Pattern of lymph node metastases in patients with squamous cell carcinoma of the thoracic esophagus who underwent three-field lymphadenectomy

BACKGROUND/AIMS: Lymph nodes in patients with squamous cell carcinoma of the thoracic esophagus might be involved with metastases at cervical, mediastinal, and abdominal sites. The range of lymph node dissection is still controversial. The pattern of lymph node metastasis and factors that are correlated with lymph node metastasis affect the surgical procedure of lymph node dissection. The purpose of the present study was to explore the pattern of lymph node metastasis and factors that are correlated with lymph node metastasis in patients with esophageal cancer who underwent three-field lymphadenectomy. METHODS: Lymph node metastases in 230 patients who underwent radical esophagectomy with three-field lymphadenectomy were analyzed. The metastatic sites of lymph nodes were correlated with tumor location by chi-square test. Logistic regression was used to analyze clinicopathological factors related to lymph node metastasis. RESULTS: Lymph node metastases were found in 133 of the 230 patients (57.8%). The average number of resected lymph nodes was 25.3 +/- 11.4 (range 11-71). The proportions of lymph node metastases were 41.6, 19.44, and 8.3% in neck, thoracic mediastinum, and abdominal cavity, respectively, for patients with upper thoracic esophageal carcinomas, 33.3, 34.7, and 14%, respectively, in those with middle thoracic esophageal carcinomas, and 36.4, 34.1, and 43.2%, respectively, for patients with lower thoracic esophageal carcinomas. We did not observe any significant difference in lymph node metastatic rates among upper, middle, and lower thoracic carcinomas for cervical or thoracic nodes. The difference in lymph node metastatic rates for nodes in the abdominal cavity was significant among upper, middle, and lower thoracic carcinomas. The lower thoracic esophageal cancers were more likely to metastasize to the abdominal cavity than tumors at other thoracic sites. A logistic regression model showed that depth of tumor invasion and lymphatic vessel invasion were factors influencing lymph node metastases. CONCLUSIONS: Based on our data, cervical and mediastinal node dissection should be performed independent of the tumor location. Abdominal node dissection should be conducted more vigorously for lower thoracic esophageal cancers than for cancers at other locations. Patients with deeper tumor invasion or lymphatic vessel invasion were more likely to develop lymph node metastases.     

Clinicopathologic Features of Superficial Esophageal Cancer: Results of Consecutive 100 Patients

BACKGROUND: The depth of tumor penetration is a crucial factor in determining the prognosis of patients with esophageal carcinoma. Patients with superficial esophageal carcinoma (SEC) have a far more favorable clinical course compared with those with advanced cancers. The outcome for patients with mucosal cancer is excellent with a 5-year survival rate exceeding 80%. On the other hand, submucosal cancer often metastasizes to regional and/or distant lymph nodes or other organs, and the prognosis of these patients are far from satisfactory. METHODS: Among 334 patients with esophageal cancer who underwent surgery between December 1980 and December 2006, 100 patients (30%) had SEC confined to the epithelium, lamina propria mucosa, or submucosa. Patient and tumor characteristics of those 100 patients were studied. RESULTS: The prevalence of SEC has increased from 13% (8 of 61) in the initial 5-year period (1985-1989) to 44% (41 of 93) in the recent 7-year period (2000-2006). Subjective symptoms were present in 7 (14%) of 51 mucosal cancers and in 13 (27%) of 49 submucosal cancers. The remaining 80 patients (80%) had no subjective symptoms. Ninety-one patients (91%) were diagnosed to have the lesions by endoscopy at the time of screening for gastric problems, and only nine were detected by gastrointestinal series. Four of 51 patients with mucosal cancer had venous or lymph vessel invasion, and among those, only one (2%) had a solitary perigastric lymph node metastasis. In 49 patients with submucosal cancer, 35 (71%) had lymph vessel invasion, 28 (57%) had venous invasion, and 16 (33%) had lymph node metastases. In particular, 15 of 35 patients with positive lymph vessel invasion had lymph node metastasis, whereas only 1 of 14 with negative lymph vessel invasion had lymph node metastasis (P < .05). Among 17 patients with nodal involvement, 4 patients with upper thoracic SEC had upper mediastinum and/or cervical nodal metastases, 11 patients with middle thoracic SEC had widespread upper and lower mediastinal and abdominal metastases, and 2 patients with lower thoracic SEC had lower and abdominal lymph node metastases. Seventy-nine patients were alive without recurrence at last follow-up. Five of 49 patients with submucosal cancer died of recurrent disease, and 4 of these developed regional nodal recurrence around the bilateral laryngeal recurrent nerves. Forty-two patients (42%) developed double cancers during the follow-up period, and 5 died of a second cancer. The 3- and 5-year survival rates of all 100 patients were 85% and 73%, and those disease-specific survival rates were 96% and 93%, respectively. The 3- and 5-year survival rates for patients with mucosal cancer were 89% and 83%, and those for submucosal cancer were 80%, and 64%, respectively. CONCLUSIONS: Esophagectomy with extensive lymphadenectomy should be carried out particularly for upper thoracic submucosal cancer, whereas esophagectomy with moderate lymphadenectomy may be preferred for mucosal cancer. Patients with SEC should be examined for another primary cancer preoperatively and periodically during follow-up.     

