pT3NOM0期胸段食管鳞癌胸腹两野根治术后的复发模式

Patterns of recurrence in patients with stage pT3NOM0 thoracic esophageal squamous cell carcinoma after two-field esophagectomy

目的探讨pT3NOM0期胸段食管鳞癌患者胸腹两野根治术后的复发模式及影响因素。方法分析2008--2009年胸段食管鳞癌患者行胸腹两野淋巴结清扫术、术后病理国际抗癌联盟分期为pT3NOM0期的208例患者的临床资料。其中男138，女70例；中位年龄60岁；病变位于胸上段33例，胸中段134例，胸下段41例。98例患者行单纯手术，110例患者行术后辅助化疗。结果208例患者的复发率为41．8％（87／208），其中局部区域复发者52例，远处转移者15例，局部区域复发合并远处转移者20例。1、3、5年无进展生存率分别为83．0％、62．8％和56．3％；术后1、2、3、4年内进展者所占比例分别为40．2％（35／87）、67．8％（59／87）、86．2％（75／87）和100％（87／87）。总局部区域复发率为34．6％（72／208），1、3、5年局部区域复发率分别为15．6％、32．2％和36．8％，中位局部区域复发时间为15．5个月；其中颈部复发9例，纵隔复发66例，腹腔复发4例，吻合口复发16例，局部瘤床区复发14例；隆突及以上部位复发者所占比例为83．3％（60／72），隆突以下复发者所占比例为16．7％（12／72）。术后总远处转移率为16．8％（35／208），以肺和骨转移最常见；术后1、3、5年远处转移率分别为4．4％、15．3％和20．1％，中位远处转移时间为24个月。单因素分析结果显示，年龄和肿瘤位置与患者术后的无进展生存有关（P〈0．05），肿瘤位置和术前纵隔小淋巴结与患者术后的局部区域复发有关（均P〈0．05），肿瘤位置、病理分化程度和术后局部区域复发与患者的远处转移有关（P〈0．05）；多因素分析结果显示，肿瘤位置为影响患者无进展生存和局部区域复发的独立危险因素（P〈0．05），病理分化程度和术后局部区域复发为影响患者远处转移的独立危险因素（均P〈0．05）。结论pT3NOM0期胸段食管鳞癌患者胸腹两野术后复发率很高，且多在术后3年内，局部区域复发率明显高于远处转移率、且出现时间早，局部区域复发最常见的部位为隆突及以上；胸上段癌复发率很高，强烈建议术后放疗；胸中段癌复发率较高，推荐术后放疗；胸下段癌复发率较低，不推荐常规术后放疗。低分化鳞癌和有局部区域复发者，远处转移率高。

Objective To evaluate the patterns of recurrence and the related factors in patients with pT3NOM0 thoracic esophageal squamous cell carcinoma （ESCC） after two-field esophageetomy. Methods From Jan 2008 to Dec 2009, 208 patients with stage pT3NOM0（2002, UICC） thoracic ESCC were treated with two-field esophagectomy in our hospital. There were 138 males and 70 females, and the median age was 60 years old （range 33-78）. There were 33 patients in the upper-, 134 in the middle-, and 41 in the lower- thoracic esophagus, with a median length of lesion of 5 era. There were 32 patients with no-, 78 with mild- and 98 patients with severe adhesions at surgery. The median number of dissected lymph nodes was 9 （ range 1-27）. 98 patients were treated with surgery alone and 110 with postoperative adjuvant chemotherapy. The statistical analysis was conducted using SPSS 13.0 software. Results The follow-up was ended on July 2013. In the total group of 208 patients, the total recurrence rate was 41.8% （87/208）. Among them, 52 patients had loeoregional recurrence （LR）, 15 had distant metastasis （DM） and 20 patients had both local recurrence and distant metastasis. 40.2% （35/87） of all recurrences were found within one year after operation, 67.8% （59/87） within 2 years, 86.2% （75/87） within 3 years, and 100% （87/87） within 4 years. The 1-, 3-, and 5-year progression-free survival （PFS） rate was 83.0%, 62.8% and 56.3%, respectively. The overall loeoregional recurrence rate was 34.6% （72/208）, among them, 9 cases had recurrence in the cervix （all were supraclavicular lymph node metastasis）, 66 cases in the mediastinum and 4 cases had para-aortic lymph node metastasis. 83.3% （60/72） of the locoregional recurrence was located in the carinal region or upper area. The 1-, 3-, 5-year locoregional recurrence rate was 15.6%, 32.2%, and 36.8%, respectively, and the median time of recurrence was 15.5 months. The overall distant metastasis （DM） rate was 16.8% （35/208）. The 1-, 3-, and 5-year DM rate was 4.4%, 15.3%, and 20.1%, respectively, and the median time of DM was 24 months. The most common site of DM was the lung and bone. The univariate analysis showed that age and tumor site were associated with PFS, tumor site and small lymph node in the mediastinum （diamter 〈 1 era） before surgery were related with LR （P〈0.05 for all） , and tumor site, histological differentiation and LR were related with distant metastasis after surgery （P〈0.05）. Multivariate analysis showed that the tumor site was an independent prognostic factor affecting the progression-free survival and locoregional recurrence （P〈0.05）, and histological differentiation and LR were independent factors associated with distant metastasis （P〈0.05 for all）. Conclusions The recurrence rate is very high in patients with pT3NOM0 thoracic ESCC after surgery, and most of them occur within 3 years after operation. Locoregional recurrence occurs more frequently and shortly than distant metastasis, and most of LR is located in the carinal region or upper-mediastinum. LR rate in upper-thoracic ESCC is very high, therefore, postoperative radiotherapy （PORT） is strongly suggested. LR rate in middle thoracic ESCC is also rather high and PORT is suggested. LR occur much less in the lower-thoracic ESCC, thus, PORT is not suggested routinely. Patients with poorly differentiated ESCC and LR have a high rate of distant metastasis.