Stark Alexander P, Blum Mariela M, Chiang Yi-Ju, Das Prajnan, Minsky Bruce D, Estrella Jeannelyn S, Ajani Jaffer A, Badgwell Brian D, Mansfield Paul, Ikoma Naruhiko
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
J Gastric Cancer. 2020 Sep;20(3):313-327. doi: 10.5230/jgc.2020.20.e29. Epub 2020 Sep 17.
Nodal downstaging after preoperative therapy for gastric cancer has been shown to impart excellent prognosis, but this has not been validated in a national cohort. The role of neoadjuvant chemoradiation (NACR) in nodal downstaging remains unclear when compared with that of neoadjuvant chemotherapy alone (NAC). Furthermore, it is unknown whether the prognostic implications of nodal downstaging differ by preoperative regimen.
Using the National Cancer Database, overall survival (OS) duration was compared among natural N0 (cN0/ypN0), downstaged N0 (cN+/ypN0), and node-positive (ypN+) gastric cancer patients treated with NACR or NAC. Factors associated with nodal downstaging were examined in a propensity score-matched cohort of cN+ patients, matched 1:1 by receipt of NACR or NAC.
Of 7,426 patients (natural N0 [n=1,858, 25.4%], downstaged N0 [n=1,813, 24.4%], node-positive [n=3,755, 50.4%]), 58.2% received NACR, and 41.9% received NAC. The median OS durations of downstaged N0 (5.1 years) and natural N0 (5.6 years) patients were similar to one another and longer than that of node-positive patients (2.1 years) (P<0.001). In the matched cohort of cN+ patients, more recent diagnosis (2010-2015 vs. 2004-2009) (odds ratio [OR], 2.57; P<0.001) and NACR (OR, 2.02; P<0.001) were independently associated with nodal downstaging. The 5-year OS rate of downstaged N0 patients was significantly lower after NACR (46.4%) than after NAC (57.7%) (P=0.003).
Downstaged N0 patients have the same prognosis as natural N0 patients. Nodal downstaging occurred more frequently after NACR; however, the survival benefit of nodal downstaging after NACR may be less than that when such is achieved by NAC.
胃癌术前治疗后区域淋巴结降期已被证明可带来良好的预后，但这尚未在全国队列中得到验证。与单纯新辅助化疗（NAC）相比，新辅助放化疗（NACR）在区域淋巴结降期方面的作用仍不明确。此外，区域淋巴结降期的预后意义是否因术前治疗方案而异尚不清楚。
利用国家癌症数据库，比较接受NACR或NAC治疗的自然N0（cN0/ypN0）、降期N0（cN+/ypN0）和淋巴结阳性（ypN+）胃癌患者的总生存期（OS）。在倾向评分匹配的cN+患者队列中，按接受NACR或NAC 1:1匹配，研究与区域淋巴结降期相关的因素。
在7426例患者中（自然N0[n = 1858，25.4%]，降期N0[n = 1813，24.4%]，淋巴结阳性[n = 3755，50.4%]），58.2%接受NACR，41.9%接受NAC。降期N0患者（5.1年）和自然N0患者（5.6年）的中位OS期相似，且长于淋巴结阳性患者（2.1年）（P<0.001）。在cN+患者的匹配队列中，更近的诊断时间（2010 - 2015年vs. 2004 - 2009年）（比值比[OR]，2.57；P<0.001）和NACR（OR，2.02；P<0.001）与区域淋巴结降期独立相关。NACR后降期N0患者的5年OS率（46.4%）显著低于NAC后（57.7%）（P = 0.003）。
降期N0患者与自然N0患者预后相同。NACR后区域淋巴结降期更常见；然而，NACR后区域淋巴结降期的生存获益可能小于NAC实现的降期。
