pN0期胸段食管鳞癌患者术后失败模式及其对术后放疗指导作用分析

Analysis of postoperative failure model in patients with stage pN0 esophageal squamous cell carcinoma and its effect on postoperative radiotherapy

目的探讨pN0期胸段食管鳞癌（TESCC）患者单纯手术治疗后失败模式及失败原因，并据此讨论患者术后放疗的可行性。方法对2007年1月至2010年12月在本院胸外科接受手术治疗且符合人组条件的473例食管癌患者进行回顾性分析，通过分析患者术后治疗的失败模式及其原因，探讨pN0期TESCC患者单纯手术治疗后辅助性放疗的可行性及意义。结果全组患者出现胸腔内-区域性复发57例（12．1％），其中多数出现在胸腔内（52例）；远处转移42例（8．9％）。复发合并远处转移13例。总失败率为20．9％。胸上段食管癌患者胸腔内-区域性复发率显著高于胸中段和胸下段患者（χ2=7．469，P〈0．05），而远处转移率差异无统计学意义（P〉0．05）。T分期越晚的食管癌患者其复发率及远处转移率均显著高于T分期早者（χ2=10．247、7．886，P〈0．05）。单因素分析结果显示，不同病变部位、食管瘤床与周边组织器官的黏连程度和术后残端情况为影响胸腔内-区域性复发率的显著性因素（χ2=14．232、9．486、7．546，P〈0．05）；患者性别、吸烟史和术前体重减轻≥5kg为影响患者远处转移率的显著性因素（χ2=10．823、10．275、6．065，P〈0．05）；而T分期对胸腔内-区域性复发率及远处转移率均有显著性影响（χ2=15．994、12．885，P〈0．05）。多因素分析结果显示，T分期和术后残端为影响胸腔内-区域性复发的独立性因素（P〈0．05），既往吸烟史为影响远处转移的独立性因素（P〈0．05）。结论pN0期TESCC患者单纯术后仍有较高的胸腔内-区域性复发率，对于胸上段食管癌患者、T分期较晚、食管瘤床与周边组织器官的黏连程度较重和术后残端阳性患者建议术后辅助性放疗。男性患者、有吸烟史和术前体重减轻≥5kg者远处转移高。

Objective To investigate the failure model of patients with stage pN0 thoracic esophageal squamous cell carcinoma （TESCC） after surgery alone and to discuss the feasibility of postoperative radiotherapy. Methods A retrospective analysis was performed on 473 patients with TESCC who received surgery alone from January 2007 to December 2010. The feasibility of adjuvant radiotherapy forpN0 TESCC patients was investigated through the failure model of postoperative patients. Results Of all patients, there were 57 cases with chest-regional recurrence （ 12.1% ） , most of which occurred in the mediastinal lymph nodes（52 case）. There were 42 （8.9%） patients were identified as distant metastasis （DM） , of which 13 cases were found to have both local recurrence and DM, and the total failure rate was 20.9%. The chest-regional recurrence rate of upper TESCC was statistically significantly higher than middle and lower （ χ2 = 7. 469, P 〈 0.05 ） , but DM rate had no statistically significant difference （P 〉 0. 05）. The chest-regional recurrence rate and DM rate of the advanced T stage were significantly higher than those of the early T stage（ χ2 = 10. 247, 7. 886, P 〈 0.05 ）. The result of univariate analysis showed that disease site, the degree of adhesion, postoperative stump were significant factors of chestregional recurrence rate （ χ2 = 14. 232, 9. 486, 7. 546, P 〈 0. 05 ）. Gender, smoking and preoperative weight loss≥ 5 kg significantly influenced DM （ χ2 = 10. 823, 10. 275, 6. 065, P 〈 0. 05 ）. In addition, the T stage was the significant influence factor of chest-regional recurrence and DM （ χ2 = 15. 994, 12. 885, P 〈0.05）. The result of multivariate analysis showed that T stage and postoperative stump were independent factors of chest-regional recurrence （P 〈 0. 05）, Smoking was an independent factor of DM （P 〈0. 05）. Conclusions There was a high rate of chest-regional recurrence in patients with stage pN0 TESCC who received surgery alone. Postoperative radiotherapy was recommended for patients with upper TESCC, advanced T stage, severe local adhesion , positive margin in and postoperative stump. Male, smoking and preoperative weight loss≥5 kg were associated with higher DM rate.