胸段食管鳞癌肝总淋巴结清扫的策略

Discussion on the strategies of common hepatic artery lymph node dissection for thoracic esophageal squa- mous cell carcinoma

目的分析胸段食管鳞癌中肝总淋巴结转移规律，探讨肝总淋巴结清扫的策略。方法回顾性分析2005年5月至2010年12月复旦大学附属肿瘤医院收治的682例食管鳞癌患者的临床资料。分析胸段食管鳞癌区域淋巴结转移情况、肝总淋巴结转移率与临床病理因素的关系及患者术后近期并发症发生情况。计数资料采用x2检验。结果682例胸段食管鳞癌患者共清扫淋巴结18277枚，平均清扫27枚／例，淋巴结转移率为55．87％（381／682），淋巴结转移度为7．87％（1438／18277）。在所有清扫的淋巴结中，贲门旁淋巴结、喉返神经旁淋巴结、胃小弯淋巴结、颈段食管旁淋巴结、胃左动脉旁淋巴结转移率较高，而肝总淋巴结转移率最低，并且无单独肝总淋巴结转移，全部伴有区域淋巴结转移。682例患者共清扫肝总淋巴结1480枚，平均清扫2枚／例。24例患者发生肝总淋巴结转移，淋巴结转移率为3．52％（24／682），淋巴结转移度为2．16％（32／1480）。胸上、中、下段食管鳞癌肝总淋巴结转移率分别为2．33％（1／43）、3．76％（16／425）、3．27％（7／214），3者比较，差异无统计学意义（x^2=0．295，P〉0．05）；T1、T2、T3期患者的肝总淋巴结转移率分别为2．35％（2／85）、5．46％（10／183）、2．90％（12／414），3者比较，差异无统计学意义（x^2=2．850，P〉0．05）；高、中、低分化食管鳞癌患者肝总淋巴结转移率分别为0（0／63）、3．50％（16／457）、4．94％（8／162），3者比较，差异无统计学意义（x^2=3．259，P〉0．05）；肿瘤直径≤3em、〉3CA且≤5cm、〉5cm的患者肝总淋巴结转移率分别为2．59％（6／232）、3．02％（11／364）、8．14％（7／86），3者比较，差异有统计学意义（X^2=6．267，P〈0．05）；N分期中N0、N1、N2、N3期患者的肝总淋巴结转移率分别为0（0／301）、2．53％（5／198）、5．65％（7／124）和20．34％（12／59），4者比较，差异有统计学意义（，=62．368，P〈0．05）；肿瘤TNM分期中I、Ⅱ、Ⅲ、Ⅳ期患者肝总淋巴结转移率分别为O（O／62）、1．78％（6／337）、5．06％（13／257）、19．23％（5／26），4者比较，差异有统计学意义（X2＝25．959，P〈0．05）。228例患者术后出现并发症，并发症发生率为33．43％（228／682），其中吻合口瘘的发生率最高，发生率为11．58％（79／682）。结论胸段食管鳞癌区域淋巴结转移中肝总淋巴结转移率最低，对于I期或者肿瘤直径45cm的食管鳞癌患者，手术过程中可考虑不常规行肝总淋巴结清扫。

Objective To analyze the metastatic rule of common hepatic artery lymph node of thoracic esophageal squamous cell carcinoma, and to investigate the strategies of common hepatic artery lymph node dissec tion. Methods The clinical data of 682 patients with esophageal squamous cell carcinoma who were admitted to the Cancer Hospital of Fudan University from May 2005 to December 2010 were retrospectively analyzed. The locoregional lymph node metastasis of thoracic esophageal squamous cell carcinoma, relationship between metastatic rates of common hepatic artery lymph node and clinicopathological factors and the postoperative complications were analyzed. The enumeration data were analyzed using the chi-square test. Results A total of 18 277 lymph nodes were dissected （27 lymph nodes per patient）. The lymph node metastatic rate was 55.87% （381/682）, and themetastatic lymph node ratio was 7.87% （ 1438/18 277）. Lymph nodes adjacent to the cardia of stomach, laryngeal nerve, lesser curvature of stomach, cervical esophagus, left gastric artery had a higher metastatic rate, while com mon hepatic artery lymph node had a lower metastatic rate. All the common hepatic artery lymph node metastasis was accompanied with locoregional metastasis. A total of 1480 common hepatic artery lymph nodes were dissected （2 common hepatic artery lymph nodes per patient）. Twenty-four patients had common hepatic artery lymph node metastasis, with the metastatic rate of 3.52% （24/682） and the lymph node ratio of 2. 16% （32/1480）. The common hepatic artery lymph node metastatic rates of upper, middle and lower esophageal squamous cell carcinoma were 2.33% （1/43）, 3.76% （16/425） and 3.27% （7/217）, with no significant difference （X2 = 0. 295, P 〉 0.05 ）. The common hepatic artery lymph node metastatic rates of patients in T1, T2 and T3 stages were 2.35% （2/85） , 5.46% （ 10/183 ） and 2.90% （ 12/414）, with no significant difference （X2 = 2. 850, P 〉 0.05 ）. The common hepatic artery lymph node metastatic rates of patients with high, moderate and poor differentiated esophageal squamous cell carcinoma were 0（0/63）, 3.50% （16/457） and 4.94% （8/162） , with no significant difference （X2= 3. 259, P 〉 0.05）. The common hepatic artery lymph node metastatic rates of patients with diameter of tumor under 3 era, 3-5 em and above 5 em were 2.59% （6/232） , 3.02% （11/364） and 8.14% （7/86）, with significant difference （X2 = 6. 267, P 〈 0.05 ）. The common hepatic artery lymph node metastatic rates of patients in NO, N1, N2, N3 stages were 0（0/301 ）, 2.53% （5/198）, 5.65% （7/124） and 20.34% （ 12/56）, with significant difference （X2 = 62. 368, P 〈 0.05 ）. The common hepatic artery lymph node metastatic rates of patients in stage Ⅰ , Ⅱ, Ⅲ and 1V were 0（0/62）, 1.78% （6/337）, 5.06% （13/257） and 19.23% （5/26）, with significant difference （X2 = 25. 959, P 〈 0.05 ）. Two hundred and twenty-eight patients had postoperative complications with the complication rate of 33.43% （228/682）. The incidence of anastomotic fistula was the highest, which was 11.58% （79/682）. Conclusions The metastatic rates of common hepatic artery lymph node in thoracic esophageal squa mous cell carcinoma is the lowest. For patients suffered from esophageal cancer in stage I or the tumor diameter under 5 cm, the dissection of common hepatic lymph node can he ommitted in surgery.