胸中段淋巴结阳性食管癌术后放疗的临床意义

目的：分析和研究淋巴结阳性的胸中段食管癌术后放疗能否提高生存率，同时对放疗范围提出进一步修改的建议。方法分析2004—2009年在我院手术的有淋巴结转移的胸中段食管鳞癌患者286例，其中手术196例，术后IMRT 90例。采用Kaplan－Meier法计算生存率并Logrank法检验，Cox模型多因素预后分析，采用χ2检验分析不同治疗方式对复发的影响。结果单一手术组（ S）和术后放疗组（ S＋R）5年OS分别为22．9％和37．8％，中位生存时间分别为23．2个月和34．7个月（P＝0．003）；淋巴结转移（LNM）1－2个S组和S＋R组的5年OS分别为27．3％和44．8％（P＝0．017）， LNM≥3个S组和S＋R组的5年OS分别为16．7％和25．0％（ P＝0．043）。 S组N1、N2、N3期腹腔淋巴结转移失败率分别为2．9％、10．9％、20．0％（P＝0．009）。 S＋R组与S组比较纵隔淋巴结转移失败率明显降低（ LNM 1－2个：S＋R 8．0％， S 35．3％， P＝0．003；LNM≥3个时， S＋R 10．0％， S 42．3％， P＝0．001）且明显延长了复发时间（ S＋R 25．1个月与S10．7个月，P＝0．000）。但LNM≥3个S＋R组的血道转移失败率明显高于S组（46．7％比26．1％，P＝0．039）。结论胸中段食管癌淋巴结阳性患者能从术后放疗中获益。 LNM 1－2个可缩小照射范围。 LNM≥3个时妥协放疗剂量是否比妥协照射范围更合理还需前瞻性研究。血道转移失败率高，为化疗提供了治疗依据。

Clinical value of postoperative radiotherapy for node-positive middle thoracic esophageal squamous cell carcinoma and modification of target volume

Objective To analyze the clinical value of postoperative radiotherapy for node-positive middle thoracic esophageal squamous cell carcinoma ( TESCC ) and to modify the target volume .Methods A total of 286 patients with node-positive middle TESCC underwent radical surgery in Cancer Hospital, Chinese Academy of Medical Sciences, from 2004 to 2009.In addition, 90 of these patients received postoperative intensity-modulated radiotherapy.The Kaplan-Meier method was used to calculate survival rates, and the log-rank test was used for survival difference analysis.The Cox model was used for multivariate prognostic analysis.The chi-square test was used for comparing the recurrence between patients receiving different treatment modalities.Results The 5-year overall survival ( OS) rates of the surgery alone ( S) group and surgery plus postoperative radiotherapy ( S+R) group were 22.9%and 37.8%, respectively, and the median OS times were 23.2 and 34.7 months, respectively ( P=0.003) .For patients with 1 or 2 lymph
node metastases (LNMs), the 5-year OS rates of the S group and S+R group were 27.3%and 44.8%, respectively ( P=0.017);for patients with more than 2 LNMs, the 5-year OS rates of the S group and S+R group were 16.7%and 25.0%, respectively (P=0.043).The peritoneal lymph node metastasis rates of N1 , N2 , and N3 patients in the S group were 2.9%, 10.9%, and 20.0%, respectively ( P=0.024) .The S+R group had a significantly lower mediastinal lymph node metastasis rate than the S group ( for patients with 1 or 2 LMNs:8.0%vs.35.3%, P=0.003;for patients with more than 2 LNMs, 10.0%vs.42.3%, P=0.001) , and had a prolonged recurrence time compared with the S group ( 25.1 vs.10.7 months, P=0.000) .However, for patients with more than 2 LNMs, the S+R group had a significantly higher hematogenous metastasis rate than the S group (46.7%vs.26.1%, P=0.039).Conclusions Patients with node-positive middle TESCC could benefit from postoperative radiotherapy.The target volume can be reduced for patients with 1 or 2 LNMs.Prospective studies are needed to examine whether it is more appropriate to reduce the radiotherapy dose than to reduce the target volume for patients with more than 2 LNMs.A high hematogenous metastasis rate warrants chemotherapy as an additional regimen.