TCBI在中老年胸段食管鳞状细胞癌放疗患者中的预后评估价值

doi:10.3760/cma.j.cn371439-20191210-00003

摘要/Abstract

摘要：

目的探究TCBI对接受放疗的中老年胸段食管鳞状细胞癌(ESCC)患者的预后价值。方法回顾性分析2010年1月至2015年12月于苏州大学附属第一医院肿瘤放疗科接受治疗的191例胸段ESCC患者的临床资料,根据入院时TCBI值[TCBI=血清甘油三酯(mg/dl)×总胆固醇(mg/dl)×体重(kg)/1 000]将患者分为TCBI低值组(n=79)和TCBI高值组(n=112)。分析TCBI与患者临床病理特征之间的关系。采用Kaplan-Meier法计算总生存期(OS),log-rank检验比较不同组别的生存差异,Cox比例风险模型分析影响中老年胸段ESCC患者放疗预后的因素,采用受试者工作特征(ROC)曲线验证TCBI在预后评估中的价值。结果所有患者治疗前的TCBI为1 082±945。TCBI的临界值为749,<749为TCBI低值组;≥749为TCBI高值组。TCBI与患者的治疗方式(χ ²=4.235,P=0.040)和老年营养风险指数(GNRI,χ ²=8.795,P=0.003)相关。单因素分析结果提示,男性(HR=2.220,95%CI为1.223~4.030,P=0.009)、N_1-3期(HR=1.453,95%CI为1.023~2.065,P=0.037)、GNRI<98(HR=1.949,95%CI为1.168~3.255,P=0.011)、TCBI<749(HR=1.846,95%CI为1.298~2.627,P=0.001)是影响中老年胸段ESCC患者OS的危险因素,术后辅助放疗(HR=0.641,95%CI为0.449~0.915,P=0.014)是其保护因素。多因素分析结果提示,男性(HR=2.147,95%CI为1.173~3.929,P=0.013)、TCBI<749(HR=1.664,95%CI为1.166~2.376,P=0.005)是影响中老年胸段ESCC患者OS的独立危险因素,术后辅助放疗(HR=0.630,95%CI为0.439~0.903,P=0.012)是其独立保护因素。ROC曲线计算得到曲线下面积为0.619,敏感性为0.742,特异性为0.496(P=0.007),肯定了TCBI在预后评估中的作用。生存分析结果显示,TCBI高值组患者中位OS为42个月,1年和3年生存率分别为86.6%、52.7%,明显好于TCBI低值组(中位OS为20个月,1年生存率68.4%,3年生存率29.1%;χ ²=12.286,P<0.001)。亚组分析结果显示,接受根治性放疗的患者中,TCBI低值的患者(n=37)3年生存率低于TCBI高值的患者(n=36)(21.6% vs. 44.4%,χ ²=8.505,P=0.004)。结论治疗前TCBI是中老年胸段ESCC患者放疗后OS的预测指标,TCBI越低,患者生存预后越差。

关键词: 食管肿瘤, 营养不良, 预后

Abstract:

Objective To investigate the prognostic value of TCBI in middle-aged and elderly patients with thoracic esophageal squamous cell carcinoma (ESCC) who received radiotherapy. Methods The clinical data of 191 patients with thoracic ESCC who underwent radiotherapy in the department of Radiation Oncology of the First Affiliated Hospital of Soochow University from January 2010 to December 2015 were retrospectively analyzed. According to the TCBI value on admission [TCBI=serum triglyceride (mg/dl) × total cholesterol (mg/dl) × body weight (kg)/1 000], patients were divided into TCBI low-value group (n=79) and TCBI high-value group (n=112). The relationships between TCBI and clinicopathological characteristics of patients were analyzed. The Kaplan-Meier method was used to calculate the overall survival (OS). The log-rank test was adopted to compare the differences in survival between different groups. The Cox proportional hazard model was used to analyze the factors affecting the prognosis of middle-aged and elderly patients with thoracic ESCC. The receiver operating characteristics (ROC) curve was applied to verify the accuracy of TCBI for survival prediction. Results The mean pre-radiotherapy TCBI was 1 082±945 in all patients. The cutoff value of the TCBI was 749. The patients with TCBI<749 served as the TCBI low-value group , and patients with TCBI≥749 served as the TCBI high-value group. TCBI was associated with treatment (χ ²=4.235, P=0.040) and geriatric nutritional risk index (GNRI, χ ²=8.795, P=0.003). Univariate analysis suggested that male (HR=2.220, 95%CI: 1.223-4.030, P=0.009), stage N_1-3 (HR=1.453, 95%CI: 1.023-2.065, P=0.037), GNRI<98 (HR=1.949, 95%CI: 1.168-3.255, P=0.011) and TCBI<749 (HR=1.846, 95% CI: 1.298-2.627, P=0.001) were risk factors affecting OS in middle-aged and elderly patients with thoracic ESCC. Besides, postoperative adjuvant radiotherapy (HR=0.641, 95%CI: 0.449-0.915, P=0.014) was a protective factor. Furthermore, multivariate analysis showed that male (HR=2.147, 95%CI: 1.173-3.929, P=0.013) and TCBI<749 (HR=1.664, 95%CI: 1.166-2.376, P=0.005) were independent risk factors for OS. Besides, postoperative adjuvant radiotherapy (HR=0.630, 95%CI: 0.439-0.903, P=0.012) was an independent protective factor. The area under the curve calculated by the ROC curve was 0.619, the sensitivity was 0.742, and the specificity was 0.496 (P=0.007), confirming the role of TCBI in the prognostic evaluation. Survival analysis showed that the median OS of patients in the TCBI high-value group was 42 months, and the 1-year and 3-year survival rates were 86.6% and 52.7%, significantly higher than those in the TCBI low-value group (20 months, 68.4% and 29.1% respectively; χ ²=12.286, P<0.001). Subgroup analysis showed that among patients with radical radiotherapy, 3-year survival rate in patients with lower TCBI (n=37) was lower than that in patients with higher values (n=36) (21.6% vs. 44.4%, χ ²=8.505, P=0.004). Conclusion TCBI is a predictor of OS for middle-aged and elderly patients with thoracic ESCC who received radiotherapy. The lower the TCBI, the poorer the survival prognosis.

