Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: When do the ends justify the means?
Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: When do the ends justify the means?
复制标题
DOI：
10.1097/00005537-200003001-00001
复制
发表时间：
2000-03-01
期刊：
影响因子：
2.6
通讯作者：
Goodwin, WJ
中科院分区：
文献类型：
--
作者：
Goodwin, WJ
目的/假设：抢救性手术被广泛认为是一把“双刃剑”。它是许多上消化道癌症复发患者的最佳选择，特别是当原始治疗包括放射治疗时，但它可能只提供适度的益处，并且对患者的个人成本很高。风险很高，因为替代方案的价值有限。本研究的主要目的是充分评估挽救性手术治疗局部和区域复发的价值。以下假设是研究设计和数据分析的重点。1)抢救手术的疗效与复发分期、复发部位、抢救前复发时间有关。2)抢救手术的经济和非经济成本随复发期的增加而增加。3)与复发分期和复发部位相关的信息将对这些患者和治疗他们的医生有用。研究设计：采用两种互补的调查方法：一种是对已发表文献的荟萃分析，另一种是对上消化道复发性癌症患者进行补救性手术的前瞻性观察研究。方法：荟萃分析了32篇已发表的报告，以获得关于生存、无病生存、手术并发症和手术死亡率的平均治疗效果的估计。这项前瞻性观察性研究包括109例接受挽救性手术的患者的详细数据。除了meta分析中研究的参数外，我们还获得了基线和间隔期生活质量数据（癌症功能生活指数[FLIC]评分）、基线和间隔期表现状态评估（头颈癌患者表现状态量表[PSS头颈评分]）、住院时间、医院和医生收费，并将这些数据主要与复发分期、复发部位和挽救前复发时间联系起来。结果：在荟萃分析中，来自28个不同机构的1080例患者的加权平均5年生存率为39%。在前瞻性研究中，109例患者的中位无病生存期为17.9个月，这与复发分期相关性强，与复发部位相关性弱，与恢复前复发时间完全无关。患者的非经济费用和经济费用与复发分期相关，而与复发部位无关。基线FLIC和PSS头颈部评分与复发分期相关，但与部位无关。挽救手术后，FLIC评分达到或超过基线的患者比例为51%，这与复发阶段有显著差异。PSS头颈部饮食和公共场所饮食亚量表评分的术后间隔“成功”也与复发期相关。结论：总体而言，对复发性头颈癌患者进行挽救性手术的预期疗效令人惊讶地好，但在III期和，特别是，成功是有限的，成本很高。IV期复发。疗效和非经济成本与复发阶段的强相关性允许创建可能对患者有用的期望概况。需要进一步的系统临床研究来改善结果。最后，是否进行挽救性手术的决定应该是患者在与外科医生坦诚和富有同情心的讨论后做出的个人选择。关键词：头颈癌，复发，挽救性手术，生活质量，预后状况。
Objectives/Hypotheses: Salvage surgery is widely viewed as a "double-edged sword." It is the best option for many patients with recurrent cancer of the upper aerodigestive tract, especially when original therapy included irradiation, yet it may provide only modest benefit at high personal cost to the patient. The stakes are high because alternatives are of limited value. The primary objective of this study was to fully assess the value of salvage surgical procedures in the treatment of local and regional recurrence. The following hypotheses were developed to focus the study design and data analysis. 1) The efficacy of salvage surgery correlates recurrent stage, recurrent site, and time to presalvage recurrence. 2) The economic and noneconomic costs of salvage surgery increase with higher recurrent stage. 3) Information relating the value of salvage surgery to recurrent stage and recurrent site will be useful to these patients and the physicians who treat them. Study Design: Two complimentary methods of investigation were used: a meta-analysis of the published literature and a prospective observational study of patients undergoing salvage surgery for recurrent cancer of the upper aerodigestive tract. Methods: The metaanalysis combined 32 published reports to obtain an estimate of average treatment effect for salvage surgery with regard to survival, disease-free survival, surgical complications, and operative mortality. The prospective observational study included detailed data in 109 patients who underwent salvage surgery. In addition to parameters studied in the metaanalysis, we obtained baseline and interval quality of Life data (Functional Living Index for Cancer [FLIC] scores), baseline and interval performance status evaluations (Performance Status Scale for Head and Neck Cancer Patients [PSS head and neck scores]), length of hospital stay, and hospital and physician charges, and related this data primarily to recurrent stage, recurrent site, and time to presalvage recurrence. Results: The weighted average of 5-year survival in the meta-analysis was 39% in 1,080 patients from 28 different institutions. In the prospective study, median disease-free survival was 17.9 months in 109 patients, and this correlated strongly with recurrent stage, weakly with recurrent site, and not at all with time to presalvage recurrence. Noneconomic costs for patients and economic costs correlated with recurrent stage, but not with site. Baseline FLIC and PSS head and neck scores correlated with recurrent stage, but not with site. After salvage surgery the percentage of patients reaching or exceeding baseline was 51% for FLIC scores, and this differed significantly with recurrent stage. Postoperative interval "success" in PSS head and neck subscale scores for diet and eating in public also correlated with recurrent stage. Conclusions: Overall, the expected efficacy for salvage surgery in patients with recurrent head and neck cancer was surprisingly good, but success was limited and costs were great in, stage III and, especially. in stage IV recurrences. A strong correlation of efficacy and noneconomic costs with recurrent stage allowed the creation of expectation profiles that may be useful to patients. Additional systematic clinical research is needed to improve results. In the end, the decision to undergo salvage surgery should be a personal choice made by the patient after honest and compassionate discussion with his or her surgeon. Key Words: Head and neck cancer, recurrence, salvage surgery, quality of life, performance status.