T2-3N0M0期食管癌R0术后失败模式分析——术后放疗潜在价值与意义

摘要

目的 比较pT2-3N0M0期食管癌根治术后和术后放疗(3DCRT、IMRT)患者失败模式,探讨术后放疗及放疗范围合理性.方法 回顾分析2004-2009年本院收治的pT2-3N0M0期食管癌病例581例,其中单纯手术543例、术后放疗38例(IMRT 31例、3DCRT 7例).pT2N0M0期153例、pT3N0M0期428例.Kaplan-Meier法计算生存率并Logrank检验,Cox模型预后多因素分析.结果 两组患者一般临床资料比较中T分期、临床分期不具可比性.随访率为94.7％.单纯手术组失败率为40.3％,术后放疗组为15.8％ (P =0.003).单纯手术组复发率最高为纵隔(18.5％),其次为锁骨上淋巴结和血道转移(均为10.7％),腹腔淋巴结、吻合口复发率均低(3.0％、3.8％).pT2N0M0、pT3N0M0期失败率分别为43.6％、39.0％(P=0.329).术后放疗组5年DFS率高于单纯手术组(65.3％、50.8％,P=0.044),5年OS率未达统计学意义(72.3％、59.2％,P=0.157).多因素分析结果显示上切缘和脉管瘤栓是影响DFS和OS因素,而性别和细胞分化程度是影响OS因素.结论 pT2-3N0M0期食管癌单纯手术后失败率较高,术后放疗可降低放疗部位失败率且提高DFS,但最终还需进一步加大样本量研究.%Objective To determine the patterns of failure and recurrence rate in patients with stage T2-3N0M0 esophageal squamous cell carcinoma (ESCC) after radical surgery and the potential value and target field of postoperative radiotherapy.Methods We retrospectively analyzed 3 480 patients initially diagnosed with ESCC from 2004 to 2009 in our hospital.Among 581 patients with stage T2-3 N0M0 ESCC,543 underwent radical surgery alone (S group),and 38 received intensity-modulated radiotherapy after R0 surgery (S + R group).A total of 150 patients (26.3％) were in stage T2N0M0 and 428 patients (73.7％) were in stage T3N0M0.The survival rate was calculated by Kaplan-Meier method,and the difference was analyzed by log-rank test.The Cox regression model was used for multivariate prognostic analysis.Results In the clinical data,T stage and clinical stage were not comparable between the two groups.The follow-up rate was 94.7％.In the S group,recurrence developed in 43.6％ of stage T2N0M0 patients and 39.0％ of stage T3N0M0 patients (P =0.329).The recurrence rate was 40.3％ in the S group and 15.8％ in the S + R group (P =0.003).The most frequent site of recurrence was mediastinum (18.5％),followed by supraclavicular region and blood metastasis (10.7％ for both),and recurrence occurred rarely at the anastomosis and celiac region (3.8％ and 3.0％,respectively).The 5-year diseases-free survival (DFS) was significantly higher in the S + R group than in the S group (65.3％ vs.50.8％,P =0.044).There was no significant difference in overall survival (OS) between the two groups.The Cox regression model revealed that the upper margin of tumor and vascular invasion were independent prognostic factors for OS and DFS,while sex and histological grade were predictors of OS.Conclusions For patients with stage T2-3N0M0 ESCC,the recurrence rate after radical surgery is higher in those treated with radical surgery alone than in those treated with radical surgery and postoperative radiotherapy.Postoperative radiotherapy significantly reduces infield recurrence and increases DFS.The value of postoperative radiotherapy should be investigated in larger studies.