应用Cox模型分析影响胸段食管癌切除术预后的因素

目的 分析影响胸段食管癌切除术后患者预知的因素,探讨各因素之间的关系。方法 采用计算机比例风险模型（Cox模型）,对影响胸段食管癌三区域淋巴结清除根治术患者预后的临床因素进行分析。结果 预后与肿瘤侵及深度、分化程度、临床分期、淋巴结转移个数及区域数呈正相关,而与年龄呈负相关（P＜0．01）;性别和肿瘤长度与预后无关。淋巴结转移个数与肿瘤分化程度和侵及深度呈正相关,与年龄呈负相关（P＜0．01）,而与3年和5年生存率显著相关（P＜0．01）。本组5年生存率为53．7％。结论 胸段食管癌的预后与肿瘤的侵及深度、分化程度、淋巴结转移个数、肿瘤的部位及患者年龄等因素密切相关;胸段食管癌三区域淋巴结清除根治术有效地提高了淋巴结转移阴性和转移较少患者的生存率。     

微创食管癌切除术后淋巴结转移规律及预后分析

目的淋巴结转移是食管癌转移的主要方式,对食管癌患者预后有重要影响,本文探讨食管癌胸腹二区淋巴结的转移规律。 方法选取2010年1月至2016年10月于山东大学齐鲁医院经微创食管癌切除术(minimally invasive esophagectomy, MIE)治疗的食管癌患者613例,参照日本食管肿瘤研究会(JEOG)淋巴结分区标准清扫淋巴结,统计各组淋巴结的转移率。对2010年1月至2013年10月行MIE治疗的203例食管癌患者进行生存分析。另外410例患者由于术后时间较短,随访数据未列入统计。 结果胸上段食管癌较多发生上纵隔淋巴结转移,其左、右喉返神经旁淋巴结转移率分别高达35.9%、40.7%,均显著高于胸中段和胸下段食管癌;胸中段食管癌既向上发生上纵隔淋巴结转移,又向下发生腹腔淋巴结转移;胸下段食管癌主要向胃周淋巴结转移,其中胃左动脉旁淋巴结转移率最高。单因素分析结果显示,病变长度、肿瘤分化程度、肿瘤浸润深度、淋巴结转移程度是影响食管癌患者预后的相关因素(P< 0.05)。COX多因素回归分析结果显示,肿瘤低分化和淋巴结转移是影响食管癌患者预后不良的独立危险因素(P< 0.05)。 结论手术治疗食管癌应重点清扫双侧喉返神经旁淋巴结和胃左动脉旁淋巴结。     