Key words: Esophageal neoplasms, Malnutrition, Prognosis

蒋婷婷, 徐晓婷, 秦颂兵, 马辰莺, 周菊英. TCBI在中老年胸段食管鳞状细胞癌放疗患者中的预后评估价值[J]. 国际肿瘤学杂志, 2020, 47(4): 205-210.

Jiang Tingting, Xu Xiaoting, Qin Songbing, Ma Chenying, Zhou Juying. Prognostic value of TCBI in middle-aged and elderly patients with thoracic esophageal squamous cell carcinoma receiving radiotherapy[J]. Journal of International Oncology, 2020, 47(4): 205-210.

图/表 6

表1

表2

表3

图1

图2

图3

参考文献 20

[1]	Guo XW, Liu YC, Gao F , et al. Pretreatment NRS-2002 scores combined with hematologic inflammation markers are independent prognostic factors in patients with resectable thoracic esophageal squamous cell carcinoma[J]. Cancer Manag Res, 2018,10:2409-2418. DOI: 10.2147/cmar.s167179. doi: 10.2147/CMAR
[2]	Mariette C, De Botton ML, Piessen G . Surgery in esophageal and gastric cancer patients: what is the role for nutrition support in your daily practice?[J]. Ann Surg Oncol, 2012,19(7):2128-2134. DOI: 10.1245/s10434-012-2225-6. doi: 10.1245/s10434-012-2225-6
[3]	Toyokawa T, Kubo N, Tamura T , et al. The pretreatment Controlling Nutritional Status (CONUT) score is an independent prognostic factor in patients with resectable thoracic esophageal squamous cell carcinoma: results from a retrospective study[J]. BMC Cancer, 2016,16:722. DOI: 10.1186/s12885-016-2696-0. doi: 10.1186/s12885-016-2696-0
[4]	Wu N, Chen G, Hu H , et al. Low pretherapeutic serum albumin as a risk factor for poor outcome in esophageal squamous cell carcinomas[J]. Nutr Cancer, 2015,67(3):481-485. DOI: 10.1080/01635581.2015.1004726. doi: 10.1080/01635581.2015.1004726
[5]	Watanabe M, Ishimoto T, Baba Y , et al. Prognostic impact of body mass index in patients with squamous cell carcinoma of the esophagus[J]. Ann Surg Oncol, 2013,20(12):3984-3991. DOI: 10.1245/s10434-013-3073-8. doi: 10.1245/s10434-013-3073-8
[6]	Doi S, Iwata H, Wada H , et al. A novel and simply calculated nutritional index serves as a useful prognostic indicator in patients with coronary artery disease[J]. Int J Cardiol, 2018,262:92-98. DOI: 10.1016/j.ijcard.2018.02.039. doi: 10.1016/j.ijcard.2018.02.039
[7]	Donohoe CL, Phillips AW . Cancer of the esophagus and esophagogastric junction: an 8th edition staging primer[J]. J Thorac Dis, 2017,9(3):E282-E284. DOI: 10.21037/jtd.2017.03.39. doi: 10.21037/jtd
[8]	Bouillanne O, Morineau G, Dupont C , et al. Geriatric nutritional risk index: a new index for evaluating at-risk elderly medical patients[J]. Am J Clin Nutr, 2005,82(4):777-783. DOI: 10.1093/ajcn/82.4.777. doi: 10.1093/ajcn/82.4.777
[9]	Shoji F, Miura N, Matsubara T , et al. Prognostic significance of immune-nutritional parameters for surgically resected elderly lung cancer patients: a multicentre retrospective study[J]. Interact Cardiovasc Thorac Surg, 2018,26(3):389-394. DOI: 10.1093/icvts/ivx337. doi: 10.1093/icvts/ivx337
