摘要
目的回顾性分析膀胱部分切除术（PC）结合放化疗治疗肌层浸润性膀胱癌（MIBC）的疗效。方法收集2002年1月—2007年12月MIBC患者136例,男108例,女28例,平均年龄为（65.9±12.1）岁。分入两组：PC组100例,其中T2期74例,T3期16例,T4期10例。根治性膀胱全切除术（RC）组36例,其中T2期12例,T3期20例,T4期4例。术后对PC组T3、T4期患者加行以顺铂为主的放化疗。随访3~66个月,平均随访时间为（33.1±1.2）个月。采用Kaplan-Meier法和log-rank检验比较两组的生存情况,多因素Cox回归模型分析与MIBC生存和复发相关的预后因素。采用欧洲癌症研究与治疗组织（EORTC）的生存质量测定量表（QLQ-C30）和MIBC生存质量测定量表（QLQ-BLM30）评估患者的生存质量。结果 MIBC患者5年肿瘤特异性生存率为64.7%（88/136）,其中PC组为68.0%（68/100）,显著高于RC组的55.6%（20/36,P〈0.05）。PC组术后发生局部复发60例（60.0%）,其中非MIBC复发46例（76.7%,46/60）,MIBC复发14例（23.3%,14/60）;术后16个月内发生局部复发75.0%（45/60）。Cox回归分析显示,肿瘤数量〉3个（RR=2.718,95%CI为1.455~5.079,P=0.002）和浸润性的生长方式（RR=4.537,95%CI为1.573~13.081,P=0.005）是膀胱癌局部复发的独立预后因素。多因素分析显示,肿瘤数量〉3个（RR=4.109,95%CI为1.676~10.072,P=0.002）,脉管侵袭（RR=6.089,95%CI为2.038~18.246,P=0.001）和PC加输尿管再植术（RR=0.129,95%CI为0.027~0.627,P=0.011）是保留膀胱手术治疗MIBC后肿瘤特异性生存相关的独立预后指标,其中PC加输尿管再植是术后患者生存的保护因素。与MIBC生存相关的独立因素包括脉管侵袭（RR=4.176,95%CI为2.152~8.105,P=0.000）、肿瘤数量〉3个（RR=3.610,95%CI为1.887~6.906,P=0.000）、有膀胱肿瘤病史（RR=2.714,95%CI为1.400~5.263,P=0.003）和高龄（〉70岁,RR=2.609,95%CI1.440~4.729,P=0.002）。PC组的躯体功能和社会功能评分均显著高于RC组（P值分别〈0.05、0.01）,且经济困难、疲劳、失眠和体象障碍评分均显著低于RC组（P值分别〈0.01、0.05）。结论 PC结合放化疗是治疗MIBC的有效方法,患者可获得与RC相似甚至更高的生存率和更好的生存质量。肿瘤数量〉3个的患者不宜行保留膀胱的手术。
Objective To retrospectively analyze the clinical outcome of partial cystectomy combined with chemo-and radiation-therapies in the treatment of muscle-invasive bladder cancer（MIBC）.Methods From January 2002to December 2007,a total of 136patients with MIBC received surgical treatment.There were 108 males and 28females with an average age of（65.9±12.1）years.Of them,100underwent partial cystectomy combined with adjuvant chemotherapy and radiation therapy（PC group,74cases at T2,16at T3 and 10at T4）.Meanwhile,36patients with MIBC underwent radical cystectomy（RC group,12cases at T2,20at T3 and 4at T4）.The survival rates were compared between the two groups by Kaplan-Meier and log-rank analysis.Predictive factors related to survival and recurrence were evaluated by multivariate Cox analysis.The quality of life（QoL）of patients was evaluated by using EORTC QLQ-C30and QLQ-BLM30questionnaires.Results The 5-year cancerspecific survival（CSS）rate of the entire cohort was 64.7%（88/136）.CSS rate in PC group was significantly higher than that in RC group（68.0%[68/100]vs.55.6%[20/36],P0.05）.In PC group,46patients（76.7%,46/60）experienced superficial recurrence and 14patients（23.3%,14/60）developed muscle-invasive recurrence;75.0%（45/60）recurrence occurred within 16months after surgery.Cox regression analysis showed that tumor numbers more than 3（RR=2.718,95%CI：1.455-5.079,P=0.002）and tumors with infiltrating growth pattern（RR=4.537,95%CI：1.573-13.081,P=0.005）were independent predictive factors for cancer recurrence.In multivariate analysis,tumor numbers more than 3（RR=4.109,95%CI：1.676-10.072,P=0.002）,lymphovascular invasion（RR =6.089,95%CI：2.038-18.246,P =0.001）,and partial cystectomy plus ureteral reimplantation（PC plus UR,RR=0.129,95%CI：0.027-0.627,P=0.011）were significantly associated with 5-year CSS in PC group and PC plus UR was indeed a protective factor for survival.By looking at the entire MIBC cohort,lymphovascular invasion（RR=4.176,95%CI：2.152-8.105,P= 0.000）,tumor numbers more than 3（RR=3.610,95%CI：1.887-6.906,P=0.000）,history of superficial bladder cancer（RR=2.714,95%CI：1.400-5.263,P=0.003）,and age greater than 70years old（RR= 2.609,95%CI：1.440-4.729,P=0.002）were identified as independent predictive factors for 5-year CSS.In terms of QoL,patients who received bladder-sparing protocol had higher scores of physical and social functions,and lower scores of financial difficulties,fatigue,insomnia and body image（P0.01,0.05）.Conclusion Combined with adjuvant chemotherapy and radiotherapy,partial cystectomy is a rational alternative to radical cystectomy for the treatment of MIBC,which provides acceptable survival rate and QoL improvement.Patients with tumor numbers more than 3should be excluded from bladder-sparing procedures.
出处
《上海医学》
CAS
CSCD
北大核心
2013年第7期581-586,共6页
Shanghai Medical Journal
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
Therapeutic effect
