消化管切除 vs 临床完整响应者在新辅助化学辐射治疗后的积极监测
Adom Bondzi-Simpson1,2, Vaibhav Gupta3,4, Tiago Ribeiro1,2
1Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
JAMA surgery
|January 21, 2026
概括
积极监测在新辅助化学辐射治疗 (nCRT) 后为食道癌患者提供短期生活质量益处. 然而,食管切除仍然是最大化长期生存和质量调整寿命 (QALYs) 的首选策略.
科学领域:
- 在瘤学瘤学.
- 手术瘤学手术瘤学
- 临床决策 临床决策
背景情况:
- 胃管癌手术 (SANO) 试验确立了积极监测,作为胃管切除术的可行替代方案,用于胃管癌患者,这些患者在经过新辅助化学辐射 (nCRT) 后获得了临床完整反应 (cCR).
- 与食道切除相比,器官保存策略对复发风险,长期存活率和生活质量 (QOL) 的影响仍然存在持久的担忧.
研究的目的:
- 在经过nCRT后获得cCR的食道癌患者中进行积极监测与标准食道切除术的长期比较有效性分析.
- 利用SANO试验的最新数据,为评估这些治疗策略的决策分析模型提供信息.
主要方法:
- 采用了马尔科夫决策模型,结合了来自SANO试验和现有文献的概率和实用输入.
- 基准病例模拟了一个60岁的男性,患有局部晚期食道癌 (cT3N1M0),在nCRT后实现cCR,比较标准食道切除与主动监测.
- 主要结局包括质量调整寿命年 (QALYs) 和寿命年 (LYs),敏感性分析探索食道切除术的复发概率和QOL影响.
主要成果:
- 在5年的时间里,标准食道切除术导致QALY (1.74对1.34) 和LYs (3.11对2.41) 与主动监测相比更高.
- 在两年时间里,积极监测显示QALY的偏好,与SANO试验的结果一致.
- 敏感性分析表明,当复发概率<43%,局部复发概率>94%或食道切除术的QOL影响显著时,积极监测是有利的.
结论:
- 虽然积极的监测提供了短期的QOL优势,可能适合特定患者 (复发风险低,手术风险高),但食管切除术对于最大限度地提高长期存活率和QALYs.
- 这些发现提倡对nCRT后管理采取个性化的方法,平衡器官保存与瘤结果.
- 消化管切除术的长期QOL益处在被建模为时间变化的共变量时更为明显.
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