Perri Tamar, Meller Elad, Ben-Baruch Gilad, Inbar Yael, Apter Sara, Heyman Lee, Dotan Zohar, Korach Jacob
Department of Gynecologic Oncology, Sheba Medical Center, Tel Hashomer, Israel
Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
BMJ Support Palliat Care. 2022 Dec;12(e6):e855-e861. doi: 10.1136/bmjspcare-2019-001771. Epub 2019 Apr 24.
To identify factors aiding the selection of patients with gynaecological cancer with malignant urinary obstruction who are least likely to benefit from palliative urinary diversion (UD), and to create a risk-stratification model for decision-making.
This historic cohort study comprised 74 consecutive patients with urinary obstruction resulting from gynaecological malignancies. All underwent palliative UD by percutaneous nephrostomy (PCN). Using the Cox proportional hazards regression model and Kaplan-Meier curves with the log-rank test, we developed a prognostic score identifying candidates least likely to benefit from the intervention.
The median follow-up was 4.72 (range 0-5.71) years. Hydronephrosis was diagnosed in most patients on recurrent or persistent disease (81%). It was bilateral in 37.8%. Intervention-related complications included urinary sepsis (8%), catheter dislodgment requiring replacement (17%) and gross haematuria necessitating blood transfusions (13%). After PCN, conversion to an internal ureteral stent was feasible in 46%. The median survival was 11.13 (range 0-67) months. Two patients died within a month of UD. Multivariate analysis identified diabetes mellitus (DM), poor Eastern Cooperative Oncology Group (ECOG) performance status >1 and ascites as significant negative survival factors. A prognostic index based on those factors identified the short-term and long-term survivors. Risk factor-based mortality HRs were 11.37 (95% CI 4.12 to 31.37) with one factor, 26.57 (95% CI 9.14 to 77.26) with two factors and 67.25 (95% CI 15.6 to 289.63) with three factors (all with p<0.0001).
Our proposed prognostic index, based on ascites, ECOG performance status and DM, might help select patients with gynaecological cancer least likely to benefit from palliative UD.
确定有助于筛选出不太可能从姑息性尿流改道（UD）中获益的妇科癌症合并恶性尿路梗阻患者的因素，并创建一个用于决策的风险分层模型。
这项历史性队列研究纳入了74例连续的因妇科恶性肿瘤导致尿路梗阻的患者。所有患者均通过经皮肾造瘘术（PCN）进行姑息性UD。使用Cox比例风险回归模型以及带有对数秩检验的Kaplan-Meier曲线，我们制定了一个预后评分，以识别最不可能从该干预措施中获益的候选患者。
中位随访时间为4.72年（范围0 - 5.71年）。大多数复发或持续性疾病患者（81%）被诊断为肾积水。其中双侧肾积水的患者占37.8%。与干预相关的并发症包括尿脓毒症（8%）、需要更换导管的导管移位（17%）以及需要输血的严重血尿（13%）。PCN术后，46%的患者可行输尿管内支架置入术。中位生存期为11.13个月（范围0 - 67个月）。两名患者在UD术后1个月内死亡。多变量分析确定糖尿病（DM）、东部肿瘤协作组（ECOG）体能状态>1以及腹水是显著的负性生存因素。基于这些因素的预后指数可识别短期和长期存活者。基于风险因素的死亡率风险比在有一个因素时为11.37（95%可信区间4.12至31.37），有两个因素时为26.57（95%可信区间9.14至77.26），有三个因素时为67.25（95%可信区间15.6至289.63）（所有p<0.0001）。
我们基于腹水、ECOG体能状态和DM提出的预后指数，可能有助于筛选出最不可能从姑息性UD中获益的妇科癌症患者。
