肺部监测策略在高级软组织肉瘤中的应用：胸部 X 光片还是 CT 扫描？
Lung Surveillance Strategy for High-Grade Soft Tissue Sarcomas: Chest X-Ray or CT Scan?
机构信息
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Atlanta, GA.
Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA.
出版信息
J Am Coll Surg. 2019 Nov;229(5):449-457. doi: 10.1016/j.jamcollsurg.2019.07.010. Epub 2019 Aug 1.
BACKGROUND
Given the propensity for lung metastases, National Comprehensive Cancer Network guidelines recommend lung surveillance with either chest x-ray (CXR) or CT in high-grade soft tissue sarcoma. Considering survival, diagnostic sensitivity, and cost, the optimal modality is unknown.
METHODS
The US Sarcoma Collaborative database (2000 to 2016) was reviewed for patients who underwent resection of a primary high-grade soft tissue sarcoma. Primary end point was overall survival (OS). Cost analysis was performed.
RESULTS
Among 909 patients, 83% had truncal/extremity and 17% had retroperitoneal tumors. Recurrence occurred in 48%, of which 54% were lung metastases. Lung surveillance was performed with CT in 80% and CXR in 20%. Both groups were clinically similar, although CT patients had more retroperitoneal tumors and recurrences. Regardless of modality, 85% to 90% of lung metastases were detected within the first 2 years with a similar re-intervention rate. When considering age, tumor size, location, margin status, and receipt of radiation, lung metastasis was independently associated with worse OS (hazard ratio 4.26; p < 0.01) and imaging modality was not (hazard ratio 1.01; p = 0.97). Chest x-ray patients did not have an inferior 5-year OS rate compared with CT (71% vs 60%; p < 0.01). When analyzing patients in whom no lung metastases were detected, both cohorts had a similar 5-year OS rate (73% vs 74%; p = 0.42), suggesting CXR was not missing clinically relevant lung nodules. When adhering to a guideline-specified protocol for 2018 projected 4,406 cases, surveillance with CXR for 5 years results in savings of $5 million to $8 million/year to the US healthcare system.
CONCLUSIONS
In this large multicenter study, lung surveillance with CXR did not result in worse overall survival compared with CT. With considerable savings, a CXR-based protocol can optimize resource use for lung surveillance in high-grade soft tissue sarcoma; prospective trials are needed.
背景
鉴于肺癌转移的倾向，国家综合癌症网络指南建议在高级软组织肉瘤中使用胸部 X 光（CXR）或 CT 进行肺部监测。考虑到生存、诊断灵敏度和成本，最佳方式尚不清楚。
方法
回顾了美国肉瘤协作数据库（2000 年至 2016 年）中接受原发性高级软组织肉瘤切除术的患者。主要终点是总生存（OS）。进行了成本分析。
结果
在 909 名患者中，83%为躯干/四肢，17%为腹膜后肿瘤。复发率为 48%，其中 54%为肺转移。80%的患者进行了 CT 监测，20%的患者进行了 CXR 监测。两组在临床方面相似，尽管 CT 组的腹膜后肿瘤和复发率更高。无论采用何种方式，85%至 90%的肺转移瘤在最初 2 年内被检出，再次干预率相似。考虑到年龄、肿瘤大小、位置、切缘状态和接受放疗，肺转移与较差的 OS 独立相关（风险比 4.26；p<0.01），而影像学方式无差异（风险比 1.01；p=0.97）。与 CT 相比，CXR 患者的 5 年 OS 率并不低（71%比 60%；p<0.01）。当分析未检出肺转移的患者时，两组的 5 年 OS 率相似（73%比 74%；p=0.42），表明 CXR 并未遗漏有临床意义的肺结节。当遵循 2018 年的指南规定的方案时，对于 4406 例患者，5 年 CXR 监测可使美国医疗保健系统每年节省 500 万至 8000 万美元。
结论
在这项大型多中心研究中，与 CT 相比，CXR 进行肺部监测并未导致总生存率下降。基于可观的节省，基于 CXR 的方案可以优化高级软组织肉瘤肺部监测的资源利用；需要前瞻性试验。
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