胸段食管癌淋巴结转移特点的临床研究

目的 探讨胸段食管癌淋巴结转移的规律和特点,从而为其手术入路和淋巴结清扫范围提供参考.方法 回顾性分析2009年1月至2012年12月间中南大学湘雅医学院附属肿瘤医院胸外科收治的72例胸段食管癌患者的临床资料,所有病例均行右胸入路手术. 记录各组淋巴结的清扫及转移情况,并分析淋巴结转移的影响因素.结果 72例患者中,有48例出现淋巴结转移,淋巴结转移率为66.7％;清扫淋巴结总数为1495枚,转移181枚,淋巴结转移度为12.1％,平均每例清扫淋巴结20.8枚.在各组淋巴结中,右喉返神经旁（1R组）淋巴结转移率最高,达30.6％（22/72）.左喉返神经旁淋巴结（2L组、4L组和5组） 转移率为12.5％（9/72）.淋巴结转移率与肿瘤大小和浸润深度有关（均P＜0.05）,而与病变部位和分化程度无关（P＞0.05）.结论 胸段食管癌淋巴结转移以右喉返神经旁淋巴结转移为主,故其手术最佳入路应是右胸入路,淋巴结清扫则应以右、左喉返神经旁淋巴结为重点的系统纵隔、腹野淋巴结清扫.     

影响胸段食管鳞癌切除术预后的因素

目的探讨影响胸段食管癌患者切除手术的预后因素。方法对217例经颈、胸、腹“3区域”淋巴结清除根治术患者,选择对食管癌切除术预后可能产生影响的9个特征性临床病理因素进行回顾性预后分析。结果全组淋巴结清除术后1、3、5年生存率分别为82.6%、59.8%、和48.8%。影响预后的单因素分析表明肿瘤浸润深度、分化程度、临床分期、淋巴结转移个数、淋巴结转移区域数和年龄对预后有影响。影响预后的Cox模型多因素分析表明,肿瘤浸润深度、分化程度、淋巴结转移区域数和肿瘤部位对预后有显著的影响。随着食管癌淋巴结转移区域数的增加,患者生存率逐渐下降(P=0.0284)。结论淋巴结转移尤其是淋巴结转移区域数是胸段食管癌切除术后影响患者预后的主要因素;因此,胸段食管癌尤其是胸上、中段食管癌在条件具备时应施行“3区域”淋巴结清扫术。     

Recurrence pattern of squamous cell carcinoma of the thoracic esophagus after extended radical esophagectomy with three-field lymphadenectomy

BACKGROUND: Extended radical esophagectomy with three-field lymphadenectomy for patients with thoracic esophageal cancer has been shown to be effective. But even if this operation is performed, some patients still experience relapse of the disease. The purpose of this study was to clarify the pattern and timing of recurrence after extended radical esophagectomy. STUDY DESIGN: Recurrence of esophageal squamous cell carcinoma was examined in 171 of 174 patients who underwent extended radical esophagectomy with three-field lymphadenectomy. Recurrence patterns were classified as locoregional (at the site of the primary tumor, the anastomotic site, or the lymph nodes), hematogenous, and other (pleura or site of gastrostomy). Factors associated with recurrence were identified using univariate and multivariate statistical methods for survival analysis. RESULTS: The overall 5-year survival rate was 55.6%. Recurrence was recognized in 74 patients (43.3%). The median disease-free interval until recurrence was 11 months. Thirty patients (17.5%) developed a locoregional recurrence, and 24 (14.0%) developed a hematogenous recurrence. Five patients (2.9%) developed both recurrences simultaneously and were classified as hematogenous recurrences. Of 30 patients with cervical lymph node metastasis, recurrent disease was recognized in 19 patients (63.3%). In multivariate analysis of 160 patients, the depth of invasion and pM-lym (cervical or celiac lymph node metastasis) were significant factors for locoregional recurrence; the depth of invasion and number of lymph node metastases at operation were significant factors for hematogenous recurrence. Survival time for patients with hematogenous recurrence (median 16 months) was significantly shorter than that of patients with locoregional recurrence (median 25.5 months). CONCLUSIONS: Locoregional recurrence is associated mainly with the extent of the local tumor and lymph node metastasis; hematogenous recurrence is not only associated with tumor stage but also with the tumor's oncologic behavior.     

