肌肉减少症对老年食管癌患者根治性放疗临床疗效及预后的影响

Effects of sarcopenia on the clinical efficacy and prognosis of radical radiotherapy in elderly patients with esophageal cancer

目的探究肌肉减少症与接受根治性放疗的老年食管癌患者疗效及预后的关系。方法回顾性分析2013年1月至2018年12月就诊于扬州大学附属医院放疗科进行根治性放疗的134例老年食管癌患者的临床病理资料。使用计算机断层扫描后的CT图像测量第3腰椎水平处的肌肉横截面积。根据放疗前骨骼肌指数将患者分为肌肉减少症组(n=56)和非肌肉减少症组(n=78)。比较两组患者的疗效及不良反应发生情况。采用Kaplan-Meier法绘制生存曲线,通过Cox回归模型分析预后影响因素。结果肌肉减少症组患者和非肌肉减少症组患者在根治性放疗结束后1个月的客观缓解率分别为53.57%(30/56)、71.79%(56/78),差异有统计学意义(χ^(2)=4.71,P=0.030)。两组的疾病控制率分别为94.64%(53/56)、91.03%(71/78),差异无统计学意义(χ^(2)=0.21,P=0.651)。肌肉减少症组和非肌肉减少症组患者不良反应总发生率分别为67.86%(38/56)、47.44%(37/78),差异有统计学意义(χ^(2)=5.52,P=0.019)。至随访结束,134例接受根治性放疗的老年食管癌患者1、3和5年生存率分别为91.0%、73.1%、55.2%。肌肉减少症组和非肌肉减少症组患者中位总生存期(OS)分别为14个月、26个月,差异有统计学意义(χ^(2)=9.84,P=0.002);两组患者中位无进展生存期(PFS)分别为7个月、18个月,差异有统计学意义(χ^(2)=9.91,P=0.002)。单因素分析显示,cT分期(HR=2.45,95%CI为1.26~4.74,P=0.008)、cN分期(HR=1.63,95%CI为1.06~2.50,P=0.027)、cTNM分期(HR=2.04,95%CI为1.28~3.27,P=0.003)、体质量指数(BMI)(HR=2.23,95%CI为1.01~4.90,P=0.046)、放疗前肌肉减少症(HR=2.45,95%CI为1.27~4.72,P=0.007)和化疗(HR=0.30,95%CI为0.11~0.83,P=0.020)是患者OS的预后影响因素;cT分期(HR=2.27,95%CI为1.18~4.39,P=0.015)、cN分期(HR=1.61,95%CI为1.04~2.47,P=0.030)、cTNM分期(HR=1.90,95%CI为1.19~3.02,P=0.007)、BMI(HR=1.98,95%CI为1.06~3.79,P=0.032)、放疗前肌肉减少症(HR=1.79,95%CI为1.06~3.04,P=0.031)和不良反应(HR=0.60,95%CI为0.38~0.97,P=0.037)是患者PFS的预后影响因素。多因素分析显示,放疗前肌肉减少症(HR=1.91,95%CI为1.22~3.00,P=0.005)是患者OS的独立预后因素;BMI(HR=1.80,95%CI为1.03~3.15,P=0.039)和放疗前肌肉减少症(HR=2.00,95%CI为1.27~3.14,P=0.003)是患者PFS的独立预后因素。结论放疗前的肌肉减少症是接受根治性放疗老年食管癌患者评价预后的有效预测指标,发生肌肉减少症的患者从治疗中获益小。

Objective To explore the relationships between sarcopenia and the clinical efficacy and prognosis of elderly patients with esophageal cancer who were treated by radical radiotherapy.Methods The clinicopathological data of 134 elderly patients with esophageal cancer who received radical radiotherapy in Department of Radiotherapy,Affiliated Hospital of Yangzhou University from January 2013 to December 2018 were retrospectively analyzed.The muscle cross-sectional area at the level of the third lumbar vertebra was measured by using computed tomography(CT)images.These patients were divided into sarcopenia group(n=56)and non-sarcopenia group(n=78)according to the skeletal muscle index before radiotherapy.The efficacy and incidence of adverse reactions of the two groups were compared.Kaplan-Meier method was used to plot the survival curve,and Cox regression model was used to analyze prognostic factors.Results There was a significant difference in the objective response rate between the sarcopenia and non-sarcopenia group at 1 month after radiotherapy[53.57%(30/56)vs.71.79%(56/78),χ^(2)=4.71,P=0.030].There was no significant difference in the disease control rate between the two groups[94.64%(53/56)vs.91.03%(71/78),χ^(2)=0.21,P=0.651].There was a significant difference in the total incidence of adverse reactions between the sarcopenia and non-sarcopenia group[67.86%(38/56)vs.47.44%(37/78),χ^(2)=5.52,P=0.019].By the end of the follow-up,the 1-,3-and 5-year overall survival(OS)rates of 134 elderly patients with esophageal cancer who received radical radiotherapy were 91.0%,73.1%and 55.2%respectively.The median OS of patients in the sarcopenia and non-sarcopenia group were 14 months and 26 months respectively,with a statistically significant difference(χ^(2)=9.84,P=0.002).The median progression-free survival(PFS)of the two groups were 7 months and 18 months respectively,with a statistically significant difference(χ^(2)=9.91,P=0.002).Univariate analysis showed that cT stage(HR=2.45,95%CI:1.26-4.74,P=0.008),cN stage(HR=1.63,95%CI:1.06-2.50,P=0.027),cTNM stage(HR=2.04,95%CI:1.28-3.27,P=0.003),body mass index(BMI)(HR=2.23,95%CI:1.01-4.90,P=0.046),pre-radiotherapy sarcopenia(HR=2.45,95%CI:1.27-4.72,P=0.007)and chemotherapy(HR=0.30,95%CI:0.11-0.83,P=0.020)were prognostic factors for OS;cT stage(HR=2.27,95%CI:1.18-4.39,P=0.015),cN stage(HR=1.61,95%CI:1.04-2.47,P=0.030),cTNM stage(HR=1.90,95%CI:1.19-3.02,P=0.007),BMI(HR=1.98,95%CI:1.06-3.79,P=0.032),pre-radiotherapy sarcopenia(HR=1.79,95%CI:1.06-3.04,P=0.031)and adverse reactions(HR=0.60,95%CI:0.38-0.97,P=0.037)were prognostic factors for PFS.Multivariate analysis showed that pre-radiotherapy sarcopenia(HR=1.91,95%CI:1.22-3.00,P=0.005)was an independent prognostic factor for OS;BMI(HR=1.80,95%CI:1.03-3.15,P=0.039)and pre-radiotherapy sarcopenia(HR=2.00,95%CI:1.27-3.14,P=0.003)were independent prognostic factors for PFS.Conclusion Sarcopenia before radiotherapy can be a useful predictor for prognosis in elderly patients with esophageal cancer who received radical radiotherapy,and patients with sarcopenia benefit less from treatment.