Prognostic Value of Clinical vs Pathologic Stage in Rectal Cancer Patients Receiving Neoadjuvant Therapy
Prognostic Value of Clinical vs Pathologic Stage in Rectal Cancer Patients Receiving Neoadjuvant Therapy
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DOI：
10.1093/jnci/djx228
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发表时间：
2018-05-01
影响因子：
10.3
通讯作者：
Iqbal, Atif
中科院分区：
文献类型：
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作者：
Delitto, Daniel;George, Thomas J., Jr.;Iqbal, Atif
背景：新辅助放化疗目前是II-III期直肠癌的标准治疗，导致治疗反应性疾病患者的肿瘤分期降低。然而，下位患者的预后仍有争议。这项工作批判性地分析了治疗前和治疗后分期对低分期患者预期生存的相对贡献。方法：查询国家癌症数据库（NCDB） 2004 - 2014年经腹切除术的直肠癌患者。II-III期患者接受新辅助放疗，与I期患者单独接受最终切除进行比较。排除手术切缘阳性的患者。使用Kaplan-Meier分析和Cox比例风险模型评估总生存率。所有统计检验均为双侧检验。结果：共有44320例患者符合分析条件。与从cT3N0（平均生存期= 114.9个月，95% CI = 110.4至119.3个月，P = 0.12）和ct3n1（平均生存期= 115.4个月，95% CI = 110.1至120.7个月，P = 0.22）降至pTINO的患者相比，接受切除的cTINO患者的生存期相同（平均生存期= 113.0个月，95%可信区间[CI] = 110.8至115.3个月）。与单纯切除cT2N0患者（平均生存期= 100.0个月，95% CI = 106.7 ~ 111.2个月，P < 0.001）相比，ct3n1患者（平均生存期= 112.8个月，95% CI = 110.0 ~ 115.7个月，P < 0.001）和cT3N0患者（平均生存期= 100.0个月，95% CI = 97.5 ~ 102.5个月）的生存期有统计学意义上的显著改善。多个生存分析证实,最终病理阶段决定长期结果的病人接受新辅助辐射(危险比[HR] pT2 = 1.24, 95% CI = 1.10到1.41;人力资源pT3 = 1.81, 95% CI = 1.61到2.05;人力资源pT4 = 2.72, 95% CI = 2.28至3.25,所有P <措施vs pTl;人力资源pNl = 1.50, 95% CI = 1.41到1.59;人力资源pN2 = 2.17, 95% CI = 2.00至2.35,两个P <措施vs pNO);而临床阶段表示没有预测价值(人力资源cT2 = 0.81, 95% CI = 0.69 ~ 0.95, P = .008;人力资源cT3 = 0.83, 95% CI = 0.72 ~ 0.96, P = .009;人力资源cT4 = 1.02, 95% CI = 0.85 ~ 1.21, P = .87点vs cTl;补偿中子测井的HR = 0.96, 95% CI = 0.91 ~ 1.02, P = .19;人力资源cN2 = 0.96, 95% CI = 0.86至1.08,P =相关性与碳氮氧)。结论：接受新辅助放疗的直肠癌患者的生存与治疗后病理分期有关，而与治疗前临床分期无关。这些数据将进一步为与患者的预后讨论提供信息。
Background: Neoadjuvant chemoradiation is currently standard of care in stage II-III rectal cancer, resulting in tumor downstaging for patients with treatment-responsive disease. However, the prognosis of the downstaged patient remains controversial. This work critically analyzes the relative contribution of pre- and post-therapy staging to the anticipated survival of downstaged patients.Methods: The National Cancer Database (NCDB) was queried for patients with rectal cancer treated with transabdominal resection between 2004 and 2014. Stage II-III patients downstaged with neoadjuvant radiation were compared with stage I patients treated with definitive resection alone. Patients with positive surgical margins were excluded. Overall survival was evaluated using both Kaplan-Meier analyses and Cox proportional hazards models. All statistical tests were two-sided.Results: A total of 44 320 patients were eligible for analysis. Survival was equivalent for patients presenting with cTINO disease undergoing resection (mean survival = 113.0 months, 95% confidence interval [CI] = 110.8 to 115.3 months) compared with those downstaged to pTINO from both cT3N0 (mean survival = 114.9 months, 95% CI = 110.4 to 119.3 months, P = .12) and cT3Nl disease (mean survival = 115.4 months, 95% CI = 110.1 to 120.7 months, P = .22). Survival statistically significantly improved in patients downstaged to pT2N0 from cT3N0 disease (mean survival = 109.0 months, 95% CI = 106.7 to 111.2 months, P < .001) and cT3Nl (mean survival = 112.8 months, 95% CI = 110.0 to 115.7 months, P < .001), compared with cT2N0 patients undergoing resection alone (mean survival = 100.0 months, 95% CI = 97.5 to 102.5 months). Multiple survival analysis confirmed that final pathologic stage dictated long-term outcomes in patients undergoing neoadjuvant radiation (hazard ratio [HR] of pT2 = 1.24, 95% CI = 1.10 to 1.41; HR of pT3 = 1.81, 95% CI = 1.61 to 2.05; HR of pT4 = 2.72, 95% CI = 2.28 to 3.25, all P < .001 vs pTl; HR of pNl = 1.50, 95% CI = 1.41 to 1.59; HR of pN2 = 2.17, 95% CI = 2.00 to 2.35, both P < .001 vs pNO); while clinical stage at presentation had little to no predictive value (HR of cT2 = 0.81, 95% CI = 0.69 to 0.95, P = .008; HR of cT3 = 0.83, 95% CI = 0.72 to 0.96, P = .009; HR of cT4 = 1.02, 95% CI = 0.85 to 1.21, P = .87 vs cTl; HR of cNl = 0.96, 95% CI = 0.91 to 1.02, P = .19; HR of cN2 = 0.96, 95% CI = 0.86 to 1.08, P = .48 vs cNO).Conclusions: Survival in patients with rectal cancer undergoing neoadjuvant radiation is driven by post-therapy pathologic stage, regardless of pretherapy clinical stage. These data will further inform prognostic discussions with patients.