食管癌疗后锁骨上淋巴结转移挽救性放疗的临床研究

A clinical study of salvage radiotherapy for supraclavicular lymph node metastasis in patients with esophageal cancer

目的：探讨食管癌首次治疗后锁骨上淋巴结转移挽救性放疗的价值。方法收集2006—2012年符合入组条件的117例患者，应用3DRT方式，1．8～2.0 Gy／次，5次／周。 Kaplan-Meier法计算生存率并Logrank法检验，Cox模型多因素分析。结果随访率100％。锁骨上淋巴结转移后的1、3年OS率分别为38.5％、14.1％。挽救放疗或放化疗（100例）与未挽救治疗（17例）的1、3年OS率分别为42％、17％与18％、0％（ P＝0.008）；放化疗（32例）的1、3年OS率分别为59％、36％，高于单纯放疗（68例，34％、11％）和未挽救者（17例，18％、0％）（P＝0.002）；未合并内脏转移（80例）和合并内脏转移（37例）患者1、3年OS率分别为44％、22％和27％、0％（P＝0.002）；锁骨上挽救放疗剂量＜60 Gy （25例）和≥60 Gy （75例）的1、3年OS率分别为25％、8％％和75％、24％（P＝0.000）。 Cox模型多因素生存分析显示锁骨上挽救放疗剂量≥60 Gy、合并纵隔失败、合并内脏转移、挽救方式为影响锁骨上淋巴结转移后生存因素（ P＝0.001、0.015、0.009、0.025）。结论食管癌锁骨上淋巴结转移挽救性放疗可使患者生存获益，单纯锁骨上淋巴结转移患者建议积极行挽救性放疗或放化疗，挽救性放疗剂量≥60 Gy者可延长生存。

Objective To evaluate the efficacy of salvage radiotherapy for supraclavicular lymph node metastasis （ SLNM） after initial treatment in patients with esophageal cancer. Methods A total of 117 patients with SLNM after radical resection for esophageal cancer were enrolled as subjects from 2006 to 2012. All patients received three-dimensional radiotherapy with 1. 8-2. 0 Gy per cycle, 5 cycles a week. The survival rates were calculated using the Kaplan-Meier method and analyzed using the log-rank test. The Cox model was used for multivariate analysis. Results The follow-up rate was 100%. In all the patients, the 1-and 3-year overall survival （OS） rates were 38. 5% and 14. 1%, respectively. The 1-and 3-year OS rates were significantly higher in patients treated with salvage radiotherapy or radiochemotherapy （ n=100） than in patients without any salvage treatment （n=17）（42% vs. 18%,P=0. 008;17% vs. 0%, P=0. 008）. The patients treated with radiochemotherapy （ n=32） had significantly higher 1-and 3-year OS rates than those treated with radiotherapy alone （n=68）（59% vs. 34%, 36% vs. 11%, P=0. 002） or without any salvage treatment （n=17）（59% vs. 18%, 36% vs. 0%, P=0. 002）. Patients without visceral metastasis （n=80） had significantly higher 1-and 3-year OS rates than those with visceral metastasis （ n=37） （ 44% vs. 27%, P=0. 002;22% vs. 0%,P=0. 002） . Patients with supraclavicular doses of ≥60 Gy in salvage radiotherapy （ n=75） had significantly higher 1-and 3-year OS rates than those with supraclavicular doses of〈60 Gy in salvage radiotherapy （ n=25） （ 75% vs. 25%,P=0. 000;24% vs. 8%,P=0. 000） . The multivariate analysis using the Cox model showed that supraclavicular doses of ≥60 Gy, mediastinal metastasis, visceral metastasis, and salvage treatment method were independent factors for survival （ P=0. 001,0. 015,0. 009, 0. 025） . Conclusions Salvage radiotherapy can improve the survival of patients with SLNM in esophageal cancer. Salvage radiotherapy or radiochemotherapy is highly recommended for patients with SLNM alone. A radiation dose of ≥60 Gy in salvage radiotherapy improves survival in patients.