改良Ivor-Lewis手术或Sweet手术联合放化疗治疗胸段食管鳞癌的疗效分析

Comparative analysis on the modified Ivor-Lewis esophagectomy or Sweet esophagectomy plus postoperative chemoradiotherapy in the treatment of thoracic esophageal squamous cell carcinoma

目的回顾性分析改良Ivor-Lewis手术或Sweet手术后辅助放化疗治疗胸段食管鳞癌的疗效及影响预后的危险因素。方法 914例胸段食管鳞癌患者按不同术式分为改良Ivor-Lewis手术组(n=424例)和Sweet手术组(n=490);其中Ⅱ期及以上患者按术后有无联合放化疗分为单纯手术组(n=297)与术后辅助放化疗组(n=446)。采用Kaplan-Meier法计算总生存(OS),Log-rank检验比较不同手术方式及术后是否联合放化疗患者的生存差异,Cox比例风险模型分析影响预后的危险因素。结果改良Ivor-Lewis术组与Sweet术组患者的1、3、5年生存率分别为86.3%、63.7%、44.5%和90.2%、64.9%、45.0%。单纯手术组与术后辅助放化疗组的中位OS分别为36.1个月和46.1个月(P=0.004)。改良Ivor-Lewis术组单纯手术者和术后辅助放化疗者的中位OS分别为34.6个月和46.8个月,差异有统计学意义(P=0.038)。Sweet术组单纯手术者和术后辅助放化疗者的中位OS分别为37.0个月和45.1个月,差异有统计学意义(P=0.036)。2种术式无论是单纯手术亚组之间或术后联合放化疗亚组之间的中位OS比较,差异均无统计学意义(P>0.05)。改良Ivor-Lewis术Ⅱ期患者术后接受放化疗的中位OS较单纯手术者并未明显获益(P>0.05),在Sweet术Ⅱ期患者中也得到相似结果(P>0.05);Ⅲ期及以上患者术后接受辅助放化疗,其中位OS相较单纯手术者获得改善(P<0.05)。Cox比例风险模型分析显示,年龄、组织学分化程度、切端、癌栓、浸润深度、阳性淋巴结数、UICC分期、是否接受术后辅助放化疗均为影响预后的独立因素,而手术方式的选择与预后无关(P>0.05)。结论改良Ivor-Lewis术和Sweet术均可选择作为胸段食管鳞癌的手术方式,应根据患者的实际情况综合分析并制定个体化治疗方案。对于Ⅲ期及以上患者,术后辅助放化疗能够有效改善预后。

Objective To retrospectively investigate the efficacy of modified Ivor-Lewis esophagectomy or Sweet esophagecto- my plus postoperative chemoradiotherapy in the treatment of thoracic esophageal squamous cell carcinoma and analyze the risk factors affecting the prognosis. Methods Ninety hundred and fourteen patients with thoracic esophageal squamous cell carcinoma were divided into modified Ivor-Lewis esophagectomy group （n = 424）or Sweet esophagectomy group （n = 490）. For the patients with stage Ⅱ and a- bove, they were divided into single operation group（ n = 297） and postoperative chemoradiotherapy group（ n = 446）. The patients were followed up and the survival time was calculated by Kaplan-Meier method. Difference in survival time was compared by Log-rank test. Cox regression analysis was performed to identify risk prognostic factors. Results The 1-, 3-, 5-year survival rates of modified Ivor- Lewis esophagectomy group and Sweet esophagectomy group were 86.3%, 63.7%, 44. 5% and 90. 2%, 64. 9%, 45.0%, respectively. In stage U and above patients, the median overall survival（OS） was 36. 1 and 46. 1 months in patients with single opera- tion and surgery plus postoperative chemoradiotherapy respectively（ P= 0. 04）. The median OS was 34. 6 and 46. 8 months in patients with single operation and surgery plus postoperative chemoradiotherapy on modified Ivor-Lewis esophagectomy respectively, between which there was significant difference （P = 0. 038）. The median OS was 37.0 and 45.1 months in patients with single operation and sur- gery plus postoperative chemoradiotherapy on Sweet esophagectomy respectively, between which there was significant difference （P = 0. 036）. The median OS were no statistical difference among the subgroups in the single operation group or surgery plus postoperative chemoradiotherapy group（ P〉0. 05）. For the patients of stage Ⅱ , the median OS of surgery plus postoperative ehemoradiotherapy group was not higher than single operation group on modified Ivor-Lewis or Sweet esophagectomy（ P〉0. 05）. For the patients with stage Ⅲ/ IV, the median OS of surgery plus postoperative chemoradiotherapy group was higher than single operation group（P〈0. 05）. Cox pro- portional hazards model showed that age, histological differentiation, positive margin, depth of invasion, vascular cancer thrombus, positive lymph node, UICC stage and adjuvant radiation and chemotherapy postoperatively were prognostic factors for overall survival （ P〈0. 05）. Conclusion Both of modified Ivor-Lewis esophagectomy and Sweet esophagectomy are ideal operation method to treat tho- racic esophageal squamous cell carcinoma. Postoperative chemoradiotherapy could improve overall survival for patients with stage Ⅲ and above.