食管癌淋巴结清扫术的沿革

对食管癌进行系统性的淋巴结清扫有助于提高手术切除的根治率和手术病理分期的准确性,改善外科治疗的长期效果,但也存在手术并发症增高的风险和对术后生活质量的影响.通过科学的临床研究合理选择清扫范围、在保证手术彻底性的同时减少淋巴结清扫的负面影响是进一步改进疗效的关键.     

40岁以下青年食管癌的外科治疗与预后分析

目的 探讨青年食管癌的外科治疗效果及影响其预后的因素.方法 回顾性分析36例40岁以下青年食管癌的临床资料.全组患者均经手术治疗,其中经左胸30例,经右胸6例.结果 总的3、5年生存率分别为32.1%和23.0%.单因素分析显示肿瘤T分期、淋巴结转移状况、病变长度、手术性质、TNM分期为影响预后的主要因素;而多因素分析显示肿瘤T分期、淋巴结转移是影响预后最重要的独立因素.结论 青年食管癌临床分期较晚,根治性手术切除率较低,应加强早诊治意识;肿瘤T分期、淋巴结转移是影响预后的最重要因素.     

食管癌分期与治疗的共识、争议和建议

目前食管癌的治疗模式仍是以外科为主的综合治疗.但到目前为止,仍在食管癌分期、手术治疗模式选择、手术入路选择、淋巴结清扫方式、术前和术后辅助治疗等方面存在较多争议,本文在复习大量国内外临床研究文献之后,对上述各问题不同观点进行了总结和评述,依据目前的临床循证医学证据形成了一些共识,并对仍有争议之处提出了未来需要进一步研究的相关建议.     

《中国肿瘤临床》2016年第12期“食管癌专栏”

我国是世界上食管癌高发地区之一,该病以中老年患者为主,长期缓解率、远期生存率并不乐观。目前食管癌治疗模式已从单一的外科手术转变为在规范化手术基础上合理应用围术期放、化疗等综合治疗模式。食管癌的术前准确分期、手术方式、淋巴结清扫范围和消化道重建方式尚有很多问题存在争议。我国食管癌诊疗需要结合国情,参考国际指南,开辟一条更经济实用且合理的道路。《中国肿瘤临床》2016年第12期由天津医科大学肿瘤医院食管肿瘤科主任于振涛教授牵头,推出“食管癌专栏”,特邀我国食管癌领域多位专家学者撰稿,发布食管癌发病相关数据、临床和基础研究进展及诊疗策略。希望通过本专栏为食管外科、放疗及病理等专业人员提供更完善、更便利的交流平台,推动我国食管癌研究成果的临床转化,造福广大患者。     

生活质量评价在食管癌外科治疗中的应用

生活质量(QOL)是健康和病情变化的评价指标,能全面地反应食管癌的治疗效果.有研究表明QOL评价为食管癌外科治疗的手术方式、淋巴结清扫、消化道重建等方面提供了新的选择.QOL评价的深入研究运用,将进一步提高外科治疗效果,改善食管癌患者的QOL.     

浙江省肿瘤医院2012~2016年食管癌手术病例临床病理特征分析

[目的]探讨杭州市及其周边地区食管癌患者发病特点和临床病理特征.[方法]收集浙江省肿瘤医院2012年1月至2016年6月所有在胸外科手术治疗的原发食管癌患者1690例,进一步搜集患者的临床病理信息,用SPSS软件进行统计分析.[结果]1690例食管癌,男性1455例,女性235例,平均手术年龄(61.46±7.62)岁.食管癌手术病例最常见的发病部位是下段,其次中段.食管癌手术患者的年龄与分期具有明显的关联(x2=48.820,P=0.009),呈现低年龄组比高年龄组病理分期较晚的趋势,且早诊早治患者的比例不断增多.[结论]食管癌手术患者中最常见的发病部位是下段;发病年龄较早的患者分期更晚;食管癌手术患者的早期诊治比例日益增多.     