[10]	Kushiyama S, Sakurai K, Kubo N , et al. The preoperative geriatric nutritional risk index predicts postoperative complications in elderly patients with gastric cancer undergoing gastrectomy[J]. In Vivo, 2018,32(6):1667-1672. DOI: 10.21873/invivo.11430. doi: 10.21873/invivo.11430
[11]	Dewys WD, Begg C, Lavin PT , et al. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group[J]. Am J Med, 1980,69(4):491-497. DOI: 10.1016/s0149-2918(05)80001-3. doi: 10.1016/S0149-2918(05)80001-3
[12]	Luo H, Yang H, Huang B , et al. Geriatric nutritional risk index (GNRI) independently predicts amputation inchronic criticallimb ischemia (CLI)[J]. PLoS One, 2016,11(3):e0152111. DOI: 10.1371/journal.pone.0152111. doi: 10.1371/journal.pone.0152111
[13]	Wada H, Dohi T, Miyauchi K , et al. Prognostic impact of the geriatric nutritional risk index on long-term outcomes in patients who underwent percutaneous coronary intervention[J]. Am J Cardiol, 2017,119(11):1740-1745. DOI: 10.1016/j.amjcard.2017.02.051. doi: 10.1016/j.amjcard.2017.02.051
[14]	Migita K, Takayama T, Saeki K , et al. The prognostic nutritional index predicts long-term outcomes of gastric cancer patients independent of tumor stage[J]. Ann Surg Oncol, 2013,20(8):2647-2654. DOI: 10.1245/s10434-013-2926-5. doi: 10.1245/s10434-013-2926-5
[15]	Migita K, Takayama T, Matsumoto S , et al. Impact of being underweight on the long-term outcomes of patients with gastric cancer[J]. Gastric Cancer, 2016,19(3):735-743. DOI: 10.1007/s10120-015-0531-y. doi: 10.1007/s10120-015-0531-y
[16]	Nugent B, Lewis S, O'Sullivan JM. Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy[J]. Cochrane Data-base Syst Rev, 2013, (1): CD007904. DOI: 10.1002/14651858.CD007904.pub3.
[17]	石汉平 . 肿瘤是一种代谢性疾病[J]. 肿瘤代谢与营养电子杂志, 2018,5(2):111-116. DOI: 10.16689/j.cnki.cn11-9349/r.2018.02.001.
[18]	Haverkort EB, Binnekade JM, de Haan RJ, et al. Suboptimal intake of nutrients after esophagectomy with gastric tube reconstruction[J]. J Acad Nutr Diet, 2012,112(7):1080-1087. DOI: 10.1016/j.jand.2012.03.032. doi: 10.1016/j.jand.2012.03.032
[19]	Lester SC, Lin SH, Chuong M , et al. A multi-institutional analysis of trimodality therapy for esophageal cancer in elderly patients[J]. Int J Radiat Oncol Biol Phys, 2017,98(4):820-828. DOI: 10.1016/j.ijrobp.2017.02.021. doi: 10.1016/j.ijrobp.2017.02.021
[20]	Guttmann DM, Mitra N, Metz JM , et al. Neoadjuvant chemoradiation is associated with improved overall survival in older patients with esophageal cancer[J]. J Geriatr Oncol, 2018,9(1):40-46. DOI: 10.1016/j.jgo.2017.08.010. doi: 10.1016/j.jgo.2017.08.010

因素	HR值	95%CI	P值
年龄(岁)
<65	1
≥65	1.014	0.991~1.037	0.228
性别
女	1
男	2.220	1.223~4.030	0.009
高血压
否	1
是	0.802	0.548~1.175	0.258
糖尿病
否	1
是	0.976	0.592~2.074	0.749
治疗方式
根治性放疗	1
术后辅助放疗	0.641	0.449~0.915	0.014
T分期
T_1-2	1
T_3-4	1.032	0.726~1.468	0.860
N分期
N₀	1
N_1-3	1.453	1.023~2.065	0.037
肿瘤位置
上中段(距门齿20~30 cm)	1
下段(距门齿30~40 cm)	0.840	0.591~1.592	0.329
GNRI
≥98	1
<98	1.949	1.168~3.255	0.011
TCBI
≥749	1
<749	1.846	1.298~2.627	0.001