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JAMA Oncology:结直肠癌同期孤立腹膜转移早期切除术后全身辅助化疗与积极监测的疗效比较

2020-08-18 王娟 肿瘤资讯

据统计,在全世界约430个治疗中心中,约有四分之一的结直肠癌同期孤立腹膜转移患者接受了细胞减灭术和腹腔热灌注化疗。一个国际上存在争议的话题是结直肠癌同期孤立腹膜转移患者是否应该接受全身辅助化疗。

据统计,在全世界约430个治疗中心中,约有四分之一的结直肠癌同期孤立腹膜转移患者接受了细胞减灭术和腹腔热灌注化疗(CRS-HIPEC)。在对接受过CRS-HIPEC的患者进行随访时,一个国际上存在争议的话题是结直肠癌同期孤立腹膜转移患者是否应该接受全身辅助化疗。为弥补这一证据空白,最新发表在JAMA Oncology上的一项研究评估了结直肠癌同期孤立腹膜转移患者术后全身辅助化疗与总生存时间的关系。

结直肠癌同期孤立腹膜转移是否应接受全身辅助化疗?最新研究给出证据!

对于接受手术切除的结直肠癌同期孤立腹膜转移患者而言,其术后全身辅助化疗是否能改善总生存?一些专家和指南建议常规使用全身辅助化疗,一些专家和指南则建议仅在淋巴结阳性的情况下进行全身辅助化疗,另有专家和指南仅表示可以考虑全身辅助化疗,这些不一致的建议反映了在这一特定人群中,缺乏全身辅助化疗与总生存时间之间关联的数据。

在当前这项基于人群的观察性队列研究中,研究者使用了来自荷兰癌症登记处的全国性数据(2005年1月1日至2017年12月31日之间确诊的病例,随访至2019年1月31日)。研究共纳入393例结直肠癌同期孤立腹膜转移患者,这些患者在接受手术及腹腔热灌注化疗后3个月仍生存。根据个体情况、肿瘤情况、治疗水平等协同变量,患者被分配到辅助全身化疗组与主动监视组(1:1)。如果患者在术后3个月内没有进行靶向治疗而开始系统化疗(氟尿嘧啶联合奥沙利铂、氟尿嘧啶单药或非特异性化疗方案),则被分配到全身辅助化疗组。所有其他患者被分配到积极监测组,包括那些在术后3个月以内接受靶向治疗或术后3个月以后开始全身化疗的患者,因为这些治疗被认为是姑息性治疗而不是辅助治疗。

当前这项研究的主要研究终点是总生存时间(OS),定义为CRS-HIPEC日期与受检患者死亡日期或最后一次随访日期之间的时间。随访至2019年1月31日。

与积极监测相比,辅助全身化疗与整体生存期改善呈正相关

在最初确定的930名患者中,共纳入393例患者(平均年龄,61岁;181例[46%]男性)。其中,172例(44%)被分配到全身辅助化疗组。这172例患者在CRS-HIPEC和全身辅助化疗开始之间的平均时间为8周。102例有资料的患者辅助治疗的中位持续时间为21周(四分位间距[IQR],14-22周)。倾向评分匹配后,全身辅助化疗组的142例患者与积极监测组的142例患者相匹配。

经比较,全身辅助化疗组和积极监测组在诊断时间、原发肿瘤位置和初始住院时间等方面存在差异。倾向评分匹配后,匹配组之间没有基线上的统计学差异。倾向评分匹配后,全身辅助化疗组和积极监测组在以下方面存在残留失衡:诊断时间(例如,2014-2017年:65 [46%] vs 77 [54%],标准差 -0.17);原发肿瘤定位(如直肠:7 [5%] vs 4 [3%],标准差0.11);组织学特征(如印戒细胞腺癌:11 [8%] vs 6 [4%],标准差0.15);初始住院时间(如> 21天:6 [4%] vs 16 [11%] ],标准差 -0.27)。

