Larenks kanserli hastalarda prognostik faktörler ve serbest tümör implantlarının prognostik değeri
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Date
2015
Authors
Alpay, Melih
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Publisher
Uludağ Üniversitesi
Abstract
Larenks kanserlerinde prognozun tespitinde TNM sınıflaması kullanılmakla birlikte TNM dışında prognostik faktörler de mevcuttur. Bu çalışmanın amacı larenks kanserlerindeki bilinen prognostik faktörlerin öneminin belirlenmesi ve rutin olarak kullanılmayan serbest tümör implantlarının (STİ) prognostik öneminin ortaya konulmasıdır. Ocak 2007 ile Aralık 2013 tarihleri arasında yassı epitel hücreli (YEH) larenks kanseri tanısıyla primer cerrahi tedavi uygulanıp boyun diseksiyonu yapılan hastaların dosyaları retrospektif olarak tarandı. Hastaların demografik bilgileri, klinik ve patolojik prognostik faktörleri; ek tedavileri, takip süreleri, nüks/metastaz gelişimi ve son durumları kaydedildi. Diğer prognostik faktörlerin STİ ile ilişkileri ve prognostik faktörlerin tek değişkenli ve çok değişkenli modeller kullanılarak hastalıksız sağkalım ve genel sağkalım üzerindeki etkileri araştırıldı. Toplam 201 hastanın ortalama takip süresi 37,74±27,0 aydı. Lokorejyonel nüks toplam 24 (%11,9), uzak metastaz 13 (%6,5) hastada tespit edildi. Takip sırasında ölen 57 (%28,3) hastanın 30'u (%15,4) tümörden kaybedildi. STİ 15 (%7.5) hastada tespit edildi. STİ olan ve olmayan hastalar arasında klinik evre (p=0,015), klinik N sınıflaması (p<0,001), patolojik N sınıflaması (p<0,001) ve boyun diseksiyonu tipi (p<0,001) anlamlı değişkenler olarak görüldü. STİ olan vakalarda ekstrakapsüler yayılımın (EKY) (p=0,002), konglomere lenfadenopatinin (LAP) (p<0,001), perinöral invazyon (PNİ) (p=0,002) ve vasküler invazyonunun (Vİ) (p<0,001) daha sık olduğu görüldü. STİ bulunan hastalarda genel sağkalımın, STİ bulunmayanlara göre anlamlı derecede düşük olduğu görüldü. (p=0,004) Tek değişkenli analizde patolojik N evresi, PNİ, EKY, boyun diseksiyonu tipi, lokal nüksün ve uzak metastazın hastalığa özgü sağkalımda ve genel sağkalımda anlamlı değişikliğe neden olduğu görüldü. Konglomere LAP'nin genel sağkalımda anlamlı değişikliğe neden olduğu görüldü. Cerrahi sınırın ve sigaranın hastalığa özgü sağkalımda anlamlı değişikliğe neden olduğu görüldü. Çok değişkenli analiz yapıldığında hastalığa özgü sağkalımda STİ, EKY ve lokorejyonel nüks; genel sağkalımda ise sadece PNİ ve lokorejyonel nüks değişkenlerinin anlamlı değişiklik yaptıkları izlendi. Cox regresyon analizi ile STİ'nın hastalığa özgü sağkalımda ölüm riskini 4,6 kat ve EKY'ın ise ölüm riskini 3,3 kat arttırdığı görüldü. Cox regresyon analizinde perinöral invazyonun genel sağkalımda ölüm riskini 2,3 kat arttırdığı görüldü. Larenks kanserlerinde STİ hastalığa bağlı ölüm riskini 4,6 kat arttıran bağımsız bir prognostik faktör olarak bulunmuştur. STİ dışında EKY, PNİ gibi faktörler de TNM evrelemesinde kullanılmayan bağımsız prognostik faktörler olarak ortaya konulmuştur. Larenks kanserlerinin boyun spesimenlerinin incelenmesinde STİ rutin olarak değerlendirilmelidir. STİ'nın larenks kanseri tedavi algoritmalarında dikkate alınması gerektiğini ancak bu konunun daha iyi anlaşılması için prospektif çalışmalara ihtiyaç olduğunu düşünmekteyiz.