序贯三切口及选择性淋巴结清扫治疗食管癌1162例临床效果分析

目的 探讨食管癌外科治疗的手术方式、淋巴结清扫范围、术后综合治疗模式.方法 对1998年1月至2007年12月间收治的不同部位的食管癌1162例采用序贯的腹、胸、颈三切口的手术径路行食管肿瘤切除,应用术前影像、超声定位下穿刺细胞学检查和术中颈部淋巴结抽样活组织快速病理检查三步筛选方法行选择性一期三野淋巴结清扫,一期规范胸腹二野清扫和二期第三野颈部淋巴结清扫.同时,术后积极实施综合治疗.观察总的临床疗效和长期生存.结果 1162例食管癌手术中,手术切除率100％.根治性切除97.6％（1134/1162）.围手术期并发症发生率16.4％（191/1162）,吻合口瘘发生率为0.6％（7/1162）,术后30 d内死亡5例.全组淋巴结转移率52.6 ％（611/1162）,淋巴结转移度12.1％（3 092/25 564）.全组实施一期三野淋巴结清扫348例,阳性准确率为94.8％（330/348）,实施一期二野清扫814例,实施二期第三野颈部淋巴结清扫89例.三野清扫术后并发症明显高于二野清扫（23.6％比13.4％）（χ^2=18.37,P＜ 0.001）,但两者的1、3、5年生存率差异无统计学意义（P＞0.05）.一期三野清扫和二期第三野清扫患者1、3、5年生存率差异亦无统计学意义（P＞0.05）.但不同的淋巴结转移程度预后差异有统计学意义（χ^2=35.57,P＜ 0.001）,不同的分期决定着患者的预后.本组术后综合治疗实施率为87.2％,手术加术后综合治疗者总的1、3、5年生存率分别为92.1％、69.2％、49.6％.结论 序贯三切口切除食管肿瘤及应用三步筛选法选择性淋巴结清扫具有根治彻底、术后并发症少、患者生存质量高、长期生存率较好等优点,是食管癌外科治疗值得临床广泛应用的一种方法.术后积极的综合治疗是今后食管癌治疗的发展方向.     

多学科团队在食管癌诊断与治疗中的作用*

食管癌目前治疗模式已从单一的外科手术转变为在规范化手术基础上合理应用围术期放、化疗等综合治疗模式。虽然在包括术前精确分期、手术径路、淋巴结清扫范围和围术期放、化疗方案在内的诸多问题上仍存在争议,但通过多学科团队协作提供诊断与治疗方案的新模式,不仅在最大程度上体现肿瘤治疗个体化和规范化原则,同时也能真正达到延长患者生存时间、提高生活质量的目的。      

盘点2020年食管癌外科治疗进展

食管癌的外科治疗进展相对缓慢,而2020年食管癌治疗因为免疫治疗的加入发生了里程碑意义的改变,如新辅助化疗或放化疗联合免疫治疗的探索带来了较新的结果.此外在手术治疗上得到进一步的探索,微创手术、机器人手术及淋巴结清扫范围都有临床试验结果的公布.全文总结论述2020年度食管癌外科治疗领域的进展.     

516例颈段和胸上段食管癌外科治疗的临床分析

目的总结516例颈段、胸上段食管癌的外科治疗经验.方法对516例颈段、胸上段食管癌进行回顾分析.结果本组手术切除率90.9%,并发症发生率11.2%,手术死亡率1.5%.T分期高是影响手术切除的重要因素,术前放疗可减低T分期;术前CT、MRI、纤支镜检查可降低手术探查率,选择正确的手术径路可提高手术安全性.结论手术是治疗颈段、胸上段食管癌的重要手段之一.     

Surgical controversies in esophageal cancer

Several controversies concerning the optimal surgical management of esophageal cancer exist. The extent of resection, the surgical approach, the optimal lymph node dissection, and the volume–outcome relationship potentially influence the overall outcome of patients undergoing a surgical treatment for esophageal cancer. Especially in the context of perioperative, randomized studies in esophageal cancer, it appears indispensable to understand the broad range of quality indicators of esophageal cancer surgery.     

