倾向评分匹配和非劣效性试验评估无事件生存期（EFS）。结果：纳入1676例患者资料(手术组，n = 1122例[66.9%]；观察组，n = 554[33.1%])，平均EFS为70.2个月（范围0.3 ~ 213.6个月）。观察组与手术组比较，A类（直径≤2 cm， CTR≤0.25）、A1类（直径≤1 cm， CTR≤0.25）、A2类（1 cm <直径≤2 cm， CTR≤0.25）、联合类（直径≤3 cm， CTR≤0.5）5年EFS发生率分别为100% vs 99.0%、100% vs 99.6%、100% vs 98.6%、100% vs 97.4%。在上述ssn类别中，观察组的EFS不低于手术组（P < 0.001为非劣效性），经倾向评分匹配后结果保持一致。A2组的最大风险比为0.0668，观察组和手术组相应的5年EFS发生率分别为100%和93.3%。结论：对于ssn直径≤2cm， CTR≤0.25的患者，观察等待可能比术前手术干预更合适。
Pulmonary Subsolid Nodules: Upfront Surgery or Watchful Waiting?
Background: Patients with pulmonary subsolid nodules (SSNs) of ≤ 2 cm in diameter and a consolidation to tumor ratio (CTR) of ≤ 0.25 have good postoperative prognoses, but their management remains controversial.
Research question: Does upfront surgical intervention lead to higher survival than watchful waiting in patients with SSNs with diameter of ≤ 2 cm and CTR of ≤ 0.25?
Study design and methods: Patients with SSNs who underwent thin-section CT scan examination between February 2005 and December 2018 were followed up retrospectively until December 2023 or until all-cause death or lung cancer recurrence or metastases. Patients were divided into observation and surgery groups and categorized further by the diameter and CTR of these SSNs. Event-free survival (EFS) was evaluated using Kaplan-Meier analysis, multivariable-adjusted Cox proportional hazards modeling, propensity score matching, and a noninferiority trial.
Results: Data from 1,676 patients were included (surgery group, n = 1,122 [66.9%]; observation group, n = 554 [33.1%]), with a median EFS of 70.2 months (range, 0.3-213.6 months). Comparing the observation group with the surgery group, the 5-year EFS rates in category A (diameter ≤ 2 cm and CTR ≤ 0.25), category A1 (diameter ≤ 1 cm and CTR ≤ 0.25), category A2 (1 cm < diameter ≤ 2 cm and CTR ≤ 0.25), and the combined category (diameter ≤ 3 cm and CTR ≤ 0.5) were 100% vs 99.0%, 100% vs 99.6%, 100% vs 98.6%, and 100% vs 97.4%, respectively. In the above categories of SSNs, the EFS of the observation group was noninferior to that of the surgery group (P < .001 for noninferiority), and the results remained consistent after propensity score matching. Category A2 achieved the maximum hazard ratio of 0.0668, with corresponding 5-year EFS rates for the observation and surgery groups being 100% vs 93.3%, respectively.
Interpretation: In patients with SSNs of ≤ 2 cm in diameter and CTR of ≤ 0.25, watchful waiting could be more appropriate than upfront surgical intervention.
期刊介绍：
At CHEST, our mission is to revolutionize patient care through the collaboration of multidisciplinary clinicians in the fields of pulmonary, critical care, and sleep medicine. We achieve this by publishing cutting-edge clinical research that addresses current challenges and brings forth future advancements. To enhance understanding in a rapidly evolving field, CHEST also features review articles, commentaries, and facilitates discussions on emerging controversies. We place great emphasis on scientific rigor, employing a rigorous peer review process, and ensuring all accepted content is published online within two weeks.
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