食管早癌内镜下黏膜剥离术后追加手术及放疗的握判

Endoscopic submucosal dissection with the following surgery or radiotherapy for early esophageal carcinoma

目的初步探讨食管早癌内镜下黏膜剥离术(ESD)后追加手术及放疗的评判依据。方法回顾性分析2009年7月-2015年10月,该院消化科112例行ESD治疗的食管早癌患者临床资料、术后病理结果及术后随访结果。结果随访期内共有7例患者进一步治疗,其中追加食管癌根治手术3例;贲门癌根治术1例,术后淋巴结阳性再次追加化疗;追加ESD术1例;放疗2例。7例患者肿瘤浸润至上皮内层(m1)和黏膜下层上1/3(sm1)各3例,浸润至黏膜肌层(m3)者1例。1例患者病理提示脉管内转移,随访13个月胃镜检查局部无复发,但CT提示腹腔淋巴结转移,随访16个月后死亡。另有1例浸润深度达m1的高级别上皮内瘤变(HGIN)患者,垂直及水平切缘均为阴性,随访7个月局部无复发,但CT提示肝及腹膜后淋巴结转移。结论术前准确判断癌灶浸润深度及有无淋巴结转移是决定患者治疗方式的重要依据;术后评估病灶是否达到了治愈性切除,随访有无局部复发及淋巴结、远处转移则决定是否需要追加手术及放疗。

Objective To evaluate the basis of following surgery or radiotherapy after endoscopic submucosal dissection （ESD） in patients with early esophageal carcinoma. Methods From July 2009 to October 2015, 112 patients with early esophageal carcinoma underwent ESD, and the characteristics of clinical information, post-op pathology results and follow-up were recorded. Results Among the patients, 7 cases received the following therapy, including 3 with esophageal radical surgery, 1 with gastric cardia radical surgery and chemotherapy for the lymphatic metastasis, 1 with another ESD and 2 with radiotherapy. Invasive depth in these 7 patients was epithelium （ml） in 3 cases, upper 1/3 in submucosa （sm1） in 3 and muscularis mucosa （m3） in 1. Vascular metastasis was found in 1 case, without endoscopic local recurrence under endoscopic follow-up. However, CT revealed abdominal lymph node metastasis, and the patient died 16 months after the procedure. In another patient with high-grade intraepithelial neoplasia （HGIN） in the depth of m1, the surrounding margin of the lesion was negative without local recurrence in the following up for 7 months. CT found the liver and retroperitoneal lymph node metastasis. Conclusion The exact evaluation of invasive depth of the lesion and lymph node metastasis were the basis of the therapies. And following surgery or radiotherapy depended on the radical resection, local recurrence, lymph node and distant metastasis in the follow up.