盆腔淋巴结清扫对根治性膀胱切除术患者预后的影响

The prognostic effect of pelvic lymph node dissection on the patients undergoing radical cystectomy

目的探讨盆腔淋巴结清扫(PLND)对根治性膀胱切除术(RC)患者预后的影响方法回顾性分析2013年11月至2019年12月南京医科大学第一附属医院接受RC且未接受新辅助化疗的339例膀胱癌患者的临床资料。男284例,女55例。年龄(67.4±10.9)岁。术后病理诊断为MIBC171例,NMIBC168例。MIBC组中124例(72.5%)接受PLND,NMIBC组中118例(70.2%)接受PLND,差异无统计学意义(P=0.643)。PLND的淋巴结清扫数量为(13.7±7.1)枚。分析MIBC组和NMIBC组的预后影响因素,以及PLND对预后的影响。结果MIBC组中26例淋巴结阳性,98例淋巴结阴性;144例为高级别尿路上皮癌;47例接受辅助治疗。NMIBC组中4例淋巴结阳性,114例淋巴结阴性;99例为高级别尿路上皮癌;15例接受辅助治疗。术后中位随访24(13,43)个月,5年总生存率(OS)为63.6%,NMIBC组为79.1%,MIBC组为47.5%。单因素分析结果显示,年龄≥65岁(HR=2.07,95%CI1.21~3.54,P=0.009)、肿瘤高级别(HR=9.76,95%CI2.39~39.90,P<0.01)、淋巴结阳性(HR=2.47,95%CI 1.27~4.78,P=0.008)是MIBC预后的危险因素,PLND(HR=0.37,95%CI 0.23~0.60,P<0.01)、辅助治疗(HR=0.21,95%CI0.10~0.46,P<0.01)是MIBC预后的保护性因素;肿瘤高级别(HR=6.66,95%CI1.51~29.50,P=0.012)是NMIBC预后的危险因素,PLND(HR=1.32,95%CI0.37~4.75,P=0.667)不是预后的影响因素。多因素分析结果显示,肿瘤高级别(HR=6.38,95%CI1.54~26.50,P=0.011)是MIBC预后的独立危险因素,PLND(HR=0.59,95%CI0.35~0.99,P=0.047)和辅助治疗(HR=0.30,95%CI0.13~0.68,P=0.004)是MIBC预后的独立保护因素。生存曲线分析结果显示,MIBC组中,淋巴结阴性组的5年OS(62.4%)优于未清扫组(16.1%)(P<0.01)和淋巴结阳性组(32.3%)(P=0.005),未清扫组与淋巴结阳性组的5年0S差异无统计学意义(P=0.438)NMIBC组中,淋巴结阴性组和未清扫组的5年OS分别81.3%和66.6%,差异无统计学意义(P=0.764)结论PLND是MIBC患者RC术后预后的独立保护因素,但对NMIBC患者预后无显著影响。

Objective To discuss the efficacy of pelvic lymph node dissection(PLND)on the patients undergoing radical cystectomy(RC).Methods The clinicopathological data of bladder cancer patients who did not receive neoadjuvant chemotherapy and underwent RC in our center from November 2013 to December 2019 were collected.The average age of the patients was(67.4±10.9)years,including 284 males and 55 females.Postoperative pathology showed that 171 cases of MIBC and 168 cases of NMIBC.In the MIBC group,124 patients received PLND.In the NMIBC group,118 patients received PLND.There was no statistical difference of the PLND ratio between the two groups(72.5%vs.65.5%,P=0.643).The average number of lymph nodes(LNs)in patients receiving PLND was(13.7±7.1).Explore the prognostic factors in NMIBC and MIBC respectively.The Kaplan-Meier method was used to analyze the effect of PLND on the prognosis of patients in MIBC and NMIBC group.Results In MIBC group,26 patients showed positive LNs,while 98 had negative LNs.144 cases were high-grade urothelial carcinoma,and 47 cases received adjuvant treatment.In NMIBC group,4 patients exhibited positive LNs,while 114 had negative LNs.99 cases were high-grade urothelial carcinoma,and 15 cases received adjuvant treatment.After a median follow-up of 24(13,43)months,Kaplan-Meier survival analysis showed that the 5-year overall survival(OS)of 395 patients was 63.6%.MIBC had a 5-year OS rate of 47.5%,while NMIBC had a rate of 79.1%.Univariate Cox regression showed that age≥65 years(HR=2.07,95%CI 1.21-3.54,P=0.009),high tumor grade(HR=9.76,95%CI 2.39-39.90,P<0.01),and positive lymph nodes(HR=2.47,95%CI 1.27-4.78,P=0.008)were risk factors for the prognosis of MIBC.PLND(HR=0.37,95%CI 0.23-0.60,P<0.01)and adjuvant therapy(HR=0.21,95%CI 0.10-0.46,P<0.01)were protective factors of MIBC.However,the only risk factor of NMIBC was high tumor grade(HR=6.66,95%CI1.51-29.50,P=0.012).PLND had no effect on the prognosis of NMIBC patients following RC(HR=1.32,95%CI 0.37-4.75,P=0.667).Multivariate COX regression analysis revealed that high tumor grade(HR=6.38,95%CI 1.54-26.50,P=0.011)was independent risk factor of MIBC,PLND(HR=0.59,95%CI 0.35-0.99,P=0.047),as well as adjuvant therapy(HR=0.30,95%CI 0.13-0.68,P=0.004)were independent protective factors of MIBC.Further analysis discovered that MIBC patients with negative LNs had a better prognosis than those with no PLND(62.4% vs.16.1%,P<0.01)and positive LNs(62.4%vs.32.3%,P=0.005).However,there was no difference in prognosis between the negative LNs and no PLND group in NMIBC patients(81.3%vs.66.6%,P=0.764).Conclusions This study found that PLND was an independent predictive factor for MIBC patients receiving radical cystectomy.