在整个匹配人群中,中位随访时间为25.9个月(IQR 15.7-46.8个月),死亡186例(65%)。全身辅助化疗组的中位随访时间为35.9个月(IQR 20.8-51.5个月),91例死亡(64%),而积极监测组的中位随访时间为21.3个月(IQR 12.5-34.7个月),95例患者死亡(67%)。

在整个匹配人群中,中位总生存期为35.2个月(IQR 18.0-64.9个月),而在全身辅助化疗组中为39.2个月(IQR 21.1-111.1个月),积极监测组为24.8个月(IQR 15.0-58.4个月)。

在整个匹配人群中,总生存率分别为86%(1年),49%(3年)和29%(5年)。全身辅助化疗组为92%(1年),55%(3年)和35%(5年);在积极监测组中,这一比例为81%(1年),41%(3年)和22%(5年)。

与积极监测相比,辅助全身化疗与整体生存期改善正相关(HR 0.64,95%CI 0.48-0.86, P = 0.003; aHR 0.66,95%CI 0.49-0.88,P = 0.006)。在以下情况下这种关联仍保持一致:排除13例术后6个月内死亡的患者(aHR 0.68,95%CI 0.50-0.93,P = 0.02),排除4例在术后3个月内开始接受靶向治疗联合全身化疗的患者(aHR 0.68,95% CI 0.50-0.91,P = 0.01),排除13例术后3到4个月之间开始全身化疗的患者(aHR 0.65,95%CI 0.48-0.87, P = 0.004),排除了所有这三组的患者(aHR 0.70,95%CI 0.50-0.97,P = 0.03)。

对由于术后重大并发症产生的无法衡量的混杂因素进行调整后,并未能消除辅助性全身化疗与总生存期改善之间的关联(aHR 0.71,95%CI,0.53-0.95)。

当前这项研究的结果表明,在接受预先切除手术的结直肠癌同期孤立腹膜转移的患者中,全身辅助化疗与改善总生存时间可能正相关。由于研究中潜在混杂因素的影响,因此未来仍需更多的大型随机研究对当前研究结果进行确认。当前这项研究的结果意义重大,或可用于结直肠癌同期孤立腹膜转移这部分患者未来临床决策的参考。

原始出处:

Koen P Rovers, Checca Bakkers, Felice N van Erning, et al.Adjuvant Systemic Chemotherapy vs Active Surveillance Following Up-front Resection of Isolated Synchronous Colorectal Peritoneal Metastases.JAMA Oncol. 2020 Jul 16;6(8):e202701. doi: 10.1001/jamaoncol.2020.2701.

