胸段食管癌选择性隆突下淋巴结清扫术的探讨

目的 本研究拟探讨胸段食管癌是否需要常规进行隆突下淋巴结清扫.方法 回顾性分析2000年1月至2004年12月中山大学肿瘤防治中心连续收治676例胸段食管癌患者的隆突下淋巴结的转移状态与临床病理因素的关系,进一步比较分析有或无清扫隆突下淋巴结对围术期并发症、术后生存期的影响.结果 全组676例,其中492例有清扫隆突下淋巴结,其转移率为10.4%;胸上、中、下段食管癌隆突下淋巴结转移率分别为0%、13.2%、6.8%,P=0.001;Tis、T1、T2、T3和T4的降突下淋巴结转移率分别为0%、0%、6.5%、13.3%和28.6%,P=0.008;有隆突下淋巴结转移者均伴有区域淋巴结转移,无单独隆突下淋巴结转移者.清扫与未清扫隆突下淋巴结的术后并发症总发生率分别为36.8%、26.6%,P=0.013,其中肺部并发症的发生率分别为22.2%、14.1%,P=0.020.生存分析显示:N0患者中,隆突下淋巴结未清扫组与清扫组的5年生存率分别为50.9%、62.8%,P=0.083;N1患者中,隆突下淋巴结未清扫组与清扫组的5年生存率分别为14.7%、29.3%,P=0.112;隆突下淋巴结阳性者与阴性者的5年生存率分别为22.6%、31.7%,P=0.142.结论 局部早期及胸上段食管癌可以不常规实施隆突下淋巴结清扫术;胸中、下段食管癌局部侵犯明显,应进行隆突下淋巴结清扫术.

Significance of subcarinal lymph node selective dissection in thoracic esophageal carcinoma

Objective Surgical resection remains the cornerstone of treatment for esophageal carcinoma. Mediastinal lymphadenectomy including subcarinal nodes has always been considered to be a reasonable extent, because of close anatomical relationship between subcarinal nodes and tracheobronchial tree. Metastatic involvement of subcarinal nodes alone is rare in esophageal carcinoma. In view of special anatomical features of subcarinal lymph nodes, it is worth exploring and discussing whether or not subcarinal lymph nodes dissection shall be routinely performed for thoracic esophageal carcinoma. Methods The data from a cohort of 676 patients with thoracic esophagus carcinoma who underwent esophagectomy with lymphadenectomy were analyzed retrospectively with respect to the impact of subcarinal lymph nodes dissection or non-dissection on the incidence of postoperative complications and patient survival. Results The rate of subcarinal lymph nodes metastasis was 10. 4%. The metastasis rates in upper, middle and lower esophageal carcinoma were 0%, 13.2% and 6. 8% respectively ( P =0. 001 ); for Tis, T1, T2, T3 and T4, they were 0%, 0%, 6. 5%, 13.3% and 28. 6% respectively ( P = 0. 008 ). The overall incidence of postoperative complications with and without subcarinal lymph nodes dissection was 36. 8% versus 26. 6%( P = 0. 013 ). And the incidence of pulmonary complications were 22. 2% versus 14. 1% ( P = 0. 020 ).Survival analysis showed that: the 5-year survival rates were 50. 9% versus 62. 8% in the groups A and B of NO patients ( P =0. 083 ); 14. 7% versus 29. 3% in N1 patients ( P =0. 112). In the group with metastasis of subcarinal lymph nodes, the 5-year survival rate was 22. 6% versus 31.7% in those without metastasis (P = 0. 142 ). Conclusion It may be unnecessary to dissect the subcarinal lymph nodes routinely for upper thoracic esophageal carcinoma. Elective subcarinal lymph nodes dissection can be planned for middle,lower, T3 or T4 thoracic esophageal carcinoma, or highly suspected subcarinal metastasis based on radiological imaging.