Comparison of a Strategy Favoring Early Surgical Resection vs a Strategy Favoring Watchful Waiting in Low-Grade Gliomas
Comparison of a Strategy Favoring Early Surgical Resection vs a Strategy Favoring Watchful Waiting in Low-Grade Gliomas
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DOI：
10.1001/jama.2012.12807
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发表时间：
2012-11-14
影响因子：
120.7
通讯作者：
Solheim, Ole
中科院分区：
文献类型：
--
作者：
Jakola, Asgeir S.;Myrmel, Kristin S.;Solheim, Ole
背景 目前还没有关于弥漫性低级别神经胶质瘤 (LGG) 手术治疗的对照研究，且治疗方法存在争议。 目的 检查来自 2 所挪威大学医院、采用不同手术治疗策略的基于人群的 LGG 平行队列的生存率。 设计、环境和患者 两个神经外科都是邻近地理区域的独家提供者，具有区域转诊实践。在 A 医院，诊断性活检和随后的“等待和扫描”方法受到青睐（活检和观察等待），而 B 医院则提倡早期切除（早期切除）。因此，个体患者的治疗策略高度依赖于患者的居住地址。对 1998 年至 2009 年诊断为 LGG 的所有成年患者的组织病理学标本进行了盲法组织病理学审查，以确保统一的分类和纳入。随访截至 2011 年 4 月 11 日。共有 153 名患者（来自中心的 66 名赞成活检和观察等待的患者，来自中心的 87 名赞成早期切除的患者）包括弥漫性 LGG。 主要结果测量 预先指定的主要终点是基于区域比较的总体生存率，无需调整所给予的治疗。 结果 中心服务的 47 名（71%）患者仅进行了初始活检，赞成活检和观察等待，该中心服务的 12 名患者 (14%) 赞成早期切除 (P < .001)。倾向于活检和观察等待的中心的中位随访时间为 7.0 年（四分位距，4.5-10.9），而倾向于早期切除的中心的中位随访时间为 7.1 年（四分位距，4.2-9.9）（P = 0.95）。两组的基线参数具有可比性。早期手术切除的总生存率显着提高 (P = .01)。仅采用活检的方法的中位生存期为 5.9 年（95% CI，4.5-7.3），而采用早期切除的方法未达到中位生存期。活检、观察等待和早期切除的估计 5 年生存率分别为 60%（95% CI，48%-72%）和 74%（95% CI，64%-84%）。在调整后的多变量分析中，在支持活检和观察等待的中心接受治疗时，相对风险比为 1.8（95% CI，1.1-2.9，P = .03）。 结论 对于挪威的 LGG 患者，在支持早期手术切除的中心接受治疗比在支持活检和观察等待的中心接受治疗与更好的总体生存率相关。在调整经过验证的预后因素后，这种生存获益仍然存在。贾马。 2012;308(18):1881-1888 2012 年 10 月 25 日在线发布。doi:10.1001/jama.2012.12807 www.jama.com
Context There are no controlled studies on surgical treatment of diffuse low-grade gliomas (LGGs), and management is controversial.Objective To examine survival in population-based parallel cohorts of LGGs from 2 Norwegian university hospitals with different surgical treatment strategies.Design, Setting, and Patients Both neurosurgical departments are exclusive providers in adjacent geographical regions with regional referral practices. In hospital A diagnostic biopsies followed by a "wait and scan" approach has been favored (biopsy and watchful waiting), while early resections have been advocated in hospital B (early resection). Thus, the treatment strategy in individual patients has been highly dependent on the patient's residential address. Histopathology specimens from all adult patients diagnosed with LGG from 1998 through 2009 underwent a blinded histopathological review to ensure uniform classification and inclusion. Follow-up ended April 11, 2011. There were 153 patients (66 from the center favoring biopsy and watchful waiting and 87 from the center favoring early resection) with diffuse LGGs included.Main Outcome Measure The prespecified primary end point was overall survival based on regional comparisons without adjusting for administered treatment.Results Initial biopsy alone was carried out in 47 (71%) patients served by the center favoring biopsy and watchful waiting and in 12 (14%) patients served by the center favoring early resection (P < .001). Median follow-up was 7.0 years (interquartile range, 4.5-10.9) at the center favoring biopsy and watchful waiting and 7.1 years (interquartile range, 4.2-9.9) at the center favoring early resection (P = .95). The 2 groups were comparable with respect to baseline parameters. Overall survival was significantly better with early surgical resection (P = .01). Median survival was 5.9 years (95% CI, 4.5-7.3) with the approach favoring biopsy only while median survival was not reached with the approach favoring early resection. Estimated 5-year survival was 60% (95% CI, 48%-72%) and 74% (95% CI, 64%-84%) for biopsy and watchful waiting and early resection, respectively. In an adjusted multivariable analysis the relative hazard ratio was 1.8 (95% CI, 1.1-2.9, P = .03) when treated at the center favoring biopsy and watchful waiting.Conclusions For patients in Norway with LGG, treatment at a center that favored early surgical resection was associated with better overall survival than treatment at a center that favored biopsy and watchful waiting. This survival benefit remained after adjusting for validated prognostic factors. JAMA. 2012;308(18):1881-1888 Published online October 25, 2012. doi:10.1001/jama.2012.12807 www.jama.com