食管上皮高度不典型增生的处理

背景与目的：改善食管癌患者预后的最有效方法是早期诊断、早期治疗。食管上皮高度不典型增生患者可能存在早期癌变，处理方法存在争议。本研究探讨对内镜活检病理诊断为食管上皮高度不典型增生患者的处理。方法：对我院1999-2006年间10例术前内镜活检病理诊断为食管上皮高度不典型增生患者的术式、手术后并发症和疗效的分析，结合文献报道食管上皮高度不典型增生的处理方法，以探讨内镜活检病理诊断为食管上皮高度不典型增生病例的合适的处理措施。结果：10例内镜活检病理诊断为食管上皮高度不典型增生的患者经食管切除术后，病理证实原位癌2例（20％），浸润性癌8例（80％），区域淋巴结转移率为零，手术后30d内死亡率为零，围手术期颈部吻合口漏1例，经处理后2周漏口愈合。1例术后因非肿瘤疾患死亡，其余患者均长期无瘤生存（术后存活时间3～66个月）。结论：根据我们的临床资料，结合文献报道，认为大部分食管上皮高度不典型增生患者已经存在原位癌或浸润性癌，且相当部分高度不典型增生患者会转变成浸润性癌。外科切除食管目前是胸外科较成型术式，手术风险小，术后患者预后好，是食管内镜活检病理诊断为高度不典型增生患者的合适的治疗方法。     

食管上皮高度不典型增生的处理

Objective： Early detection and treatment in patients with esophageal cancer is the most effective way to improve the prognosis. Patients with high-grade dysplasia （HGD） in esophageal mucosa might be involved with early esophageal cancer, but the management of the disease is controversial. The purpose of our study was to explore the management of esophageal mucosa with HGD. Methods： We retrospectively analyzed 10 patients with HGD in esophageal mucosa, who underwent esophagectomy in Cancer Hospital of Fudan University from 1999 to 2006. The surgical approach, postoperative morbidity, in-hospital complications and pathological results of the patients were analyzed. Basing on our data together with other studies, we aimed at looking for an appropriate management for patients with HGD. Results： Of the 10 patients who received esophagectomy, the pathological results showed that 2 （20%） cases were in situ carcinoma and 8 （80%） cases were invasive cancer with no regional lymph nodes involved. 30-day mortality was 0. One patient experienced cervical anastomotic leakage, but healed in 2 weeks. There was no pulmonary complication. Conclusion： Most patients with HGD actually have occult carcinoma. High percentage of patients with HGD would develop into cancer during their lifetime. Esophagectomy is now a selective approach for the treatment of the patients with HGD.     

Resection of esophageal cancer infiltrating the left main bronchus following complete response to preoperative radiochemotherapy--a case report

We report a case of esophageal cancer infiltrating the left main bronchus in which radical esophagectomy with clear surgical margins could be performed after preoperative radiochemotherapy. The patient was a 57-year-old man, who was found to have esophageal squamous cell carcinoma of the middle thoracic esophagus during a work-up of dysphagia. Bronchoscopy revealed an elevated region protruding into the lumen of the left main bronchus. After radiochemotherapy (liniac irradiation + low-dose FP therapy), the esophageal and bronchial lesion became smaller. The case was evaluated as a clinically complete response. Bronchoscopic ultrasonography showed a clear boundary between the membranous portion of the trachea and the esophageal wall. Based on these findings, the lesion was considered resectable and radical surgery, including 3-field lymph node dissection, was performed. The resected esophageal specimen had residual cancer cells in the muscularis propria covered with normal mucosa. However, the patient is currently healthy with no evidence of disease. The indication for surgical resection in cases of esophageal cancer with contiguous spread, and a good response to preoperative radiochemotherapy, is controversial. It is necessary to verify the effectiveness of surgical resection, as a secondary treatment, by accumulating data on cases such as the present one.     

Combined modality therapy of esophageal cancer

Esophageal cancer is a deadly disease. Only one third of patients with localized disease experience long-term survival. Over the past 20 years, investigators have evaluated neoadjuvant strategies to improve the outcomes of surgical management. Chemotherapy and radiation have been evaluated individually and in combination for preoperative management of patients with localized esophageal cancer. This article provides a critical review of the data on multimodality approaches to the management of esophageal cancer.     

