新辅助治疗后 ypT0-1 期直肠腺癌患者行局部切除与直肠切除术的比较：基于国家癌症数据库的倾向评分匹配分析。
Local excision vs. proctectomy in patients with ypT0-1 rectal cancer following neoadjuvant therapy: a propensity score matched analysis of the National Cancer Database.
机构信息
Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Israel.
出版信息
Tech Coloproctol. 2024 Sep 21;28(1):128. doi: 10.1007/s10151-024-02994-4.
BACKGROUND
We aimed to evaluate outcomes of organ preservation by local excision (LE) compared to proctectomy following neoadjuvant therapy for rectal cancer.
METHODS
This retrospective observational study using the National Cancer Database (NCDB) included patients with locally advanced non-metastatic rectal cancer (ypT0-1 tumors) treated with neoadjuvant therapy between 2004 and 2019. Outcomes of patients who underwent LE or proctectomy were compared. 1:1 propensity score matching including patient demographics, clinical and therapeutic factors was used to minimize selection bias. Main outcome was overall survival (OS).
RESULTS
11,256 of 318,548 patients were included, 526 (4.6%) of whom underwent LE. After matching, mean 5-year OS was similar between the groups (54.1 vs. 54.2 months; p = 0.881). Positive resection margins (1.2% vs. 0.6%; p = 0.45), pathologic T stage (p = 0.07), 30-day mortality (0.6% vs. 0.6%; p = 1), and 90-day mortality (1.5% vs. 1.2%; p = 0.75) were comparable between the groups. Length of stay (1 vs. 6 days; p < 0.001) and 30-day readmission rate (5.3% vs. 10.3%; p = 0.02) were lower in LE patients. Multivariate analysis of predictors of OS demonstrated male sex (HR 1.38, 95% CI 1.08-1.77; p = 0.009), higher Charlson score (HR 1.52, 95% CI 1.29-1.79; p < 0.001), poorly differentiated carcinoma (HR 1.61, 95% CI 1.08-2.39; p = 0.02), mucinous carcinoma (HR 3.53, 95% CI 1.72-7.24; p < 0.001), and pathological T1 (HR 1.45, 95% CI 1.14-1.84; p = 0.002) were independent predictors of increased mortality. LE did not correlate with worse OS (HR 0.91, 95% CI 0.42-1.97; p = 0.82).
CONCLUSION
Our findings show no overall significant survival difference between LE and total mesorectal excision, including ypT1 tumors. Moreover, patients with poorly differentiated or mucinous adenocarcinomas generally had poorer outcomes, regardless of surgical method.
背景
我们旨在评估新辅助治疗后局部切除（LE）与直肠前切除术在保存器官方面的结果，用于治疗局部进展期非转移性直肠癌。
方法
本研究使用国家癌症数据库（NCDB）进行回顾性观察性研究，纳入了 2004 年至 2019 年间接受新辅助治疗的局部晚期非转移性直肠癌（ypT0-1 肿瘤）患者。比较接受 LE 或直肠前切除术患者的结局。采用包括患者人口统计学、临床和治疗因素的 1:1 倾向评分匹配来最小化选择偏倚。主要结局是总生存（OS）。
结果
318548 例患者中有 11256 例（4.6%）接受了 LE。匹配后，两组的 5 年平均 OS 相似（54.1 与 54.2 个月；p=0.881）。切缘阳性（1.2%比 0.6%；p=0.45）、病理 T 分期（p=0.07）、30 天死亡率（0.6%比 0.6%；p=1）和 90 天死亡率（1.5%比 1.2%；p=0.75）在两组之间相似。LE 患者的住院时间（1 天比 6 天；p<0.001）和 30 天再入院率（5.3%比 10.3%；p=0.02）较低。OS 的多变量分析表明，男性（HR 1.38，95%CI 1.08-1.77；p=0.009）、较高的 Charlson 评分（HR 1.52，95%CI 1.29-1.79；p<0.001）、低分化癌（HR 1.61，95%CI 1.08-2.39；p=0.02）、黏液腺癌（HR 3.53，95%CI 1.72-7.24；p<0.001）和病理 T1（HR 1.45，95%CI 1.14-1.84；p=0.002）是死亡率增加的独立预测因素。LE 与总直肠系膜切除术相比，与 OS 无显著相关性（HR 0.91，95%CI 0.42-1.97；p=0.82）。
结论
我们的研究结果表明，LE 与完全直肠系膜切除术在保存器官方面没有总体生存差异，包括 ypT1 肿瘤。此外，无论手术方法如何，低分化或黏液性腺癌患者的总体预后较差。
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