局部晚期下咽鳞状细胞癌的预后及其影响因素分析

Prognosis of locally advanced squamous cell carcinoma of the hypopharynx and analysis of its influencing factor

目的探讨局部晚期下咽鳞状细胞癌(HPSCC)患者的生存情况及其影响患者预后的相关危险因素。方法回顾性队列研究。纳入2013年1月—2018年12月蚌埠医学院第一附属医院耳鼻咽喉头颈外科115例确诊为局部晚期HPSCC患者的临床资料。其中,男110例,女5例;年龄42~84(62.9±9.8)岁。按照治疗方式不同分组:手术组65例,采用手术为主的综合治疗模式;非手术组50例,采用非手术综合治疗模式。观察指标:(1)观察2组患者的并发症情况,比较手术组与非手术组患者的喉功能保留率(以随访中喉功能评估最优结果为最终结果);(2)分析患者3、5年生存情况,使用Kaplan-Meier法计算患者累积生存率;(3)利用log-rank检验分析局部晚期HPSCC患者预后的影响因素,Cox比例风险回归模型分析其独立危险因素;(4)根据患者预后独立危险因素进一步分组:有1个危险因素纳入低风险组,有2个及以上危险因素纳入高风险组,观察不同风险组中不同治疗模式患者的5年累积生存率,比较其预后。结果(1)手术组与非手术组患者性别、年龄、吸烟、饮酒、病变解剖亚区、肿瘤分期、肿瘤分化程度等基线资料比较,差异均无统计学意义(P值均>0.05)。手术组患者术后出现咽瘘4例,均经抗感染及局部长期换药后愈合;行术区缺损皮瓣修补术的患者出现3例皮瓣感染或部分坏死,均经抗感染及局部换药或二次手术修补后愈合。非手术组患者出现呼吸困难行气管切开3例、吞咽困难行胃造瘘2例。手术组患者的喉功能保留率为35.4%(23/65),非手术组为68.0%(34/50),差异有统计学意义(χ^(2)=12.03,P<0.001)。(2)115例患者的3、5年累积生存率分别为47.0%、39.9%,中位生存时间为32.0个月。其中手术组患者的3、5年累积生存率分别是56.9%、50.7%,非手术组患者的3、5年累积生存率分别是34.0%、25.8%。(3)单因素分析显示,肿瘤病变解剖亚区、T分期、N分期、临床分期和治疗方式是患者预后的影响因素(P值均<0.05)。多因素分析结果显示,肿瘤T3~T4期[风险比(HR)=2.729,95%可信区间(CI)1.626~4.581]、N+期(HR=3.296,95%CI 1.521~7.144)、非手术治疗(HR=1.720,95%CI 1.104~2.680)、环后区型/咽后壁型(HR=1.736,95%CI 1.064~2.834)是患者预后的独立危险因素。(4)低风险组中,手术患者的5年累积生存率为67.2%,非手术患者为48.6%,其生存差异无统计学意义(χ^(2)=0.21,P=0.647);高风险组中,手术患者的5年累积生存率为37.5%,非手术患者为15.4%,其生存差异有统计学意义(χ^(2)=4.54,P=0.033)。结论局部晚期HPSCC患者的预后较差,肿瘤T3~T4期、N+期、病变解剖亚区为环后区型/咽后壁型、非手术治疗是影响患者预后的独立危险因素。非手术治疗相比手术治疗患者喉功能保留率高,但对于存在2个或3个危险因素的患者,以手术为主的综合治疗较非手术治疗5年累积生存率更高。

Objective This study aims to investigate the survival of patients with locally advanced hypopharyngeal squamous cell carcinoma(HPSCC)and its associated risk factors affecting prognosis.Methods A retrospective cohort study was conducted.The clinical data of 115 patients diagnosed with locally advanced HPSCC in the Department of Otolaryngology Head and Neck Surgery of the First Affiliated Hospital of Bengbu Medical College from January 2013 to December 2018 were included.The patients included 110 males and 5 females aged 42-84(62.9±9.8)years,with a median age of 64 years.The patients were grouped according to different treatment modalities:65 cases in the surgical group,with a comprehensive treatment mode based on surgery;and 50 cases in the non-surgical group,with a non-surgical comprehensive treatment mode.The observation indicators were as follows.(1)The complications of the two groups were observed,and the laryngeal function retention rate was compared between the operation and non-operation groups(the optimal laryngeal function evaluation result in the follow-up was the final result);(2)3-year and 5-year survival rates were analyzed,and Kaplan-Meier method was used to calculate the cumulative survival rate of patients;(3)prognostic factors of patients with locally advanced HPSCC were analyzed by log-rank test,and independent risk factors were analyzed by Cox proportional risk regression model;and(4)patients were further divided according to prognostic independent risk factors:one risk factor was included in the low-risk group,and two or more risk factors were included in the high-risk group.The 5-year cumulative survival rate of patients with different treatment modes in different risk groups was observed and the prognosis was compared.Results(1)No significant differences in baseline data of gender,age,smoking,drinking,anatomical subarea of lesions,tumor stage,and tumor differentiation were found between the operation and non-operation groups(all P values>0.05).Pharyngeal fistula occurred in 4 patients in the operation group,all of which were healed after anti-inflammatory and local long-term dressing change.Three cases of skin flap infection or partial necrosis occurred in the patients undergoing flap repair,all of which were healed after anti-inflammatory,local dressing change,or secondary surgical repair.In the non-operation group,3 patients with dyspnea received tracheotomy and 2 patients with dysphagia received gastrostomy.The scores of laryngeal function in patients with retention rate was 35.4%(23/65),and the surgical group was 68.0%(34/50);the difference was statistically significant(χ^(2)=12.03,P<0.001).(2)The 3-year and 5-year cumulative survival rates of 115 patients were 47.0%and 39.9%,respectively.The median survival time was 32.0 months.The 3-year and 5-year cumulative survival rates of the surgery group were 56.9%and 50.7%,respectively,while those of the non-surgery group were 34.0%and 25.8%,respectively.(3)Univariate analysis showed that the anatomic subarea of tumor lesion,T stage,N stage,clinical stage,and treatment method were factors influencing the prognosis of patients(all P<0.05).The results of multivariate analysis showed that tumor T3-T4 stage(hazard ratio[HR]=2.729,95%confidence interval[CI]1.626-4.581),N+stage(HR=3.296,95%CI 1.521-7.144),non-surgical treatment(HR=1.720,95%CI 1.104-2.680),and retrocyclic/retropharyngeal type(HR=1.736,95%CI 1.064-2.834)were independent risk factors for prognosis.(4)In the low-risk group,the 5-years cumulative survival rate was 67.2%of patients in the operation group,the non-surgical patients was 48.6%,and the difference was not statistically significant to its survival(χ^(2)=0.21,P=0.647).In the high-risk group,the 5-year cumulative survival rate of surgical patients was 37.5%,the non-surgical patients was 15.4%,its survival difference was statistically significant(χ^(2)=4.54,P=0.033).Conclusion Patients with locally advanced HPSCC have a poor prognosis,with the T3-T4 stage of the tumor,N+stage,anatomical subzone of the lesion being the posterior cricoid/posterior pharyngeal wall type,and non-surgical treatment as independent risk factors affecting patient prognosis.Non-surgical treatment has a higher rate of preservation of laryngeal function than surgical treatment.The 5-year cumulative survival rate of patients with 2 or 3 risk factors is higher with surgery-based combination therapy compared with non-surgical treatment.