Department of Surgery, University of Arizona, Tucson, Arizona.
Ann Surg. 2020 Sep 1;272(3):438-446. doi: 10.1097/SLA.0000000000004181.
Gastrointestinal cancers are increasingly being treated with NAT before surgical resection. Currently, quality metrics are linked to the number of LNs resected to determine subsequent treatment and prognosis. We hypothesize that NAT decreases LN metastasis, downstages patients, and decreases overall lymph node yields (LNY) compared to initial surgical resection. With increasing use of NAT, this brings into question the validity of quality metrics.
Gastric (stage II/III), pancreatic (stage I/II/III), and rectal cancers (stage II/III) (2010-2015) treated with surgery with/without NAT were identified in National Cancer Database. We evaluated total LNY and LN metastasis with/without NAT and clinical and pathological stage to evaluate rates of downstaging.
A total of 7934 gastric, 15,908 pancreatic, and 21,354 rectal cancer patients were included of which 61.1%, 21.2%, and 85.7% received NAT, respectively. NAT patients were more likely to be downstaged (39.9% vs 11.1% gastric P< 0.001, 30.6% vs 3.2% pancreatic P< 0.001, 52.0% vs 16.3% rectal P< 0.001), have lower LNYs (18.8 vs 19.1 gastric P = 0.239, 18.4 vs 17.5 pancreatic P< 0.001, 15.7 vs 20.0 rectal P< 0.001) and have N0 pathologic disease (43.6% vs 26.7% gastric P< 0.001, 51.1% vs 30.9% pancreatic P< 0.001, 65.9% vs 49.4% rectal P< 0.001) when compared to initial surgical resection.
NAT for gastrointestinal cancers results in overall lower LN yields, lower LN metastases, and significant downstaging of tumors. As all patients undergoing NAT receive multimodality therapy, LN yield recommendations may not be true quality metric changing.
在手术切除前，越来越多的胃肠道癌症患者接受新辅助治疗（NAT）。目前，质量指标与切除的淋巴结数量相关联，以确定后续治疗和预后。我们假设与初始手术切除相比，NAT 可降低淋巴结转移率、降低患者分期并减少总体淋巴结产量（LNY）。随着 NAT 使用的增加，这对质量指标的有效性提出了质疑。
在国家癌症数据库中确定了 2010 年至 2015 年间接受手术联合/不联合 NAT 治疗的胃（II/III 期）、胰腺（I/II/III 期）和直肠（II/III 期）癌患者。我们评估了有/无 NAT 的总 LNY 和淋巴结转移情况以及临床和病理分期，以评估降级率。
共纳入 7934 例胃癌、15908 例胰腺癌和 21354 例直肠癌患者，其中分别有 61.1%、21.2%和 85.7%接受了 NAT。NAT 患者更有可能降级（39.9%比 11.1%的胃癌 P<0.001，30.6%比 3.2%的胰腺癌 P<0.001，52.0%比 16.3%的直肠癌 P<0.001），LNY 更低（18.8 比 19.1 的胃癌 P=0.239，18.4 比 17.5 的胰腺癌 P<0.001，15.7 比 20.0 的直肠癌 P<0.001），并且无病理疾病的淋巴结（43.6%比 26.7%的胃癌 P<0.001，51.1%比 30.9%的胰腺癌 P<0.001，65.9%比 49.4%的直肠癌 P<0.001）。
胃肠道癌症的 NAT 治疗总体上导致较低的淋巴结产量、较低的淋巴结转移和肿瘤显著降级。由于所有接受 NAT 的患者都接受了多模式治疗，因此淋巴结产量推荐可能不是真正的质量指标变化。
