胸段食管鳞状细胞癌术后病理淋巴结转移区域数目对预后的影响

Impact of the number of postoperative pathological lymph node metastasis areas on prognosis of thoracic esophageal squamous cell carcinoma

目的探索胸段食管鳞状细胞癌根治术术后病理淋巴结转移区域数目对患者预后的影响。方法回顾性分析2012年1月至2014年12月在扬州大学附属泰兴人民医院胸外科接受食管癌根治术的153例患者的临床病理资料,其中76例患者术后无辅助治疗、77例患者术后接受辅助放疗或放化疗,根据美国胸科协会淋巴结分组标准和患者术后病理淋巴结转移区域数目将患者分为无区域淋巴结转移组(n=68)、寡区域淋巴结转移组(1~2个淋巴结区域转移,n=54)和多区域淋巴结转移组(≥3个淋巴结区域转移,n=31)。采用Kaplan-Meier法估算生存率并进行log-rank检验,Cox比例风险模型分析预后因素,受试者工作特征(ROC)曲线分析淋巴结转移区域数目对患者预后的预测价值。结果153例患者中位总生存期(OS)为37.0个月,1、3、5年OS率分别为97.4%、51.0%和30.7%。无区域淋巴结转移组患者中位OS为46.0个月,1、3、5年OS率分别为97.1%、58.8%、39.7%;寡区域淋巴结转移组患者中位OS为39.0个月,1、3、5年OS率分别为94.4%、55.6%、35.2%;多区域淋巴结转移组患者中位OS为26.0个月,1、3、5年OS率分别为98.1%、25.8%、3.2%,3组差异具有统计学意义(χ^(2)=18.257,P<0.001)。在76例术后无辅助治疗的患者中,无区域淋巴结转移患者的1、3、5年OS率分别为94.7%、50.0%、34.2%,寡区域淋巴结转移患者分别为90.9%、36.4%、9.1%,多区域淋巴结转移患者分别为97.4%、18.8%、0,差异具有统计学意义(χ^(2)=8.201,P=0.017)。在77例术后辅助治疗的患者中,无区域淋巴结转移患者的1、3、5年OS率分别为97.7%、66.7%、46.7%,寡区域淋巴结转移患者分别为96.9%、68.8%、53.1%,多区域淋巴结转移患者分别为93.3%、26.7%、6.7%,差异具有统计学意义(χ^(2)=18.083,P<0.001)。单因素分析显示,年龄(HR=1.534,95%CI为1.041~2.260,P=0.030)、T分期(HR=1.757,95%CI为1.197~2.579,P=0.004)、N分期(HR=1.548,95%CI为1.043~2.297,P=0.030)、TNM分期(HR=1.392,95%CI为1.114~2.459,P=0.015)、辅助治疗(HR=0.545,95%CI为0.370~0.803,P=0.002)、淋巴结转移区域数目(多区域淋巴结转移与无区域淋巴结转移相比:HR=0.385,95%CI为0.238~0.624,P<0.001;多区域淋巴结转移与寡区域淋巴结转移相比:HR=0.442,95%CI为0.269~0.726,P=0.001)均与食管鳞状细胞癌术后患者的OS密切相关;多因素分析显示,T分期(HR=1.699,95%CI为1.143~2.525,P=0.009)、辅助治疗(HR=0.577,95%CI为0.386~0.864,P=0.008)、淋巴结转移区域数目(多区域淋巴结转移与无区域淋巴结转移相比:HR=0.553,95%CI为0.411~0.996,P=0.011;多区域淋巴结转移与寡区域淋巴结转移相比:HR=0.550,95%CI为0.328~0.924,P=0.024)是OS的独立预后因素。ROC曲线分析显示淋巴结转移区域数目(AUC为0.648,95%CI为0.560~0.735,P=0.004)在预测食管鳞状细胞癌根治术患者的OS方面优于淋巴结转移数目(AUC为0.595,95%CI为0.497~0.694,P=0.061)。结论胸段食管鳞状细胞癌术后病理淋巴结转移区域数目在预测生存预后方面具有重要价值,而辅助治疗能显著提高寡区域淋巴结转移患者的OS。