从食管癌多癌灶及壁内外播散探讨手术范围

目的 探讨胸段食管癌根治性手术切除的长度和广度。方法 对1992年3月～1996年1月食管癌全胸段食管切除标本连续切片结果及淋巴结转移情况进行研究。结果 癌灶黏膜下浸润食管长度在3.3 cm以下;黏膜多灶癌相距最长长度7.4 cm;黏膜下癌栓可扩散2.48 cm。4％的病例食管肿瘤上缘5 cm以上的食管壁有多灶癌,食管中段癌淋巴结转移特点为上下双向转移;食管下段癌主要沿食管壁下行转移至腹腔淋巴结,4％的病例有颈部及上纵隔淋巴结转移。结论 建议胸内各段食管癌均作全胸段食管切除及纵隔和腹腔淋巴结清扫,有利于癌瘤彻底切除。     

DNA含量和S期细胞比值与食管癌生物学特性的关系

目的 :研究食管癌患者不同组织细胞的DNA含量、S期细胞比值 (SPF)及倍体状态与临床病理特性的关系。方法 :应用流式细胞仪检测食管癌患者新鲜手术标本食管癌组织、癌旁组织、正常食管粘膜及淋巴结中DNA含量及S期细胞比值。结果 :食管癌组织的异倍体发生率明显高于癌旁组织、正常食管粘膜和淋巴结 (P <0 0 5)。二倍体组织之间的细胞DI差异无显著性 (P >0 0 5)。异倍体与二倍体细胞同一组织之间、异倍体组癌组织与癌旁组织、癌组织与正常组织、癌旁组织与淋巴结、正常组织与淋巴结之间DI差异显著 (P <0 0 5)。在二倍体组中癌组织与正常组织、癌组织与淋巴结之间SPE之间差异显著 (P <0 0 5)。DNA倍体与患者性别、肿瘤部位及大体病理类型等无关 (P >0 0 5) ,而与肿瘤分化程度、浸润深度及淋巴结状况有关 (P <0 0 5)。结论 :食管癌DNA倍体及SPF均与肿瘤的增殖活性有关 ,有助于对食管癌生物学行为的了解和患者预后的判断。     

食管癌全食管系膜切除术的现状

食管癌外科中关于手术方式和淋巴结清扫范围仍存在相当大的争议。近年来食管癌全食管系膜切除术的概念倍受重视。全食管系膜切除术代表着一种手术原则而非手术方式,可在各种开放以及微创食管切除术中应用。全食管系膜切除术适用于T1-T3期食管癌。结合二野或三野淋巴结清扫,全食管系膜切除术旨在获得食管癌的R0切除。外科切缘（尤其是径向切缘）和切除淋巴结数目是评价手术质量的重要指标。     

Prevention and management of early esophageal cancer

Opinion statement Early esophageal cancer is defined by its limitation to the esophageal mucosa and submucosa. It has become a curable malignant disease, in sharp contrast to the dis-mal prognosis of esophageal cancer at advanced stages, which still represents the majority of patients. Understanding the risk factors, establishing surveillance pro-grams for patients at risk, and developing preventative interventions such as dietary and lifestyle changes or pharmacologic interventions hold the potential of reducing the incidence of the disease and of shifting the stage distribution toward early cancer. Endoscopic ultrasound examination is pivotal for distinguishing early from advanced stages of the disease because it allows for accurate assessment of tumor infiltration and regional lymph node involvement. The therapeutic mainstay for early esophageal cancer remains surgery. New, less invasive surgical techniques are being tested that are associated with less morbidity and mortality than standard radical esophagectomies. For patients who are not candidates for surgery, definitive chemoradiation is a viable alternative. New endoscopic ablation techniques, such as endoscopic mucosa resection and photodynamic therapy, are potential alternatives to surgery in patients with cancers limited to the mucosa. For patients with adenocarcinoma of the gastroesophageal junction with submucosal involvement, adjuvant chemoradiation should be considered because of its potential to increase survival.