新辅助治疗后ypT0-1直肠癌患者的局部切除与直肠切除术：一项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

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Techniques in Coloproctology

影响因子:2.9

分区:医学3区 / 胃肠肝病学3区外科3区

发表日期:2024 Sep 21

作者: N Horesh, S H Emile, M R Freund, Z Garoufalia, R Gefen, A Nagarajan, S D Wexner

DOI: 10.1007/s10151-024-02994-4

摘要

我们旨在评估通过局部切除（LE）与直肠切除术（proctectomy）在接受新辅助治疗的直肠癌患者中的器官保护效果。本回顾性观察研究利用国家癌症数据库（NCDB），纳入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或直肠切除术的患者的结果。采用1:1倾向评分匹配，包括患者人口统计学、临床和治疗因素，以最小化选择偏差。主要结局指标为总生存期（OS）。共纳入11,256例患者，526例（4.6%）接受了LE。匹配后，两组的平均5年生存期相似（54.1个月对54.2个月；p=0.881）。切除边缘阳性率（1.2%对0.6%；p=0.45）、病理T期（p=0.07）、术后30天死亡率（0.6%对0.6%；p=1）以及术后90天死亡率（1.5%对1.2%；p=0.75）在两组间差异无统计学意义。住院天数（1天对6天；p<0.001）和30天再入院率（5.3%对10.3%；p=0.02）在LE组较低。多变量分析显示，男性（风险比HR 1.38，95%置信区间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）以及病理T1（HR 1.45，95%CI 1.14-1.84；p=0.002）均为死亡风险的独立预测因素。LE与较差的OS无相关（HR 0.91，95%CI 0.42-1.97；p=0.82）。我们的结果显示，包含ypT1肿瘤在内，LE与全结直肠切除相比的总体生存差异不大。此外，低分化或黏液腺癌患者的预后普遍较差，无论采用何种手术方式。

Abstract

We aimed to evaluate outcomes of organ preservation by local excision (LE) compared to proctectomy following neoadjuvant therapy for rectal cancer.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).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).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.