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目的回顾性分析膀胱部分切除术(PC)结合放化疗治疗肌层浸润性膀胱癌(MIBC)的疗效。方法收集2002年1月—2007年12月MIBC患者136例,男108例,女28例,平均年龄为(65.9±12.1)岁。分入两组:PC组100例,其中T2期74例,T3期16例,T4期10例。根治性膀胱全切除术(RC)组36例,其中T2期12例,T3期20例,T4期4例。术后对PC组T3、T4期患者加行以顺铂为主的放化疗。随访3~66个月,平均随访时间为(33.1±1.2)个月。采用Kaplan-Meier法和log-rank检验比较两组的生存情况,多因素Cox回归模型分析与MIBC生存和复发相关的预后因素。采用欧洲癌症研究与治疗组织(EORTC)的生存质量测定量表(QLQ-C30)和MIBC生存质量测定量表(QLQ-BLM30)评估患者的生存质量。结果 MIBC患者5年肿瘤特异性生存率为64.7%(88/136),其中PC组为68.0%(68/100),显著高于RC组的55.6%(20/36,P<0.05)。PC组术后发生局部复发60例(60.0%),其中非MIBC复发46例(76.7%,46/60),MIBC复发14例(23.3%,14/60);术后16个月内发生局部复发75.0%(45/60)。Cox回归分析显示,肿瘤数量>3个(RR=2.718,95%CI为1.455~5.079,P=0.002)和浸润性的生长方式(RR=4.537,95%CI为1.573~13.081,P=0.005)是膀胱癌局部复发的独立预后因素。多因素分析显示,肿瘤数量>3个(RR=4.109,95%CI为1.676~10.072,P=0.002),脉管侵袭(RR=6.089,95%CI为2.038~18.246,P=0.001)和PC加输尿管再植术(RR=0.129,95%CI为0.027~0.627,P=0.011)是保留膀胱手术治疗MIBC后肿瘤特异性生存相关的独立预后指标,其中PC加输尿管再植是术后患者生存的保护因素。与MIBC生存相关的独立因素包括脉管侵袭(RR=4.176,95%CI为2.152~8.105,P=0.000)、肿瘤数量>3个(RR=3.610,95%CI为1.887~6.906,P=0.000)、有膀胱肿瘤病史(RR=2.714,95%CI为1.400~5.263,P=0.003)和高龄(>70岁,RR=2.609,95%CI1.440~4.729,P=0.002)。PC组的躯体功能和社会功能评分均显著高于RC组(P值分别<0.05、0.01),且经济困难、疲劳、失眠和体象障碍评分均显著低于RC组(P值分别<0.01、0.05)。结论 PC结合放化疗是治疗MIBC的有效方法,患者可获得与RC相似甚至更高的生存率和更好的生存质量。肿瘤数量>3个的患者不宜行保留膀胱的手术。
Objective To retrospectively analyze the curative effect of partial mastectomy (PC) combined with chemoradiotherapy in the treatment of muscular layer invasive bladder cancer (MIBC). Methods One hundred and sixty-six MIBC patients from January 2002 to December 2007 were collected, including 108 males and 28 females, with an average age of (65.9 ± 12.1) years. Divided into two groups: PC group of 100 cases, of which 74 cases of T2, T3 in 16 cases, T4 in 10 cases. There were 36 cases of radical cystectomy (RC), including 12 cases of T2, 20 cases of T3 and 4 cases of T4. Postoperative PC group T3, T4 patients with cisplatin-based chemoradiation. The patients were followed up for 3 to 66 months with an average follow-up of (33.1 ± 1.2) months. Kaplan-Meier method and log-rank test were used to compare the survival of the two groups. Multivariate Cox regression model was used to analyze the prognostic factors associated with MIBC survival and recurrence. The quality of life of the patients was assessed using the Quality of Life Measurements Scale (QLQ-C30) and the MIBC Quality of Life Scale (QLQ-BLM30) of the European Organization for Research and Treatment of Cancer (EORTC). Results The 5-year tumor-specific survival rate was 64.7% (88/136) in MIBC patients, 68.0% (68/100) in PC group and 55.6% (20/36, P <0.05) in RC group. There were 46 cases (76.7%, 46/60) of non-MIBC recurrence and 14 cases (23.3%, 14/60) of MIBC recurrence in PC group. The local recurrence occurred in 16 months after operation Recurrent 75.0% (45/60). Cox regression analysis showed that the number of tumors> 3 (RR = 2.718, 95% CI 1.455-5.079, P = 0.002) and invasive growth patterns (RR = 4.537, 95% CI 1.573-13.081, P = 0.005) Bladder cancer is an independent prognostic factor for local recurrence. Multivariate analysis showed that the number of tumors was> 3 (RR = 4.109, 95% CI 1.676-10,072, P = 0.002), vessel invasion (RR = 6.089, 95% CI 2.038-18.246, P = 0.001) Plus ureteral replantation (RR = 0.129, 95% CI 0.027-0.627, P = 0.011) was an independent prognostic indicator of tumor-specific survival after bladder surgery for MIBC, with PC plus ureteral replantation being postoperative survival Protection factor. Independent factors associated with MIBC survival included vascular invasion (RR = 4.176, 95% CI 2.152-8.105, P = 0.000) and tumor numbers> 3 (RR = 3.610, 95% CI 1.887-6.906, P = 0.000 ) Had a history of bladder cancer (RR = 2.714, 95% CI 1.400-5.263, P = 0.003) and advanced age (> 70 years, RR = 2.609, 95% CI 1.440-4.729, P = 0.002). The scores of physical function and social function in PC group were significantly higher than those in RC group (P <0.05, 0.01 respectively), and the scores of economic difficulties, fatigue, insomnia and dyskinesia were significantly lower than those in RC group (P < 0.05). Conclusions PC combined with chemoradiotherapy is an effective method for the treatment of MIBC. Patients can get similar or even higher survival rate and better quality of life than RC. Patients with> 3 neoplasms should not undergo bladder surgery.