食管癌术前3DRT和同期放化疗疗效分析

Clinical efficacy of preoperative three.dimensional radiotherapy with or without concurrent chemotherapy for esophageal carcinoma

目的探讨术前3DRT、同期放化疗联合手术对食管癌疗效的影响。方法回顾比较我院2004--2014年间103例食管癌术前3DRT（25例）、同期放化疗（78例）的疗效。两组中位放疗剂量40Gv。同期化疗以铂类为主的TP或PF方案。Kaplan—Meier法计算Os和DFS，Logrank法检验单因素预后情况，Cox模型多因素预后分析。结果全组3年样本量为54例，3年OS、DFS分别为61．1％、54．9％。术前3DRT、同期放化疗病理反应率相近（P=0．953），OS、DFS均相近（P=0．876、0．521）。术后原发灶为重、中、轻度病理反应率分别为48．0％、40．2％、11．8％，其0s和DFS均不同（P=0．037、0．003）。术后淋巴结转移率为26．5％，随原发灶病理反应程度降低淋巴结转移率增高，重、中、轻度的分别14％、30％、67％（P=0．001）。淋巴结阴性组OS、DFS明显高于淋巴结阳性组（P=0．034、0．020）。全组手术相关死亡率为7．8％，术前同期放化疗组白细胞下降、中性粒细胞下降、放射性食管炎、胃肠道反应发生率均较术前3DRT高（P=0．002、0．023、0．008、0．023）。多因素分析结果显示病理反应、疗前体重下降是OS和DFS的影响因素（P=0．030、0．024和0．003、0．042）。结论术前3DRT无论是否合并化疗均获得较高重度病理反应率，从而提高了生存率。术前同期放化疗在不增加不良反应前提下是否较术前3DRT生存更高还需进一步随机研究结果的证实。

Objective To investigate the clinical efficacy of preoperative three-dimensional radiotherapy （3DRT） with or without concurrent chemotherapy for esophageal carcinoma. Methods We retrospectively analyzed 103 esophageal carcinoma patients who received preoperative 3DRT with or without concurrent chemotherapy from 2004 to 2014 in Cancer Hospital CAMS. The median radiation dose was 40 Gy, and the TP or PF regimen was adopted for concurrent chemotherapy if needed. The overall survival （OS） and disease-free survival （DFS） were calculated by the Kaplan-Meier method, and the survival difference and univariate prognostic analyses were performed by the log-rank test. The Cox proportional hazards model was used for multivariate prognostic analysis. Results The number of patients followed at 3- years was 54.The 3-year OS and DFS rates were 61.1% and 54. 9%, respectively, for all patients. There were no significant differences between the 3DRT and concurrent chemoradiotherapy （CCRT） groups as to OS （P= 0. 876） and DFS （P= 0. 521 ）. The rates of complete, partial, and minimal pathologic responses of the primary tumor were 48.0%, 40.2%, and 11.8%, respectively. There were significant differences in OS and DFS between the complete, partial, and minimal pathologic response groups （P= 0. 037 and 0. 003）. No significant difference in pathologic response rate was found between the 3DRT and CCRT groups （P= 0. 953）. The lymph node metastasis rate was 26. 5%, and this rate for the complete, partial, and minimal pathologic response groups was 14%, 30%, and 67%, respectively, with a significant difference between the three groups （ P= 0. 001 ）. The OS and DFS were significantly higher in patients without lymph node metastasis than in those with lymph node metastasis （P= O. 034 and 0. 020）. The surgery-related mortality was 7.8% in all patients. Compared with the 3DRT group, the CCRT group had significantly higher incidence rates of leukopenia （P= 0. 002）, neutropenia （ P= 0. 023）, radiation esophagitis （ P= 0. 008）, and radiation esophagitis （ P= O. 023 ）. Pathologic response of the primary tumor and weight loss before treatment were independent prognostic factors for OS and DFS （P= 0. 030,0. 024 and P= 0. 003,0. 042）. Conclusions Preoperative 3DRT alone or with concurrent chemotherapy can result in a relatively high complete pathologic response rate, hence increasing the survival rate. Further randomized clinical trials are needed to confirm whether preoperative CCRT is better than 3DRT in improving survival without increasing the incidence of adverse reactions.