食管癌术后纵隔各分区的淋巴结转移概率研究

Research on the probability of lymph nodes metastasis in mediastinum partition after esophageal carcinoma surgery

目的:分析各段食管癌术后局部复发模式,探讨食管癌术后辅助性调强放疗的靶区勾画技巧,缩小照射野,降低放疗毒副作用。方法:收集589例接受根治性切除的食管癌患者临床资料。其中术后复发157例,淋巴结复发83.4%(131例),瘤床复发9.6%(15例,包括合并淋巴结复发6例),吻合口复发5.7%(9例,包括合并淋巴结复发4例,合并残胃复发1例),残胃复发1.3%(2例)。结果:各段食管癌术后的复发模式以区域淋巴结转移为主,食管癌淋巴结复发仍以纵隔淋巴结转移为主,纵隔1R区淋巴结复发明显高于其他分区,并且没有纵隔5区淋巴结复发。贲门癌以腹腔淋巴结复发为主;T4、T3、T2期患者手术后瘤床复发的风险分别为19.1%、1.4%、1.5%,瘤床复发主要为T4期患者。结论:临床上做食管癌术后辅助性调强放疗时,CTV可以根据不同部位食管癌的复发模式及淋巴结转移规律进一步缩小照射野。食管癌根治术后放疗靶区应设计为:上段食管癌应包括双锁骨上,纵隔1、2、4、7、3P区,瘤床,吻合口;中、下段食管癌术后放疗靶区包括双锁骨上,纵隔1、2、4、7、3P区,吻合口。T4期患者包括瘤床即可,瘤床下界置于原发灶下界即可。T3以上患者由于瘤床复发几率很低,可甩掉瘤床的照射。对于术后清扫贲门或胃左淋巴结阳性的患者可照射腹腔淋巴结引流区,包括腹腔3、7、8、9、16a组淋巴引流区;贲门癌包括瘤床,腹腔3、7、8、9、10、11、16a组淋巴引流区。

Objective：To analyze the recurrence patterns at different parts of esophagus,and discuss the skill of delineating the target area which underwent adjuvant postoperative intensity - modulated radiotherapy, so that both the radiation field and side effects of radiotherapy can be reduced. Methods： Clinical data of 589 patients, who accepted radical resection of esophageal neoplasm, were collected, 157 cases relapsed after the surgery,83. 4% （131 cases） lymph node recurrence,9. 6% recurrence of the tumor bed（15 cases including 6 cases lymph node recurrence）, 5.7% anastomot- ic recurrence（9 cases,including 4 cases lymph node recurrence and 1 case merger remnant stomach）, 1.3% recur- rence of gastric remnant（2 cases）. Results ：Regional lymph node metastasis was the mainly recurrence patterns after esophageal carcinoma surgery. For the patients who accepted esophageal carcinoma surgery, mediastinal lymph node metastases was main pattern of lymph node recurrence. Rate of mediastinal 1 R lymph node recurrence was significant- ly higher than other divisions, and there was no mediastinal lymph node recurrence in division 5. Abdominal lymph re- currence was main pattern to cardia cancer. T4 ,T3 ,T2 ,patients with risk of recurrence of the tumor bed after surgery was 19.1%, 1.4%, 1.5 %, T4 patients had a much higher rate than others. Conclusion： When we do postoperative in- tensity - modulated radiotherapy clinically, according to the recurrence pattern of the different parts of the esophageal cancer and lymph node metastasis, CTV can further reduce the radiation field. Radical resection of esophageal cancer should be designed as follows：After surgery for upper esophageal carcinoma, the area should include double supracla- vicular, mediastinal 1,2,4,7,3P region, tumor bed, anastomosis ; For the middle and lower esophageal cancer, postop- erative radiotherapy target volume should include double clavicle mediastinal 1,2,4,7,3P region, anastomotic. The target area for T4 patients can just include tumor bed and keep tumor bed~ lower bound together with the lower bound of primary focus. Get rid of tumor bed irradiation for T3 , T2, Tl patients because of their low recurrence rate. After the surgery, the patient who accepts cardia cleaning or whose left gastric lymph node tests positive, should be given an ir- radiation for abdominal lymph drainage area,including abdominal lymph drainage area 3/7/8/9/16a;The target area for patients with cardiac cancer include tumor bed and abdominal lymph drainage area 3/7/8/9/10/11/16a.