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    2020-11-28 minlingfeng
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    2021-01-01 zhaojie88
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  4. 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  5. 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encryptionId=493ae869206, topicName=结直肠癌), TopicDto(id=46600, encryptionId=b0484660060, topicName=寡转移)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Tue Aug 18 19:35:16 CST 2020, time=2020-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032618, encodeId=8bb510326183c, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Tue Aug 18 18:29:41 CST 2020, time=2020-08-18, status=1, ipAttribution=)]
  7. [GetPortalCommentsPageByObjectIdResponse(id=1865892, encodeId=20bd1865892de, content=<a href='/topic/show?id=16ce133504e' target=_blank style='color:#2F92EE;'>#Oncol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13350, encryptionId=16ce133504e, topicName=Oncol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b63894, createdName=minlingfeng, createdTime=Sat Nov 28 14:29:41 CST 2020, time=2020-11-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1709135, encodeId=7f741e09135d5, content=<a href='/topic/show?id=cd013896021' target=_blank style='color:#2F92EE;'>#同期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=139, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=38960, encryptionId=cd013896021, topicName=同期)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Fri Jan 01 11:29:41 CST 2021, time=2021-01-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1877323, encodeId=0d0c18e732322, content=<a href='/topic/show?id=67c5319121e' target=_blank style='color:#2F92EE;'>#切除术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=85, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31912, encryptionId=67c5319121e, topicName=切除术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9d8a96, createdName=doctorzheng, createdTime=Fri Feb 19 07:29:41 CST 2021, time=2021-02-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1674480, encodeId=8c0d16e4480e5, content=<a href='/topic/show?id=e8aa13359b1' target=_blank style='color:#2F92EE;'>#Oncology#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13359, encryptionId=e8aa13359b1, topicName=Oncology)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=cb7226973259, createdName=circumcision, createdTime=Fri Nov 20 04:29:41 CST 2020, time=2020-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1953296, encodeId=c66019532968f, content=<a href='/topic/show?id=8dbae512483' target=_blank style='color:#2F92EE;'>#积极监测#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75124, encryptionId=8dbae512483, topicName=积极监测)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b70c362, createdName=jiadan198782, createdTime=Sun Jan 24 16:29:41 CST 2021, time=2021-01-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1453415, encodeId=508d145341544, content=<a href='/topic/show?id=098ee8679ad' target=_blank style='color:#2F92EE;'>#结直肠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=78679, encryptionId=098ee8679ad, topicName=结直肠)], attachment=null, authenticateStatus=null, createdAvatar=/v1.0.0/img/user_icon.png, createdBy=9ace5575596, createdName=crystal0564, createdTime=Thu Aug 20 06:29:41 CST 2020, time=2020-08-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579001, encodeId=a90915e90014e, content=<a href='/topic/show?id=0ff4856621f' target=_blank style='color:#2F92EE;'>#腹膜转移#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=101, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85662, encryptionId=0ff4856621f, topicName=腹膜转移)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6e6d16475304, createdName=新生儿张玉军, createdTime=Thu Aug 20 06:29:41 CST 2020, time=2020-08-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1623852, encodeId=aa2016238520c, content=<a href='/topic/show?id=16ba8564526' target=_blank style='color:#2F92EE;'>#腹膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85645, encryptionId=16ba8564526, topicName=腹膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=93e220615097, createdName=xuyong530, createdTime=Thu Aug 20 06:29:41 CST 2020, time=2020-08-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=810500, encodeId=efb4810500a7, content=<a href='/topic/show?id=493ae869206' target=_blank style='color:#2F92EE;'>#结直肠癌#</a>的<a href='/topic/show?id=b0484660060' target=_blank style='color:#2F92EE;'>#寡转移#</a>是最近几年的研究热点,包括肝转移,腹膜转移。, beContent=null, objectType=article, channel=null, level=null, likeNumber=272, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=78692, encryptionId=493ae869206, topicName=结直肠癌), TopicDto(id=46600, encryptionId=b0484660060, topicName=寡转移)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Tue Aug 18 19:35:16 CST 2020, time=2020-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032618, encodeId=8bb510326183c, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Tue Aug 18 18:29:41 CST 2020, time=2020-08-18, status=1, ipAttribution=)]
  8. [GetPortalCommentsPageByObjectIdResponse(id=1865892, encodeId=20bd1865892de, content=<a href='/topic/show?id=16ce133504e' target=_blank style='color:#2F92EE;'>#Oncol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13350, encryptionId=16ce133504e, topicName=Oncol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b63894, createdName=minlingfeng, createdTime=Sat Nov 28 14:29:41 CST 2020, time=2020-11-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1709135, encodeId=7f741e09135d5, content=<a href='/topic/show?id=cd013896021' target=_blank style='color:#2F92EE;'>#同期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=139, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=38960, encryptionId=cd013896021, topicName=同期)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, 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objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=78679, encryptionId=098ee8679ad, topicName=结直肠)], attachment=null, authenticateStatus=null, createdAvatar=/v1.0.0/img/user_icon.png, createdBy=9ace5575596, createdName=crystal0564, createdTime=Thu Aug 20 06:29:41 CST 2020, time=2020-08-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579001, encodeId=a90915e90014e, content=<a href='/topic/show?id=0ff4856621f' target=_blank style='color:#2F92EE;'>#腹膜转移#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=101, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85662, encryptionId=0ff4856621f, topicName=腹膜转移)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6e6d16475304, createdName=新生儿张玉军, createdTime=Thu Aug 20 06:29:41 CST 2020, time=2020-08-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1623852, encodeId=aa2016238520c, content=<a href='/topic/show?id=16ba8564526' target=_blank style='color:#2F92EE;'>#腹膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85645, encryptionId=16ba8564526, topicName=腹膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=93e220615097, createdName=xuyong530, createdTime=Thu Aug 20 06:29:41 CST 2020, time=2020-08-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=810500, encodeId=efb4810500a7, content=<a href='/topic/show?id=493ae869206' target=_blank style='color:#2F92EE;'>#结直肠癌#</a>的<a href='/topic/show?id=b0484660060' target=_blank style='color:#2F92EE;'>#寡转移#</a>是最近几年的研究热点,包括肝转移,腹膜转移。, beContent=null, objectType=article, channel=null, level=null, likeNumber=272, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=78692, encryptionId=493ae869206, topicName=结直肠癌), TopicDto(id=46600, encryptionId=b0484660060, topicName=寡转移)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Tue Aug 18 19:35:16 CST 2020, time=2020-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032618, encodeId=8bb510326183c, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Tue Aug 18 18:29:41 CST 2020, time=2020-08-18, status=1, ipAttribution=)]
    2020-08-20 xuyong530
  9. 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encryptionId=493ae869206, topicName=结直肠癌), TopicDto(id=46600, encryptionId=b0484660060, topicName=寡转移)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Tue Aug 18 19:35:16 CST 2020, time=2020-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032618, encodeId=8bb510326183c, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Tue Aug 18 18:29:41 CST 2020, time=2020-08-18, status=1, ipAttribution=)]
    2020-08-18 lovetcm