TNM classification is used in determination of prognosis of larynx cancers but there are other prognostic factors also. The aim of this study was to determine the significance of known prognostic factors in larynx cancers and reveal the prognostic value of free tumor implants (FTI) which are not surveyed routinely. A retrospective chart review was performed to identify patients who were treated surgically and underwent neck dissection as the primary treatment with the diagnosis of laryngeal squamous cell carcinoma between January 2007 and December 2013. The demographic data, clinical and pathological prognostic factors, adjuvant treatments, follow up durations, development of recurrence/metastasis and final outcomes of the patients were recorded. Relationships between FTI and other prognostic factors, and the influence of prognostic factors on disease free and overall survival rates were investigated by using univariate and multivariate analysis. Mean follow up duration of 201 patients was 37.74±26.98 months. Twenty-four (11.9%) patients had loco-regional recurrence and 13 (6.5%) had developed distant metastasis. Thirty (15.4%) of 57 patients (28.3%) who died during follow up were related to tumor. FTI was identified in 15 (7.5%) patients. Clinical stage (p=0.015), clinical N classification (p<0.001), pathological N classification (p<0.001) and type of neck dissection (p<0.001) were found to be significant variables between patients diagnosed with or without FTI. Cases with FTI had extra-capsular spread (ECS) (p=0.002), conglomerated lymphadenopathy (LAP) (p<0.001), perineural invasion (PNI) (p=0.002) and vascular invasion (VI) (p<0.001) more frequently. Overall survival of cases with FTI was found to be significantly shorter compared to patients without FTI. (p=0.004) In univariate analysis pathological N stage, PNI, ECS, type of neck dissection, local recurrence and distant metastasis were found to have significant effect on disease specific and overall survival. Conglomerated LAP caused significant difference on overall survival. Surgical margin and smoking were found to have significant effect to disease specific survival. When multivariate analysis was applied, FTI, ECS and loco-regional recurrence were found to have significant impact on disease specific survival whereas, only PNI and loco-regional recurrence were important for overall survival. Cox regression analysis of disease specific survival revealed that, FTI and ECS increased the mortality 4.6 and 3.3 times respectively. PNI increased mortality 2.3 times Cox regression analysis of overall survival. FTI was found as an independent prognostic factor which increased mortality rate 4.6 times in disease specific survival in larynx cancer. Beside the FTI; factors like ECS and PNI, which are not employed in TNM classification, have been demonstrated as independent prognostic factors. FTI should be assessed routinely in examination of neck specimens in larynx cancers. We concluded that FTI should be taken into consideration in treatment algorithms of larynx cancer however; further prospective studies are necessary for better realization of the subject.
TNM classification is used in determination of prognosis of larynx cancers but there are other prognostic factors also. The aim of this study was to determine the significance of known prognostic factors in larynx cancers and reveal the prognostic value of free tumor implants (FTI) which are not surveyed routinely. A retrospective chart review was performed to identify patients who were treated surgically and underwent neck dissection as the primary treatment with the diagnosis of laryngeal squamous cell carcinoma between January 2007 and December 2013. The demographic data, clinical and pathological prognostic factors, adjuvant treatments, follow up durations, development of recurrence/metastasis and final outcomes of the patients were recorded. Relationships between FTI and other prognostic factors, and the influence of prognostic factors on disease free and overall survival rates were investigated by using univariate and multivariate analysis. Mean follow up duration of 201 patients was 37.74±26.98 months. Twenty-four (11.9%) patients had loco-regional recurrence and 13 (6.5%) had developed distant metastasis. Thirty (15.4%) of 57 patients (28.3%) who died during follow up were related to tumor. FTI was identified in 15 (7.5%) patients. Clinical stage (p=0.015), clinical N classification (p<0.001), pathological N classification (p<0.001) and type of neck dissection (p<0.001) were found to be significant variables between patients diagnosed with or without FTI. Cases with FTI had extra-capsular spread (ECS) (p=0.002), conglomerated lymphadenopathy (LAP) (p<0.001), perineural invasion (PNI) (p=0.002) and vascular invasion (VI) (p<0.001) more frequently. Overall survival of cases with FTI was found to be significantly shorter compared to patients without FTI. (p=0.004) In univariate analysis pathological N stage, PNI, ECS, type of neck dissection, local recurrence and distant metastasis were found to have significant effect on disease specific and overall survival. Conglomerated LAP caused significant difference on overall survival. Surgical margin and smoking were found to have significant effect to disease specific survival. When multivariate analysis was applied, FTI, ECS and loco-regional recurrence were found to have significant impact on disease specific survival whereas, only PNI and loco-regional recurrence were important for overall survival. Cox regression analysis of disease specific survival revealed that, FTI and ECS increased the mortality 4.6 and 3.3 times respectively. PNI increased mortality 2.3 times Cox regression analysis of overall survival. FTI was found as an independent prognostic factor which increased mortality rate 4.6 times in disease specific survival in larynx cancer. Beside the FTI; factors like ECS and PNI, which are not employed in TNM classification, have been demonstrated as independent prognostic factors. FTI should be assessed routinely in examination of neck specimens in larynx cancers. We concluded that FTI should be taken into consideration in treatment algorithms of larynx cancer however; further prospective studies are necessary for better realization of the subject.
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Keywords
Serbest tümör implantı, Larenks, Yassı epitel hücreli karsinom, Prognostik faktör, Free tumor implant, Larynx, Squamous cell carcinoma, Prognostic factor
Citation
Alpay, M. (2015). Larenks kanserli hastalarda prognostik faktörler ve serbest tümör implantlarının prognostik değeri. Yayınlanmamış uzmanlık tezi. Uludağ Üniversitesi Tıp Fakültesi.