Lyon Timothy D, Gershman Boris, Shah Paras H, Thompson R Houston, Boorjian Stephen A, Lohse Christine M, Costello Brian A, Cheville John C, Leibovich Bradley C
Department of Urology, Mayo Clinic, Rochester, MN.
Warren Alpert Medical School of Brown University, Providence, RI; Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI.
Urol Oncol. 2018 Nov;36(11):499.e1-499.e7. doi: 10.1016/j.urolonc.2018.08.008. Epub 2018 Sep 15.
To develop a risk-stratification model for cancer-specific survival (CSS) following cytoreductive nephrectomy (CN) in the contemporary era.
A retrospective review was performed of 313 patients who underwent CN for M1 renal cell carcinoma (RCC) from 1990 to 2010. To account for the introduction of targeted therapies, timing of surgery was classified as immunotherapy era (1990-2004) or contemporary era (2005-2010). Risk scores were developed to predict CSS using Cox proportional hazards regression models.
A total of 215 (69%) and 98 (31%) patients were treated in the immunotherapy and contemporary eras, respectively. Median follow-up among survivors was 9.6 years, during which time 291 patients died, including 279 from RCC. On multivariable analysis limited to preoperative features, age ≥ 75, (hazard ratio [HR] 1.9), female sex (HR 1.9), constitutional symptoms (HR 1.61), radiographic lymphadenopathy (HR 1.59), and IVC tumor thrombus (HR 1.65) were significantly associated with CSS. On multivariable analysis including pathologic features, the features above as well as coagulative necrosis (HR 1.51) and sarcomatoid differentiation (HR 1.44) were significantly associated with CSS (all P < 0.05). Risk scores were developed for each model and used to predict CSS according to era. Decision curve analysis revealed that the preoperative risk score conferred a net benefit over a treat-all or treat-none approach beyond a 1-year cancer-specific mortality threshold of 25%.
We developed risk scores to predict CSS for patients treated with CN in the contemporary era. Patients with poor predicted survival may consider avoiding CN as initial management.
建立当代减瘤性肾切除术后癌症特异性生存（CSS）的风险分层模型。
对1990年至2010年因M1期肾细胞癌（RCC）接受减瘤性肾切除术的313例患者进行回顾性研究。为考虑靶向治疗的引入，手术时间分为免疫治疗时代（1990 - 2004年）或当代时代（2005 - 2010年）。使用Cox比例风险回归模型建立风险评分以预测CSS。
免疫治疗时代和当代时代分别有215例（69%）和98例（31%）患者接受治疗。幸存者的中位随访时间为9.6年，在此期间291例患者死亡，其中279例死于RCC。在仅限于术前特征的多变量分析中，年龄≥75岁（风险比[HR] 1.9）、女性（HR 1.9）、全身症状（HR 1.61）、影像学显示的淋巴结病（HR 1.59）和下腔静脉肿瘤血栓（HR 1.65）与CSS显著相关。在包括病理特征的多变量分析中，上述特征以及凝固性坏死（HR 1.51）和肉瘤样分化（HR 1.44）与CSS显著相关（所有P < 0.05）。为每个模型建立风险评分，并根据时代用于预测CSS。决策曲线分析显示，术前风险评分在癌症特异性死亡率阈值为25%的1年以上时，相对于全治疗或不治疗方法具有净效益。
我们建立了风险评分以预测当代接受减瘤性肾切除术患者的CSS。预测生存较差的患者可考虑避免将减瘤性肾切除术作为初始治疗手段。
