新版食管癌TNM分期对外科治疗的指导意义

Clinical implications of the new TNM staging system for thoracic esophageal squamous cell carcinoma

目的以胸段食管鳞癌患者手术治疗结果来验证2009年第7版国际抗癌联盟制定的食管癌TNM分期（以下简称新版分期）对外科临床的指导意义。方法同顾性分析209例胸段食管鳞癌患者颈胸腹三野清扫或胸腹二野清扫的手术治疗结果，按照新版分期标准重新分期，并分析其与患者术后生存之间的关系。结果全组209例患者的术后5年总生存率为35．0％，病因生存率为38．8％。肿瘤浸润深度（T，P=0．004）、转移淋巴结枚数（N，P〈0．001）、远处淋巴结转移（M，P=0．003）、根治性切除（R，P=0．005）均与患者的术后5年生存率显著相关，而原发肿瘤部位（L，P=0．743）、肿瘤分化程度（G，P=0．653）与预后无关。进一步分层分析显示，T3期与T4a期患者的5年生存率差异无统计学意义（28．4％和32．0％，P=0．288），而与T4b期患者的5年生存率差异有统计学意义（28．4％和0，P〈0．001）。按转移淋巴结组数和野数进行单因素分析的结果显示，NO期（47．8％）、单组淋巴结转移（37．5％）与2组以上淋巴结转移者（11．3％）的5年生存率差异有统计学意义（P〈0．001）；NO期（47．8％）、1野淋巴结转移（34．2％）与2野淋巴结转移（12．1％）、3野淋巴结转移者（0）的5年生存率差异有统计学意义（P〈0．001）。颈淋巴结转移的M1期患者行根治性切除后的5年生存率为20．0％。Cox多因素回归分析的结果显示，肿瘤的浸润深度（P=0．001，RR=1．635）、淋巴结转移组数（P=0．043，RR=1．540）、淋巴结转移野数（P=0．010，RR=2．187）是影响食管癌患者术后生存的独立预后因素。结论新版分期能较好地反映胸段食管鳞癌患者的预后，肿瘤浸润程度和淋巴结转移范围是最再要的预后因素。提高术前临床分期的准确性，通过有效的综合治疗来提高手术切除根治性是改善食管癌患者长期疗效的关键。

Objective To evaluate THE clinical significance of the 2009 UICC staging system for thoracic esophageal squamous cell carcinoma. Methods Two hundred and nine patients with thoracic esophageal squamous cell carcinoma undergone selective cervico-thoraco-abdominal lymphadenectomy were reviewed retrospectively and restaged according to the new 2009 UICC staging system. The relationship between individual stages and survival were analyzed accordingly. Results The five-year overall and causespecific survivals were 35.0% and 38.8% , respectively. Depth of invasion （T, P = 0. 004 ） , number of metastatic lymph nodes （N, P 〈 0.001 ）, distant lymph node metastasis （M, P = 0.003）, complete resection （R, P = 0. 005 ） were significantly related to postoperative survival. On the other hand, location of primary tumor （L, P = 0. 743 ） and histological grade （G,P =0. 653 ） were not significantly related to longterm prognosis. Upon stratification, the 5-year survival for T4a （ 32.0% ） was significantly better than that of T4b （0, P 〈0.001）, but was similar to that of T3 （28.4%, P =0. 288）. Patients without nodal involvement （47.8%, P 〈 0. 001 ） and those with single station nodal disease （37.5%, P 〈 0. 001 ） had significantly better survival than patients having 2 or more stations of lymph node metastasis （ 11.3% ）. Also patients without nodal involvement and those with metastasis confined to a single field （34.2%） had significantly better survival than patients having nodal diseases in 2 fields （ 12.1% ） and 3 fields （0, P 〈 0. 001 ）. The 5-year survival for cervical metastasis after complete resection was 20.0%. Upon multivariate analysis, depth of tumor invasion （ P = 0. 001, RR = 1. 635 ） , numbers of metastatic nodal stations （ P =0. 043, RR = 1. 540） and fields （ P = 0. 010, RR = 2. 187 ） were revealed as independent risk factors for long-term survival. Conclusions The new UICC staging system effectively predicts long-term prognosis for thoracic esophageal squamous cell carcinoma. Depth of tumor invasion and extent of lymph node involvement are two most important prognostic factors. To improve surgical outcomes, much effort is needed to increase the accuracy of preoperative stag＇inK and to include effective induction therapies into a multidisciplinary setting.