非肌层浸润性膀胱癌首次电切术后肿瘤残余及二次电切术后复发相关因素分析

Correlation factors analysis of tumor residue and recurrence of the second transurethral resection in non-muscle-invasive bladder cancer

目的:分析非肌层浸润性膀胱癌(non-muscular-invasive bladder cancer,NMIBC)首次电切术后肿瘤残余发生率,肿瘤残余及术后复发的相关因素分析,探讨二次电切术(repeat transurethral resection,Re-TUR)对NMIBC的临床意义及需改进措施。方法:回顾性分析我院2014年1月—2019年12月收治的经尿道膀胱肿瘤电切术(transurethral resection of bladder tumor,TURBT)后行Re-TUR的膀胱癌患者的临床病理资料。统计患者Re-TUR后肿瘤残余状态;利用Logistic回归模型分析肿瘤残余的相关因素,利用Cox危险因素模型分析无复发生存期(RFS)的相关因素。应用Kaplan-Meier法来描绘RFS,并用Log-rank检验进行生存比较。结果:共计247例膀胱癌患者接受Re-TUR,病理结果显示肿瘤残余78例(31.6%),平均随访时间22(1~65)个月,随访期间31例(14.7%)患者复发,其中1年复发率为12.8%,3年复发率为14.2%,其中8例(3.8%)复发患者出现疾病进展。Logistic回归分析结果显示肿瘤残余与肿瘤多发(OR=2.12,P=0.035),卫星灶(OR=3.86,P=0),首次电切标本可见肌肉组织(OR=0.48,P=0.047),肿瘤距输尿管开口<2 cm(OR=2.02,P=0.005)显著相关。疾病复发相关因素分析中,Cox单因素分析显示肿瘤残余(HR=4.31,P=0),肿瘤带蒂(HR=0.32,P=0.002),合并原位癌(HR=5.14,P=0.002),肿瘤再发(HR=3.52,P=0.006)和BCG膀胱灌注(HR=0.478,P=0.041)与RFS显著相关,进一步多因素分析结果显示肿瘤残余(HR=3.31,P=0.003)为RFS的独立相关因素。Kaplan-Meier生存分析(P=0 Log-rank)显示肿瘤残余与患者RFS显著相关。结论:膀胱肿瘤首次电切术后存在一定的肿瘤残余,二次电切病理阳性较阴性患者预后差,二次电切可进一步清除残余肿瘤;肿瘤多发,卫星灶,原位癌及肿瘤距输尿管开口<2 cm为肿瘤残余正相关因素,推荐此类患者行二次电切;患者RFS与肿瘤残余、肿瘤带蒂、原位癌、BCG膀胱灌注及肿瘤再发显著相关,其中肿瘤残余为RFS的独立相关因素,肿瘤残余患者较无残余患者RFS明显缩短。

Objective:Residual tumor at repeat transurethral resection(Re-TUR)was not uncommon in non-muscle-invasive bladder cancer(NMIBC).The risk factors for tumor residual and recurrence were investigated to explore the prognostic value of pathological positive after Re-TUR for NMIBC.Methods:The clinicopathological data of patients with bladder cancer who underwent Re-TUR after transurethral resection of bladder tumor(TURBT)in our hospital from January 2014 to December 2019 were retrospectively analyzed.The residual tumor status after Re-TUR was calculated.The correlation factors of tumor residual were analyzed by multivariate logistic regression,and the predictors of recurrence-free survival(RFS)were analyzed by Cox regression models.The Kaplan-Meier method was used to describe RFS and the log-rank test was used for survival comparison.Results:A total of 247 patients with bladder cancer received Re-TUR,and the pathological results after Re-TUR showed tumor residual in 78(31.6%)patients.The mean follow-up time was 22(1-65)months.During the follow-up,31 patients(14.7%)relapsed,with a 1-year recurrence rate of 12.8%and a 3-year recurrence rate of 14.2%.Logistic regression analysis showed that tumor residual was significantly correlated with multiple tumors(OR=2.12,95%CI:1.05-2.46;P=0.035),satellite focus(OR=3.86,95%CI:1.87-7.94;P=0),muscle included in the specimen of the first TURBT(OR=0.48,95%CI:0.24-0.99;P=0.047),and tumor less than 2 cm away from the ureteral orifice(OR=2.02,95%CI:1.01-4.08;P=0.005).Cox univariate analysis showed that tumor residual(HR=4.31,95%CI:2.06-9.02;P=0),pedicle tumors(HR=0.32,95%CI:0.15-0.67;P=0.002),presence of carcinoma in situ(HR=5.14,95%CI:1.78-14.83;P=0.002),intravesical instillation therapy with BCG or other agents(HR=0.478,95%CI:0.235-0.969;P=0.041)and previous bladder cancer history(HR=3.52,95%CI:1.44-8.60;P=0.006)were significantly correlated with RFS.Further multivariate analysis showed that tumor residual(HR=3.31,95%CI:1.51-7.26;P=0.003)was an independent predictor for RFS.Kaplan-Meier survival analysis(P=0 log-rank)showed a significant correlation between tumor residue and RFS.Conclusion:After the initial TURBT,there were some residual tumors,and the prognosis of the patients with positive pathology of Re-TUR was worse than that of the patients with negative pathology.Re-TUR could further remove residual tumors and benefit patients.Re-TUR is recommended for patients with one of tumor residual risk factors,and more specific and close follow-up should be conducted.