Esophagectomy for squamous cell carcinoma of the esophagus isolated or associated with head and neck cancer: long-term survival

STUDY AIM: Esophageal squamous cell carcinomas are frequently associated with head and neck cancers. This retrospective study was conducted to compare the long-term outcome of the patients with a double cancer and of the patients with a solitary esophageal cancer after curative management. PATIENTS AND METHODS: From 1989 to 1999, 114 patients with an esophageal carcinoma were included in the study. Among them, 52 had an associated head and neck cancer (metachronous: n = 17 and synchronous: n = 35). Curative treatment was achieved in all patients. The patients were divided in "solitary" and "associated" group. RESULTS: Age, sex distribution, tumor location and histological findings were similar in the two groups. The esophageal resection was an esopharyngolaryngectomy (n = 13), a subtotal esophagectomy with cervical anastomosis (n = 92) and a Lewis-Santy esophagectomy with thoracic anastomosis (n = 9). Operative mortality (8 versus 7.7%), anastomotic leaks rate (14.5 versus 21%) and pneumonia rate (21 versus 9.6%) were not significantly different in the two groups. The mean hospital stay was 27 days. The mean follow-up was 85 +/- 50 months. Five-year survival rates were not significantly different in the two groups (p = 0.6411). In univariate survival analysis the only significant predictive factors were the depth of esophageal tumor invasion (p = 0.0002) and node involvement (p = 0.0373). The presence of head and neck cancer did not affect survival after esophagectomy. CONCLUSION: With an aggressive therapeutic plan, the survival of patients with an esophageal cancer associated to head and neck cancer was similar to the survival of patients with an isolated esophageal carcinoma. Long term esophageal survey seems to be useful to detect more superficial esophageal carcinomas in patients with head and neck cancer.     

胸段食管鳞状细胞癌外科治疗与预后分析

目的 探讨胸段食管鳞状细胞癌切除术后生存率的影响因素.方法 回顾性分析1990年1月至1998年12月716例胸段食管鳞状细胞癌手术患者的临床病理资料,其中男性538例,女性178例;年龄24-78岁,中位年龄57岁.应用Kaplan-Meier法进行生存分析,组间比较用Logrank检验,采用COX模型进行多因素分析.结果 总的1、3、5和10年生存率分别为82.9%、44.3%、34.2%和25.7%.Ⅰ期、ⅡA期、ⅡB期和Ⅲ期患者的5年生存率分别为80.0%、51.2%、19.7%和13.3%.术后复发转移151例,占21.1%;其中ⅡA期、ⅡB期和Ⅲ期复发患者3年内复发率分别为84.2%、91.7%和90.O%.单因素分析表明性别、肿瘤浸润深度、淋巴结转移、病理分期、淋巴结转移区域数、组织分化、手术切缘和肿瘤复发均为预后影响因素.多因素分析显示肿瘤浸润深度、淋巴结转移、病理分期和肿瘤复发是食管癌预后的独立影响因素.结论 胸段食管鳞状细胞癌患者术后生存率的独立影响因素有肿瘤浸润深度、淋巴结转移、病理分期和肿瘤复发.手术是Ⅰ-ⅡA期食管癌的主要治疗方法,ⅡB-Ⅲ期食管癌应采用以手术为主的综合治疗.     

食管癌淋巴结转移特点及其危险因素

目的 探讨食管癌淋巴结转移情况及其危险因素,为外科手术行淋巴结清扫提供参考。方法回顾总结2006年1月至2010年12月在复旦大学附属肿瘤医院胸外科行三野淋巴结清扫食管癌根治术308例患者的临床资料．分析淋巴结的转移规律及特点。结果308例患者平均清扫淋巴结（35．6±14．5）枚,197例（64％）患者出现淋巴结转移。Logistic单因素分析结果显示,脉管（淋巴管及血管）侵犯（P=0．019）及肿瘤浸润深度（P〈0．001）是发生淋巴结转移的危险因素。各站淋巴结中,胸部气管旁淋巴结转移率最高（25．0％）。上段食管癌腹部淋巴结转移率显著低于中段或下段食管癌（P=0．001）,而各段食管癌颈胸部淋巴结转移率比较,差异无统计学意义（P〉0．05）。颈胸部和颈胸腹部淋巴结转移率分别为14．6％和11．0％,而颈腹部和胸腹部则分别为3．6％和4．9％。脉管侵犯（P〈0．001）和胸部气管旁淋巴结转移（P=0．014）是食管癌发生颈部淋巴结转移的危险因素。结论食管癌淋巴结转移具有上、下双向和跳跃性的特点．胸部气管旁淋巴结转移可作为行颈部淋巴结清扫的指征。     

