pT3N0M0期胸段食管鳞癌患者术后失败原因分析及其术后放疗思考

Analysis of postoperative failure in patients with stage pT3N0M0 thoracic esophageal squamous cell carcinoma and consideration of postoperative radiotherapy

目的 探讨pT3N0M0期胸段食管鳞癌患者术后失败模式,并依据其失败模式讨论术后放疗意义及可行性.方法 对2007-2010年符合人组条件的227例pT3N0M0期食管癌术后患者进行回顾分析,主要分析其单纯手术后失败模式,同时结合相关研究来探讨pT3N0M0期胸段食管鳞癌患者术后辅助性放疗意义及适合人群.应用Kaplan-Meier法计算OS、LR、DM并Logrank法检验和单因素预后分析,Cox模型多因素预后分析.结果 治疗后出现胸腔内LR 58例（25.6％）,DM 27例（11.9％）,其中10例为LR＋DM.单纯胸腔内纵隔淋巴结复发所占比率为50％（29/58）.单因素分析显示胸上段食管癌患者术后3、5年OS率低于胸中、下段患者（P=0.000）,而其胸腔-区域复发率高于后两者（P=0.047）;低分化鳞癌患者3、5年OS率低于中高分化鳞癌患者（P=0.005）,而其DM率高于后者（P=0.000）.多因素分析显示患者不同病变部位、不同病理分化程度为患者OS的影响因素（P=0.014、0.010）;病变部位为影响患者胸腔内LR的影响因素（P=0.046）;不同病理分化程度为DM的影响因素（P=0.000）.结论 pT3N0M0期胸段食管鳞癌患者行常规胸腹两野根治术后胸腔内LR为其主要治疗失败模式,且胸上段食管癌高于胸中、下段食管癌患者,建议pT3N0M0期胸段食管鳞癌胸上段患者行术后放疗.

Objective To investigate the failure mode in patients with stage pT3N0M0 thoracic esophageal squamous cell carcinoma （TESCC） after surgery,and to discuss the significance and feasibility of postoperative radiotherapy according to the failure mode.Methods A retrospective analysis was performed on 227 patients with stage pT3N0M0 TESCC who met the inclusion criteria from January 2007 to December 2010.Their postoperative failure mode was analyzed,and,with reference to relevant research,the significance of postoperative radiotherapy and its target patients were explored.The Kaplan-Meier method was used to calculate overall survival （OS）,local recurrence （LR）,and distant metastasis （DM） rates,and the log-rank test was used for survival difference analysis and univariate prognostic analysis.The Cox model was used for multivariate prognostic analysis.Results After surgery,there were 58 patients （25.6％） with LR in the thoracic cavity and 27 patients （11.9％） with DM,and 10 patients had both LR and DM.Twentynine （50％） of the 58 patients had recurrence in the thoracic mediastinal lymph nodes.The results of univariate analysis showed that the 3-and 5-year OS rates of patients with upper thoracic esophageal cancer were significantly lower than those of patients with middle and lower esophageal cancer （P =0.000）,and the chest-regional recurrence rate was significantly higher in the former group than in the latter two groups （P=0.047）;the 3-and 5-year OS rates of patients with poorly differentiated squamous cell carcinoma were significantly lower than those of patients with moderately and well differentiated squamous cell carcinoma （P =0.005）,and the DM rate was significantly higher than in the former group than in the latter two groups （P=0.000）.The results of multivariate analysis showed that lesion site and the degree of pathological differentiation were independent prognostic factors for OS （P=0.014 and 0.010）;lesion site was the independent prognostic factor for chest-regional recurrence （P=0.046）;the degree of pathological differentiation was the independent prognostic factor for DM （P=0.000）.Conclusions For patients with stage pT3N0M0 TESCC after two-field esophagectomy,the most common failure mode is chest-regional recurrence,especially in patients with upper thoracic esophageal cancer.Therefore,postoperative radiotherapy is suggested for upper-thoracic TESCC.