胰腺肿瘤多学科协作团队模式优化诊疗和改善预后的价值分析

Pancreas multidisciplinary team optimizes the diagnosis and treatment of pancreas-related diseases and improves the prognosis of pancreatic cancer patients

目的探讨胰腺肿瘤多学科协作团队(MDT)模式的诊断价值和患者依从性,以及MDT对胰腺癌患者术后生存的影响。方法回顾性收集2015年5月至2021年12月复旦大学附属中山医院胰腺肿瘤MDT门诊接诊的927例患者的临床和病理学资料[男性554例,女性373例,年龄(58.1±13.3)岁(范围:15~89岁)],以及2012年1月至2020年12月于复旦大学附属中山医院行根治性手术切除并经病理学检查结果证实为胰腺导管腺癌的677例患者的资料[男性396例,女性281例,年龄(63.6±8.9)岁(范围:32~95岁),其中79例经胰腺肿瘤MDT讨论]。根据WHO 2010消化系统肿瘤分类和临床诊疗常规对入组病例进行分类。采用Kaplan-Meier法绘制生存曲线和计算存活率,使用Log-rank检验法行单因素分析,使用Cox比例风险回归模型进行多因素分析,通过χ^(2)检验进行生存率的比较。结果927例讨论病例中,诊断不明病例233例(25.1%),MDT门诊对109例患者(46.8%,109/233)做出直接诊断,其中98例与最终诊断相一致,正确率为89.9%(98/109)。后期(2019年6月至2021年12月)MDT门诊做出直接诊断的比例(36.6%,41/112)较前期(2015年5月至2019年5月)(56.2%,68/121)有所下降,而诊断正确率(90.2%,37/41)则与前期(89.7%,61/68)基本一致。MDT门诊患者的总体依从率为71.5%(663/927),后期患者的依从率(81.4%,338/415)较前期(63.4%,325/512)明显升高。经过MDT制定诊疗方案的胰腺癌患者术后中位生存期较未参与的患者有延长的趋势,但两组差异无统计学意义(35.2个月比30.2个月,P>0.05)。MDT组患者术后1年及3年生存率高于未参加MDT组(1年:88.6%比78.4%,P<0.05;3年:32.9%比21.9%,P<0.05),但两组5年生存率差异无统计学意义(7.6%比4.8%,P>0.05)。结论MDT门诊是较为准确、便捷诊断胰腺疑难病例的方式,近年来MDT门诊患者的依从率有所升高。经MDT制定诊疗方案的胰腺癌患者有更高的1年及3年术后生存率,但患者的长期生存获益仍需要更大样本量的研究结果来验证。

Objectives To evaluate the role of pancreas multidisciplinary team(MDT)clinic in the diagnosis of pancreatic diseases,patient compliance with MDT advice,and the impact of MDT on the postoperative survival of patients with pancreatic cancer.Methods The study included 927 patients(554 males,373 females,aged(58.1±13.3)years(range:15 to 89 years))that had visited the pancreas MDT clinic of Zhongshan Hospital from May 2015 to December 2021,and 677 patients(396 males,281 females,aged(63.6±8.9)years(range:32 to 95 years))who underwent radical surgery and with pathologically confirmed pancreatic adenocarcinoma from January 2012 to December 2020,of whom 79 patients had attended the pancreas MDT.The clinical and pathological data were collected and analyzed retrospectively.Diseases were classified in accordance with 2010 WHO classification of tumors of the digestive system and usual clinical practices.The Kaplan-Meier method was used for drawing the survival curve and calculating the survival rate.The univariate analysis was done by Log-rank test and the multivariate analysis was done by COX proportional hazards model.Survival rates were compared usingχ^(2) test.Results Among the 927 patients that had visited the MDT clinic,233 patients(25.1%)were referred due to undetermined diagnosis.A direct diagnosis was made in 109 cases(46.8%,109/233)by the MDT clinic,of which 98 were consistent with the final diagnosis,resulting in an accuracy of 89.9%(98/109).The direct diagnosis rate in the recent years(36.6%(41/112),from June 2019 to December 2021)decreased compared to that in the previous years(56.2%(68/121),from May 2015 to May 2019),yet the accuracy in the recent years(90.2%,37/41)was basically the same as before(89.7%,61/68).The rate of compliance of the entire cohort was 71.5%(663/927),with the compliance rate in the recent two and a half years(81.4%,338/415)remarkably higher than that in the previous four years(63.4%,325/512).Patients with pancreatic cancer that attended the MDT exhibited a trend toward longer median postoperative survival than patients that did not attend the MDT,but the difference was not statistically significant(35.2 months vs.30.2 months,P>0.05).The 1-year and 3-year survival rates of patients that attended the MDT were significanly higher than patients that did not attend the MDT(88.6%vs.78.4%,P<0.05;32.9%vs.21.9%,P<0.05,respectively),but the 5-year survival rate was not statistically different(7.6%vs.4.8%,P>0.05).Conclusions The pancreas MDT clinic is an accurate and convenient way to diagnose intractable pancreatic diseases,and in the recent years the patients′compliance rate with MDT advice has increased.Pancreatic cancer patients that have attended the MDT have higher 1-year and 3-year postoperative survival rates,but the long-term survival benefits of MDT still needs to be proved by clinical studies on a larger scale.