选择性颈胸腹三野淋巴结清扫治疗胸段食管鳞癌

Selective three-field lymphadenectomy for thoracic esophageal squamous carcinoma

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%、23．0%、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。

Objective To investigate the lymph node metastasis and the rational lymphadenectomy in thoracic esophageal carcinoma. Methods Eighty-seven patients with thoracic esophageal squamous carcinoma received esophagectomy plus two-field or three-field lymphadenectomy based on cervical uhrasonography. Results Thirty-five patients （40.2%） with enlarged cervical nodes revealed by cervical uhrasonography received cervical lymphadenectomy. The proportion of cervical lymphadenectomy was 66. 7% （16/24） in upper thoracic esophageal carcinomas, significantly higher than 30.2% （19/63） in middle and lower esophageal carcinomas （ P = 0. 002） . Regional and cervical lymph node metastasis were found in 48（55.2% ） and 17 （19.5%） patients respectively. The regional lymph node metastatic rates were 37. 5% （9/24）, 62. 3% （33/53） and 60. 0% （6/10） respectively in the patients with upper, middle, and lower thoracic esophageal carcinoma. The cervical lymph node metastatic rates in the patients with or without regional lymph node metastasis were 31.3% （15/48） and 5.1% （2/39） respectively（P=0. 002） . The rates of upper, mid, lower mediastinal and upper abdominal lymph node metastasis were 25.3%, 23.0%, 5.7%, and 24. 1% respectively. Cervical lymph node metastasis was significandy correlated with upper and mid mediastinal metastssis（both P 〈 0. 01 ）, but not with lower mediastinal and upper abdominal lymph node metastasis. The overall postoperative morbidity rate was significantly higher in three field lymphadenectomy group than that in two field group（60. 0% vs. 34.6%, P =0.020） . Conclusion Selective 3-field lymphadenectomy based on cervical tdtrasonography should be performed in thoracic esophageal carcinoma, especially with upper and mid mediastinal lymph node metastasis.