根据胸段食管癌淋巴结转移规律探讨术后预防性照射范围和适应证

Pattern of lymph nade metastasis in determining the indication and target of post-operative prophylactic radiotherapy for thoracic esophageal carcinoma

目的研究胸段食管癌淋巴结转移规律，探讨术后预防性照射范围和适应证。方法选择行根治性切除、胸腹2个野淋巴结清扫术的胸段食管癌229例，分析不同病变部位淋巴结转移主要方式和转移规律，探讨不同病变长度和病理学分期对淋巴结转移度的影响，为胸段食管癌术后预防性照射范围和适应证选择提供参考。结果胸上段食管癌局部转移达57．1％；胸中段食管癌局部转移、跳跃转移、上行转移、下行转移和双向转移分别为39．0％、19．5％、5．2％、28．6％和7．8％；胸下段食管癌下行转移占72．2％。上纵隔、中纵隔、下纵隔和腹部淋巴结转移度胸上段食管癌分别为19．0％、6．7％、9．8％和14．3％（X^2=2．75，P=0．433），胸中段食管癌分别为26．1％、7．4％、11．8％和11．9％（X^2=17．98，P=0．000），胸下段食管癌分别为0％、1．6％、5．3％和10．0％（X^2=5．96，P=0．051）。食管癌标本病变长度≤3、〉3～5、〉5cm组淋巴结转移度分别为9．1％、11．6％、11．7％（X^2=3．93，P=0．140）。Ⅲ期食管癌淋巴结转移度为19．3％，明显高于0-Ⅱ期的4．8％（X^2=131．06，P=0．000）。结论胸段食管癌淋巴结转移情况极为复杂且较为广泛，胸上和胸中段食管癌大野照射有一定理论依据，上纵隔应为重点照射区域；而胸下段食管癌似乎可适当缩小照射范围。Ⅲ期患者淋巴结转移度较高，是术后预防性照射的主要适应证。

Objective To study the pattern of lymphatic metastasis in patients with thoracic esophageal carcinoma, and to determine the indication and the target volume for post-operative radiotherapy. Methods 229 patients with thoracic esophageal carcinoma who had undergone radical esophageetomy and twofield lymph node dissection were included in this study. The pattern and ratio of lymph node metastasis were analyzed. The effect of the tumor length and pathology stage on lymph node metastasis was studied. Then the indication and target of post-operative radiotherapy for the thoracic esophageal carcinoma was determined. Results Regional lymph node metastasis was found in 57.1% patients with upper thoracic esophageal carcinoma. For the middle thoracic esophageal carcinoma, the ratio of regional metastasis, skip, upward, downward and two-way spread were 39.0% , 19.5% ,5.2% ,28.6% and 7.8% , respectively. For lower thoracic esophageal carcinoma, downward spread was found in 77.2% patients. For upper thoracic esophageal carcinoma,the proportions of patients with lymph node metastasis were 19.0% ,6.7% ,9.8% and 14.3% in the superior mediastinum, middle mediastinum, inferior mediastinum and abdominal cavity （ X2 = 2.75, P = 0. 433）. The corresponding figures were 26.1% ,7.4% , 11.8% and 11.9% （ X2 = 17.98,P = O. 000） for middle thoracic esophageal carcinoma, and 0% , 1.6% ,5.3% and 10.0% （X2 = 5.96,P = 0. 051 ） for lower thoracic esophageal carcinoma. The lymph node metastasis ratios were 9.1% , 11.6% and 11.7% in patients with tumor ≤3 cm,3-5 cm and 1〉5 cm,respectively （X2=3.93,P=0,140）, and were much higher in stage m disease than those in stage 0 to Ⅱ （ 19.3% vs 4.8% ;X2 = 131.06,P =0. 000）. Conclusions he pattern of lymph node metastasis is complex and extensive in patients with thoracic esophageal carcinoma.For upper and middle thoracic esophageal carcinoma, the extended prophylactic portal is suggested and the superior mediastinum is an important target area. For the lower thoracic esophageal carcinoma,it seems that regional fields could be applied. Post-operative radiotherapy should be performed in stage Ⅲ disease because of the high lymph node metastasis ratio.