胸腹二野淋巴结清扫结合术后辅助化疗治疗食管癌

Thoraco-abdominal two-field lymphadenectomy combined with adjuvant chemotherapy in the management of thoracic esophageal carcinoma

目的探讨如何提高食管癌手术根治性、减少术后复发以改善食管癌治疗长期疗效。方法104例胸段食管鳞癌病人,56例按传统术式行食管切除+肿大淋巴结摘除术,48例行系统性胸腹二野淋巴结清扫术。3例手术死亡(2.9%),余101例病人中29例术后接受顺铂+氟脲嘧啶辅助化疗,其中15例为传统术式病例,14例为二野清扫病例。结果胸腹二野清扫手术时间虽然较传统术式延长,但手术出血量、术后并发症及病死率未见增高。二野清扫组清扫淋巴结组数(10.5组对3.2组,P<0.001)及转移淋巴结检出组数(1.1组对0.6组,P=0.038)均显著多于传统术式组。通过淋巴结清扫发现,双侧喉返神经旁(16.8%)、食管旁(22.9%)和胃左动脉旁(16.8%)淋巴结为胸段食管癌常见转移部位,10.4%病例存在跳跃性淋巴结转移,上纵隔(20.8%)与中下纵隔(31.3%)及上腹部(25.0%)3个区域间淋巴结转移频度差异无统计学意义。二野清扫组25.0%病例因扫除了传统术式可能遗漏的转移淋巴结使手术根治性提高,另有12.5%病例手术病理分期因此由pN0上升至pN1。术后辅助化疗病人中86.2%完成2个以上疗程,平均化疗3.1个疗程,无严重毒副作用或死亡。淋巴结清扫组5年生存率显著高于传统术式组(36.4%对24.9%,P=0.049),术后化疗组显著高于未化疗组(44.8%对20.7%,P=0.023),接受淋巴结清扫及术后化疗者5年生存率最高(46.2%),显著高于单纯进行传统手术且未行化疗的病例(19.4%,P=0.018)。结论系统的胸腹二野淋巴结清扫有助于提高食管癌手术根治性和病理分期准确性,淋巴结清扫与术后辅助化疗相结合的优化治疗方法有助于提高胸段食管鳞癌的长期疗效。

Objective To increase the radical resection rate and decrease local-regional relapse rate in thoracic esophageal carcinoma. Methods One-hundred and four patients were prospectively randomized to receive esophagectomy with thoraco-abdominal 2-field lymphadenectomy （48 cases） or with lymph node sampling （56 cases）. In 101 patients who survived after surgery, 29 received adjuvant chemotherapy with cisplatin and fluorouracil （FP）. Results Comparing with lymph node sampling, the operation time for lymphadenectomy was prolonged. However, there was no increase in blood hiss, surgical morbidity, or mortality. Mean stations of lymph node dissected （ 10.5 stations vs. 3.2 stations, P 〈 0.001 ） and those proved of metastasis （ 1.1 stations vs. 0.6 stations, P = 0.038）were significantly increased through lymphadenectomy. The most frequent stations of lymph node metastasis were recurrent laryngeal nerve nodes （16.8%）, paraesophageal nodes （22.9%）, and left gastric artery nodes （16.8%）. Skip nodal metastasis was found in 10.4% cases. There was no significant difference between lymph node metastasis in the upper modiastinal （20.8%）, midand lower mediastinal （31.3%）, or upper abdominal regions （25.0%）. In 25% cases, surgery would have been palliative if not for metastatic lymph nodes be removed via lymphadenectomy. Moreover, in 12.5% cases the lunar was up-stagod as from pN0 to pN1 after lymphadenectomy. More than 2 courses （mean 3.1 courses） of FP were completed in 86.2% patients in adjuvant chemotherapy group and there was no treatment-related death. The 5-year survival after lymphadenectomy was signifieantly higher than that after lymph node sampling （36.4% vs. 24.9%, P = 0.049）. The 5-year survival of patients with adjuvant chemotherapy was also significantly higher than those were without chemotherapy （44.8% vs. 20.7%, P = 0.023）. Patients receiving lymphadenectomy and adjuvant chemotherapy had the highest 5-year survival （46.2%）, significantly higher than those were receiving lymph node sampling alone （ 19.4%, P = 0. 018）. Conclusion Thoraco-abdominal 2-field lymphadenectomy helps in 1 increasing the radical resection rate and the accuracy of surgical-pathological staging of thoracic esophageal carcinoma, with adjuvant chemotherapy, the combined modality treatment may improve the long-term prognosis of the disease.