T1-4N0-1M0期胸段食管鳞癌根治性切除术后失败模式对术后辅助治疗的意义

Failure patterns of radical surgery in patients with T1-4 No.1 M0 thoracic esophageal squamous cell carcinoma： implications for the target area design of postoperative therapy

目的 分析接受根治性切除（R0）术后的胸段食管鳞癌（thoracic esophageal squamous cell carcinoma，TESCC）患者的失败模式，并分析其影响因素和其对术后辅助治疗意义。方法 回顾性分析1 191例接受R0手术的TESCC患者，分析其失败模式、失败模式的影响因素及不同病变部位和N分期对失败模式的影响。结果 全组患者胸腔-区域复发率为31.7%，远处转移率为16.4%。多因素分析结果显示病变部位、术中病变炎性粘连程度、T和N分期及阳性淋巴结转移率均为影响患者胸腔-区域复发的独立性因素（P〈0.05）；患者性别、肿瘤组织分化程度和阳性淋巴结转移率为影响患者远处转移的独立性因素（P〈0.05）。胸上/中段食管癌患者的胸腔内淋巴结复发率高于胸下段患者（χ2=6.179，P=0.046），而后者的腹腔淋巴结复发率高于前两者（χ2=15.853，P〈0.05）。N1期患者的各项复发率和远处转移率均高于N0期患者（χ2=7.764~56.495，P〈0.05）。胸上段N1期食管癌患者中腹腔淋巴复发率高于N0期（χ2=7.905，P〈0.05）；胸中段N1期食管癌患者中锁骨上淋巴结和胸腔内淋巴结复发率均高于N0期（χ2=12.506、18.436，P〈0.05）；胸下段N1期食管癌患者中锁骨上淋巴结、吻合口和腹腔淋巴结复发率均高于N0期（χ2=5.272、4.878、18.006，P〈0.05）；T3＋4期患者中的胸中/下段癌的吻合口复发率高于T1＋2期（χ2=4.341、7.154，P〈0.05），且前者的胸下段癌的腹腔淋巴结复发率亦高于后者（χ2=5.366，P〈0.05）。结论 食管癌术后靶区设计应该有选择性，术后靶区范围除常规应该依据不同病变部位制定外，建议对于胸上段N1期患者应该注意腹腔淋巴结引流区、胸下段N1期患者应该注意锁骨上区淋巴结引流区的预防性照射，另外T3、T4期胸中/下段癌患者的术后靶区建议包括吻合口。

Objective To analyze the failure patterns and prognostic factors of radical surgery in patients with T1-4N0-1M0 thoracic esophageal squamous cell carcinoma （TESCC）, and the implications for the target area design of postoperative therapy. Methods We retrospectively analyzed 1 191 patients with TESCC who underwent radical surgery at our institution. The failure patterns, the prognostic factors, as well as the effects of lesion locations and N stage on the failure patterns were analyzed. Results The thoracic-region recurrence rate and the distant metastasis rate was 31.7% and 16.4% in all patients. The multivariate analysis showed that the lesion locations, the degree of inflammatory adhesion, T staging, N staging and the rate of lymph nodes metastasis were independent factors affecting the regional recurrence （P〈0.05）.Gender, tumor differentiation and the rate of lymph nodes metastasis were independent factors affecting distant metastasis （P〈0.05）. The intrathoracic lymph nodes recurrence rate of upper/middle TESCC was significantly higher than that of the lower TESCC （χ2=6.179, P=0.046）, while the abdomen lymph nodes recurrence rate of the lower was significantly higher than that of upper/middle TESCC （χ2=15.853,P〈0.05）. The recurrence rate and distant metastasis rate of stage N1 patients were significantly higher than that of N0 patients （χ2=7.764-56.495, P〈0.05）. The abdomen lymph nodes recurrence rate of stage N1 patients was significantly higher than that of N0 in upper TESCC （χ2=7.905, P〈0.05）. The supraclavicular and intrathoracic lymph nodes recurrence rates of stage N1 patients were significantly higher than that of N0 patients in middle TESCC （χ2=12.506, 18.436, P〈0.05）. The supraclavicular lymph nodes, anastomosis and abdomen lymph node recurrence rates of stage N1 were significantly higher than that of N0 patients in lower TESCC （χ2=5.272,4.878,18.006, P〈0.05）. The anastomotic recurrence rate of stage T3＋4 was higher than that of T1＋2 in middle/lower TESCC （χ2=4.341, 7.154, P〈0.05）, and the abdominal lymph nodes recurrence rate of stage T3＋4 was higher than that of T1＋2 in lower TESCC（χ2=5.366, P〈0.05）. Conclusions The lymphatic drainage regions for postoperative radiotherapy （PORT） are selective. We suggest that abdominal lymph nodes drainage area should be noted for the stage N1 patients with upper TESCC, and the supraclavicular lymph nodes drainage area should be noted for the N1 patients with lower TESCC. In addition, the anastomosis is suggested to be included in PORT target area for stage T3/T4 middle/lower TESCC patients.