三野与二野淋巴结清扫对胸段食管鳞癌患者术后生存的影响

Comparison of survival between three-field and two-field lymph node dissections for thoracic esophageal squamous cell carcinoma

目的 对照三野与二野淋巴结清扫对胸段食管鳞癌患者术后生存的影响,探讨能从三野淋巴结清扫中获益的患者亚群.方法 1999年至2007年福建省肿瘤医院接受颈胸腹三切口根治性手术的胸段食管鳞癌患者1 551例,分别接受三野淋巴结清扫（1 131例）与二野淋巴结清扫（420例）.回顾性分析患者的临床资料及区域淋巴结转移情况,采用Kaplan-Meier方法分析食管癌患者的术后生存,不同组别之间的生存比较采用Log-Rank检验;采用Cox比例模型对食管癌患者预后相关因素进行多因素回归分析.结果 三野组与二野组在患者年龄、性别及肿瘤浸润深度方面无显著差异;两组患者在肿瘤位置、淋巴结转移及病理分期上具有明显差异,三野组相对二野组胸上段癌比例更高（17.6％对9.8％）,淋巴结转移率更高（62.7％对52.9％）;三野组N分期及TNM分期均偏晚.Cox多因素回归分析显示,淋巴结清扫方式（三野组对二野组,P =0.001）是胸段食管鳞癌患者的独立预后因素.对胸上段食管鳞癌,三野淋巴结清扫相对于二野淋巴结清扫能显著延长患者术后生存（P=0.002,5年生存率53.2％对34.1％）.胸中下段食管鳞癌患者,如无淋巴结转移（N0）,三野清扫有延长术后生存的趋势（5年生存率77.5％对70.7％）,但差异无统计学意义（P=0.235）;淋巴结转移个数为1～6个（N1～2）的胸中下段食管鳞癌,如伴有纵隔淋巴结转移,三野淋巴结清扫相对于二野清扫能显著延长患者术后生存（P =0.006,5年生存率41.1％对32.8％）;淋巴结转移≥7个（N3）的胸中下段食管鳞癌,增加颈部淋巴结清扫无明显的生存获益.结论 淋巴结清扫方式是胸段食管鳞癌患者的独立预后因素.胸上段食管鳞癌及淋巴结转移1～6个且伴有纵隔淋巴结转移的胸中下段食管鳞癌,行三野淋巴结清扫较二野淋巴结清扫能显著延长患者术后生存.

Objective To compare survival according to the extent of lymph node dissection in patients with thoracic esophageal squamous cell carcinoma.To identify the subgroups of patients that could get survival benefit from three-field lymph node dissection.Methods Between January 1999 and December 2007,1551 patients with thoracic esophageal squamous cell carcinoma received esophagectomy plus three-field lymph node dissection （3 FL） （n =1131） or two-field lymph node dissection （2FL） （n =420）.We retrospectively analyzed the clinical characteristics and patterns of lymphatic spread of thoracic esophageal squamous cell carcinoma.Survival rates between 3FL and 2FL were compared using the Kaplan-Meier method and Log-Rank test.Multivariate analysis were also performed to assess the element which affect the survival in 3FL and 2FL group by Cox regression.Results No significant differences in age,gender and depth of tumor invasion were found between 3 FL group and 2FL group.The 3FL group included more patients with upper thoracic esophageal tumors（17.6% vs.9.8%） and patients with lymph node metastasis（LNM） （62.7% vs.52.9%）.Cox-proportional multivariate analysis showed that extent of lymph node dissection（3FL vs 2FL） was a significant prognostic factor in overall survival; 3 FL was beneficial for patients with upper thoracic esophageal tumors（P =0.002,5-year survival rate 53.2% vs.34.1%）.The 3FL group in patients with middle/lower thoracic esophageal tumors who had no LNMs（N0） had better 5-year survival than the 2FL group（5-year survival rate 77.5% vs.70.7%）,but no significant differences were found （P =0.235）.or; Among patients with middle/lower thoracic esophageal tumors who had 1-6 LNMs （N1-N2）,3 FL was beneficial for patients with mediastinum LNMs （P =0.006,5-year survival rate 41.1% vs.32.8%） For patients with ≥7 LNMs（N3）,cervical lymphadenectomy did not show additional survival benefits.Conclusion Our findings suggest that extent of lymph node dissection（3FL vs 2FL） is a significant prognostic factor for thoracic esophageal squamous cell carcinoma.3FL offers survival benefit over 2FL in patients with upper thoracic esophageal tumors or patients with middle/lower thoracic esophageal tumors who have 1-6 LNMs with mediastinum lymph node metastasis.