食管癌的放化疗：治疗方式的选择。

Chemoradiation for oesophageal cancer: the choice of treatment modality.

机构信息

Department of Oncology, HUS Comprehensive Cancer Centre and University of Helsinki, Paciuksenkatu 3, PL 180, 00029 HUS, Helsinki, Finland.

Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.

出版信息

Radiat Oncol. 2023 May 31;18(1):93. doi: 10.1186/s13014-023-02290-9.

DOI:10.1186/s13014-023-02290-9

PMID:37259100

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10230716/

Abstract

BACKGROUND

Locally advanced oesophageal cancer can be treated with definitive chemoradiation (dCRT) or with neoadjuvant chemoradiation followed by surgery (nCRT + S), but treatment modality choice is not always clear. The aim of this study was to investigate the factors associated with the choice of treatment modality in locally advanced oesophageal cancer.

METHODS

This was a retrospective cohort study of 149 patients treated with dCRT(n = 85) or nCRT + S (n = 64) for oesophageal cancer in Helsinki University Hospital in 2008-2018. Logistic regression was used to analyse factors associated with choice of treatment modality and to compare dosimetric factors with postoperative complications. Multivariate analyses identified factors associated with survival.

RESULTS

Surgery was performed after chemoradiation as planned on 64/91 patients (70%). 28/64 had pathological complete response (44%). Probability of nCRT + S was higher in stages I-III versus IV (OR 3.62, 95% CI 1.53-8.53; P = .003), ECOG 0-1 versus 2 (OR 6.99, 95% CI 1.81-26.96; P = .005) or in the middle/lower vs upper oesophageal tumours (OR 5.61, 95% CI 1.83-17.16, P = .003). Probability for surgery was lower, if patient had lost > 10% of body weight (OR 0.46, 95% CI 0.21-0.98, P = 0.043). Patients in the nCRT + S group had significantly better median overall survival (mOS) and local control than the dCRT group (60 vs. 10 months, P < .001 and 53 vs. 6 months, P < 0.0001, respectively). 10/85 (12%) patients died within three months after dCRT. In multivariate analysis, nCRT + S was associated with improved mOS (HR 0.28, 95% CI 0.17-0.44, P < .001). Current smokers had worse mOS (HR 2.02, 95% CI 1.04-3.92, P = .037) compared to never-smokers. No significant dosimetric factor associated with postoperative complications was found.

CONCLUSION

The overall clinical status of the patients and the stage of the cancer guide the choice of treatment modalities, leading to overtreatment. Patients with better prognoses were more likely operated after chemoradiation, although there is no evidence of OS benefit in previous randomized trials. On the other hand, the prognosis was poor for patients with poor general health and advanced cancers, despite the chemoradiation. Thus, there are signs of overtreatment. MDT practice should be recommended to optimise the choice of treatment modalities. Smoking status is an independent factor associated with survival.

摘要

背景

局部晚期食管癌可采用根治性放化疗（dCRT）或新辅助放化疗后手术（nCRT+S）进行治疗，但治疗方式的选择并不总是明确的。本研究旨在探讨局部晚期食管癌治疗方式选择的相关因素。

方法

这是一项回顾性队列研究，纳入了 2008 年至 2018 年在赫尔辛基大学医院接受 dCRT（n=85）或 nCRT+S（n=64）治疗的 149 例食管癌患者。采用逻辑回归分析与治疗方式选择相关的因素，并比较了术后并发症与剂量学因素。多变量分析确定了与生存相关的因素。

结果

91 例患者中有 64 例（70%）按计划在放化疗后进行了手术。28 例（44%）患者的病理完全缓解。与 IV 期相比，I-III 期患者接受 nCRT+S 的可能性更高（OR 3.62，95%CI 1.53-8.53；P=0.003），ECOG 0-1 与 2 相比（OR 6.99，95%CI 1.81-26.96；P=0.005），或中/下段食管肿瘤与上段食管肿瘤相比（OR 5.61，95%CI 1.83-17.16，P=0.003）。如果患者体重减轻超过 10%（OR 0.46，95%CI 0.21-0.98，P=0.043），则手术的可能性较低。nCRT+S 组的中位总生存期（mOS）和局部控制率明显优于 dCRT 组（60 个月 vs. 10 个月，P<0.001；53 个月 vs. 6 个月，P<0.0001）。85 例患者中有 10 例（12%）在 dCRT 后三个月内死亡。多变量分析显示，nCRT+S 与 mOS 改善相关（HR 0.28，95%CI 0.17-0.44，P<0.001）。与从不吸烟者相比，当前吸烟者的 mOS 更差（HR 2.02，95%CI 1.04-3.92，P=0.037）。未发现与术后并发症相关的显著剂量学因素。

结论

患者的整体临床状况和癌症分期指导着治疗方式的选择，导致过度治疗。预后较好的患者在放化疗后更有可能接受手术，但之前的随机试验并未显示 OS 获益。另一方面，尽管进行了放化疗，但身体状况较差和癌症晚期的患者预后较差。因此，存在过度治疗的迹象。建议采用多学科治疗实践，以优化治疗方式的选择。吸烟状况是与生存相关的独立因素。