高强度调强放疗在大容量中心改善了接受三联疗法的食管腺癌患者的生存。

Intensity-modulated radiotherapy at high-volume centers improves survival in patients with esophageal adenocarcinoma receiving trimodality therapy.

机构信息

Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.

Center for Evidence Based Medicine and Health Outcomes Research, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.

出版信息

Dis Esophagus. 2019 Aug 1;32(8). doi: 10.1093/dote/doy124.

DOI:10.1093/dote/doy124

PMID:30597022

Abstract

The standard of care trimodality therapy for resectable locally advanced esophageal adenocarcinoma is complex and necessitates multidisciplinary care and expertise. In this work, it is hypothesized that facility clinical volume and utilization of intensity-modulated radiotherapy (IMRT) may influence outcomes. The National Cancer Data Base was queried for patients with cT1-4-N0-3 M0 esophageal adenocarcinoma undergoing trimodality therapy from 2004 to 2013 (n = 2445). All patients received chemoradiation followed by esophagectomy at a Commission on Cancer facility. The facility volume was categorized into tertiles: high-volume centers (HVCs) in the highest 25th percentile of cases per year, intermediate-volume centers (IVCs) with the next highest 25th percentile of cases, and low- and very low-volume centers (LVCs) in the lowest 50th percentile. Overall survival (OS) was estimated using Kaplan-Meier methods and Cox proportional hazard regression. Propensity score matching to balance patient characteristics between volume centers was performed. Subgroup analysis was done comparing IMRT versus 3D conformal radiotherapy. The median follow-up was 26 months. Treatment at an HVC (hazard ratio 0.63, 95% CI 0.49-0.81, P < 0.001) was found to be independently associated with improved overall survival in multivariable analysis. Three-year OS was 58.4%, 46.2%, and 47.5% for HVCs, IVCs, and LVCs, respectively (P < 0.001). Patients at HVCs were more likely to receive IMRT over 3D chemoradiation (CRT; OR 3.45, 95% CI 2.4-5.0, P < 0.001). Patients treated using IMRT at HVCs had improved OS compared to those treated at IVCs or LVCs (HR 0.68, 95% CI 0.52-0.90, P < 0.01), while patients treated with 3D CRT at HVCs had no survival advantage over those at IVCs or LVCs (P = 0.28). Patients with locally advanced esophageal adenocarcinoma treated with IMRT and at HVCs appear to have improved survival.

摘要

局部晚期食管腺癌可切除患者的标准治疗方法是三联疗法，这种疗法复杂，需要多学科的护理和专业知识。在这项工作中，假设机构临床量和强度调制放疗（IMRT）的利用可能会影响结果。从 2004 年到 2013 年，国家癌症数据库（National Cancer Data Base）对接受三联疗法的 cT1-4-N0-3 M0 食管腺癌患者进行了查询（n=2445）。所有患者均接受放化疗，然后在癌症委员会设施进行食管切除术。机构数量分为三部分：每年病例数最高的 25%为高容量中心（HVC），其次的 25%为中等容量中心（IVC），最低的 50%为低容量和超低容量中心（LVC）。使用 Kaplan-Meier 方法和 Cox 比例风险回归估计总生存率（OS）。对体积中心之间的患者特征进行了倾向评分匹配。对 IMRT 与 3D 适形放疗进行了亚组分析。中位随访时间为 26 个月。多变量分析发现，在 HVC 接受治疗（危险比 0.63，95%CI 0.49-0.81，P<0.001）与总体生存率的提高独立相关。HVC、IVC 和 LVC 的 3 年 OS 分别为 58.4%、46.2%和 47.5%（P<0.001）。HVC 患者更有可能接受 IMRT 而不是 3D 放化疗（OR 3.45，95%CI 2.4-5.0，P<0.001）。与 IVC 或 LVC 相比，在 HVC 接受 IMRT 治疗的患者的 OS 得到改善（HR 0.68，95%CI 0.52-0.90，P<0.01），而在 HVC 接受 3D CRT 治疗的患者与 IVC 或 LVC 相比，生存优势无差异（P=0.28）。接受 IMRT 和 HVC 治疗的局部晚期食管腺癌患者的生存似乎有所改善。