aCenter for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
bDepartment of Medicine, Baylor College of Medicine, Houston, Texas.
J Natl Compr Canc Netw. 2019 Feb;17(2):161-168. doi: 10.6004/jnccn.2018.7093.
Pathologically positive lymph nodes (ypN+) after preoperative chemotherapy are associated with poor survival in patients with gastric cancer. Little is known about the association between response to preoperative therapy and the benefit of postoperative therapy. This retrospective cohort study of the National Cancer Database included patients with clinically node-positive (cN+) gastric cancer treated with preoperative therapy followed by surgery (2006-2014). Preoperative treatment modality was categorized as the inclusion of radiation therapy (RT) or chemotherapy alone. Pretreatment clinical and pathologic stages were used to determine pathologic treatment response rates. The association between overall risk of death and preoperative treatment, disease response, and adjuvant therapy use was evaluated using multivariable Cox regression. Preoperative RT was used in 53.6% of 1,976 patients with cN+ gastric cancer, (74.3% cardia and 10.1% noncardia). The nodal response rate was 38.9% and was higher with RT than with chemotherapy alone (cardia, 46.0% vs 29.1%; <.001; noncardia, 43.8% vs 31.9%; =.06). Preoperative RT was associated with an approximate 2-fold increase in the odds of pathologic response compared with chemotherapy. Overall, use of adjuvant therapy was not associated with a decreased risk of death. A primary tumor response with residual nodal disease was not associated with survival (hazard ratio [HR], 1.03; 95% CI, 0.66-1.60). However, a nodal response with residual primary disease was significantly associated with survival (HR, 0.54; 95% CI, 0.44-0.65). More than one-third of node-positive gastric cancers showed pathologic nodal response with preoperative treatment. RT is associated with a higher response than chemotherapy. Patients with ypN+ disease have worse survival, regardless of whether they receive postoperative therapy. Future gastric cancer trials should evaluate the role of preoperative RT and individualize postoperative therapy use.
术前化疗后病理性阳性淋巴结（ypN+）与胃癌患者的生存不良相关。对于术前治疗反应与术后治疗获益之间的关系，知之甚少。本研究回顾性分析了国家癌症数据库中的病例，纳入了接受术前治疗（2006-2014 年）后行手术治疗的临床淋巴结阳性（cN+）胃癌患者。术前治疗方式分为包括放疗（RT）或单独化疗。术前临床和病理分期用于确定病理治疗反应率。使用多变量 Cox 回归评估总死亡风险与术前治疗、疾病反应和辅助治疗的使用之间的关系。在 1976 例 cN+胃癌患者中，53.6%的患者接受了术前 RT（贲门癌 74.3%，非贲门癌 10.1%）。淋巴结反应率为 38.9%，RT 组高于单独化疗组（贲门癌：46.0%比 29.1%；<.001；非贲门癌：43.8%比 31.9%；=.06）。与单独化疗相比，术前 RT 使病理反应的可能性增加了近 2 倍。总体而言，辅助治疗的使用与死亡风险降低无关。原发肿瘤有反应但残留淋巴结疾病与生存无关（危险比 [HR]，1.03；95%CI，0.66-1.60）。然而，原发肿瘤有反应但残留淋巴结疾病与生存显著相关（HR，0.54；95%CI，0.44-0.65）。超过三分之一的阳性淋巴结胃癌患者经术前治疗后出现病理性淋巴结反应。RT 比化疗的反应更高。ypN+疾病患者的生存更差，无论是否接受术后治疗。未来的胃癌临床试验应评估术前 RT 的作用，并个体化应用术后治疗。