Clinicopathologic Characteristics and Clinical Outcomes of Esophageal Basaloid Squamous Carcinoma: Experience at a Single Institution

This retrospective study investigated the clinicopathologic characteristics and clinical outcomes of esophageal basaloid squamous carcinoma (BSC). Among 190 patients with esophageal carcinoma treated surgically between 1998 and 2011, we identified 9 (4.7%) with BSC. All of the patients were male, with a median age of 65 years. The frequencies of venous invasion, lymphatic invasion, and lymph node metastasis were 56%, 89%, and 67%, respectively. A total of 2 patients were pathologic stage 1, 5 were stage 2, and 2 were stage 3. Tumor recurrence was observed in 56% of the patients. The 5-year survival rate for patients with esophageal BSC was 40%, which was compatible with the figure of 53.8% for control patients (n = 18) with typical squamous cell carcinoma matched for sex, age, tumor location, and pathologic stage (P = 0.45). Although esophageal BSC shows aggressive lymph-vascular invasion and has a high likelihood of recurrence, its prognosis seems identical to that of typical squamous cell carcinoma.     

胸段食管癌隆突下淋巴结转移影响因素分析

目的探讨胸管食管癌隆突下淋巴结的转移规律及相关影响因素。方法回顾性分析安阳肿瘤医院2015-06—2018-05间1402例行食管癌根治术患者的病例资料(淋巴结清扫包括隆突下淋巴结)。结果胸段食管癌隆突下转移发生率为8.35%,与患者的性别、年龄、病理类型及手术方式等无关(P>0.05);与肿瘤部位、浸润深度、淋巴结转移程度、分化程度、TNM分期、脉管癌栓、神经侵犯及术前治疗方法等有关(P<0.05)。结论胸段食管癌隆突下淋巴结转移率较高,但食管胸上段癌、cT1期的食管癌患者隆突下淋巴结转移发生率较低,可行选择性清扫;胸中下段食管癌术中仍应作为淋巴结常规清扫部位。术前行放疗或同步放化疗后患者隆突下淋巴结转移发生明显降低,对局部晚期食管癌患者推荐术前放疗或同步放化疗。     

Prognostic factors in patients with submucosal esophageal cancer

The detection rate of early-stage esophageal cancer has increased recently. Various types of treatment including endoscopic mucosal resection, blunt dissection, and esophagectomy with extended lymphadenectomy are employed in patients with submucosal esophageal cancer. The purpose of the present study was to analyze prognostic factors in patients with submucosal esophageal cancer. Univariate analysis showed that lymph node metastasis, subdivision of tumor depth, and lymphatic invasion were correlated with prognosis, whereas sex, age, tumor location, surgical procedure, adjuvant therapy, histologic findings, and venous invasion did not affect prognosis. Multivariate analysis demonstrated lymph node metastasis to be the only significant prognostic factor in submucosal esophageal cancer. Although subdivisions of tumor depth did not reach significance as prognostic factors, lymph node metastasis was strongly related to tumor depth. To select the individualized treatment in patients with submucosal esophageal cancer, accurate diagnosis of lymph node metastasis necessitates a combination of imaging methods such as endoscopic ultrasound-guided fine-needle aspiration, computed tomography, and positron emission tomography.     

