高危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危险因素分析

Analysis of risk factors associated with tumor residue after first resection and recurrence after repeat transurethral resection for high risk non-muscle-invasive bladder cancer

目的:探讨高危非肌层浸润性膀胱癌(non-muscle-invasive bladder cancer,NMIBC)患者首次电切术后肿瘤残余的危险因素以及二次电切(repeat transurethral resection,re-TUR)术后患者的复发情况及相关危险因素,旨在为临床开展re-TUR提供更多依据。方法:回顾性分析四川大学华西医院2020年1月—2023年8月收治的行经尿道膀胱肿瘤电切术(transurethral resection of bladder tumor,TURBT)后并于2~6周内行re-TUR的高危NMIBC患者的临床及病理资料。统计本中心首次电切术后肿瘤残余的发生率;利用logistic回归模型分析可能影响首次电切术后肿瘤残余的因素;利用Cox回归模型分析可能影响re-TUR术后肿瘤复发的危险因素。结果:本研究共纳入171例患者,re-TUR术后发现肿瘤残余65例(38.01%),中位随访时间24.03(0.9,49.2)个月。随访期间,42例(24.56%)患者复发,其中1年复发率为15.20%,2年复发率为23.98%,其中9例(5.26%)复发患者出现疾病进展。单因素logistic回归分析结果显示,肿瘤残余与肿瘤高级别(P=0.012)、合并卫星灶(P=0.022)显著相关。多因素logistic回归分析显示:合并卫星灶(P=0.024)是肿瘤残余的独立相关危险因素。单因素Cox回归分析结果显示,术后膀胱灌注卡介苗(BCG)(P=0.012)、肿瘤残余(P=0.006)、高白蛋白与碱性磷酸酶比值(albumin to alkaline phosphatase ratio,AAPR)(P=0.010)、高白蛋白与纤维蛋白原比值(albumin to fibrinogen ratio,AFR)(P=0.018)与无复发生存期(recurrence-free survival,RFS)显著相关。多因素Cox回归分析结果显示,肿瘤残余(P=0.002)是肿瘤复发的独立相关危险因素,术后膀胱灌注BCG(P=0.001)和高AFR(P=0.017)是影响肿瘤复发的保护因素。结论:在高危NMIBC患者中,肿瘤残余与肿瘤高级别、合并卫星灶显著相关,合并卫星灶是影响首次电切后肿瘤残余的独立相关危险因素,推荐具有肿瘤残余高危因素(合并卫星灶)的患者接受re-TUR。术后膀胱灌注BCG、肿瘤残余、高AAPR、高AFR与接受re-TUR患者的疾病复发显著相关。其中,肿瘤残余是肿瘤复发的独立相关危险因素。术后膀胱灌注BCG和高AFR是影响肿瘤复发的保护因素。结合上述3个指标可预测re-TUR术后肿瘤的复发情况。接受了re-TUR的NMIBC患者若具有上述危险因素,建议进行更严密的术后复查,甚至早期的医疗干预。

Objective To investigate risk factors of residual tumor after first resection and recurrence after repeat transurethral resection in high-risk non-muscle-invasive bladder cancer(NMIBC)patients,and related risk factors were reported to provide more evidence for clinical repeat transurethral resection(re-TUR).Methods We retrospectively analysed the clinicopathological data of high-risk NMIBC patients admitted to our center from January 2020 to August 2023 who underwent transurethral resection of bladder tumor(TURBT)and underwent re-TUR within 2 to 6 weeks.The incidence of tumor residual after the first resection was analyzed.Logistic regression model was used to analyze the factors that might affect the tumor residual after the first resection.Cox regression model was used to analyze the risk factors that may affect tumor recurrence after re-TUR.Results A total of 171 patients were included in this study.After re-TUR,tumor residual was found in 65 cases(38.01%).The median follow-up time was 24.03(0.9,49.2)months.During the follow-up period,42 patients(24.56%)relapsed,of which the 1-year recurrence rate was 15.20%,and the 2-year recurrence rate was 23.98%,and 9 patients(5.26%)had disease progression.Univariate logistic regression analysis showed that tumor residual was significantly correlated with tumor grade(P=0.012)and satellite focus(P=0.022).Multivariate logistic regression analysis showed that combined satellite focus(P=0.024)was an independent risk factor for tumor residual.Univariate Cox regression analysis showed that postoperative bladder perfusion BCG(P=0.012),tumor residual(P=0.006),high albumin to alkaline phosphatase ratio(AAPR)(P=0.010)and high albumin to fibrinogen ratio(AFR)(P=0.018)were significantly associated with recurrence-free survival(RFS).Multivariate Cox regression analysis showed that tumor residual(P=0.002)was an independent risk factor for tumor recurrence,and postoperative bladder perfusion with BCG(P=0.001)and high AFR(P=0.017)were protective factors for tumor recurrence.Conclusion In high-risk NMIBC patients,tumor residual is significantly associated with tumor grade and combined satellite focus.Combined satellite focus is an independent risk factor for tumor residual after first resection.Patients with high risk factors for tumor residual(combined satellite focus)are recommended to receive re-TUR.Postoperative bladder perfusion with BCG,tumor residual,high AAPR,and high AFR were significantly associated with disease recurrence in patients receiving re-TUR.Tumor residue was an independent risk factor for tumor recurrence.BCG perfusion and high AFR were protective factors for tumor recurrence.The combination of the above three indexes can predict the recurrence of the tumor after re-TUR.In NMIBC patients who have received re-TUR and have these risk factors,more intensive postoperative review and even early medical intervention are recommended.