    #结直肠癌##寡转移#是最近几年的研究热点,包括肝转移,腹膜转移。

    0

  10. [GetPortalCommentsPageByObjectIdResponse(id=1865892, encodeId=20bd1865892de, content=<a href='/topic/show?id=16ce133504e' target=_blank style='color:#2F92EE;'>#Oncol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13350, encryptionId=16ce133504e, topicName=Oncol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b63894, createdName=minlingfeng, createdTime=Sat Nov 28 14:29:41 CST 2020, time=2020-11-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1709135, encodeId=7f741e09135d5, content=<a href='/topic/show?id=cd013896021' target=_blank style='color:#2F92EE;'>#同期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=139, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=38960, encryptionId=cd013896021, topicName=同期)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Fri Jan 01 11:29:41 CST 2021, time=2021-01-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1877323, encodeId=0d0c18e732322, content=<a href='/topic/show?id=67c5319121e' target=_blank style='color:#2F92EE;'>#切除术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=85, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31912, encryptionId=67c5319121e, topicName=切除术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9d8a96, createdName=doctorzheng, createdTime=Fri Feb 19 07:29:41 CST 2021, time=2021-02-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1674480, encodeId=8c0d16e4480e5, content=<a href='/topic/show?id=e8aa13359b1' target=_blank style='color:#2F92EE;'>#Oncology#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13359, encryptionId=e8aa13359b1, topicName=Oncology)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=cb7226973259, createdName=circumcision, createdTime=Fri Nov 20 04:29:41 CST 2020, time=2020-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1953296, encodeId=c66019532968f, content=<a href='/topic/show?id=8dbae512483' target=_blank style='color:#2F92EE;'>#积极监测#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75124, encryptionId=8dbae512483, topicName=积极监测)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b70c362, createdName=jiadan198782, createdTime=Sun Jan 24 16:29:41 CST 2021, time=2021-01-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1453415, encodeId=508d145341544, content=<a href='/topic/show?id=098ee8679ad' target=_blank style='color:#2F92EE;'>#结直肠#</a>, beContent=null, 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encryptionId=493ae869206, topicName=结直肠癌), TopicDto(id=46600, encryptionId=b0484660060, topicName=寡转移)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Tue Aug 18 19:35:16 CST 2020, time=2020-08-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032618, encodeId=8bb510326183c, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Tue Aug 18 18:29:41 CST 2020, time=2020-08-18, status=1, ipAttribution=)]
    2020-08-18 内科新手

    谢谢梅斯提供这么好的信息,学到很多

    0

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