基于右胸径路完全两野/三野清扫的胸段食管癌术后治疗失败模式分析

Patterns of treatment failure after right thoracotomy among patients with thoracic esophageal carcinoma

目的:观察胸腹完全两野清扫或颈胸腹三野清扫条件下,胸段食管癌术后复发率及复发模式,筛选术后高危复发人群,为辅助治疗合理策略制定提供依据。方法:对接受右胸径路根治性手术的胸段食管行回顾性分析,采用Kaplan-Meier法推算生存率,Binary Logistic回归模型筛选肿瘤复发风险因素。结果:共235例符合入排条件者纳入分析,基于术后病理的淋巴结转移率为51.9%,其中胸上段癌上纵隔区淋巴结转移率最高(44.1%),胸中段癌下纵隔区淋巴结转移率最高(35.3%),胸下段癌腹区淋巴结转移率最高(41.2%),同时任何部位食管癌都具有较高的上纵隔淋巴结转移率(25.5%~44.1%)。235例患者中有163例随访出具体治疗失败模式,疾病总复发率为47.9%(78/163)。区域性淋巴结转移是最常见的疾病复发模式,其次为远处转移(22.7%),吻合口和瘤床复发少见(6.7%)。在区域性淋巴结转移中,以颈区+上纵隔区淋巴结转移率较高(28.2%)。Logistic回归分析显示,男性、pT3-4期、pN+期及淋巴结清扫术式均是治疗失败的危险因素。结论:在右胸径路手术条件下,胸段食管癌仍然具有较高的术后高总复发率,区域性淋巴结转移和血行转移是最常见的治疗失败模式,在区域性复发中,仍以颈区+上纵隔区淋巴结转移率居高,对合并高危因素者(男性、胸上段癌、pT3-4期及pN+期),建议系统性系治疗联合辅助放疗。

Objective:To observe the postoperative recurrence rate and pattern of thoracic esophageal cancer under the conditions of complete two field clearance of chest and abdomen or three field clearance of neck,chest and abdomen,screening high-risk recurrence population after surgery,and to provide basis for formulating reasonable strategies for adjuvant therapy.Methods:A total of 235 thoracic esophageal cancer patients who had undergone right thoracotomy and lymphadenectomy were retrospectively enrolled.Kaplan Meier method was used to calculate survival rate,and Binary Logistic regression model was used to screen for tumor recurrence risk factors.Results:The LNM rate was 51.9%for the entire group.The LNM rate was highest in the upper mediastinal region for upper thoracic cancer(44.1%),in the lower mediastinal region for middle thoracic cancer(35.3%),and in the abdominal region for lower thoracic cancer(41.2%).Additionally,the LNM rates in the upper mediastinal region(25.5%~44.1%)were high in any location of esophageal cancer.Among the 235 patients,163 patients exhibited specific treatment failure patterns upon follow-up,of which 78 experienced recurrent or metastatic diseases.The overall disease recurrence rate was 47.9%(78/163).Regional LNM was the most common treatment failure pattern,followed by distant metastasis(22.7%),while anastomotic and tumor bed recurrence were relatively rare(6.7%).In regional LNM,mediastinal lymph node metastasis was common(25.2%).If the cervical and upper mediastinum region were observed as a whole,the LNM rate was 28.2%.Logistic regression analysis showed that male,pT3-4 stage,pN+stage,and lymphadenectomy were all risk factors for treatment failure.Conclusion:Thoracic esophageal cancer has a high overall recurrence rate,even after a right thoracotomy and lymphadenectomy.Regional lymph node metastasis and hematogenous metastasis are the most common treatment failure modes.In regional recurrence,the cervical and upper mediastinal lymph node metastasis rate is still high.For patients with combined high-risk factors(male,upper thoracic cancer,pT3-4 stage,and pN+stage),it is recommended to undergo systematic treatment combined with adjuvant radiotherapy.