Thornblade Lucas W, Warner Susanne G, Melstrom Laleh, Ituarte Philip H G, Chang Sue, Li Daneng, Fong Yuman, Singh Gagandeep
Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA. Electronic address: https://twitter.com/LThornblade.
Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA. Electronic address: https://twitter.com/drsuswarner.
Surgery. 2021 Jun;169(6):1417-1423. doi: 10.1016/j.surg.2021.01.026. Epub 2021 Feb 23.
Attributable to the high likelihood of developing distant metastatic disease, resection of poorly differentiated gastroenteropancreatic neuroendocrine neoplasms is generally contraindicated. Some patients with no distant metastatic disease will nonetheless undergo surgical resection and their outcomes are not known. We aimed to determine whether surgery confers survival advantage over systemic therapy alone for patients with non-metastatic poorly differentiated gastroenteropancreatic neuroendocrine neoplasms.
We performed a retrospective cohort study (2000-2012) of adults in the California Cancer Registry who had poorly differentiated gastroenteropancreatic neuroendocrine neoplasms (World Health Organization Grade 3) and no clinical evidence of distant metastasis (M0). Patients who underwent surgery were compared with those managed non-operatively. The adjusted Cox proportional hazards model was used to assess the risk of death.
Among 2,245 patients (45% female, 21% pancreatic, 79% gastrointestinal), 1,549 (69%) were treated with surgery, and 696 (31%) received either systemic therapy or palliative measures alone. Median survival was 31 months after surgery versus 9 months after non-operative therapy (log-rank test, P < .001). Rates of 5-year overall survival were 39% after surgery versus 10% in the non-operative group. Adjusting for age, sex, comorbidities, receipt of chemotherapy, and tumor size and location, patients treated with surgery had a 58% lower likelihood of death compared with non-operative therapy (hazard ratio: 0.42, 95% confidence interval: 0.36-0.50, P < .001). Restricting our results to those patients who were found to have no distant metastasis intraoperatively (ie, pathologically M0), 5-year survival after surgery reached 44%.
While poorly differentiated gastroenteropancreatic neuroendocrine neoplasms carries a poor prognosis, for patients with no evidence of metastatic disease, resection appears to confer significant improvement in long-term survival. Although caution and an individualized approach in treating poorly differentiated gastroenteropancreatic neuroendocrine neoplasms is advised, future guidelines might reflect this survival advantage.
由于发生远处转移性疾病的可能性很高，一般不建议对低分化胃肠胰神经内分泌肿瘤进行手术切除。一些没有远处转移性疾病的患者仍会接受手术切除，但其预后情况尚不清楚。我们旨在确定对于非转移性低分化胃肠胰神经内分泌肿瘤患者，手术治疗相对于单纯全身治疗是否具有生存优势。
我们对加利福尼亚癌症登记处2000年至2012年的成年患者进行了一项回顾性队列研究，这些患者患有低分化胃肠胰神经内分泌肿瘤（世界卫生组织3级）且无远处转移的临床证据（M0）。将接受手术的患者与非手术治疗的患者进行比较。采用校正后的Cox比例风险模型评估死亡风险。
在2245例患者中（45%为女性，21%为胰腺肿瘤，79%为胃肠道肿瘤），1549例（69%）接受了手术治疗，696例（31%）仅接受了全身治疗或姑息治疗。手术后的中位生存期为31个月，而非手术治疗后的中位生存期为9个月（对数秩检验，P <.001）。手术组的5年总生存率为39%，非手术组为10%。在对年龄、性别、合并症、化疗情况以及肿瘤大小和位置进行校正后，接受手术治疗的患者死亡可能性比非手术治疗低58%（风险比：0.42，95%置信区间：0.36 - 0.50，P <.001）。将结果限定于术中发现无远处转移（即病理M0）的患者，手术后的5年生存率达到44%。
虽然低分化胃肠胰神经内分泌肿瘤预后较差，但对于无转移证据的患者，手术切除似乎能显著提高长期生存率。尽管在治疗低分化胃肠胰神经内分泌肿瘤时建议谨慎并采用个体化方法，但未来的指南可能会体现这种生存优势。