选择性三野淋巴结清扫术治疗胸段食管鳞癌的临床研究

目的分析行选择性三野淋巴结清扫术对胸段食管鳞癌患者的预后影响。 方法2009年6月至2012年9月,四川省肿瘤医院对127例胸段食管癌患者根据肿瘤的位置、外侵程度、术前颈部超声检查结果,进行选择性三野淋巴结清扫。全组共127例患者,其中上段49例;中段67例;下段11例;Ⅰ期2例,Ⅱ期26例,Ⅲ期99例。 结果127例患者共清扫淋巴结4963枚,平均每例清扫淋巴结39.3枚;手术时间(325.6±9.3)min,出血量(316.0±18.7)ml。术后76例患者发生并发症,发生率为59.8%(76/127)病死率为1.6%(2/127)。选择性三野淋巴结清扫术后喉返神经旁淋巴结转移率40.2%(51/127);颈部淋巴结转移率55.9%(71/127),其中,胸中下段食管鳞癌颈部淋巴结转移与喉返神经转移显著相关(χ²＝0.005,P＝0.006)。全组中位生存时间(35.0±1.9)个月,3年生存率51.8%。其中Ⅱ期中位生存时间(42.1±3.4)个月,3年生存率74.5%;Ⅲ期生存时间(32.3±2.0)个月,3年生存率44.8%,两组间比较差异有统计学意义(χ²＝3.940,P＝0.047)。颈部淋巴结阳性患者的中位生存时间(26.2±2.1)个月,3年生存率34.9%;阴性患者中位生存时间(41.5±2.3)个月,3年生存率67.6%,差异有统计学意义(χ²＝15.283,P<0.001)。 结论选择性三野淋巴结清扫术是一种安全可行、可提高颈部淋巴结清扫率,同时又能筛选出潜在获益患者、延长生存的手术方式。     

Prediction of lymph node status in patients with superficial esophageal carcinoma: analysis of 160 surgically resected cancers

BACKGROUND: The ability to predict lymph node metastasis in cases of superficial esophageal carcinoma before surgery would allow the identification of specific patients who do not require additional surgical resection after endoscopic local resection. METHODS: From 1980 to 2002 a total of 160 patients with superficial esophageal carcinoma, Tis or T1 tumors, underwent subtotal esophagectomy with lymph node dissection. On the basis of clinicopathologic data the risk factors for lymph node metastases are discussed. RESULTS: Patients with tumors that showed submucosal invasion, a nonflat shape, and lymphatic invasion had a higher risk for lymph node metastasis than the other patients. Multivariate analysis showed that the tumor depth and the macroscopic shape of the tumor were independent risk factors for lymph node metastases. CONCLUSIONS: Esophagectomy with lymph node dissection is recommended for patients with submucosal cancer. Local tumor resection can be recommended for patients with mucosal cancer without lymphatic invasion.     

Prognostic Significance of VEGF Expression in Correlation With COX-2, Microvessel Density,and Clinicopathological Characteristics in Human Gastric Carcinoma

Background Many studies have shown that angiogenesis plays an important role in the process of cancer development and progression. Vascular endothelial growth factor (VEGF) has a potent angiogenic activity, and cyclooxygenase-2 (COX-2) supports angiogenesis by regulated production of angiogenic factors, including VEGF. The purpose of this study was to examine the expression of VEGF in combination with COX-2 and CD34, their correlation with various clinicopathological factors, and their prognostic significance in human gastric carcinoma. Methods Specimens from 169 patients with different grade and stage gastric carcinoma were investigated by immunohistochemistry for COX-2 and VEGF expression. Tumor microvessel density was assessed with CD34 immunostaining. Correlations between the expression of VEGF, COX-2, CD34, and various clinicopathological factors were studied. The effect of these proteins on patient survival was determined. Results COX-2 and VEGF were positively expressed in 36.7% and 50.3% of the patients, respectively. Positive correlation was found between VEGF and COX-2 and between VEGF and CD34. VEGF expression was correlated with depth of invasion; metastatic lymph nodes; lymphatic and venous invasion; and tumor, node, metastasis system stage. Patients with positive staining for VEGF showed far lower disease-free (64.9% vs. 81.3%) and overall (58.3% vs. 76.9%) survival rates than VEGF-negative patients. In multivariate analysis, only tumor location, depth of invasion, and lymph node metastasis were shown to be independent prognostic factors. Conclusions VEGF expression correlates with angiogenesis and tumor progression and is a valuable prognostic factor in patients with gastric carcinoma.     

