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膀胱部分切除术结合放化疗治疗肌层浸润性膀胱癌的疗效分析
The efficacy analysis of partial cystectomy combined with chemotherapy and radiotherapy in the treatment of muscle-invasive bladder cancer
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DOI:
作者:
张敏光, 沈周俊,张存明,吴瑜璇,周文龙,祝 宇,张荣明,孙福康,邵 远,何 威
ZHANG Minguang, SHEN Zhoujun, ZHANG Cunming, WU Yuxuan, ZHOU Wenlong, ZHU Yu, ZHANG Rongming, SUN Fukang, SHAO Yuan, HE Wei
作者单位:
上海交通大学医学院附属瑞金医院
Department of Urology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
关键词:
膀胱尿路上皮癌;肌层浸润;膀胱部分切除术;保留膀胱;疗效分析
bladder urothelial carcinoma, muscle-invasive, partial cystectomy, bladder-sparing therapy, efficacy analysis
摘要:
【摘要】目的 分析膀胱部分切除结合放化疗治疗肌层浸润性膀胱癌(MIBC)的疗效。方法 回顾性分析2002年——2007年MIBC病例136例(男108例,女28例;年龄65.9±12.1岁),分为PC组(膀胱部分切除术组;共100例:T2 74例,T3 16例,T4 10例)和RC组(根治性膀胱全切术组;共36例:T2 12例,T3 20例,T4 4例)。PC组术后对T3、T4病例加行顺铂为主的放化疗。随访时间33.1±1.2(3-66)个月。应用Kaplan-Meier法和log-rank检验比较2组生存情况,多因素Cox回归模型分析与MIBC生存和复发相关的预后因素,EORTC QLQ-C30和QLQ-BLM30量表评估生活质量(QoL)。结果 总体MIBC病例5年肿瘤特异性生存率为65%,其中PC组和RC组分别为68% 与 55% (P=0.033)。PC组术后出现浅表性膀胱癌复发46例(46%),出现肌层浸润性膀胱癌复发14例(14%);其中术后16月内局部复发75%(45例)。PC组中,与肿瘤复发相关的独立因素包括肿瘤数量>3个(RR=2.718)和浸润性生长方式(RR=4.537);与生存相关的独立因素包括:肿瘤数量超过3个(RR=4.109),脉管侵袭(RR=6.098)和膀胱部分切除加输尿管再植术(PC+UR)(RR=0.129),其中PC+UR是保护因素;与MIBC生存相关的独立因素包括:脉管侵袭(RR=4.176)、肿瘤数量>3个(3.610)、高龄(>70岁)(RR=2.609)、复发性膀胱癌(RR=2.714)。PC组术后QoL高于RC组。结论 PC结合放化疗是治疗MIBC的有效方法,可达到与RC相似甚至更高的生存率和更好的生活质量。肿瘤数量>3个者不宜行保留膀胱手术。
【Abstracts】 Objective Partial cystectomy is a bladder-sparing procedure that has been used in highly selective patients with muscle-invasive bladder cancer (MIBC). We reviewed our experience with partial cystectomy combined with chemo- and radiation therapies in the treatment of MIBC to assess the local control and survival rates, and to identify predictive factors for recurrence and survival. Also, the quality of life (QoL) was measured to appraise the value of partial cystectomy. Methods From 2002 through 2007, a total of 100 patients with MIBC underwent partial cystectomy combined with adjuvant chemotherapy and radiation therapy (PC group). Of note, the inclusion criteria were expanded in our cohort compared to the published experience. Meanwhile, 36 patients with MIBC underwent radical cystectomy (RC group). The clinical and pathological data of these patients were retrospectively reviewed. Primary endpoints were cancer-specific survival (CSS), bladder-intact cancer-specific survival and bladder cancer recurrence. The QoL of patients at least 2 years after completion of their treatments was evaluated using EORTC QLQ-C30 and QLQ-BLM30 questionnaires. Results The 5-y CSS rate of the entire cohort was 65%, which was higher in PC group than in RC group (68% vs 55%, P=0.033). In PC group, only 2 patients (2%) were confirmed to have residual tumor at the time of re-evaluation TUR 3 months after partial cystectomy. After a mean of 33.1 months, 46 patients (46%) experienced superficial recurrence and 14 patients (14%) developed muscle-invasive recurrence. 75% of recurrence occurred within 16 months. 8 patients underwent salvage cystectomy. The 5-year bladder-intact survival rate was 63% in PC group. In multivariate analysis, tumor numbers more than 3 and tumors with infiltrating growth pattern were 2 predictive factors for cancer recurrence in PC group. In terms of survival, tumor numbers more than 3, lymphovascular invasion and partial cystectomy plus ureteral reimplantation (PC plus UR) were significantly associated with 5-y CSS in PC group and PC plus UR was indeed a protective factor for survival. By looking at the entire MIBC cohort, lymphovascular invasion, tumor numbers more than 3, history of superficial bladder cancer and age greater than 70 years old were identified as independent predictive factors for 5-y CSS. In terms of QoL, patients who received bladder-sparing protocol had higher (better) scores of physical and social functions, as well as lower (better) scores of financial difficulties, fatigue, insomnia and body image. Conclusions Combined with adjuvant chemo- and radiation therapies, partial cystectomy is a rational alternative to radical cystectomy for the treatment of MIBC, which provides adequate local control in selected patients, acceptable survival rate, as well as improvement of QoL. The inclusion criteria for partial cystectomy-based multimodality bladder-sparing treatment for MIBC with curative intent can be expanded. Patients with tumor numbers more than 3 should be excluded from bladder-sparing procedures. For tumors adjacent to ureteral orifice, ureteral reimplantation should be performed. Lymphovascular invasion, tumor numbers more than 3, recurrent bladder cancer and age greater than 70 years old are independent predictive factors for long-term CSS of patients with MIBC.
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