食管鳞癌术后局部区域复发调强放疗预后影响因素分析

Analysis of prognostic factors of local recurrence and intensity-modulated radiotherapy for postoperative esophageal squamous cell carcinoma

目的局部区域复发为食管癌患者术后主要失败模式,患者一旦出现复发则预示预后不良,目前对于术后局部区域复发患者可选择的治疗不多,其中放化疗为其主要治疗方法。本研究目的在于探讨食管鳞癌术后局部区域复发患者接受调强放(化)疗的疗效及其预后影响因素。方法对2007-01-01—2011-12-31在河北医科大学第四医院单中心符合入组条件的231例食管鳞癌术后局部区域复发患者临床资料进行回顾性分析,分析其复发时间、复发部位、复发区域数、复发后治疗疗效和影响其治疗疗效的因素等。采用Log-rank检验和Kaplan-Meier法进行单因素生存分析,得出预后影响因素;采用Cox比例风险模型(应用向前Wald法)进行多因素分析,得出独立性影响因素。结果231例患者复发治疗后1、3和5年生存率分别为54.2%、23.9%和19.6%,中位生存期为14.0个月。患者出现复发的时间为1.0~91.0个月,中位15.0个月,68.4%(158/231)的患者复发时间≤2年,31.6%(73/231)的复发时间>2年。单个局部区域复发175例(75.8%),≥2个局部区域复发56例(24.2%)。单因素分析结果显示,患者性别(χ^2=6.536,P=0.011)、吸烟史(χ^2=5.021,P=0.025)、pT分期(χ^2=4.841,P=0.049)、pN分期(χ^2=8.781,P=0.003)、pTNM分期(χ^2=12.228,P<0.001)、术后复发区域数(χ^2=9.387,P=0.002)、术后复发部位(χ^2=19.206,P<0.001)、放疗剂量(χ^2=14.205,P<0.001)、合并远处转移(χ^2=5.958,P=0.015)和复发时间(χ~2=7.800,P=0.005)等为影响患者预后的关联性因素。多因素分析结果显示,患者性别(HR=0.619,95%CI为0.437~0.875)、pTNM分期(HR=1.346,95%CI为1.103~1.642)、放疗处方剂量(HR=0.656,95%CI为0.465~0.926)、复发区域数(HR=1.201,95%CI为1.100~1.312)和复发时间(HR=0.316,95%CI为0.218~0.458)为影响患者预后的独立性因素。结论食管鳞癌术后复发挽救性调强放(化)疗在其预后有重要意义,并可以改善预后。男性患者、pTNM分期为Ⅲ/Ⅳ期、放疗处方剂量<60Gy、复发区域数>1个和复发时间<2年术后复发患者预后较差,临床应该予以重视和密切关注。

OBJECTIVE Local recurrence is the main failure mode for patients with esophageal cancer after operation.Once recurrence occurs,the prognosis is poor.At present,there are few alternative therapies for patients with local recurrence after operation.Radiotherapy and chemotherapy are the main treatment methods.The purpose of this paper was to investigate the efficacy and prognostic factors of intensity modulated radiation therapy(IMRT)in patients with local recurrence of esophageal squamous cell carcinoma after operation.METHODS A retrospective analysis was made on 231 patients with local recurrence of esophageal squamous cell carcinoma who met the admission criteria from January2007 to December 2011 in the single center of the Fourth Hospital of Hebei Medical University.The recurrence time,recurrence site,number of recurrence areas,therapeutic effect after recurrence and the factors affecting the therapeutic effect were analyzed.SPSS19.0 software was used for statistical analysis,Log-rank test and Kaplan-Meier method were used for univariate survival analysis,and prognostic factors were obtained.Cox proportional risk model(forward Wald method)was used for multivariate analysis,and independent factors were obtained.RESULTS The 1-,3-and 5-year survival rates were 54.2%,23.9%and 19.6%respectively,and the median survival time was 14.0 months.The recurrence time was1.0-91.0 months(median 15.0 months).68.4%(158/231)of the patients had recurrence time less than 2 years and31.6%(73/231)had recurrence time more than 2 years.Univariate analysis showed that gender(χ^2=6.536,P=0.011),smoking history(χ^2=5.021,P=0.025),pT stage(χ^2=4.841,P=0.049),pN stage(χ~2=8.781,P=0.003),pTNM staging(χ~2=12.228,P<0.001),number of postoperative recurrences(χ^2=9.387,P=0.002),postoperative recurrence site(χ~2=19.206,P<0.001),radiotherapy dose(χ~2=14.205,P<0.001),combined distant metastasis(χ^2=5.958,P=0.015)and recurrence time(χ^2=7.800,P=0.005)were the factors that have a statistically significant correlation with the prognosis of patients.Multivariate analysis showed that gender(HR:0.619,95%CI:0.437-0.875),pTNM staging(HR:1.346,95%CI:1.103-1.642),radiotherapy prescription dose(HR:0.656,95%CI:0.465-0.926),recurrence area Number(HR:1.201,95%CI:1.100-1.312)and time to relapse(HR:0.316,95%CI:0.218-0.458)were independent factors influencing prognosis.CONCLUSIONS IMRT for recurrent esophageal squamous cell carcinoma is of great significance in its prognosis and can improve its prognosis.Male patients,pTNM stageⅢ/Ⅳ,radiation prescription dose<60 Gy,number of recurrence areas>1 and recurrence time<2 years have poor prognosis,so clinical attention should be paid to it.