Status of Involved Lymph Nodes and Direction of Metastatic Lymphatic Flow Between Submucosal and T2-4 Thoracic Squamous Cell Esophageal Cancers

Background  Three-field lymph node dissection for thoracic esophageal cancer is associated with high morbidity and reduced quality of life after surgery. Consequently, minimized lymphadenectomy would be desirable, if appropriate. In the present study, we retrospectively analyzed the status of involved nodes and the direction of metastatic lymphatic flow from tumors into involved nodes to determine whether submucosal squamous cell esophageal cancers are potential candidates for minimized lymphadenectomy. Methods  We enrolled 199 patients who received esophagectomy with extensive lymph node dissection between 1989 and 2005 and retrospectively analyzed their prognoses, distribution of solitary metastatic lymph nodes, and the direction of metastatic lymphatic flow from the tumor, taking into consideration tumor location and depth. Results  Of these patients with submucosal cancers, 83% had 1 or 2 involved nodes, and their esophageal cancer-specific 5-year survival rate was 66%. Solitary lymph node metastasis did not occur in neck lymph nodes in lower thoracic submucosal esophageal cancers, and the direction of metastatic lymphatic flow from the tumor was almost always in one direction. By contrast, T2–4 cancers with 2–4 involved nodes had bidirectional metastatic lymphatic flow from the tumor. Conclusions  There was a difference in the status of lymph node metastasis and the direction of metastatic lymphatic flow from tumors into involved nodes between submucosal and T2–4 thoracic squamous cell esophageal cancers. This analysis may be useful for developing an approach to minimized lymphadenectomy for thoracic esophageal cancers.     

选择性颈胸腹三野淋巴结清扫治疗胸段食管鳞癌

目的 研究胸段食管鳞癌的淋巴结转移规律，探讨合适的淋巴结清扫范围。方法 87例接受食管次全切除术的胸段食管鳞癌患者，根据术前食管腔内超声和颈部超声检查结果，选择性进行胸腹二野或颈胸腹三野淋巴结清扫。结果 超声发现颈部淋巴结肿大并行三野清扫35例（40．2％，三野清扫组），其中原发肿瘤位于胸上段食管者的比例（16／24例，66．7％）显著高于中、下段肿瘤者（19／63例，30．2％）（P=0．002）。三野清扫术扫除淋巴结13．7组／例，显著多于二野清扫组（52例，59．8％）的10．5组／例（P〈0．001）。术后病理检测三野清扫组转移淋巴结1．5组／例，也显著多于二野清扫组的0．8组／例（P〈0．01）。颈淋巴结转移（pM1-LN）17例（占全组19．5％，占三野清扫组48．6％），有区域淋巴结转移者的颈淋巴结转移比例（15／48例，31．3％）显著高于无区域淋巴结转移者（2／39例，5．1％）（P〈0．01）。上、中、下纵隔及上腹部的淋巴结转移率分别为25．3％、23．O％、5．7％和24．1％，颈淋巴结转移与上纵隔（P〈0．01）及中纵隔（P〈0．01）淋巴结转移显著相关，但与下纵隔及上腹部淋巴结转移无关。三野清扫组术后并发症发生率（60．0％）显著高于二野清扫组（34．6％，P=0．020）。喉返神经损伤发生率两组差异无统计学意义（P〉0．05）；但喉返神经损伤者吻合口瘘发生率（7／13例，53．8％）显著高于无喉返神经损伤者（10／74例，13．5％，P=0．001）。术后死亡率两组差异无统计学意义（P〉0．05）。结论 应对肿瘤位于胸上段食管、或上纵隔及中纵隔淋巴结已发生转移的食管癌患者在超声指导下进行选择性颈胸腹三野淋巴结清扫术，以降低手术风险、提高手术根治效果。     

Esophagectomy. The role of the intrathoracic anastomosis

Esophagectomy for carcinoma continues to play a vital role in the treatment of patients with esophageal carcinoma. Safe resection with minimal short-term mortality and good swallowing palliation can be performed via the use of multiple, well-described resection techniques. Tumor location and the possibility of direct mediastinal invasion may dictate the need for transthoracic dissection and extension of the resection to the cervical esophagus for ideal margins. Differences in survival, short-term outcome, and swallowing function have yet to be proven for procedures with extended lymph node dissection versus those with minimal intrathoracic or cervical node dissections. The surgeon's ability and familiarity with various techniques may enhance the overall treatment of the patient with esophageal carcinoma as their treatment becomes more directed by the initial pathologic stage at presentation.