Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois2Department of Radiation Oncology, University of Illinois at Chicago Medical Center, Chicago.
Department of Radiation Oncology, University of Illinois at Chicago Medical Center, Chicago.
JAMA Otolaryngol Head Neck Surg. 2014 Jan;140(1):12-21. doi: 10.1001/jamaoto.2013.5754.
After chemoradiation for head and neck cancer, more than 90% of patients who achieve a complete clinical response on imaging have their disease regionally controlled without postradiotherapy neck dissections (PRNDs). Because several groups have reported that lymph node involvement also predicts failure at both the primary and distant sites, the extent to which PRND affects nonregional sites of disease remains unclear.
To evaluate how PRND affects local control (LC) and distant control in patients who achieve a complete clinical response.
DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed 287 patients (74 of whom underwent PRND) from the University of Illinois at Chicago Medical Center who were treated for stage III/IV disease with definitive chemoradiation from January 1, 1990, through December 31, 2012.
Chemoradiation followed by lymph node dissection or observation.
End points evaluated included LC, regional control, freedom from distant metastasis, progression-free survival (PFS), and overall survival using first-failure analysis.
Patients with advanced nodal disease (stage N2b or greater; n = 176) had improved PFS (74.6% vs 39.1%; P < .001), whereas patients with lesser nodal disease had similar PFS. For patients with advanced nodal disease, PRND improved 2-year LC (85.5% vs 53.5%; P < .001), locoregional control with PRND (78.9% vs 45.7%; P < .001), freedom from distant metastasis (79.5% vs 67.5%; P = .03), and overall survival (84.5% vs 61.7%; P = .004) but not regional control (96.9% vs 90.1%; P = .21). The benefit in LC (87.4% vs 66.2%; P = .02) and PFS (80.7% vs 53.4%; P = .01) persisted for those with negative posttreatment imaging results who underwent PRND. On univariate analysis, PRND, alcohol use, nodal stage, and chemoradiation significantly affected 2-year LC and/or PFS. On multivariate analysis, PRND remained strongly prognostic for 2-year LC (hazard ratio, 0.22; 95% CI, 0.07-0.54; P < .001) and PFS (hazard ratio, 0.42; 95% CI, 0.23-0.74; P = .002).
Postradiotherapy neck dissection improved control of nonregional sites of disease in patients with advanced nodal disease who achieved a complete response after chemoradiation. Thus, PRND may affect the control of nonnodal sites through possible mechanisms, such as clearance of incompetent lymphatics and prevention of reseeding of the primary and distant sites.
背景:在头颈部癌症的放化疗后,超过 90%在影像学上完全缓解的患者在不接受放疗后颈部清扫术(PRND)的情况下实现了区域性疾病控制。由于有几个小组报告说淋巴结受累也预测原发和远处部位的失败,PRND 对非区域性疾病部位的影响程度仍不清楚。
目的:评估 PRND 在完全缓解的患者中对局部控制(LC)和远处控制的影响。
设计、设置和参与者:我们回顾性地分析了来自伊利诺伊大学芝加哥医疗中心的 287 名患者(其中 74 名接受了 PRND)的资料,这些患者在 1990 年 1 月 1 日至 2012 年 12 月 31 日期间因 III/IV 期疾病接受了确定性放化疗。
干预措施:放化疗后行淋巴结清扫或观察。
主要结局和测量:采用首次失败分析评估的终点包括 LC、区域控制、无远处转移、无进展生存期(PFS)和总生存期。
结果:患有晚期淋巴结疾病(N2b 期或更晚;n=176)的患者 PFS 得到改善(74.6%比 39.1%;P<.001),而淋巴结疾病较轻的患者 PFS 相似。对于患有晚期淋巴结疾病的患者,PRND 提高了 2 年 LC(85.5%比 53.5%;P<.001)、PRND 下的局部区域控制(78.9%比 45.7%;P<.001)、无远处转移(79.5%比 67.5%;P=.03)和总生存期(84.5%比 61.7%;P=.004),但不包括区域控制(96.9%比 90.1%;P=.21)。在接受 PRND 的影像学检查结果为阴性的患者中,LC(87.4%比 66.2%;P=.02)和 PFS(80.7%比 53.4%;P=.01)的获益仍持续存在。单因素分析显示,PRND、饮酒、淋巴结分期和放化疗显著影响 2 年 LC 和/或 PFS。多因素分析显示,PRND 对 2 年 LC(风险比,0.22;95%CI,0.07-0.54;P<.001)和 PFS(风险比,0.42;95%CI,0.23-0.74;P=.002)仍然具有强烈的预后意义。
结论和相关性:在放化疗后完全缓解的淋巴结疾病晚期患者中,放疗后颈部清扫术改善了非区域性疾病部位的控制。因此,PRND 可能通过清除功能不全的淋巴管和预防原发和远处部位的再播种等可能的机制来影响非淋巴结部位的控制。