Objective To explore the impact of the number of pathological lymph node metastasis areas on the prognosis of patients with thoracic esophageal squamous cell carcinoma(ESCC)after radical surgery.Methods The clinicopathologic data of 153 patients with ESCC treated by radical surgery at the Department of Thoracic Surgery of the Affiliated Taixing People′s Hospital of Yangzhou University from January 2012 to December 2014 were retrospectively analyzed.Among these patients,76 had no adjuvant therapy,and 77 received adjuvant radiotherapy or chemoradiotherapy after surgery.According to the lymph node classification criteria of American Thoracic Association and the number of pathological lymph node metastasis areas,the patients were divided into non-regional lymph node metastasis group(n=68),oligo-regional lymph node metastasis group(1-2 regional lymph node metastasis,n=54)and multi-regional lymph node metastasis group(≥3 regional lymph node metastasis,n=31).Kaplan-Meier method was used to calculate survival rate and survival comparison was performed by log-rank test.The Cox proportional hazards model was used to analyze prognostic factors,receiver operating characteristic(ROC)curve was used to analyze the predictive value of the number of lymph node metastasis areas.Results The median overall survival(OS)was 37.0 months for the 153 patients,and the 1-,3-and 5-year OS rates were 97.4%,51.0%and 30.7%respectively.In the non-regional lymph node metastasis group,the median OS was 46.0 months,and the 1-,3-and 5-year OS rates were 97.1%,58.8%and 39.7%separately.In the oligo-regional lymph node metastasis group,the median OS was 39.0 months,and the 1-,3-and 5-year OS rates were 94.4%,55.6%and 35.2%respectively.In the multi-regional lymph node metastasis group,the median OS was 26.0 months,and the 1-,3-and 5-year OS rates were 98.1%,25.8%and 3.2%separately.There was a statistically significant difference among the three groups(χ^(2)=18.257,P<0.001).Among the 76 patients without adjuvant treatment,the 1-,3-and 5-year OS rates were 94.7%,50.0%and 34.2%in patients with non-regional lymph node metastasis,90.9%,36.4%and 9.1%in patients with oligo-regional lymph node metastasis,97.4%,18.8%and 0 in patients with multi-regional lymph node metastasis,and there was a statistically significant difference(χ^(2)=8.201,P=0.017).Among the 77 patients with adjuvant therapy,the 1-,3-and 5-year OS rates were 97.7%,66.7%and 46.7%in patients with non-regional lymph node metastasis,96.9%,68.8%and 53.1%in patients with oligo-regional lymph node metastasis,93.3%,26.7%and 6.7%in patients with multi-regional lymph node metastasis,and there was a statistically significant difference(χ^(2)=18.083,P<0.001).Univariate analysis showed that age(HR=1.534,95%CI:1.041-2.260,P=0.030),T stage(HR=1.757,95%CI:1.197-2.579,P=0.004),N stage(HR=1.548,95%CI:1.043-2.297,P=0.030),TNM stage(HR=1.392,95%CI:1.114-2.459,P=0.015),adjuvant therapy(HR=0.545,95%CI:0.370-0.803,P=0.002)and number of lymph node metastasis areas(multi-regional lymph node metastasis versus non-regional lymph node metastasis:HR=0.385,95%CI:0.238-0.624,P<0.001;multi-regional lymph node metastasis versus oligo-regional lymph node metastasis:HR=0.442,95%CI:0.269-0.726,P=0.001)were closely related to OS in patients with ESCC after operation.Multivariate analysis showed that T stage(HR=1.699,95%CI:1.143-2.525,P=0.009),adjuvant therapy(HR=0.577,95%CI:0.386-0.864,P=0.008)and number of lymph node metastasis areas(multi-regional lymph node metastasis versus non-regional lymph node metastasis:HR=0.553,95%CI:0.411-0.996,P=0.011;multi-regional lymph node metastasis versus oligo-regional lymph node metastasis:HR=0.550,95%CI:0.328-0.924,P=0.024)were independent prognostic factors for OS.The number of lymph node metastasis areas(AUC=0.648,95%CI:0.560-0.735,P=0.004)was better than the number of lymph node metastasis(AUC=0.595,95%CI:0.497-0.694,P=0.061)in predicting OS of patients with ESCC after radical surgery.Conclusion The number of postoperative pathological lymph node metastasis areas in thoracic ESCC has important value in predicting survival prognosis,and adjuvant therapy can significantly improve the OS of patients with oligo-regional lymph node metastasis.