胸段食管鳞癌三野淋巴结清扫术的治疗效果和选择条件

Clinical outcomes and selection conditions of three-field lymph node dissection for thoracic esophageal squamous cell carcinoma

目的分析胸段食管鳞癌患者选择性行三野淋巴结清扫术的颈部淋巴结清扫效率和手术并发症。方法根据患者的全身情况、术前估计肿瘤T分期、肿瘤部位、术前颈部CT和彩超检查颈部淋巴结长短径大小以及术中判断转移淋巴结数目，将符合入选条件的85例胸段食管鳞癌患者进行选择性三野淋巴结清扫术。结果在187例同期手术的胸段食管鳞癌患者中，根据条件共选择85例（45．5％）患者实施三野淋巴结清扫术，颈部淋巴结转移率为40．0％（34／85）。颈部CT和彩超检查提示，颈部淋巴结肿大者73例，而胸上段、胸中段、胸下段食管癌病理检测淋巴结阳性率分别为68．4％（13／19）、41．7％（20／48）和16．7％（1／6）。12例胸上段癌术前颈部CT和彩超未发现淋巴结肿大者均无颈部淋巴结转移。上纵隔淋巴结有转移者中，颈淋巴结转移率为79．3％（23／29），与无转移者（8．9％，5／56）的差异有统计学意义（r=42．844，P〈0．001）。中纵隔淋巴结有转移者中，颈淋巴结的转移率为58．6％（17／29），与无转移者（7．1％，4／56）的差异亦有统计学意义（x^2=27．217，P〈0．001）。全组85例患者均无围手术期死亡，术后肺部并发症和总的并发症的发生率分别为24．7％（21／85）和42．4％（36／85）。结论胸段食管鳞癌患者根据条件选择进行三野淋巴结清扫术可以降低手术并发症的风险，提高颈部转移淋巴结的清扫效率。胸部CT显示胸段气管食管沟淋巴结阳性也应作为胸段食管癌患者实施三野淋巴结清扫术的条件之一。胸上段食管癌亦应选择性实施三野淋巴结清扫术，胸下段食管癌应提高选择条件的标准。

Objective To analyze the efficiency of cervical lymph node metastasis dissection and postoperative morbidity after selective three-field lymph node dissection （3FLND） for thoracic esophageal squamous cell carcinoma, and explore the proper selection conditions. Methods According to the conditions as follows ： systemic evaluation, tumor T staging, tumor location, cervical CT and ultrasonography and the number of lymph nodes metastases, 85 patients with thoracic esophageal squamous cell carcinoma were selected and received 3FLND. Results In the same period 45.5% （ 85/187 ） of the patients received 3FLND selectively based on the conditions. The rate of the cervical lymph nodes metastasis was 40.0% （ 34/85 ）. The rate of the cervical positive lymph nodes of the upper, middle and lower thoracic esophageal carcinomas with enlarged lymph nodes suggested by cervical CT and ultrasonography was 68.4% （13/19） , 41.7% （20/48） and 16. 7% （1/6） , respectively. Twelve patients with upper thoracic esophageal carcinoma with enlarged lymph nodes unrevealed by cervical CT and ultrasonography showed no histopathological lymph node metastasis. In the same period 17. 1% （32/187） of the patients were selectively not undergone three-field lymph node dissection. The cervical lymph node metastasis rates in patients with upper and middle mediastinal lymph node metastasis were 79.3% （23/29） and 58.6% （17/29）, significantly higher than 8. 9% （5/56） and 7. 1% （4/56） in the patients without upper and middle mediastinal lymph node metastasis （ P 〈 0. 05 ）. There was no in-hospital mortality in the group. The incidence of pulmonary complications and over-all postoperative morbidity was 24. 7% and 42.4% ,respectively.Conclusions Selective 3FLND based on certain conditions can reduce the risk of postoperative morbidity and improve the efficiency of metastatic cervical lymph node dissection in thoracic esophageal squamous cell carcinoma. The thoracic tracheoesophageal groove positve lymph node indicated by CT scans should be one of selective conditions for 3FLND. The upper thoracic esophageal carcinoma should selectively receive 3FLND. The selection standards should be more strict for the lower thoracic esophageal carcinoma.