老年營養風險因子與上泌尿道泌尿上皮癌之預後分析

泌尿上皮惡癌 (Urothelial cell carcinoma, UCC) 是泌尿系統常見之惡性腫瘤之一。上泌尿道上皮癌相較於膀胱泌尿上皮癌罕見，但臺灣的上泌尿道上皮癌患者相較其他國家佔了整體泌尿上皮癌比例相對較多。營養不良常為癌症患者面臨的問題，且影響患者的預後以及生活品質。本研究旨探討在老年營養風險因子(geriatric nutritional risk index, GNRI)用於評估上泌尿上皮癌(upper tract urothelial cell carcinoma, UTUC)經腎臟輸尿管切除術之預後。本研究收錄自2001年1月至2015年12月，共488位於臺中榮民總醫院接受腎臟輸尿管切除術之上泌尿上皮癌病患。在接受腎臟輸尿管切除術前，使用血液中蛋白(serum albumin)以及身體質量指數(body mass index)計算老年營養風險因子。使用Kaplan–Meier analyses以及Cox proportional hazards models 分析無疾病存活率(disease-free survival, DFS)，特定癌症死亡存活率(cancer specific survival, CSS)以及整體存活率(overall survival, OS)。共386位病患為正常營養狀態(geriatric nutritional risk index ? 92)，而102位病患為營養不良(geriatric nutritional risk index < 92)。本研究使用receiver operating characteristic (ROC) 曲線評估老年營養風險因子與整體存活之相關連性，其area under the curve (AUC)為0.69。5年的無疾病存活率、特定癌症死亡存活率以及整體存活率在正常營養狀態之組別分別為48.6%、80.5%以及80.5%；而在營養不良之組別分別為28.0%、53.2%以及40%。經多變相分析後營養不良為影響整體存活率之獨立風險因子 (hazard ratio [HR] = 3.94, 95% confidence interval [CI] 2.70–5.74)，此外年齡 (HR = 1.04, 95% CI 1.02–1.06)、手術邊緣腫瘤陽性(HR = 1.78, 95% CI 1.13–2.82)、病理期別T3 (HR = 2.54, 95% CI 1.53–4.21)、病理期別T4 (HR = 6.75, 95% CI 3.17–14.37) 以及腫瘤淋巴血管侵犯 (HR = 1.81, 95% CI 1.16–2.81)皆為影響整體存活率之獨立風險因子。此外，老年營養風險因子也是影響無疾病存活率(HR = 1.90, 95% CI 1.42–2.54)及特定癌症死亡存活率(HR = 5.42, 95% CI 3.24–9.06)之獨立風險因子。此為第一篇探討老年營養風險因子與上泌尿道上皮癌患者接受腎臟輸尿管切除手術後預後之相關聯性的研究，術前營養狀態不佳，即低的老年營養風險因子為影響上泌尿上皮癌病患經腎臟輸尿管切除術之無疾病存活率、特定癌症死亡存活率以及整體存活率之獨立風險因子。

Urothelial cell carcinoma (UCC) is one of the common malignant tumors of the urinary system. Upper tract urothelial carcinoma is relatively rare compared to bladder urothelial carcinoma, but in Taiwan, patients with upper tract urothelial carcinoma constitute a relatively higher proportion of overall urothelial carcinoma cases compared to other countries. Malnutrition is a frequent issue faced by cancer patients, impacting their prognosis and quality of life. The aim of this study is to examine the prognostic significance of the geriatric nutritional risk index (GNRI) among individuals diagnosed with upper tract urothelial cell carcinoma (UTUC) who undergo radical nephroureterectomy (RNU). From January 2001 to December 2015, a total of 488 patients diagnosed with UTUC underwent RNU at Taichung Veterans General Hospital. GNRI scores were computed prior to radical surgery utilizing serum albumin levels and body mass index. Malnutrition was categorized as GNRI < 92.0. Kaplan-Meier analyses and Cox proportional hazards models were employed to assess the impact of various risk factors on disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS). Out of 488 patients, 386 were identified as having normal nutritional status (GNRI ? 92), while 102 were categorized as malnourished (GNRI < 92). Utilizing receiver operating characteristic (ROC) curve analysis, we determined the association between GNRI and OS, yielding an area under the curve (AUC) of 0.69. The 5-year survival rates for DFS, CSS, and OS were 48.6%, 80.5%, and 80.5% respectively in the normal nutritional group, compared to 28.0%, 53.2%, and 40% respectively in the malnourished group. Through multivariate analysis, malnutrition emerged as an independent risk factor for OS (hazard ratio [HR] = 3.94, 95% confidence interval [CI] 2.70–5.74), alongside age (HR = 1.04, 95% CI 1.02–1.06), positive surgical margins (HR = 1.78, 95% CI 1.13–2.82), pathological T3 (HR = 2.54, 95% CI 1.53–4.21), pathological T4 (HR = 6.75, 95% CI 3.17–14.37), and lymphovascular invasion (HR = 1.81, 95% CI 1.16–2.81). Additionally, the GNRI index was identified as an independent risk factor for DFS (HR = 1.90, 95% CI 1.42–2.54) and CSS (HR = 5.42, 95% CI 3.24–9.06). This is the first study to explore the association between the Geriatric Nutritional Risk Index and the prognosis of patients with upper tract urothelial carcinoma following nephroureterectomy. Preoperative malnutrition, characterized by low GNRI, serves as an independent predictor for DFS, CSS, and OS in UTUC patients undergoing RNU.