肾部分切除术对Ⅰ期局限性肾透明细胞癌患者预后的影响研究

Prognostic Value of Partial Ephrectomy in Patients with Localized Ⅰ Clear Cell Renal Cell Carcinoma

背景目前,T1a期局限性肾透明细胞癌(ccRCC)患者首选肾部分切除术(PN),而对于T1b期局限性患者是否首选PN方案尚存在争议。目的分析PN对Ⅰ期局限性ccRCC患者总体生存率(OS)和肿瘤特异生存率(CSS)的影响。方法2020年4—5月申请获得监测、流行病学和最终结果(SEER)数据库使用权限并从数据库下载1975—2016年经病理诊断为Ⅰ期局限性ccRCC患者的临床病理资料(诊断年份、年龄、性别、人种、婚姻、肿瘤患侧性、病理分级、T分期、手术方式),根据手术方式不同将患者分为PN组与根治性肾切除术(RN)组。采用Cox比例风险回归模型分析Ⅰ期局限性ccRCC患者CSS的独立预后因素;采用多因素Logistic回归分析探讨患者手术方式的影响因素;采用倾向性评分匹配法校正样本,Kaplan-Meier曲线和多因素Cox比例风险回归模型分析匹配前后两种手术方式对患者OS和CSS的影响。结果单因素Cox比例风险回归模型结果显示,年龄、婚姻、病理分级、T分期、手术方式均是Ⅰ期局限性ccRCC患者CSS的预后因素(P<0.05);多因素Cox比例风险回归模型结果显示,年龄、婚姻、病理分级、T分期、手术方式均是Ⅰ期局限性ccRCC患者CSS的独立预后因素(P<0.05)。在总体生存人群及肿瘤特异性生存人群中,两组T1b期局限性ccRCC患者诊断年份、年龄、肿瘤患侧性、病理分级比较,差异均有统计学意义(P<0.05);多因素Logistic回归分析结果显示,诊断年份、年龄、肿瘤患侧性、病理分级是T1b期局限性ccRCC患者手术方式的影响因素(P<0.05)。与RN相比,匹配前后的Kaplan-Meier曲线发现,PN对患者OS有益(P<0.05),而对CSS无明显影响(P>0.05);PSM调整后的多因素Cox比例风险回归模型分析发现PN是患者OS独立保护因素(HR=0.695,P=0.009),对CSS无明显影响(HR=0.804,P=0.301)。结论基于患者的远期生存角度,在手术可行的情况下,建议Ⅰ期局限性ccRCC患者优先考虑PN治疗。

Background At present,partial nephrectomy(PN)is preferred for patients with localized T1a clear cell renal cell carcinoma(ccRCC).However,it remains controversial whether PN is the first-choice surgical procedure for patients with localized T1b ccRCC.Objective To estimate the effects of PN on overall survival(OS)and cancer-specific survival(CSS)of patients with localized Ⅰ ccRCC.Methods From April to May 2020,we downloaded the clinicopathological data of patients diagnosed with ccRCC pathologically from 1975 to 2016(year of diagnosis,age,sex,race,marital status,tumor laterality,pathological stage,T stage,surgical method)from SEER after getting permission to use the database.According to the use of surgical techniques,the patients were divided into PN group and radical nephrectomy(RN)group.Cox proportional hazards regression model was used to identify independent prognostic factors of CSS in patients with localized Ⅰ ccRCC.Multivariate Logistic regression analysis was used to explore the the influencing factors of surgical methods in patients with ccRCC.Propensity score matching method was used to adjust samples.Kaplan-Meier curve and multivariate Cox proportional hazards regression model were used to estimate the effects of two surgical methods on the OS and CSS of patients before and after matching.Results The results of univariate Cox proportional hazard regression model showed that age,marital status,pathological stage,T stage and surgical method were factors associated with CSS in patients with localized Ⅰ ccRCC(P<0.05).The results of multivariate Cox proportional hazard regression model showed that age,marital status,pathological stage,T stage and surgical method were all independent factors for CSS in patients with localized Ⅰ ccRCC(P<0.05).In terms of evaluating the prognostic value of surgical method by overall survival population and tumor specific survival population,localized T1b stage ccRCC with PN and those with RN had statistically significant differences in the year of diagnosis,age,tumor laterality and pathological stage(P<0.05).Multivariate Logistic regression analysis revealed that year of diagnosis,age,tumor laterality and pathological stage were associated with the use of surgery method in patients with localized T1b stage ccRCC(P<0.05).Kaplan-Meier survival analysis found that either before or after propensity score matching,PN significantly prolonged the OS(P<0.05),but showed similar effect on the CSS(P>0.05)of patients compared with RN.After propensity score matching,multivariate Cox regression analysis found that PN was independently associated with prolonged OS of patients(HR=0.695,P=0.009),but was not significantly associated with CSS(HR=0.804,P=0.301).Conclusion When surgery is feasible,PN is recommended as the first-choice surgical mode for patients with stage Ⅰ ccRCC in light of long-term survival.